Health and Health Care in India
National opportunities, global impacts
Summary
• India’s evolving social structure has throughout recorded history allowed extremes of poverty and wealth.
The country covers only a little over 2 per cent of the earth’s land surface. Yet its population is approaching
20 per cent of the world total. Because of its scale, strengths and vulnerabilities the future of India and its
ability to safeguard the health and wellbeing of its citizens raises issues of importance to the entire world
community.
• Since independence in 1947 life expectancy at birth for men and women combined has doubled to 65 years.
However, India has experienced delayed demographic and epidemiological transitions as compared with
China and many other parts of Asia. Despite the gradual progress of recent decades infant mortality is still
over 40 per 1000, while maternal mortality is 2 per 1000 live births. Healthy life expectancy in India remains
about 55 years, compared with close to 70 years reported in countries such as China, the US and Japan.
• India’s population of 1.2 billion is still rising by approaching 1.5 per cent per annum, or about 18 million
people a year. Some commentators see this as a strength. Others regard it as a major threat to future
prosperity and social stability. Although the Indian economy grew strongly since liberalising reforms in the
late 1980s, it has recently slowed. In exchange rate adjusted terms average per capita income is only about
US $1,500, compared to about $50,000 in America and Western Europe. Even in purchasing power parity
terms it is under a tenth of the EU/US average.
• About 40 per cent of all deaths in India are still due to infections. The majority of the remainder are mainly due
to non-communicable conditions such as cardiovascular diseases (heart attacks and associated conditions,
including strokes, are alone responsible for a quarter of all mortality), chronic respiratory disorders and
cancers.
• Presently, the burden of ill health imposed on Indian society is equivalent in lost potential welfare terms to
12.5 per cent of GDP for infectious and allied complaints and 12.5 per cent of GDP for NCDs. However, the
harm and loss caused by NCDs will in future rise in its relative significance, especially if tobacco consumption
does not fall and the use of medicines along with other interventions to prevent and manage disorders such
as hypertension, hyperlipidaemia and type 2 diabetes is not markedly increased. It is anticipated that 100
million people in India will be living with type 2 diabetes by 2040.
• India currently spends only 1.2 per cent of its GDP on publicly funded health care. This is considerably less
than most other comparable countries. Total Indian health spending is conventionally estimated at a little over
4 per cent of GDP. The public health care system has been strengthened since the start of the 21st century
by initiatives such as the National Rural Health Mission (NRHM). But it still suffers from significant limitations
in areas such as the (free) provision of essential medicines to the 400-600 million poorest Indians.
c
• Most health care in India is presently provided via the private sector. Because of a lack of affordable insurance
protection it is principally funded via out-of-pocket payments. A majority of Indians believe they have adequate
access to services. But there is evidence that the current system often fails to meet medically defined
need and is ill-suited to meeting the requirements of communities characterised by increasing chronic/noncommunicable disease burdens.
• The Planning Commission for India, which complements the directly elected elements of Government, instituted a
High Level Expert Group (HLEG) on Universal Healthcare Coverage (UHC). This was chaired by Dr Srinath Reddy
of the Public Health Foundation of India and reported in 2011. Subsequently, the country’s 12th Five Year Plan
projected an increase in public health spending to 2.5 per cent of GDP by 2017. The Indian Prime Minister, Dr
Monmahan Singh, has set a goal of this total reaching at least 3 per cent of GDP by 2022.
• The Prime Minister also announced extensions in the publicly funded supply of free generic medicines to
the less advantaged half of the Indian population by 2017. A five year cumulative sum of US $5 billion, or
about 0.3 per cent of annual GDP, was to be allocated to this reform. However, the HLG on Universal Health
Coverage recommended increasing Indian annual public spending on medicines from 0.1 per cent of GDP
to 0.5 per cent of GDP, and it now appears that because of reductions in India’s rate of economic growth
improvements to generic medicines supply are to be delayed or abandoned.
• About 70 per cent of overall Indian health spending is presently met by private out-of-pocket outlays. A
similar proportion of this total is accounted for by medicine costs. These figures imply that 50 per cent of
India’s low health spending is accounted for by pharmaceutical costs. But the household survey data from
which such estimates are derived may include professional fees and other items, including the purchase
of traditional remedies. The cost of allopathic (western) medicines is at manufacturers’ prices unlikely to
account for more than 20 per cent of total Indian health spending.
• Many members of the Indian public appear to believe that a key way of achieving better public health is via
reducing the prices of medicines for treating conditions such as advanced cancers. Yet this is not the case.
Measures like issuing compulsory licenses on such products can at best benefit only small numbers of
better-off people and some local pharmaceutical companies. The public as a whole will benefit much more
from the introduction of universal health coverage and a wider use of medicines for preventing and treating
early stage vascular diseases, diabetes and cancers.
• India is now the world’s 3rd largest medicines producer by volume. But it is not yet in the top 10 by value. The
available sources indicate that the domestic Indian pharmaceutical market for allopathic drugs is today worth
in the order of US $13-14 billion a year. India’s pharmaceutical exports – which the Government is seeking
to expand – are of comparable value.
• In financial terms India’s most important external pharmaceutical markets are the US and the EU. Low
cost Indian made medicines have been important in extending access to treatments for conditions such
as HIV in poorer parts of the world. However, India does not as yet have a strong record in fundamental
pharmaceutical innovation.
• Critics argue that current Indian policies are narrowing and limiting intellectual property protection for products
such as medicines and that this is inconsistent with long term Indian as well as global public interests in
both enhancing universal access to essential medicines and increasing world-wide investment in biomedical
research and development. A future global way forward could be to strengthen intellectual property rights for
new medicines while in addition extending the requirements placed on IPR holders to provide affordable and/
or free essential treatment in poor areas through measures such as stratified pricing.
• Another route to further progress could be through enabling Indian public service users to report problems
such as failures to provide public services to which people are entitled via, for example, SMS texting to
confidential monitoring centres. The country is vulnerable to internal and external challenges associated
with, for example, continuing gender inequalities and global warming. At worst there is a risk of a stalled
demographic transition coupled with increased rates of non-communicable illnesses. But if India invests
adequately in improving universally accessible health care and preventing and treating not only infectious
disorders but also NCDs these dangers should prove avoidable. The country could in time again become
one of the world’s wealthiest and healthiest nations.
2
Health and Health Care in India
Introduction
Indian commentators have observed that there are two
ways of looking at their country in its modern context.
Viewed positively, the information presented in Box 1
underlines the fact that India has long enjoyed centres
of wealth and a rich social diversity. Seen from this
perspective, it is today in the process of recovering its
position as a global ‘super-power’. Discounting the EU
as a collective entity and as measured in purchasing
power parity (PPP) based terms, India’s economy is
already the third largest in the world.
Since market oriented reforms introduced at the end of
the 1980s it has enjoyed strong growth, driven by success
in areas ranging from pharmaceutical manufacturing and
exporting to information technology. Although China’s
economic development from around that time has been
faster (even in 1990 the two countries had roughly the
same per capita GDP) India, which is home to over 1.2
billion people, has made important progress. For example,
average life expectancy at birth has risen to over 65 years
for men and women combined. This is about twice the
figure recorded when the nation became independent in
the late 1940s. In the southern State of Kerala average life
expectancy is, at 74 years, comparable to that presently
reported for China as a whole.
For comparison, when health care systems such as the
UK’s NHS were established at the end of the 1940s, life
expectancy at birth in Western Europe and the US was
at the same level that India enjoys today. Since then it
has increased in the ‘mature industrialised’ economies
by another 10 years. This is only a third of the absolute
gain achieved by India in the same period, albeit that
enhancing fitness and survival rates in older people is
a fundamentally different task from that of cutting infant
and child mortality. The challenges facing India today
relate to bridging the transition from fighting infections
to reducing the burden of chronic disease and living
healthily in later life.
Conventional proponents of the ‘demographic dividend’
associated with when the relative numbers of children
in a population fall and the proportion of people over
‘retirement age’ has not yet risen markedly believe that
India’s still young population is a valuable resource in
terms of future world-wide competition. The number of
people in India is presently increasing by approaching 1.5
per cent per annum (Figure 1). Two thirds of its population
is aged 35 or less. Some authorities argue that as the
Box 1. Wealth, caste and class in India
In modern India a little under 20 per cent of the world’s
people live on a little over 2 per cent of earth’s land
surface. They collectively enjoy an income of – in
purchasing power adjusted terms – between 5 and
6 per cent of global GDP. However, within that overall
picture there are major disparities in wealth. The country
has about 50 billionaires whose combined personal
revenues represent in the order of 10 per cent of India’s
total earnings, and approaching 100 million citizens
with standards of living comparable to those of affluent
people in countries like the US and Germany. Against
this some 400 million Indians live in severe poverty.
Extremes of wealth and deprivation have been a long
standing characteristic of Indian society, albeit that
over the millennia of its existence there have also been
periods of relatively evenly distributed prosperity. The
country was until the last few centuries one of the
richest on earth. At the start of the seventeenth century,
at the time the term caste was first gaining currency,
India was responsible for about a quarter of all global
wealth generation. In the early 1600s only China was of
a similar standing.
In the Mughal, Marathan and British dominated periods
that followed the country’s relative prosperity gradually
declined. Yet some individual Maharajahs (local
‘Great Kings’) retained considerable (and often highly
conspicuous) personal fortunes into the current era. This
pattern of ‘accepted inequity’ has been underpinned by
India’s unique system of social stratification. The latter
evolved over two to three thousand years in response
to various waves of invasion and economic as well as
military struggle and enterprise.
Health and Health Care in India
The word ‘caste’ is of European (Portuguese and English)
origin. In the colonial period British and other external actors
exploited social, religious and racial divides between the
peoples of the Indian sub-continent for administrative and
social control purposes. The consequences of this may to
a degree live on in – for example – the continuing tensions
between today’s India and Pakistan. Yet ‘foreigners’ did
not create the Jati (in essence, non inter-marrying clan
and occupational/community group) based structure that,
along with ancient Hindu categorisations such as the four
Varna, have served to underpin what is now referred to as
the caste system. Nor were the inequitable gender divides
that still exist within substantial parts of India and in many
other Asian communities introduced by Europeans.
A detailed analysis of how caste and broader socioeconomic class based values and practices continue to
influence Indian social and economic development cannot
be attempted here. But from a health perspective there is
compelling evidence that steep gradients in the distribution
of wealth within societies impact negatively upon not only the
poorest within them, but the physical and mental wellbeing
of all sections of the community (see CSDH, 2008). In order
to overcome the remaining barriers to extending overall and
healthy life expectancy to or beyond the levels presently
observed in, for instance, Western Europe and Japan, it is
likely that twenty first century Indian policy makers will need
to find ways of further promoting a communally accepted
commitment to greater equity. Developing better funded
and ethically provided public health services will probably
prove integral to achieving this fundamental goal, as well
as to more specific objectives such as improving access
to medicines for the prevention and treatment of noncommunicable diseases.
3
twenty first century progresses India will become a vital
source of the skilled workers needed in the more mature
communities of regions such as Europe, North America
and East Asia (Kurian, 2007).
Figure 2: Healthy life expectancy, selected
countries, circa 2010
Figure 1: Crude birth and death rates and
population size, India 1901-2011
Source: (Salomon et al., 2012)
Source: Office of the Registrar General and Census
Commisioner of India, various years
However, there is an alternative to this positive picture.
Viewed less favourably, India’s nominal (exchange rate
based) GDP per capita currently stands at only a little
over US $1,500 ($3,700 PPP adjusted). This contrasts
with figures of about US $50,000 per head recorded
in North America and Western Europe, and a current
Chinese real per capita income of over twice the Indian
level. Although a relatively small minority in the Indian
population enjoy standards of living above EU and US
norms, 400 million or more of the nation’s citizen’s live
in severe poverty. In rural areas, where two thirds of the
nation’s people are still located, the median household
income is little more than US $500 a year. Such figures
help to explain why a quarter of the current global total
of child deaths occurs in India, along with a similar
proportion of the world’s maternal deaths.
Concerned Indian observers might also regard the
nation’s large, young and mainly poor population as a
potential social ‘time bomb’, rather than an unalloyed
economic asset. They may in addition point to the
sometimes under-estimated strengths of communities
with higher proportions of older people. Provided that due
attention is paid to preventing and treating conditions like
strokes, type 2 diabetes, cancers and the dementias the
potentially undesirable aspects of longer life spans can to
a considerable degree, if not entirely, be counterbalanced
by increases in healthy life expectancy and extended
working and active social lives. As Figure 2 indicates,
healthy life expectancy in India is about 15 years less than
that recorded in Japan (Salomon et al, 2012).
Furthermore, despite its reputation for plurality and
tolerance, the Indian community is fractured by multiple
social and allied divides. These relate to not only ethnicity
and religion, but also caste, class and gender (see again
Box 1 – Balarajan et al, 2011). Such factors help in part
to explain not only why birth rates have remained high,
but also why – notwithstanding sixty years of existence
4
as an independent republic – large sections of the Indian
population do not as yet have reliable and affordable
access to good quality health care (High Level Expert
Group on Universal Health Coverage, 2011).
Comprehensive private health insurance covering
chronic as well as acute health needs is not as yet
generally available, while reported public spending on
health care in India is presently only a little above 1 per
cent of GDP. Notwithstanding the increase to 2.5 per
cent of GDP by 2017 anticipated in the country’s 12th
Five Year Plan, this is one of the lowest proportions
recorded anywhere in the world. Recent figures from
sources such as the OECD and the World Bank put total
Indian health spending at just over 4 per cent of GDP,
compared with about 5 per cent in ‘BRICS’ like China
and Russia and 9 per cent in Brazil and South Africa.
In the US some 18 per cent of GDP is now spent on
health care. In India out-of-pocket personal and family
payments provide the largest reported element (about
70 percent) of health care funding.
Indian health service users are already facing increasing
difficulties with regard to the prevention and treatment of
non-communicable conditions (IMS 2012; Reddy et al,
2005). This threatens health in middle life and beyond.
At the same time there is a significant residual burden
of infectious disorders. Diarrhoeal diseases, for example,
still represent – along with pneumonia – a major threat to
infants in less advantaged rural and urban communities
living without adequate clean water supplies. Rates of
TB related mortality and morbidity remain high in adults.
In the area of pharmaceutical care the low prices and
generally good quality of Indian manufactured generic
products ought to have facilitated the supply of essential
medicines and vaccines for all. Yet the existence of an
often apparently dysfunctional private market for nonpatented branded medicines, coupled with problems such
as ‘stock outs’ and corruption affecting the public sector
pharmaceutical supply chain, has meant that standards of
treatment are not as high as could otherwise have been
attained. Some observers interviewed during research for
Health and Health Care in India
this analysis1 fear that controversies about, for instance,
the prices of patent protected medicines developed by
‘multinationals’ for conditions like cancer (and that in the
main have – at least to date – limited life extending rather
than saving applications) have served to conceal much
more important public health questions about the supply of
basic established treatments to the mass of the population.
It is understandable that the Indian public is concerned
about the cost of pharmaceutical products. On a day-today basis many people experience outlays on drugs (which
to varying degrees also encompass professional and
institutional fees, as well as taxes) as the dominant element
in the out-of-pocket expenditures they believe are needed
to protect their health. Many sources suggest that a half of
total health care outlays are spent on purchasing ‘drugs’.
Yet the available data can be difficult to interpret. It is
concluded here that spending on allopathic (western
science based as opposed to other traditional) medicines
expressed in manufacturer’s prices (net of mark-ups by
suppliers of all sorts, which may encompass practitioners’
fees) is unlikely to account for more than about 20 per cent
of total health spending in India2. This is not far out of line
with equivalent figures reported elsewhere. What has been
more atypical is India’s to date low overall level of health
investment. It is also worth stressing that tragedies such
as families being driven into poverty because of health
care costs can in large part be seen as resulting from a
collective failure adequately to provide systems that protect
patients from potentially catastrophic risks, including those
of hospital care that is not available via public agencies.
There is a widespread perception that ‘health care has
not been a political priority in India’. To the extent to which
this is genuinely the case today, an undue concentration
on controversies in areas like pharmaceutical pricing as
opposed to the importance of achieving equitable – risk
sharing – financial arrangements for enabling universal
health care access could, despite the recent efforts of
bodies such as the High Level Expert Group (HLEG) on
Universal Health Coverage established by the Planning
Commission for India, have perpetuated an absence of
well grounded political and wider public debate about
health improvement.
Against this background, the central goal of this analysis is to
inform in a balanced and welfare oriented manner European
and North American stakeholders’ understandings of
the challenges and opportunities facing India and her
people. As already indicated, it is particularly concerned
with the growing burden of long-term non-communicable
conditions (NCDs) being recorded in India, along with other
emergent economies such as, for instance, China and
Turkey. (See, for example, Carter et al, 2012).
1 In addition to a structured literature review, twenty semi-structured
interviews were conducted in India and elsewhere with relevant
experts on health and health care over a period of about 18 months.
2 Sources such as IMS suggest that the domestic market for
allopathic medicines in India was worth in the order of US $13-14
billion in 2011/12. This is roughly the same as the value of Indian
pharmaceutical exports to the US and other countries. The Indian
GDP stood at about US $1.8 trillion at that time. Even allowing for
incomplete reporting these data indicate a domestic sale value of
under 1 per cent of GDP.
Health and Health Care in India
The experience of countries like Russia where, despite
relatively low infant mortality and a relatively high per
capita GDP, male life expectancy has in recent decades
been similar to or even below the Indian average,
underlines the importance of addressing the threat of
rising NCD and lifestyle linked mortality and morbidity
in timely and effective ways. That is, by combinations
of health behaviour change and the judicious use of
medicines and other health care interventions for the
primary, secondary and tertiary prevention of conditions
such as vascular and renal diseases.
This study also explores how the strategies India adopts
may impinge on global human interests in areas such as
assuring continuing investment in high risk biomedical
research and development, as well as facilitating
affordable world-wide access to medicines. It begins
with an overview of demographic and epidemiological
transition in India, followed by a discussion of the
present provision of health care and the potential
importance of recently proposed reforms. It then turns
to issues relating to the ongoing development of better
medicines and India’s ambitions to be ‘the pharmacy
of the world’.
Continuing concerns surrounding TRIPS (the Agreement
on Trade Related Aspects of Intellectual Property Rights)
are explored, alongside the significance of recent Indian
decisions to issue compulsory licenses (CLs) for a number
of patented medicines. Such actions – which are clearly
popular with the Indian public – have been applauded
by some observers. But they are seen by others as
threatening not only industrial but global public health
improvement related interests. A secondary objective
of this report is to explore why this is the case, and to
suggest ways of reducing the potential for damage.
However, there are two more introductory points
that first require emphasis. It is important initially to
emphasise that, for successful implementation, public
health initiatives of all types need to be consistent
with the beliefs, values, resources and needs of the
communities they are intended to benefit. They cannot
normally be imposed without meaningful consultation,
or be copied uncritically across from one cultural setting
to another. Academic and other commentators should
be aware that solutions to problems that have proven
effective in countries such as, say, the US, the UK or
Brazil may not work in India’s social and economic
context. Likewise, within a country the size of India it
should not be assumed that approaches that are viable
and demonstrably cost effective in one State will prove
equally desirable in another.
Following on from this, today’s India covers less than
2.5 per cent of the world’s land surface. Yet a second
point to stress is that the 28 States included in its
Federal structure (along with the 7 centrally administered
Union territories) typically have populations that are
comparable in size to, or larger than, those of nations
such as, for instance, Spain or Canada. Some, such
as Uttar Pradesh, Maharashtra and West Bengal, have
individual populations as great as those of countries like
Brazil, Mexico and Turkey – see Figure 3.
5
Figure 3: Population and literacy per Indian state, 2011
Source: Office of the Registrar General and Census Commisioner of India, 2011
India’s total population is over twice that of the entire
European Union and four times that of the US. Within the
country States differ greatly in respect of, for instance,
average literacy rates and in their capacity locally to fund
and deliver health care. At the same time the power of
the Federal Government to provide support for activities
such as health services development has to date been
limited. The reasons for this include not only the physical
scale of the tasks involved but also the social distance
between elites in Delhi and the leaderships of national
programmes and Institutes located in or near other major
cities and the equally important but far less advantaged
people working to provide local services.
Such factors mean that it is often difficult and/or potentially
misleading to attempt to understand India as a single
entity. Parts of the country are much more resistant than
others to change, and to concepts such as universal
health coverage and care. If disputes relating to this last
and those surrounding Indian as opposed to American
and European approaches to issues such as intellectual
property protection are to be equitably resolved, the
wider global community will need to be sensitively aware
of the immediate physical needs of India’s people. Those
seeking to support the country’s ongoing development
will also need to understand the fundamental social
drivers beneath current patterns of national and local
governance, and the historically defined concepts of
status and justice underpinning the modern day working
of the world’s most populace democracy.
6
Population trends and changing
patterns of disease – health in India
in the early 21st Century
The terms demographic and epidemiological transition
relate to the closely intertwined population and
disease incidence and prevalence changes that have
characterised the global human development process
of the last two centuries. These accompany movements
from rural subsistence living towards more urbanised and
affluent ways of life. The nature and timing of the shifts
involved, which include both individual life expectancy
gains and population ageing, are outlined in Figures 4
and 5.
Before the early 1800s – that is, 200 years after the
establishment of the British and Dutch East India trading
companies and over 2,000 years after the nations of the
Indian peninsula had begun routinely trading spices with
the Roman Empire – no population group anywhere on
earth had an average life expectancy of much over 40
years. This was first and foremost a consequence of
high – typically up to 20 per cent – annual infant mortality
rates. But because of the benefits of ‘low pressure’
demographic systems3, coupled with agricultural
3 There is evidence – for instance – of planned family size limitation
in the UK dating from the 1600s. This was achieved partly via a
later age of marriage than that typically recorded elsewhere in the
world in the same period.
Health and Health Care in India
Figure 4: Stages of demographic and
epidemiological transition
Stages of epidemiological transition
Pestilence and
famine
Receding
pandemics
Increasing NCDs
(lifestyle related)
Delayed NCDs
and emerging
infections
Population
growth
Stages of demographic transition
Pre
Early
Late
Post
Crude death rate
Crude birth rate
Source: The authors
advances and early stage industrialisation, people in
England and The Netherlands were by the end of the
Napoleonic wars (in 1815) a little wealthier and healthier
than populations elsewhere.
The technical progress such countries made in time
helped to open the way to the global developments
taking place today. But this was at the price of the
colonialism initially facilitated by the demographic,
technical and material advantages enjoyed by Western
Europe as compared to the rest of the world. Global
average life expectancy at birth remained under 35 years
throughout the nineteenth century. In both India and
China, for example, it did not rise much above this level
until the second half of the twentieth century. It is still
(in part due to the only partially contained, if declining,
HIV pandemic, as well as ongoing military conflicts) little
more than 40 years in parts of Africa today.
However, once commenced demographic transition
– despite exceptional experiences, most notably like
that of France – tends to follow the same basic path
everywhere. As environmental conditions and food
supplies start to improve, death rates among younger
adults begin gradually to fall. This is at first because of
reduced risks from infectious diseases. Better sanitation,
for example, cuts the spread of water borne conditions.
So too does an improved immune status in individuals
and across populations. Enhanced immune responses
resulting from improved nutrition (coupled in the modern
era with access to pharmaceutical products like vaccines
and antibiotic and anti-parasitic drugs) boost recovery
rates and classically facilitate further productivity gains.
Child and then infant survival rates also rise, as conditions
become still more favourable.
Although cultures vary in the speed at which religious
and other variables inhibit or encourage behavioural
and societal adaptations, declines in birth rates and
increases in the status of women follow the achievement
of lowered infant mortality. Protection from malnutrition
and debilitating parasitic and other infectious illnesses
in infancy and childhood coupled with the additional
benefits of smaller families, better child care and changed
patterns of education lead on to other gains. These
include a 15-20 point rise in average IQ, as between preand post transitional communities (Flynn, 2009).
Such advances enhance workforce participation and
reduce the ratio of ‘dependents’ to working age adults,
partly by allowing older people to use their skills for
longer. This supports continued economic and societal
development, including improved health and social
care provision. The social processes that help result
in the establishment of universal health coverage and
care (UHC) systems have been termed ‘care transition’
(Taylor and Bury, 2007). From the perspective of
this analysis the achievement of UHC is a common
characteristic of all mature post-transitional societies.
(See, for example, Rodin and de Ferranti, 2012.) Yet
as the contrasting patterns of health service provision
in, say, the US and the UK illustrate, this end point can
be achieved in different ways and with differing levels
of efficiency.
Figure 5: Population ageing: time for the proportion of the population aged 65 or older to increase
from 7 per cent to 14 per cent, selected nations
1860
1880
1900
1920
1940
1960
1980
2000
2020
2040
2060
Percentage of population
aged 65+
14%
India
Brazil
Rep. of Korea
China
Thailand
Japan
USA
UK
Sweden
France
7%
Source: The authors adapted from WHO, 2012
Health and Health Care in India
7
There is evidence that, when poorly planned and
regulated, market based ‘solutions’ are (at least in the
‘late infectious disease’ transitional phase) more costly
and less beneficial to the health of populations than well
planned, effectively regulated, tax funded health services.
But in order to enhance public (health) interests and
provide good individual care, systems of the latter type
demand greater pre-existing levels of social infrastructure
and political/electoral support for equitable care than is
sometimes recognised4. They may therefore be very
difficult, if not impossible, to introduce successfully in
heterogeneous nations in the mid-transition phase.
Russian history might be taken to illustrate the price that
may have to be paid for attempts to force cohesion and/
or change before communities are ready ‘naturally’ to
accept it.
In the Indian context continuing economic and social
development will demand intensified efforts to introduce
UHC. However, despite the recent findings of the High
Level Working Group on Universal Health Coverage
instituted by the Planning Commission of India (see
below) it could prove counter-productive to prescribe
a single theoretically ‘optimal’ national model. Many
commentators believe that in the foreseeable future a
flexible mix of public and private systems designed to
facilitate better health service funding and provision is
likely to emerge, albeit that in the case of the poorer
segments of the Indian population better medicines and
care provision will very probably require free-at-the-pointof-use supply. To be viable, such measures must be
supported by resource transfers from richer community
groups to their less advantaged peers. These may well
need to be introduced via Federal action and sustained
by Federally supported mechanisms.
The special characteristics of India’s
demographic development
The earliest stages of demographic transition in India date
back to before the 1940s. As Figure 1 on page 4 shows,
the crude birth rate in the sub-continent as a whole initially
commenced its gradual fall two to three decades before
the partition into what were at first called the ‘dominions’
of India and East and West Pakistan. With subsequent
support from the Republic of India the latter became the
fully independent People’s Republic of Bangladesh in
1971.
4 It was not a coincidence that the establishment of the UK NHS
took place at the end of the 1939-45 conflict, close to what can
be regarded as the final stage of Western Europe’s demographic
transition and around the opening of the Indian process. The social
and psychological impacts of the 1939-45 war, combined with
the anticipated loss of Empire, created a ‘window of opportunity’
for those wishing to create a new welfare state in Britain. Similar
conditions will not necessarily exist again elsewhere. Global
population movements may also mean that relatively few future
diverse communities will be as united and willing to accept a
centralised and fully public funded UHC system as Britain was in
the late 1940s. India is today in some ways more comparable to
America in the early decades of the twentieth century, even though
its history and population density are very different.
8
At the start of the 1970s India was arguably ahead
of China in terms of its economic development. The
nation’s GDP per capita was still marginally higher than
that recorded in the Chinese People’s Republic. Yet it
was also around that time that the Cultural Revolution
heralded dramatic declines in the latter nation’s fertility
rate. The ‘one child’ policy introduced in China in 1979
can be seen as securing the initial falls in birth rate
triggered by the painful social upheaval of the late 1960s
and early 1970s. Until that point most Confucians,
like many believers in the other monotheistic religions
founded around 2,500 to 1,500 years ago5, had
espoused the view that women should be subservient
to men. By the end of the Cultural Revolution such views
were less likely to be expressed, albeit that the extent of
fundamental social change achieved even today in areas
as complex and deep rooted as gender relationships
should not be exaggerated.
By contrast, in the Indian democracy of the early 1970s
Ghandi administration led attempts to curb population
growth by measures such as encouraging men (and
often forcing poorer males) to have vasectomies were
not successful. This strategy was rejected by the
Indian democracy – see Box 2. Reactions against it,
some commentators believe, set back attempts to
extend family planning in India by several decades.
Figures 6a and 6b describe relevant trends, and from a
demographic perspective cast light on the core reasons
why China’s economic performance has in recent
decades outstripped that of India.
In summary, India can be said to be in the process of
a protracted demographic transition. It has lagged that
of countries such as France and the UK by a century or
more, that of the US and Japan by over 50 years, and that
of China and Brazil by around three decades. This record
in some ways reflects the strengths of India’s traditions
and the fact that its domestic population has not been
directly victim to a major war in living memory. Yet the
slowness of India’s demographic and epidemiological
adaptation means that at the beginning of the 21st
century the nation’s population is still challenged by a
high prevalence of infectious disease, alongside an
already large and growing non-communicable illness
burden.
The next section of this brief UCL School of Pharmacy
report considers the part that public health interventions
5 The first pharmacopeias and comprehensive medical treatises,
such as in Asia the Charak(a) Samhita and the Huangdi Neijing
and in Europe the Hippocratic Corpus, also date from roughly
2,500 to 1,500 years ago. As human populations slowly grew
and consolidated it became possible to draw together verbal
traditions into substantive collections of written knowledge.
However, the threats of large scale organised conflict also grew.
This was a factor in the development of patriarchal, militaristic,
societies. The values and belief structures of the latter may now
be becoming redundant in post-transition settings, depending
perhaps on the future state of the environment and the global
availability of energy and raw materials. Hinduism draws on a
variety of beliefs and traditions that date back well over 2,500
years. It can hence claim to be the ‘oldest living’ major religion,
albeit that Hindus are now faced with a rapidly changing world.
Health and Health Care in India
and universally accessible health care could play in
further reducing factors like infant mortality and maternal
deaths, and extending healthy life expectancy in India.
Before this, however, the remainder of this section offers
an overview of the disease specific issues and trends of
particular relevance to achieving better health in India.
Box 2: Family planning in India
The first family planning clinic in India opened in 1915 in
Karnataka, at around the time that the crude birth rate
for India as whole initially started slowly to fall. However,
the latter was still 40 per 1000 population at the time
of independence. In 1951 the first Five Year Plan for
the then new nation highlighted family planning and
welfare. These topics have been explicitly addressed
in all subsequent Five Year Plans. Yet it was not until
the start of the 1970s that India moved to adopt a proactive family planning programme. At that time only
about one in ten married women was using ‘modern’
contraceptive methods (including female sterilisation).
It is claimed that Sanjay Gandhi influenced his mother,
the then Prime Minister Indira Gandhi, to introduce
a radically new approach to birth control (Mukhuti,
2010). As well as seeking to incentivise men who had
had two or more children to accept a vasectomy, the
approach he and the wider Ghandi administration
promulgated sought to abolish the dowry and caste
systems and to focus increased national effort on goals
such as protecting the natural environment. Viewed
sympathetically, this initiative can be seen as an attempt
to enhance per capita prosperity in a self-sufficient and
sustainable manner. It sought to tackle ‘head on’ some
if not all of the reasons for continuing mass poverty and
widespread ill health.
However, in practice this programme did not challenge
entrenched interests and questionable male attitudes to
women and reproduction in an effective and acceptable
manner. It in fact turned into little more than a forced
sterilisation campaign. Local officials, police officers
and doctors reportedly behaved in authoritarian ways
in order to meet vasectomy and allied quotas, in some
cases sterilising both young men and women against
their will. It was in particular feared that unmarried males
of low socioeconomic status or with ‘anti-Congress’
political views were being targeted and involuntarily
sterilised. Such concerns have been widely blamed for
setting back the uptake of family planning in India for
decades. Even though steady declines in fertility have
been achieved since the end of the 1960s, this in turn
may be seen as one of the reasons why China has in
economic and some other respects out-performed
India since the mid 1970s – see main text.
Currently, about a half of all married women are
using contraception, including sterilisation. However,
there remain large regional variations. Uptake rates
in, for instance Bihar, Sikkim and Assam have been
lower than in States such as the Punjab, Karnataka,
Gujarat, Andhra Pradesh and Maharashtra. The latter,
for instance, introduced in 2010 a scheme whereby
couples are paid a little over US $100 if they wait two
years after marriage to have their first child. The current
fertility rate in India is about 2.5 children per woman,
compared with 3.4 in Pakistan and 1.6 (below the
long term replacement rate) in China. This means that
average fertility in India has halved since the start of the
1970s. But it is still driving an overall growth of over 1.4
per cent per annum, which is adding 18 million extra
people a year to the Indian population.
Figures 6a and 6b: Demographic changes in India and China, 1950-2050
6
3.0
projected
projected
Ratio of working-age to
non-working population
Children per woman
7
5
4
3
2
1
1950 19752000 2025 2050
China India
2.5
2.0
1.5
1.0
1950 19752000 2025 2050
China India
Source: Bloom, 2011
Health and Health Care in India
9
Figure 7a: Estimated number of deaths due to
selected diseases and injuries in India (2004).
Figure 7b: Estimated disability burden of
selected diseases and injuries in India (2004)
Source: Patel et al., 2011
Parasitic, bacterial and viral disorders
Poor standards of reproductive and child health are
associated with inadequate maternal and infant nutrition
in all less advantaged communities. Relevant health
determinants include those linked to religious beliefs and
taboos, together with factors like caste and the status of
women (Paul et al, 2011, Pall 2012)6. There is evidence,
for example, that there are still about 50 million children
in India suffering from stunted growth. Female infants
appear to be at greater risk of malnutrition than males.
Likewise, unlike the case in any other world region,
women in India are at greater risk of death from causes
such as burns than men.
Along with associated indicators such as the relatively
high reported prevalence of acid attacks by men on
women and data revealing the selective medical abortion
of female foetuses, this suggests a community that has
not as yet universally undergone the social transitions
needed to sustain ‘post transitional’ health development.
High levels of infection may in addition be related to
problems such as the fact that microbial pathogens tend
not to be recognised as the root cause of infections in
traditionally based forms of medicine7. This may help to
explain why, for instance, open-field defecation continues
to be widespread in poor rural communities. Coupled
with the inadequate sewage removal problems that have
been compounded by rapid urbanisation, this can lead
to the contamination of water supplies and domestic
environments alike (John et al., 2011).
6 India scores 0.54 on the Human Development Index, an
aggregate measure of wellbeing devised by (with colleagues) the
Nobel Prize winning Indian economist Amartya Sen (UNDP, 2011).
This relatively low score, which is similar to that of African nations
such as Ghana, is in part due to high levels of inequality within the
country. For comparison Norway (with a population of less than
0.5 per cent that of India) has an HDI score of over 0.95, the US
0.94, South Korea 0.9, the UK 0.87, Russia 0.79, Brazil 0.73,
China 0.7 and Nigeria 0.47.
7 Such medicines remain important for many people in India. There
is evidence that world-wide approaching 50 per cent of the global
population still relies on traditional medicines as their most widely
used form of day-to-day treatment.
10
Figures 7a and 7b illustrate the fact that diarrhoeal illness
remains a major cause of child morbidity and mortality
in India, alongside respiratory tract infections. Around
a quarter of all child deaths are due to pneumonia.
Infectious conditions ranging from tuberculosis and HIV
infection through to parasitic complaints like lymphatic
filariasis and visceral leishmaniasis are also relatively
prevalent, while Dengue fever is an important example
of a potentially life threatening viral infection which, like
malaria, is spread via mosquitoes.
In aggregate, infections still cause some 40 per cent of
deaths in India, as compared with about 60 per cent
in 1990. (Global Burden of Disease Study, 2012). In
the case of TB, for instance, 2 million new cases were
recorded in 2009, along with close to 300,000 deaths
(John et al, 2011). Despite the establishment of a
National Tuberculosis Control Progamme in the 1960s,
the incidence of this condition has remained stubbornly
high for decades. There is now a growing risk from drug
resistant strains.
Dengue fever provides an example of a condition which,
as may also be true with malaria in India, is widely
under-recorded. Published figures, based on laboratory
confirmed infections identified in public hospitals, fall far
short of the 30 million cases that probably occur annually
(Harris, 2012). Some authorities argue that tracking
hospital confirmed data gives a consistent basis for
disease monitoring. Yet the reality remains that India is
suffering a large Dengue fever epidemic which is being
poorly recorded.
A lack of the local (State) level public health resources
needed to generate disease surveillance information
required to inform specific efforts to control infections
and when possible eliminate their sources has impaired
the nation’s capacity to respond to such challenges
efficiently and effectively. Indian observers have noted
that the fact that the British inspired 1897 Public Health
Act remained un-amended for over a century implies
that this area has not received a level of attention
Health and Health Care in India
commensurate with public interests in health protection
and improvement. One suggested reason for this has
been an inappropriate division of Federal and State
responsibilities. Actors at the former level are empowered
to invest in national (public) health programmes. But less
well resourced people working at the State and locality
levels carry responsibility for service delivery (Reddy et
al, 2011).
Having said this, malaria control national prevention
and treatment policies appear to have been relatively
successful. However, even in this field mortality underrecording is a controversial topic. The ratio of the
actual number of deaths occurring to those officially
acknowledged may, as with Dengue fever, be over 100:1.
The total number of recognised malaria cases in India
was 1.6 million in 2009, with a steadily rising proportion
being due to Plasmodium falciparum. Treatment failures
due to drug resistance also appear to be increasing.
This underlines the need for good access to high quality
anti-malarial medicines, and sufficient strategic and field
professional support to facilitate their appropriate use
and preserve their effectiveness.
HIV/AIDS rates provide a further example of infectious
disease related controversy and partial success in India.
It is presently estimated that there are about 2.5 million
people with this infection. Its prevalence is highest in
southern peninsula States like Andhra Pradesh and
Karnataka and also in the extreme north east, where
viral transmission has been associated with drug use –
see Figure 8. Yet overall the nationally reported incidence
of HIV is falling. The available data indicate that there
are now over 300,000 individuals in receipt of publicly
funded first line anti-retroviral treatment.
Figure 8: Estimated adult HIV/AIDS prevalence
in the States of India, 2007
HIV/AIDS prevalence
<0.25%
Jammu and Kashmir
0.25%–0.50%
0.51%–0.75%
Himachal
Pradesh
0.76%–1.00%
>1.00%
Chandigarh
Punjab
Uttarakhand
Haryana
Delhi
Rajasthan
Arunachal
Pradesh
Sikkim
Uttar Pradesh
Assam
Bihar
Nagaland
Meghalaya
Manipur
Jharkhand
Madhya Pradesh
Gujarat
Tripura
West
Bengal
Mizoram
Chhattisgarh
Orissa
Daman
and Diu
Dadra and
Nagar Haveli
Maharashtra
Andhra Pradesh
Goa
Karnataka
Pondicherry
Kerala
Tamil Nadu
Lakshadweep
Source: John et al., 2011
Health and Health Care in India
Andaman and Nicobar Islands
The establishment of the National Aids Control
Programme in 1987 and the subsequent launch – with
financial support from agencies such as the World Bank
– of the National Aids Control Organisation (NACO)
has, together with programmes in areas such as the
prevention of mother-to-child-transmission and sex
worker and other ‘at risk’ group education, been credited
with the country’s success in this area. By 2009 over
13 million Indian citizens had, for instance, been tested
for HIV infection in integrated counselling and testing
centres (ICTCs) dedicated to this purpose.
However, the WHO has claimed that only about a
quarter of the Indian citizens infected with HIV/AIDS who
could benefit from antiretroviral medicines are receiving
them. About a half of those living with HIV are said to
be unaware of their diagnosis. Access to second and
third line treatment also appears very limited. In the order
of 150,000 people a year die from HIV linked causes
(Sinha, 2012). A combination of a strong emphasis in States such as
Tamil Nadu on preventing viral transmission amongst
sex workers and other groups at high risk, coupled with
the limited but important nationally supported access
to life saving anti-retroviral drugs available, helps to
explain falling prevalence rates. Given the Indian based
pharmaceutical industry’s capacity to supply low cost
anti-HIV medicines in areas such as sub-Saharan Africa
it is perhaps disappointing that better domestic supply
has not as yet been achieved, albeit that – as in other
care contexts – providing low cost drugs alone does not
in itself ensure that effective care is affordable.
Further improvements in India’s HIV/AIDS prevention
and treatment record is again likely to depend on
strengthening local capacity to understand and respond
to relevant aspects of the disease’s epidemiology
and transmission, while also successfully integrating
this aspect of health protection and care into a more
unified overall system. As with many other conditions,
the establishment of nationally led top-down, vertically
oriented, specialist Institutes and programmes has
brought benefits. But achieving greater health gain in the
future may well demand horizontal integration and an
enhanced emphasis on the robust provision of generalist
primary and community services, backed by specialists
only when genuinely needed.
A final point to make in the infectious disease context
is that although in the past India’s delivery of vaccines
to children in rural and poor urban communities has
been variable, performance is also improving in this
area. There is good reason to hope, for instance, that
(notwithstanding a continuing threat from the disease in
Pakistan) polio has now been eradicated. Immunisation
rates for other conditions are continuing to rise. In most
of south India over 60 per cent of infants aged under
two years now receive full immunisation courses, as
defined by national protocols. However, in the so-called
BIMARU (which translates from Hindi as ‘sick’) States
of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh
the equivalent proportion was still under 50 per cent
in 2007/08. The lowest under-two immunisation rate
11
recorded at that time was 30 per cent in Uttar Pradesh,
India’s most populace State (Paul et al, 2011).
Given the nation’s proven capacity to develop and
manufacture vaccines, there is good reason to hope that
in future well managed immunisation programmes using
an expanded range of products will facilitate further
health gains in areas such as reducing the toll of child
deaths caused by respiratory tract infections. Ongoing
investment by Government agencies and research based
pharmaceutical companies will in time lead to new and/
or enhanced vaccines in areas like TB and Dengue fever
prevention8, and the control of other currently prevalent
bacterial, viral and parasitic conditions. Alongside
progress in areas such as improving the heat stability
of vaccines and, when and where needed, more rapid
and accurate diagnostic testing and better curative
treatment, Indian children and adults have as much
or more to gain from continuing investment in better
pharmaceutical products for infectious indications as
any other population on earth.
Preventing and managing vascular diseases
and type 2 diabetes
As noted earlier, India was until the 1980s unique in the
world for having a longer life expectancy at birth for males
than for females. But now that both women and men
are enjoying longer lives, the burdens imposed by noncommunicable disease such as heart disease, stroke
and the physical and sensory problems associated with
type 2 diabetes are becoming more apparent. So too
are the impacts of respiratory conditions such as COPD
and mental health disorders. Box 3 describes issues
relating to the very limited provision of psychiatric and
other forms of mental health care in India.
At one stage it was believed that at any given age the
harm caused by conditions like CHD/ischaemic heart
disease and other consequences of raised blood
pressure and high low density lipoprotein (LDL) lipid
levels rises as countries grow more affluent, and people
can afford more fatty foods and sedentary lifestyles
as well as the use of (more) tobacco, alcohol and/or
other harmful leisure drugs. But the full picture is more
complex, not least because in today’s global society
age specific death rates from vascular diseases of all
types are (as with COPD) typically greater in low income
countries than they are in more affluent nations (WHO,
2012).
This is partly due to the fact that poorer populations
are often exposed to multiple risk factors like untreated
hypertension and indoor cooking smoke. Figure 9
provides an outline of the relative levels of mortality
associated with such variables in India, although it
8 For example, Sabchareon et al (2012) recently reported a Thai trial
of a Dengue vaccine produced by the French company Sanofi
Pasteur. It achieved a limited protective effect but nevertheless
marks an important step forward. Other vaccines are being
developed for the protection of the global population against
parasitic diseases such as leishmaniasis and malaria, as well as
for additional viral and bacterial indications. Immunology based
technologies may also have an important future role to play in
areas such as preventing and treating cancers.
12
Figure 9: Estimated percentages of deaths in
India attributable to the major chronic disease
risk factors
Source: Patel et al., 2011
should be noted there are significant difficulties in
accurately ascribing cause and effect. Vested interests
may also influence the appreciation of the extent of the
relative harm due to commercially supplied goods such
as tobacco products. Prolonged smoking kills 50 per
cent of all smokers, and contributes to disabling the
great majority of the remainder.
Post transitional communities have proportionately
more older people than those at earlier stages in the
development cycle, and so normally have to carry
increased absolute chronic disease burdens. Yet the
factors that enable people in richer countries to survive
longer also tend keep them in better health at any given
age than their contemporaries living in less advantaged
settings.
Over and above care access variables, another
sometimes neglected consideration is that people living
in settings such as rural India are at relatively high risk from
infections that can, for example, cause kidney damage.
This may lead on to non-communicable complaints in
later life, as too may problems such as foetal and child
malnutrition. The thrifty phenotype hypothesis (Hales
and Barker, 1992; Barker, 1997) could help to explain
why India already suffers an unusually high loss of
potentially productive years of life due to deaths from
cardiovascular disease in people aged 35-64 years.
By 2030 the volume of premature disability and loss of
life suffered by Indians of working age is projected to
have doubled to almost 10 times the corresponding loss
experienced in the US (Reddy et al., 2005). By that time
non-communicable conditions will probably account for
about three-quarters of all deaths in India (Patel et al.,
2011).
Estimates from different sources vary, but approaching
60 million Indians are already believed to have type 2
diabetes (Shetty, 2012). This figure is also projected to
almost double to around 100 million within twenty years.
Rates of diagnosed type 2 diabetes are increasing in all
world regions. However, India is unusual with regard to the
age of onset. This may be because of thrifty phenotype
or other epigenetic phenomena of the type touched on
above, or perhaps because of immutable inheritable
variances. In populations of European ethnicity type 2
diabetes is relatively unusual below the age of 50. But in
Health and Health Care in India
Box 3: Mental health care in India
As with other NCDs, mental illnesses tend to be better
recognised as societies develop and infectious disease
burdens fall, so revealing other forms of distress.
Communities typically become more able and willing
to fund services for their most vulnerable members
as they progress on from subsistence agriculture as
their main means of production. With development,
people become less likely to ascribe religious or other
supernatural causes to psychiatric and psychological
phenomena. Stigma against individuals living with
mental illness – driven by combinations of ignorance,
superstition, prejudice and excluding behaviours –
also tends to decline as populations become better
educated and physically and socially more secure.
Such trends increase rates of openly recognised anxiety,
depression and psychotic distress, along with problems
like learning disabilities. Due to factors associated with
the transition processes presently in progress there are
significant variances in the estimated incidence and
prevalence rates for mental health problems in India.
But a number of studies suggest that roughly six per
cent of the current Indian population have significant
mental illnesses. This implies that in the order of 70
million people could directly benefit from appropriate
treatment and support (Chatterjee, 2012). The global
epidemiological evidence suggests that about twice
that number are likely to be experiencing less serious
emotional and allied problems like anxiety states at any
one time, a burden which could also be relieved by
more effective services.
One indicator of the scale of potential demand
for mental health care is the fact that there are
approaching 140,000 recorded suicides each year in
India. Notwithstanding differences in population age
structures, such data imply a rate at least equivalent to
or above those recorded in post transitional societies
like, for example, the UK and France. Some challenges,
such as increases in the risk of suicide amongst
poor Indian farmers, may on occasions have been
exaggerated. But in international terms there is clear
evidence that younger women are at particularly high
risk of suicide and other forms of violent death in India.
Despite the fact that the country was in 1982 one of
the first in the developing world to initiate a ‘high level’
India it often occurs one or two decades earlier (Mohan
et al, 2007). Some southern Indian cities are already
reporting type 2 diabetes prevalence rates of 20 per cent
in their adult populations, and there are now said to be
rising rates of this disease in village settings.
As discussed in Box 4, attaching valid economic costs
to losses of life and/or disability adjusted life years is
problematic. Nevertheless, in welfare terms the harm
caused by non-communicable diseases can already
reasonably be said to represent in the order of 12.5 per
cent of Indian GDP foregone. In currency equivalent terms
Health and Health Care in India
National Mental Health Programme (NMHP - Sinha and
Kaur, 2011), access to effective publicly funded mental
health care remains very limited. In 1996 a District
Mental Health Programme (DMHP) was launched under
the umbrella of the NMHP. It was intended to focus on
areas like early detection and treatment, rapid training
for primary care doctors on the diagnosis and treatment
of common mental illnesses, raising public awareness
of mental health issues and monitoring trends in the
occurrence of mental health problems. By the end of the
ninth Five Year Plan the programme was established in
27 of India’s 600 plus districts. Yet its overall impact has
been judged disappointing (Patel et al., 2011).
In 2009 a revised NMHP was approved, partly in the
face of a recognised national shortage of psychiatrists.
With only one such medically qualified individual
for every 500,000 people and one publicly funded
psychiatric hospital bed for every 50,000 persons, India
has amongst the lowest levels of medical psychiatric
care provision in the world. Access to psychiatric
nursing, clinical psychology and specialised psychiatric
pharmaceutical care appears to be even more limited.
The 2009 NMHP aimed to increase psychiatric
‘manpower’, upgrade mental health hospitals and destigmatise mental illness via interventions such as public
advertising campaigns. Primary healthcare doctors
working in villages were also to receive additional mental
health training (Sinha, 2009; Sinha and Kaur, 2011).
Such attempts to improve provision are to be
welcomed, particularly when they can be backed by
adequate financial investment. But there are clearly
major challenges still to be overcome in this area of
health and social care, and in developing appropriately
sensitive local understandings of the cultural and allied
social as well as the biomedical determinates of mental
health in India (UCL Cultural Consultation Service,
2012). As suggested above, for example, the difficult
situation for many women in India can exacerbate
mental health problems (Basu, 2012). Members of
marginalised populations such as Dalits (once termed
‘untouchables’) may also suffer particular forms of
mental distress that might be relieved by appropriate
forms of care and support, alongside wider social
interventions.
this represents a welfare loss of between US $250 (nominal
value) and US $500 billion (PPP adjusted $) a year.
The scale of such welfare opportunity costs will continue
to rise to the detriment of the happiness and wellbeing
of India’s people and, potentially at least, the ability of
the nation’s economy to compete with others unless
prompt and effective action is taken to prevent and/or
treat conditions such as such a CHD, COPD and type
2 diabetes. The recent establishment of the National
Programme of Prevention and Control of Cancer,
Diabetes and Cardiovascular Disease and Stroke
13
Box 4. The costs of acute and chronic illness in India
Attaching meaningful economic costs to losses of life
and/or the impacts of avoidable disability in India is
inherently difficult, as it is in all other environments. This
is not least because it is debateable from a theoretical
perspective as to whether or not the lives of people
living in poor communities should be valued any less
than those of people in richer ones. Important questions
also exist as to whether or not future health gains
should be discounted in the same way as other forms
of investment benefit, and about the extent to which in
countries that have large labour surpluses premature
losses of life and/or functional capacity have negative
impacts for people other than those directly involved.
However, it can broadly be estimated that noncommunicable conditions (including mental health
problems) and infectious and allied forms of harm
(including injuries) presently each cost Indian society
about 150 million Disability Adjusted Life Years (DALYs)
per annum. This 300 million lost DALY million total
implies a gross welfare loss equivalent to some 25
per cent of the country’s productive potential, or 12.5
per cent of GDP for NCD imposed costs and 12.5 per
cent of GDP for those caused by infections and other
acute/external causes (Patel et al, 2011). Assuming a
present gross national product of a little under US $2
(NPCDCS) indicates national level recognition of the
importance of this task. Key ways forward range from
curbing tobacco use and promoting increased physical
activity through to extending the use of medicines that
can lower risk factors such as high blood pressure,
hyper-glycaemia and/or hyper-cholesterolaemia.
Cancer in modern India
Reported cancer incidence and mortality levels vary
significantly within the country. For instance, relatively
recent reports show the age adjusted male cancer death
rate in Delhi is 121/100,000, compared with 44/100,000
in rural Maharashtra. The probable reasons for such
observations include differing patterns of alcohol and
tobacco use, together perhaps with varying rates of
access to diagnostic testing. Smoking and other forms
of tobacco use is associated with about a half of all male
and approaching a fifth of female cancers in India, which
is globally the third largest producer and consumer of
tobacco products. Because of the traditionally high use
of ‘smokeless’ products the country suffers the highest
rate of oral cancers in the world (Coelho, 2012).
Dietary and environmental factors such as low fruit
and vegetable consumption amongst some groups
and exposure to pollutants also impact on cancer
incidence. India has unusually high rates of oral and
cervical cancer, the occurrence of which is in part
related to HPV infections (which could if afforded be
prevented by immunisation) and a subsequent lack of
screening services. Nevertheless, because cancer is an
acquired genetic disease associated with breakdowns
14
trillion, current levels of non-communicable disease can
therefore be said to be costing India (in lost welfare as
opposed to realisable cash based terms) approaching
$250 billion a year at exchange rate values. When
expressed in purchasing power parity (PPP) adjusted
terms this figure rises to some $500 billion.
Over the next 20 years the losses due to chronic
non-communicable disease are presently projected
to remain constant in terms of lost DALYs, while the
infectious disease burden should halve. However, such
estimates (which are set against an anticipated further
rise in India’s population of some 250 million people
between 2010 and 2030) are subject to a number
of caveats. If either or both infectious and chronic
illnesses mortality and morbidity rates were to fall at
an accelerated rate, considerable additional welfare
gains would be generated. To illustrate this, if healthy
life expectancy in India could be enhanced by 10 years
(that is, to the level China is currently reporting – see
Figure 2, page 4) by reducing the currently growing
burden of disability associated with vascular disease
and type 2 diabetes, then a conservative view is that
this would lead to annual welfare gains similar to India’s
total investment in health care. That is, some 4-5 per
cent of GDP.
in the integrity of cell division regulation, individual and
population ageing is the single most important driver
of its occurrence. This helps to explain the ‘across the
board’ rise in projected cancer case numbers shown in
Figure 10.
For a country with a ‘young’ population India was
unusually advanced when the National Cancer Control
Programme (NCCP) was established in 1975, shortly after
Figure 10: Projected cancer incidence rates in
India to 2020
Note: Tobacco related (lip, tongue, mouth, pharynx, oesophagus, larynx, lung,
bladder), digestive system (oesophagus, stomach, small intestine, colon,
rectum, anus, anal canal), head and neck (lip, tongue, mouth, salivary gland,
tonsil, oropharynx, nasopharynx, hypopharynx, pharynx, nose, thyroid, sinus,
larynx), lymphoid and haemopoitic system (Hodgkins disease, NHL, multiple
myeloma, lymphoid leukaemia, myeloid leukaemia), gynaecological (vulva,
vagina, cervix uteri, corpus uteri, ovary, placenta)
Source: Takiar et al., 2010
Health and Health Care in India
the then US President Richard Nixon’s declaration of a
‘war against cancer’. There was an understanding at that
time that cancers affect poor people in large numbers,
primarily because the less affluent communities are the
more likely people in them are to contract cancer causing
infections (Reddy, 2005). But it is also true that better-off
sections of the community have to date arguably had the
most to gain from public as well as private investments
in specialist hospital care and the enhanced supply of
medicines (other than analgesics like morphine, which
are currently inadequately available to many less affluent
Indians) for later stage cancer treatment.
Recent developments such as the actual or proposed
granting by the Indian Courts of Compulsory Licences
for some oncology products should be understood from
this perspective. However, the NCCP has highlighted
the importance of primary prevention, and Indian policy
makers are now taking active steps to discourage
smoking and other forms of hazardous tobacco use. The
Cancer Control Programme has also been pro-active in
areas like screening for cervical cancer and its precursor
states, and improving pain relief during end of life care.
But despite this, access to early stage disease detection
and treatment services remains very limited in much
of the country. Raising the rate of early stage cancer
identification is a vital first step in improving cancer care
quality. It is to the organisation of health care in India that
this study therefore turns.
Transforming Health Care in India
In 2012 the agency IMS, with research based
pharmaceutical industry funding, conducted nearly
15,000 household interviews across 12 Indian States. This
work took place in rural and urban areas and examined
experiences of both hospital and outpatient care. It found
that over 90 per cent of respondents said they felt able
to get medical help when they are ill, albeit that this was
less often the case in rural areas than in urban localities.
This research also confirmed that the cost of medicines
is the health care concern most frequently expressed by
modern Indians, and that affordable access to treatment
for chronic illnesses is more of a problem than access to
drugs for acute illness episodes.
Box 5: Better access to essential medicines – the Prime Minister’s initiative
The Indian Prime Minister Manmohan Singh announced
on the country’s 66th Independence Day in August 2012
that his Government’s National Common Minimum
Programme would be extended, starting later in that
year, to supply free medicines through public hospitals
and health centres. He indicated that by 2017 over half
the total population will have access to free public health
care (as opposed to about a fifth in 2013) that includes
a comprehensive range of essential generic medicines
supplied via the country’s 160,000 sub-centres, 23,000
primary health centres, 5000 community health centres
and 600-plus district hospitals. It was proposed that
the Federal Government would directly fund 75 per
cent of the relatively limited cost of extending public
health service generic medicines supply.
This important, although now postponed or abandoned,
policy initiative also envisaged that doctors working in the
public service should cease prescribing branded drugs
and that the National List of Essential Medicines (NLEM),
which presently includes some 350 treatments ranging
from anti-HIV medicines to analgesics, was to be used
by States as a guide to what should be supplied free of
charge to all those entitled to publicly funded treatment
(Munshi, 2012). It is of note that a number of States, such
as, for example, Chhattisgarh, are already seeking to
introduce extended free medicines supply arrangements.
A proposal to set up a Central Procurement Agency
for the bulk ordering of drugs was also approved by
the UPA Government Cabinet, albeit that this too
may now have been abandoned. States should still,
however, be required to procure medicinal drugs
directly from their manufacturers or importers through
an open tender system, and should provide state-ofthe-art warehouses for drug storage and distribution
Health and Health Care in India
(Dutta, 2012). Such actions help to address criticisms
made by agencies such as the WHO to the effect that,
although India has rapidly developed pharmaceutical
manufacturing capabilities and achieved a relatively
strong exporting record, its health policy makers have
not to date been as effective as their industrial policy
equivalents in ensuring that free or low cost, good
quality, medicines are consistently available to the
poorer half to two thirds of the domestic population.
The country’s future success in this area will in large part
depend on reducing levels of corrupt and allied perverse
behaviours amongst prescribers and publicly funded
medicines suppliers and purchasers. One possible
way forward in this context could be the development
of enhanced mechanisms for consumer reporting of
public health service failures to supply free medicines,
through – for example – the anonymous use of SMS
(short message service) texting to independently run
national health service quality surveillance centres (see
main text conclusions).
To date, local Indian pharmaceutical manufacturers
have had little or no need for intellectual property
protection other than the use of trade names. Their
domestic earnings have been in large part derived from
promoting the sale of branded mature medicines. But if
the use of minimum cost high quality generic medicines
is significantly extended progressive Indian companies
may become more motivated to invest in developing
new, more effective, products. It is by no means certain
this will prove possible. But if it can be achieved they will
consequently become more dependent on provisions
other than brand name protection, including patents or
alternatives such as periods of ‘regulatory exclusivity’,
for the successful continuation of their businesses.
15
In the case of outpatient (ie primary and community
care) services, private facilities are today typically more
accessible – in the sense that most people find it easier
to travel to them – than publicly provided services. This
was not found to be so with hospital care. People in
rural and poorer urban areas are, unsurprisingly, more
likely to be public service users than the remainder of the
population. This is mainly – respondents said – because
of the opportunity to obtain free medication. Yet it is of note that other observers have reported
recurrent drug shortages in public service settings.
There is evidence that patients – for reasons often
related to provider side corruption, and inappropriate
purchasing and/or the diversion of products away from
public facilities – have frequently been denied access to
free medicines they are in fact entitled to receive. It was
also found by IMS that most people said that they would
use public services if their quality was felt to be as good
as that of private sector services (IMS, 2012).
Improving perceptions of the adequacy, integrity and
responsiveness of public services is therefore an important
goal, if they are in future to play a more extensive role. Presently, the Indian health care system is, in urban areas
especially, largely private provider dominated. Taking
the findings of this research in the round, they help to
explain why the provision of health care has not been a
high profile political issue in India. In essence, the majority
of interviewees said that they feel subjectively that they
have satisfactory access to services. They may also
value looking to their families rather than publicly funded
agencies for help when in particular need.
Because medicine costs are a clear public concern the
above findings may also be taken to confirm that it is
understandable that political and media attention has
often focused on cutting the prices of medicines, even if in
reality the latter can have little impact on overall care costs
and/or outcomes in poorly structured markets and health
service environments. What is relatively certain is that no
informed observer of the Indian situation would argue
that the recent (but now postponed or abandoned) Indian
Federal Government announcement of a US $5 billion
nationwide programme aimed at improving the provision
of good quality, free to the consumer, generic medicines
via the public health system in the five years to 2017
was anything less than timely and appropriate (Box 5).
Free publicly funded medicines supply has fundamental
advantages for poor and vulnerable service users.
Potentially distorting factors such as the fact that
household expenditure based surveys cannot show the
extent to which reported drug spending involves outlays
on not only items such as distributor margins and national
or local taxes but also professional and institutional fees
need to be understood when approaching the issue of
controlling pharmaceutical costs in India. It should also
be stressed that the IMS research referred to above
did not investigate the extent to which respondents
were receiving good quality care as defined in terms of
evidence based medical, nursing and/or pharmaceutical
best practice.
In a country where a significant proportion of practitioners
do not have the qualifications they may or may not
claim, and in which the importance of preventing and
managing chronic illnesses as opposed to treating
acute conditions is as yet inadequately appreciated,
evidence of subjective public satisfaction does not
confirm diagnostic quality or service appropriateness. It
is of note, for instance, that past analyses have shown
that the self reported health status of people in India is
typically higher than it is in countries such as the US,
despite a plethora of epidemiological evidence showing
that the inverse is true (Sen, 2002).
Figure 11, taken from the IMS analysis, highlights the
fact that Indian States differ significantly with regard to
the longevity of their populations and their health policy
Figure 11: A categorisation of States based on selected healthcare and economic indicators
Source: IMS, 2012
16
Health and Health Care in India
related competencies. Its categorisation of, for instance,
Uttar Pradesh as a ‘middling’ rather than a lagging State
may – on the basis of recorded life expectancies and
infant mortality rates – seem questionable, despite recent
progress there. But the key point to make is that health
progress in the south of India has been more satisfactory
than in most other parts of the country.
The central band of BIMARU States faces special
challenges linked to factors such as illiteracy and high
population density, as compared to the relative success
of examples such as Punjab and Himachal Pradesh9
to the north and the Dravidian tradition States of Tamil
Nadu and Kerala to the south. In Kerala there is a long
standing and internationally celebrated combination of
female education, near universal literacy and low infant
mortality. Kerala also enjoys relatively high spending on
health and low levels of corruption as compared to the
rest of the country.
Early origins
India has, in the shape of the knowledge and practices
like those embodied in Ayurvedic medicine, health care
traditions dating back as far as those found anywhere
else in the world. For instance, over 2,300 years ago in
Ashoka’s Mauryan Empire10 (Ashoka lived shortly after
Hippocrates was alive in Greece, and ruled over almost
the whole Indian sub-continent) there was a relatively
sophisticated health system. It included public hospitals
and the allocation of physicians to serve rural areas.
Some commentators argue that concepts like that of
‘humoral balance’, which existed in the Galenical beliefs
of medieval Europe and in related forms survive in Indian
traditional medicine in its various manifestations today,
draw attention away from science based explanations of
disease and its effective treatment. But viewed positively
the focus of Ayurveda and allied AYUSH11 disciplines on
lifestyle moderation, coupled with the use of biologically
active therapies as and when available, remains relevant
to promoting good health in the modern world.
Around a millennium ago practitioners of Indian traditional
medicine adapted to accommodate the use of opiates
and other drugs associated with the introduction of Islamic
9 Himachal Pradesh is in economic terms relatively successful and
has been classed as the second-least corrupt State in India after
Kerala. However, in contrast to Kerala, Punjab, along with nearby
Haryana, reportedly has the highest rates of sex selective abortion
in the country. In the latter State in particular this has allegedly
become linked to the trafficking of young women from other
poorer parts of India. Such observations underline the complexity
of the current Indian situation.
10 Ashoka Maurya or Ashoka the Great (whose name means pain
free or without sorrow) ruled nearly all of modern Indian, Pakistan
and Bangladesh for a period of approaching 40 years in the 3rd
century BC. He played a significant part in establishing Buddhism
as a world religion and is widely regarded as, after an initial
period of war, having become a philanthropic and effective ruler.
Historians suggest that he saw both sharing Buddhist philosophy
and practical interventions such as health care provision as of
value in creating an equitable and stable social order. Ashoka and
his edicts, through which he sought to communicate the practical
implications of Buddhist philosophy, are referred to again in the
conclusions of this report.
11 Ayurveda, Yoga and Naturopathy, Unani, Siddha and
Homoeopathy
Health and Health Care in India
medicinal expertise into India. They were able, as was so
in the case of European medical practice at about the
same time, to accommodate new knowledge and skills
into their thinking and therapeutic approaches. Arguably,
Ayurveda and other forms of Indian (and other) traditional
medicine should go on progressing in similar ways today.
During the 19th and early 20th century decades of the
British colonial State traditional Indian medicine remained
at the heart of the population’s care. Some new facilities
and services were established and important individual
contributions were made, not least in areas such as
understanding the epidemiology and causation of
infectious diseases, by European physicians. Yet it is fair
to say that the British were principally concerned with
the health of the armed forces and the small numbers of
expatriate staff responsible for administrative functions. In
the context of medicines, relatively little effort was made
to supply allopathic products to the Indian population or
– more importantly at that time – to share surgical good
practice, including concepts of antisepsis and effective
anaesthesia.
Even when available, ‘western’ treatments were expensive
and tended to be of low quality. Colonial policy involved
taxing pharmaceutical and other products imported from
anywhere other than the UK highly, and doing virtually
nothing to support Indian based manufacturing (Thum
Bonanno et al, 2012).
In the period between the end of the first World War
(in which Punjabi and other Indian Army divisions were
extensively involved) and India’s independence after the
1939-46 conflict, progress in developing health care
facilities for the mass of the population remained slow.
Following very limited constitutional changes in 1919 –
which some Indian and British reformers had originally
hoped would open a ‘painless path’ to independence
– and the subsequent and (in Winston Churchill’s
contemporary words) deeply shameful massacre
perpetrated by British officer led Gurkha riflemen on
Punjabi civilians in Amritsar, health improvement was
further impeded by the delegation of key public health
related duties to what were then termed ‘the Provinces’.
The failings of this last measure were related to a lack
of the effort and investment needed to ensure the
competent execution of delegated responsibilities in local
settings. As commentators such as Professor Srinath
Reddy of the Public Health Foundation for India have
observed, kindred problems have lived on into modern
India. Nevertheless, in the run up to independence the
then Indian Government in 194312 recognised a need
to improve the public health system. A Health Survey
and Development Committee (HSDC) was formed and
charged with making recommendations for future health
service reform and improvement.
The Bhore report (as it became known after the HSDC’s
civil servant chairman) noted in 1946 that ‘if it were possible
to evaluate the loss which this country annually suffers
through the avoidable waste of valuable human material
12 Immediately after the publication of the Beveridge Report in the
UK. This heralded the establishment of the British welfare state.
17
and the lowering of human efficiency through malnutrition
and preventable morbidity, we feel that the result would be
so startling that the whole country would be aroused and
would not rest until a radical change had been brought
about’ (Health Survey and Development Committee,
1946). At this point there were only 1.5 doctors per 10,000
population in India and hospitals largely ran in the absence
of trained nurses (Rao et al., 2011).
The report also stated, in line with the subsequently
established Indian Republic’s Constitution, that access
to primary care is a basic right to be respected regardless
of an individual’s socioeconomic standing. It saw primary
care as the foundation of an improved national health
care system and proposed a three tiered system of
primary health centres and local sub-centres, served
by community centres and district hospitals to which
patients could be referred. The structure of the Indian
public health service of today (see Figure 12) still partly
reflects that early vision.
The Bhore Committee in addition introduced the concept
of five year planning to the health arena. The latter
chimed well with the overall approach to economic and
social development planning instituted by Jawaharlal
Nehru soon after the establishment of India as a newly
independent State (Box 6).
Improving the public’s health was from the inception of
modern India accepted as an important end. Yet despite the
good will of the Government of the newly independent India
and the fact that the nation’s leaders wanted to address
health inequalities, the 1959 Mudaliar Committee was able
to report only very limited success. Established to evaluate
the health progress made during India’s first two Five Year
Plans, it found that while epidemic disease management
was working relatively well too little importance was being
assigned to assuring excellence at the Primary Health
Centre (PHC) level (Nayar, 2011). This particularly negated
the interests of the poorest half of the nation.
Much the same can be said half a century later (High Level
Expert Group on Universal Health Coverage, 2011). In 1978
the WHO led Alma Ata declaration highlighted the importance
of good quality primary care. In India this prompted at the
start of the 1980s the adoption of the country’s first free
standing National Health Policy. But progress remained
‘patchy’, and problems of uneven development were
arguably compounded by the increasing reliance on private
investment engendered by the in many respects highly
beneficial liberalisation of the Indian economy in the 1990s.
Private resources have tended to flow more towards States
with higher levels of social and material infrastructure, like –
for example – Maharashtra, Gujarat, Tamil Nadu, Karnataka
and Andra Pradesh. Poorer States have fared less well in
Box 6: Planning in India
When India gained independence on August 15th 1947
its leaders sought to establish governance mechanisms
capable of promoting robust economic growth and
defending the wider social interests of the country’s
citizens. The then Prime Minister, Jawaharlal Nehru, had
witnessed the rapid industrialisation of the Soviet Union
in the pre-war era. Joseph Stalin adopted a system
based on Five Year Plans in the USSR in 1928. Nehru
believed – notwithstanding the disadvantages of Stalin’s
autocratic and murderous rule – that this had contributed
significantly to Soviet advancement (Maheshwari et
al., 2008). Building on measures first introduced in
India during the 1930s and early 1940s, Nehru and his
colleagues decided to incorporate a similar planning
function into India’s much more democratic political
system. The Indian leadership of the late 1940s tried
to create an alternative to extreme versions of both
socialism and capitalism, combining the best features of
these two contrasting approaches to organising society.
They were seeking to establish a ‘third way’.
To put this decision into its historical context, the USSR
had very recently played a decisive role in defeating
Nazi Germany. Further, its economy (as symbolised by
the launch of Sputnik 1) was to grow faster than that
of the US throughout the 1950s. It was not until the
1960s that Soviet progress began to falter, and the life
expectancy of Russian working age men in particular
began to gradually to decline.
In 1950 the Planning Commission was formed as an
expert advisory organisation. It was (and is) positioned
in parallel with the directly elected organs of State, with
18
Nehru (by right as Prime Minister) as its chairman. Its
role was then, as it is today, to assess the physical,
capital and human resources available within India, and
to prepare plans for their optimally effective utilisation.
The Planning Commission seeks to advise central
government and the State administrations on priority
issues as they arise, to evaluate policy successes and
failures, and to identify barriers to continuing economic
and social development.
The first Five Year Plan (1951-1956) was primarily focused
on raising the standard of living of the nation’s at that time
300 million people through strengthening agricultural
output. Since then the structure of the Commission
and its links with other branches of government has
been substantially reformed. Yet it’s underlying purpose
remains – despite trends such as industrialisation and
the country’s shift to a less regulated, freer market
oriented, economic approach – essentially similar to
that envisaged in the 1950s. The demise of the original
Soviet model was related to the fact that although in
the health context it had contained infectious disease it
proved unable to respond to subsequent chronic/noncommunicable disease related public health challenges,
which are more reliant on autonomous citizen action for
their solution. The core issues the Planning Commission
for India faces today in large part centre on understanding
the long term dynamics of (healthy) population ageing.
Effectively responding to this transition will be as or more
critical to the success of twenty first century India as
improving agricultural practices was to the nation at the
start of the 1950s.
Health and Health Care in India
Figure 12: Rural Health Care system, with
numbers of centre type
District Hospitals
613 in the country’s 640 districts
•Secondary referral level responsible for a district of a defined
geographical area with a defined population
•Provides comprehensive secondary health care to the
population of the district
•Responsive and sensitive to the needs of the people and
referring centres
•Should be at least one in each district
Sub-District Hospitals
Roughly 1000 in the country
•Receive referred cases from CHCs, PHCs and SCs
•Provide emergency obstetrics care and neonatal care helping
reduce maternal and infant mortality
Community Health Centres (CHC):
Aim = one per 100,000 people (on average)
Actual = one per 200,000 people
•Four medical specialists (surgeon, physician, gynaecologist and
paediatrician) supported by paramedical and other staff
•Thirty inpatient beds plus X-ray, labour and laboratory facilities
•Serves as referral centre for four PHCs
Primary Health Centres (PHC):
Aim = one per 25,000 people
Actual = one per 50,000 people
•1st contact between village community and medical officer
•Medical officer supported by 14 paramedical and other staff
•Integrated curative and preventive health care
•Each acts as referral unit for six sub centres and has roughly five
inpatient beds
Sub Centres:
Aim = one per 4000 people
Actual = one per 8000 people
•1st contact between community and health care
•One Auxiliary Nurse Midwife (ANM) and one Male Health Worker
•Skills/medicines to cover essential health needs of men, women
and children
•Maternal and child health, welfare, nutrition, immunisation,
diarrhoea control and control of communicable diseases
Source: The authors based on various primary sources
terms of attracting both inward financial investment and
skilled people, so perpetuating the ‘healthier is wealthier’
cycle within the Indian environment (Bloom, 2011).
Injections of money from organisations such as the
World Bank and USAID may also have meant that Indian
Government funds and attention were on occasions
(paradoxically) diverted away from health to other
priorities. This opened the way to a greater reliance on
the private sector for health development resources
(Ma and Sood, 2008), while at Federal level the Indian
Government continued to concentrate more on areas
like defence and the development of an enhanced
transport system.
Health and Health Care in India
Advances such as providing better road connections can
be of great value to not only industry but also in improving
the lives of people residing in isolated villages. Even so, in
failing to address robustly issues such as primary health
care improvement, successive Indian administrations
could well have missed important opportunities to
promote demographic and epidemiological transition
and fundamentally enhance welfare and productivity. In
relation to this key issues include:
1.An over-reliance on vertically organised, single
condition, programmes
Such initiatives can be very attractive to politicians and
policy makers seeking highly visible successes within
a specific time frame. They also tend to be popular
amongst specialist medical and allied professional
interests, and with external funding agencies. In areas
ranging from malaria and HIV control to recent actions
aimed at eradicating polio in India and elsewhere, there
is evidence from across the world of positive vertical
programme achievements. Yet because of the need
for independent staffing for each separate disease
programme they are relatively expensive to sustain
(Ministry of Health and Family Welfare, 2002). Over and
above this they are normally ill-fitted to supporting the
integrated care developments needed to extend healthy
and/or valued life as populations age and chronic illness
related problems become more prevalent.
2.Low Federal and State (public) expenditures on
health services, coupled with high out-of-pocket
(OOP) payments by (private) service users
As noted previously, total public spending on health
in India is – at presently little more that 1.2 per cent of
GDP – unusually low in international terms. At the same
time private spending frequently takes the form of direct
personal payments rather than insurance contributions.
This combination can, amongst other things, serve
to make expenditure on medicines seem a particular
problem, despite the fact that absolute pharmaceutical
outlays in India are low (Figures 13a and 13b). In fact,
recorded overall Indian spending on medicines is average
for the BRIC nations when expressed as a percentage
of GDP (WHO-EMP, 2012), despite the fact that (as
discussed earlier) the use of household survey based data
leads to confusions as to the amount of money spent on
allopathic medicines charged at manufacturers’ prices13.
If, as Nayar (2011) has suggested, the quality of public
health services can be defined by the demonstrable
efficacy, safety and epidemiological rational of their
provision together with the attitudes and behaviours of
staff and the extent of their affordability and accessibility
13 Some observers may take trends such as the growing levels of
antibiotic resistance associated with the weakly regulated use of
such drugs in India as evidence that access to medicines is not
unduly restricted. However, the capacity to grossly over-use such
pharmaceutical products is likely to be confined to more affluent
sections of the population, while the fact that poorer people may
contribute to resistance problems by taking only partial courses
arguably reflects inadequate basic health care provision. Factors
such as counterfeiting and poor quality production may also be
relevant to resistence, although they should not be exaggerated.
19
Figure 13a: Total pharmaceutical expenditure
in the BRICS countries (per capita in US $)
Figure 13b: Total recorded pharmaceutical
spending as a percentage of total recorded
health spending
Source: WHO-EMP Department, 2012
to all sections of society, then India is facing challenges
on multiple fronts. The divide between Federal and State
financing responsibilities has been a key structural driver
of the problems the country is now fighting to overcome.
Table 1: A comparison of healthcare personnel
numbers in India and the OECD average
3.State level variances in the willingness and ability of
responsible bodies to fund health services, purchase
supplies and manage the delivery of care
Doctors
3.1
0.6
Nurses
8.6
0.8
Kerala, for example, spends three times as much on
health per capita as Bihar, and has three times as many
doctors relative to its population than less well off States
like, for instance, Odisha and Chhattisgarh (De et al.,
2012). The latter are disproportionately dependent on
central Government finances for health care support,
even though the per-person funding dispersed to the
States is fairly constant, irrespective of their differing
capabilities and needs (Balarajan et al., 2011).
Midwives
0.27*
0.47
Dentists
0.61*
0.06
Pharmacists
0.76*
0.56
Around 80 per cent of outpatient treatment is currently
undertaken in the private sector, which can on occasions
be both unreliable and expensive for vulnerable users.
Because of the lack of health insurance some ten per
cent of households devote ten per cent or more of their
total expenditure to obtaining health care in any one
year. About three per cent of the population are annually
reduced to poverty because of health related expenses.
Notwithstanding the IMS findings presented earlier, it is
also the case that around 15 per cent of recognised illness
episodes are left untreated because of financial concerns
(Ernst and Young and FICCI, 2012). Rural households are
most at risk of impoverishment because of ‘catastrophic’
health costs (Government of India Ministry of Health and
Family Welfare, 2011).
4.Inadequate numbers of appropriately qualified staff in
areas of deprivation
Table 1 presents data on the numbers of qualified health
personnel in India as compared with mean OECD levels.
Although the contributions of traditional practitioners
and unqualified care workers ought also to be taken into
account, it is apparent that substantial shortfalls exist. There
is evidence that these are often most acute in areas of high
need. Similar concerns apply to facilities such as hospitals.
It is sometimes claimed that those in urban areas are at risk
of being ‘overrun’ with people from rural areas who cannot
access adequate care nearer their homes.
20
OECD average (per India Ratio (per
1000 population) 1000 population)
Source: WHO, 2006 and OECD 2012.
* OECD Health Data 2009.
Relatively recent data indicate that rural India, with two
thirds of the nation’s total population, has only a little
over ten percent of the hospital beds and a quarter of
the human health resources available in the country as
a whole. It is also the case that at the start of the 21st
century, before the introduction of the National Rural
Health Mission (NRHM – see below) only a third of the
(publicly funded) primary health centres and two thirds
of the community health centres were judged to have
adequate human and other infrastructural resources
(Paul et al, 2011).
Many commentators have stressed the service
constraints caused by the lack of adequate numbers
of qualified doctors14, especially in rural areas (see, for
example, Das et al., 2012). This is an important concern,
albeit that shortages of qualified nursing staff in both
hospital and community settings might be seen as an
even more pressing issue. The shortfalls in nursing
resources apparent in India may to a degree be linked to
religious and allied beliefs which have affected attitudes
to female (and male) employment in ‘unclean’ areas of
14 India trains roughly 40,000 doctors per year in 335 medical
colleges. However, a significant proportion of able individuals
have historically chosen to emigrate, while relatively few have
elected to work in public health centres. The fact that over two
thirds of medical workers in the country are male may also affect
poorer women’s access to health care. Despite recent measures
to increase medical manpower (Garg et al., 2012) it appears
likely that radically new forms of financial incentive will in time be
needed to ensure significantly improved access to conventionally
trained doctors in less advantaged regions.
Health and Health Care in India
work. Southern States like Kerala have comparatively
strong nursing traditions.
Pharmacy, by contrast, has not been affected by the
stigma sometimes associated with nursing and ‘unclean’
physical contact. But within the health arena its social
status is not comparable with that of medicine (which
can in a sense be seen as either more warrior-like or more
priest-like). The pharmacy profession’s clinical and wider
public health (as opposed to it’s commercially driven
supply) role has not – as yet at least – been developed
in the Indian setting. Many better qualified Indian
pharmacists15 have to date worked in pharmaceutical
manufacturing and/or areas such as the marketing of
branded medicines to doctors.
In an effort to address human resource shortages, a
three year ‘intermediate’ medical course for a qualification
termed the Bachelor of Science in Community Health is
being introduced. Strong objections to this were expressed
by the Indian Medical Association (IMA). Yet from a public
health as opposed to sectional interest perspective
the case for this and similar initiatives appears strong.
Professional categorisations and boundaries that evolved
in 19th century Europe are not necessarily fit for meeting
the requirements of modern Asian super-States, or indeed
those of modern European and the US service users.
It is currently planned that those completing the
intermediate course will be employed as Community
Health Officers in sub-centres or primary health
centres, following further training in district hospitals.
They will contribute to the diagnosis and treatment of
common illnesses and acute health problems, and to
immunisation and other preventive and public health
programmes (Sinha, 2012). The Government has in
addition pledged to add over 4,000 under-graduate and
2,000 post graduate places to the existing numbers
of conventionally defined places available in medical
schools.
It has been suggested that in order to strengthen
primary care provisions Indian policy makers might wish
to establish an independent contractor based General
Medical Practitioner (GP) system like that embodied in the
original UK NHS (Rao and Mant, 2012). There is a case for
this. However, the extent to which it would be practicable
across the whole of India is questionable. It may be that in
the 21st century a more flexible use of less highly qualified
health professionals backed by robust IT support systems
could, at least in environments that do not attract doctors,
offer a more viable ‘first line’ service tier.
5.Problems associated with conflicted values and
corrupt behaviours
All societies are to varying levels affected by public
and private sector corruption, as along with other
types of criminality. In emergent economies individuals
15 Schools of pharmacy in India are in many instances located within
University faculties such as engineering, rather than with medicine
or even ‘life sciences’. There are various levels of pharmacy
qualification. It is claimed that individuals with longer periods of
education do not typically elect to work in health care as opposed
to industrial settings.
Health and Health Care in India
are particularly likely to find themselves torn between
traditionally defined personal responsibilities to
their families and wider kinship groups on the one
hand and their ‘impersonal’ duties as members of
modern communities on the other. Such tensions are
exacerbated by factors such as low wages and/or weak
regulatory infrastructures. India provides a clear example
of an environment in which undesirable behaviours have
become widespread in the health sector, along with
the rest of the economy. Effective reform needs to be
systematic and based on a humane understanding of the
causes of institutionalised corruption and the individually
and collectively damaging behaviours to which it leads.
As in parts of the EU, demand for ‘informal’ payments
are common in all Indian health service contexts,
from childbirth support to conducting post mortems.
It is typically the poorest people who are in relative
terms hardest hit by such practices. Drug supply and
procurement is a well recognised example of an area in
which there is evidence of corruption, in part because
of the actions of local companies operating outside the
ambit of legislation like the US Foreign Corrupt Practices
Act. Unethical practices (including doctors and other
professionals inappropriately charging fees for referring
patients to specialists, or for delivering care to which
patients are legally entitled) may also have been driven by
the fact that healthcare in India in the past few decades
has often been provided on a primarily commercial basis
(Mudur, 2012).
But even if this is true it cannot alone explain the full
extent of the problems being encountered. Research
in Karnataka has, for example, found that a quarter of
the public health budget was at one time being diverted
away from its intended use by people at all levels, ranging
from low-paid workers to the investigational officers
responsible for maintaining ethical practice standards.
Subsequent action involved the introduction of fresh
approaches to community planning and health service
monitoring. This followed the recognition that seeking
to police people’s behaviour without enabling them to
participate in making the policies, plans and service
rules intended to govern their daily lives tends to be futile
(Sudarshan and Prashanth, 2011).
6.The need to understand and modify the social
determinants of health and health care
The observation that concepts of ‘clean’ as opposed
to ‘unclean’ work may have affected the evolution of
nursing, medicine and pharmacy in India illustrates the
fact that deep rooted beliefs, coupled with a population’s
related values and behaviours, often impinge upon
health service development. The influence of caste
linked judgements and assumptions combined with the
impacts of superficially more meritocratic class based
and related stratification systems has also shaped health
care provision in India, as well as determining access to
educational and other services/resources.
Approaches towards illness prevention, early stage
disease detection and the treatment of chronic
as opposed acute illnesses are also important to
21
understand. As indicated earlier, traditional beliefs about
the importance of lifestyle moderation can fit with
modern messages about the protection of both physical
and mental health. However, attitudes that are fatalistic
or negatively prejudiced in the sense that individuals
affected by painful and or disabling conditions are seen
as the authors of their own misfortune because of, say,
their actions in a previous life, cannot be reconciled with
a science based approach to individual and population
wide welfare improvement.
Likewise, the idea that some groups of people should
be classified as ‘untouchables’ or Dalits, and hence
deprived of opportunities enjoyed by others as of right
should – as Indian law makes clear – have no place
in a modern community. Although social change is
continuing, one in every seven people in the Indian
population were recorded as being Dalits at the start of
the 21st century.
Accelerated progress since 2000
The barriers to improving health in India are, as described
above, plural and substantive. Yet as the scale and scope
of initiatives like the Individual Identification Project (IIP)16
16 Which is giving all Indian citizens individual identification numbers
in order, it is intended, to clarify and assure benefit rights and
extend access to services such as banking and insurance.
now highlight, the country is modernising and seeking to
respond effectively to the challenges and opportunities
ahead. As, for instance, the potential for computer based
systems to support both self care and personal care
provided by doctors or other health professionals grows,
health and health care in India will also be likely to improve.
One of the most important successes achieved in the
last decade has been the establishment of the National
Rural Health Mission (NRHM – see Box 7). This had the
initial objective of providing more accessible, affordable
and good quality health care to the rural population. As
with the Karnataka anti-corruption programme referred
to above, the NRHM has sought to decentralise planning
and increase community involvement in decision making,
together with introducing more flexible financing and
allied grant arrangements.
Although the initial implementation of the NRHM
appeared slow (Ghuman and Mehta, 2009) it is today
credited with significantly reducing the incidence of
a range of infectious diseases. As a result of this a
new National Urban Health Mission (NUHM) is being
launched to cater for the health needs of the urban poor.
This may in future be combined with the NRHM to form
a single National Health Mission. The NUHM will cover
the country’s seven large metropolitan areas and 772
cities with a population of more than 50,000 individuals
(Bhaumik, 2012).
Box 7: The National Rural Health Mission
First launched in April 2005, the National Rural Health
Mission’s (NRHM’s) aim is to provide accessible,
affordable and good quality healthcare to the rural
population (Government of India Ministry of Health and
Family Welfare, 2011). Its introduction can be seen as
an indication of the Indian Government’s increasing if
still cautious willingness to increase public spending
on health. The NRHM has principally been focused on
18 northern States with relatively weak public health
indicators and infrastructures. These include Arunachal
Pradesh, Assam, Bihar, Chhattisgarh, Himachal
Pradesh, Jharkhand, Jammu and Kashmir, Manipur,
Mizoram, Meghalaya, Madhya Pradesh, Nagaland,
Odisha (formerly Orissa), Rajasthan, Sikkim, Tripura,
Uttaranchal and Uttar Pradesh.
The Mission has sought to enhance healthcare
delivery via a comprehensive series of measures
revolving around local communities. Key programme
components include supporting the work of female
health activists in each village; the promotion of village
health plans prepared via local teams headed by the
Health and Sanitation Committees of the Panchayats
(local assemblies of elders); strengthening rural
hospitals; and integrating previously ‘vertical’ health
and family welfare programmes and funds into more
effective horizontally oriented models (Ministry of Health
and Family Welfare, 2005).
The NRHM’s initial goals were to reduce maternal
mortality to 100 (from over 400) per 100,000 live births,
22
to cut infant mortality from 60 to 30 per 1000 live
births and to reduce the Indian total fertility rate from
3 to 2.1 by 2012. To facilitate this sub centres, primary
health centres and community health centres were
strengthened and the AYUSH disciplines (Ayurveda,
Yoga and Naturopathy, Unani, Siddha, Sowa Rigpa and
Homoeopathy) were ‘mainstreamed’ in an attempt to
revitalise and enhance local traditional health care. Limitations in the implementation of NRHM programmes
have been associated with administrative constraints,
governance issues, inadequacies in human resources
and sub-optimal investment in public health services
(Ghuman and Mehta, 2009). In particular, there has
recently been a major scandal in Uttar Pradesh. This
involved the murder and unexplained deaths of a
number of health officials and the reported misuse of
approaching US $2 billion of public funds.
As yet the 2012 health improvement targets have not
yet been fully attained. Maternal mortality currently
stands at about 200 deaths per 100,000 live births. The
overall Indian infant mortality rate is still 40 per 1000 (or
one in every 25) live births, while the total fertility rate is
presently about 2.5 births per woman. Nevertheless,
the NRHM is widely regarded as a success. Hence the
development of a wider National Health Mission has
recently been supported. This will extend the NRHM
approach to the protection of less advantaged urban
populations.
Health and Health Care in India
With regard to the widespread lack of affordable health
insurance the Rashitriya Swasthya Bima Yojana (RSBY)
was launched in 2008. This gives poor families the
freedom to seek care at almost 1000 public and over
3000 private hospitals. In excess of 14 million people
were already able to use it by 2010, and the RSBY has
since been extended to cover workers in the informal
sector. The latter include beneficiaries of the Mahatma
Gandhi National Rural Employment Guarantee Scheme,
street vendors, domestic workers and construction
workers.
Funded through general public revenues, it employs
‘smart card’ technology to permit the immediate
enrolment of new beneficiaries and facilitate cashless
provider reimbursement payments (Lagomarsino et
al., 2012). However, the scheme is only availabe to the
poorest families, and is restricted to meeting the cost
of serious episodes of illness normally needing hospital
admission. Day-to-day outpatient care and drug
expenses are not covered.
Some States have also established local health insurance
arrangements. For example, Assam has, despite being
relatively poor, set up such a scheme, while more affluent
Goa has contracted with a private insurer to provide
cover to anyone who has lived there for more than five
years. However, both these arrangements are focused
on acute rather than chronic care provision.
Incentivising employment in rural settings
With regard to enhancing (health sector) labour supply
a number of incentives designed to attract staff to and
retain them in rural areas are now in place. These stand
in addition to the establishment of the new three year
medical training programme referred to earlier. For
example, a majority of States already offer relatively high
salaries to public sector doctors serving in rural and
remote areas. Compulsory rural service bonds have also
been introduced in parts of India. In essence, medical
education costs are subsidised in exchange for graduates
working in less advantaged areas for an agreed period
of time. Accredited AYUSH practitioners are additionally being recruited to primary health centres, where they are
able to serve as medical officers (Rao et al., 2011).
Targeting maternal care
A number of schemes have also been developed to
provide better care for women and promote infant health.
Established as a part of the NRHM, the Janani Suraksha
Yojana (JSY) is – for example – a ‘safe motherhood’
intervention which provides cash rewards for women to
give birth in health centres or Government hospitals. In
2009-10 almost a half of all women who had a baby
in India received such an incentive. However, many
mothers and babies are discharged from hospital only
hours after delivery. Some commentators say this means
that there is too little time for the stabilisation of postpartum conditions and the detection of danger signs in
either mothers or their babies, or for activities such as
supporting the establishment of breastfeeding.
Health and Health Care in India
Another illustration of a service innovation aimed at
protecting mothers and children stems from Gujarat.
There a public private partnership (PPP) called the
Chiranjeevi scheme provides childbirth and emergency
obstetric services in private hospitals free of charge
to those entitled to benefit. This model is now being
replicated in other States (Paul et al., 2011). Likewise, in
2011 the Ministry of Health and Family Welfare launched
the Janani-Shishu Suraksha Karyakram, or JSSK. This
too aims to make better health facilities available to
women and children. Women benefit from delivery in
a public health institution where caesarean sections,
medication, food and diagnostics are supplied free of
charge.
The JSSK is intended to benefit over one crore17 (that
is, 10 million) women and babies a year. The service
provided should also improve immunisation rates for
conditions like measles, administer vitamin A as and
when required, and facilitate activities such as paediatric
anaemia and worm/helminthic disease management (Government of India Ministry of Health and Family
Welfare, 2011).
Improving pharmaceutical care NCD prevention and
management
Other examples of nationally and internationally
supported initiatives intended to further accelerate health
improvement in India range from the establishment
in 2010 of an India-UK Forum intended to both boost
mutual trade and promote collaborations and shared
learning in areas like primary care development (Rao
and Mant, 2012) to the Jan Aushadhi initiative. This last
was intended to supply good quality low cost branded
medicines via Government supported pharmacies,
although in practice it has encountered a number of
problems (Box 8).
In the context of the rising burden of ‘later life’ illnesses,
States like Kerala and Tamil Nadu have already identified
chronic disease prevention and control as a high priority.
Across India more widely The National Programme
of Prevention and Control of Cancer, Diabetes and
Cardiovascular Diseases and Stroke (NPCDCS) was
established in 2010, initially to cover 100 districts in 21
States. It is intended to encourage healthy lifestyles,
foster early disease diagnosis and promote better disease
management in the contexts of diabetes, hypertension,
vascular diseases and common cancers, and aims
initially to cover roughly 200 million people (Government
of India Ministry of Health and Family Welfare, 2011).
A ‘National Programme for Health Care of the Elderly’
(NPHCE) was also launched around the same time.
17 One crore is 10 million, written 1,00,00,000. A lakh is 100
thousand, written 1,00,000. There are therefore 100 lakh to a
crore. In the Indian numbering system a US billion (ie 100 crore) is
an arab, while a US trillion can be referred to either as a lakh crore
or 10 kharab.
23
Box 8. The Jan Aushadhi initiative
The Jan Aushadhi initiative was launched in 2008
under the chairmanship of Shri Ram Vilas Paswan (the
Minister of Chemicals and Fertilisers and Steel, who
has pharmaceutical sector responsibilities) as a vehicle
for putting into practice recommendations made by
the Pronab Sen Task Force on improving medicines
supply – see main text. It involved the development of
publicly supported pharmacies, tasked with providing
unbranded good quality generic medicines at low cost
to the public. The goal was to supply most products at
50 per cent below the average market price of branded
generic versions. It was hoped that a proportion might
be supplied for as little as 10 per cent of the branded
product average (John et al., 2011).
By 2009 there were in total twenty such pharmacy
stores. It was intended that each of the 660 districts of
India (with average populations of nearing two million)
would eventually have at least one Jan Aushadhi
outlet. However, the fact that they were supplied
by India’s five Central Public Sector Pharmaceutical
Manufacturing Units (CPSUs) limited the impact of
this measure. Because other domestic manufacturers
did not wish to offer undifferentiated generic products
at commodity or near commodity prices (Gopal,
2011) only those medicines produced by the CPSUs
were normally available, rather than a full range of
the treatments on the national and/or State lists of
essential medicines.
Some critics suggested that the true purpose of the
Jan Aushadhi scheme was to protect the interests
of government-owned CPSU companies (Kotwani,
2010). Its problems were compounded by the fact that
A universal health system for India – the third
transition?
Initiatives such as those outlined above should be
welcomed in as much as they will lead on to better
individual and community health outcomes. But in
looking to the future they at best represent a patchwork
of measures that in the absence of further over-arching
steps is unlikely to lead on to a fully comprehensive
universal health coverage (UHC) system. In addition, an
increased spend on health services alone will, it can be
argued, probably be insufficient to improve the health
status of the poorer people of India to the level they
are likely to desire in the future, unless accompanied by
additional interventions aimed at facilitating informed self
care and enhancing the efficiency and effectiveness of
professional care.
Dr Margaret Chan, the present Director-General of the
WHO, recently described UHC as ‘the single most
powerful concept that public health has to offer’. The
development of universally available, collectively funded,
health systems is arguably so central to the wellbeing of
ageing nations that it is – as previously noted – becoming
increasingly seen as a third key health transition.
Advocates of this line of thought argue that, unless
24
a significant proportion of Indian consumers presently
have little faith in the quality of unbranded generics.
Those who can afford it often prefer to buy branded
products from private retail pharmacies, albeit that the
available research suggests that if people were sure of
the quality of the medicines being supplied a majority
would be happy to receive free unbranded treatments
from publicly funded dispensaries.
It is in addition apparent that very poor people are often
unable to purchase allopathic medicines at any price.
Hence by 2011 it had become clear that the initiative
was failing. Some observers blamed doctors for this
because of their continued prescribing of branded
generic medicines. This may on occasions have been
related to financial rather than patient interests.
It now appears that the Jan Aushadhi pharmacies
will not be able to make the contribution to improving
medicines supply that was originally hoped for.
However, their introduction in 2008 helped to open
up a debate about pharmaceutical care in India, and
the extent to which the nation’s 500,000 community
pharmacies might in time be able to offer an extended
range of preventive and/or clinical services directly to
the public. Presently, they tend to be clustered close to
doctor’/prescribers’ premises, and relatively few have
appropriately trained staff in constant attendance. But
as India continues to develop and technical advances in
not only pharmaceutical treatment but also ICT assisted
diagnostics and self care support continue to be made,
it may in future be possible to develop extended roles
for pharmacists similar to those already being explored
in settings like the USA and the UK.
India’s development is to stall, ‘care transition’ (defined
in terms that include the establishment of universally
accessible health services) must follow closely on the
processes of demographic and epidemiological change
through which the nation is currently passing.
At his Independence Day Address in August 2011 the
Prime Minister of India, Dr Manmohan Singh, announced
that health would be given high priority in the 12th
Five Year Plan for 2012-2017. He said that it was his
Government’s intent to increase the public financing of
health care to 2.5 per cent of GDP during the period to
2017, from the 1.2 per cent recorded in 2011/12. He
also set a goal for this total to reach at least 3 per cent
of GDP by 2022.
These plans are now in some doubt because of a
reduced rate of economic growth. But if private outlays
on items such as medicines and private medical and
hospital fees were to decline by corresponding amounts
in the same period (which is perhaps possible – Nayar,
2011) the overall proportion of Indian GDP devoted to
health would stay constant. That is, real growth in the
sector would have run parallel with real growth in the
economy as a whole. However, there is in reality likely
to be considerable pressure from health care providers
Health and Health Care in India
The scenario indicated by Dr Singh was consistent with
the report on Universal Health Coverage published by
the High Level Expert Group (HLEG) in November 2011 –
see, for instance, Figure 14. The HLEG had 15 members
from organisations such as the Public Health Foundation
of India (PHFI), the All India Institute of Medical Sciences
(AIIMS) and the Ministry of Health and Family Welfare.
Its mandate was to develop a framework for providing
optimally accessible and affordable healthcare in India
by reconfiguring and strengthening the existing health
system to ensure its alignment with the key objectives of
UHC. It defined providing UHC in terms of:
“Ensuring equitable access for all Indian
citizens, resident in any part of the country,
regardless of income level, social status, gender,
caste or religion, to affordable, accountable,
appropriate health services of assured quality
(promotive, preventive, curative, rehabilitative)
as well as public health services addressing
the wider determinants of health delivered to
individuals and populations, with the Government
being the guarantor and enabler, although not
necessarily the only provider, of health and related
services.” (High Level Expert Group on UHC, 2011)
The extensive analysis offered by the HLEG indicated
that moving towards a tax-based system of financing
will be essential for achieving UHC in India. This was
because it judged systems of private health insurance
as being unable – at least at the country’s current stage
of development – to fund universal coverage for chronic
disease as well as acute condition risks in all parts of the
nation.
Other authorities have commented that even if it is not
as yet possible to raise taxes via European or North
American style income taxes (only about 3 per cent of
Indian’s currently pay the latter) or payroll or other social
security levies, extensions of consumption taxes on
items like alcohol, tobacco or processed food products
might offer a viable way forward (Kumar et al., 2011).
However, although perhaps politically attractive in
India and increasingly other developing and developed
country settings, this option would potentially carry
highly inequitable consequences.
The HLEG also stressed the fact that India’s extended
public health care system will need to be flexible
enough to accommodate rapid urbanisation, increased
socio-cultural diversity and the differential health care
requirements of all the nation’s minority groups. Its vision
was that every citizen should be entitled to essential
primary, secondary and tertiary health care, guaranteed
by central Government in the form of a National Health
Package (NHP). This, the Group argued, should cover all
common conditions and provide as of right high-impact,
Health and Health Care in India
Figure 14: Projected proportions of public
and private health spending in India,
2011/12-2021/22
Percentage of total spending on health
and service users alike to increase the proportion of
India’s income that is spent on preventing and treating ill
health, over and above any possible increases in public
sector service spending funded by the Federal or State
Governments.
100%
90%
80%
33
53
70%
60%
67
50%
40%
30%
20%
Private
spending
67
47
10%
0%
Public
spending
33
2011-12 2016-172021-22
Source: High Level Expert Group on UHC, 2011
cost effective health care interventions for reducing
health-related mortality and disability.
The NHP services will, were the HLEG’s approach to
be fully endorsed and implemented, be available either
through public sector facilities or via contracted-in private
providers working within a public-private partnership
(PPP) framework. States will be free to supplement the
NHP with additional services using their own funds and
patients would also be able to add to their care by paying
out-of-pocket (OOP) for services not covered by the NHP.
Cashless transactions were, the HLEG envisaged, to be
facilitated by National Health Entitlement Cards (NHEC)
distributed to each citizen. Health worker density was to
be increased to achieve WHO suggested norms of 25
doctors, nurses and midwives per 10,000 population.
A key component of all UHC systems involves meeting
costs incurred in the process of treating the sick and
relatively poor via a common system of pooled financing.
Raising money through equitably designed taxes or other
hypothecated contributions that everyone must pay will
result in everyone paying less at times of ill health.
The latter could and arguably should contribute to
increased health spending by raising demand for health
care. Yet against this it could decrease costs as and
when care is managed more efficiently than would
otherwise be possible. Although the latter prospect may
seem unattractive to some sectional interests, containing
health care costs while improving health outcomes is
increasingly being regarded as a high priority goal in all
parts of the world.
Overcoming barriers
There is a strong Indian public interest case for
supporting the HLEG’s proposals. However, it is not as
yet clear whether or not they will be accepted in their
entirety by either the Government or by the wider Indian
community, or how those elements which are accepted
will in practice be taken forward.
25
Examples of issues to be addressed include:
• gaining acceptance for transferring significantly
more resources gathered via taxation from
the richest and healthiest to less advantaged
individuals and communities. The current situation
in India appears to be that although the country’s
overall ‘fiscal capacity’ is comparable to or greater
than that of other similar nations, there has not in
most instances been the will needed to use the funds
raised via national or State taxes to increase transfer
payments to the levels needed to sustain universal
health coverage. It might be that political debate
has lagged behind private sentiment. But the size,
plurality and diverse traditions of India may mean that
it will continue to face special problems in this area as
compared to those encountered in Western European
countries at similar points in their development;
• the challenges associated with increasing
demand for ‘high tech’ medicine in ‘first world’
India, while hundreds of millions of people in
‘third world’ India do not as yet enjoy assured
access to essential medicines and basic health
care. Following on from the above, when much
smaller OECD countries like say Denmark, Germany
or Italy were first introducing their UHC systems
the medical technologies then available were far
less sophisticated than is the case today. Hence
the perceived needs and consequent care costs of
people in the ‘higher’ and ‘lower’ social strata were
less divergent than is so in emergent societies today
(Savedoff et al., 2012). The extent to which it will over
time be acceptable to all but the richest Indian citizens
for their future health service to offer a basic health
package which then has to be topped up by private
outlays in order to obtain more costly and/or less cost
effective treatments is uncertain; and
• the difficulties inherent in resisting popular
demands for ‘irrational care’ and overcoming
sectional political, professional and commercial
interests in its provision. At present the Indian
market for health services and products such
as medicines is in some respects chaotic, and
sometimes characterised by patterns of service
provision and consumer behaviour that are – at least
in conventional evidence based medicine terms –
sub-optimal. Failures to invest sufficiently in the long
term protective use of medicines to reduce vascular
disease and type 2 diabetes linked risks, while at the
same time permitting poorly regulated and sometimes
excessive antibiotic usage, illustrate this point. Yet
many aspects of the current system and its relative
freedom from intrusive regulation are popular with
professionals and patients alike, and can on many
occasions deliver what users say they experience as
satisfactory results. Many groups may therefore wish
to oppose better planned approaches.
It is also the case that in countries such as the UK, where
NHS managerial and professional staff have significant
‘demand management’ and allied public health justified
control and optimisation roles, abuses and scandals have
26
occurred because of institutionalised power imbalances
between those receiving care and those providing it.
Similar events might be more likely to occur in India if
staff employed in expanded publicly funded facilities
were required to take on an extended role in rationing
access to treatments. Reduced private expenditure
driven competition could exacerbate such risks.
Such concerns do not imply that the HLEG’s
recommendations should not be pursued. Universal
health coverage and allied care systems can have
important advantages over alternative approaches,
not least in terms of reducing incentives for supplying
unnecessary treatments. But such proposals will need to
be implemented with care, and may at first need to focus
most firmly on those areas where there is the greatest
publicly agreed need for enhanced public service
provision. Improving affordable access to demonstrably
essential medicines and the support needed to help
ensure their effective use amongst the less well off areas
of rural and urban India provides an important example
of this type of opportunity.
Better Access and Better
Medicines?
Instituting reliable access to essential medicines is not
the only, or necessarily the most important, measure
needed for protecting personal health or assuring long
term population health improvement. However, the
fact that good quality manufacture, supply (including
appropriate prescribing, safe dispensing and effective
patient support) and use of medicines is nevertheless a
vital part of good quality modern health care provision in
affluent and less affluent countries alike is reflected in, for
instance, the UN’s Millennium Development Goals.
Along with the wider national economy, the Indian
pharmaceutical industry has developed rapidly in recent
decades. Its exports alone are presently reported to be
worth some US $13 billion a year. This is approaching
the total reported value of the domestic Indian market
for allopathic medicines18. In the 1950s 20 per cent or
less of the pharmaceuticals consumed in India were
manufactured in the country. Today the proportion
is in the order of 80 per cent. It is widely claimed that
India is in volume terms now the third largest producer
of medicines in the world, albeit that by value of the
pharmaceuticals it makes and sells it is not yet in the
top ten.
The US and EU markets currently account for some 70
per cent of the Indian based export industry’s returns. The
country is also a large supplier of lower cost medicines
and vaccines to international aid programmes. In settings
such as Nigeria Indian made drugs now account for
18 Data from both Government and private sources are consistent
with these estimates, although they should nevertheless be
treated with caution. If it were accurate that the total market for
allopathic pharmaceuticals in India is worth only US $13-14 billion,
this would represent no more than 15 per cent of the country’s
unusually low public and private health spending as expressed in
international exchange rate terms.
Health and Health Care in India
about a third of all sales, and the Government of India
is seeking to double the nation’s global pharmaceutical
exports in the next two to three years. There are also
good prospects for a continuing expansion of both
privately and publicly funded demand within the nation’s
borders. A number of sources suggest that India is able
to produce many medicines and – subject to regulatory,
clinical and other relevant capacities and capabilities –
undertake research for about a tenth of the costs likely
to be incurred in Europe and America.
But notwithstanding these data the scale and
sustainability of this success should not be over-stated.
Set against the whole Indian economy, the total value of
conventionally defined pharmaceutical industry activity
probably amounts to no more than 1.5-2 per cent of
GDP, even though some sources imply 3 per cent plus.
The proportion of world pharmaceutical sector revenues
enjoyed by the Indian industry is similarly only around 3
per cent. Indian companies are in addition facing strong
competition from Chinese and other emergent producers
of small molecule and other pharmaceutical products.
This will intensify, not least as major international
companies seek to enhance their performance in
response to their changing environment and highly
capable and resource rich countries like Russia move to
invest more in manufacturing ‘biologicals’.
Alongside this there is criticism from within the US and
India’s other more profitable external markets that its
policies in areas like narrowing the opportunities available
for obtaining patent protection for new medicines and
issuing compulsory licenses for treatments that have
been successfully patented are undermining international
public (along with research based corporate) interests
in financing high risk biomedical development projects.
Combined with concerns in India about the to date
disappointing domestic access to medicines despite
the low prices of essential generic drugs19 amongst
the nation’s most needy, such observations pose
significant policy questions for the future. Issues such
as the undesirability of some local branded generic
medicine marketing practices and the extent to which
private manufacturing investments (which may be
supplemented by individual State grants) are benefiting
the wider community as opposed to only a privileged
minority might also be raised.
Aspects of the hurdles to be overcome in assuring better
medicines supply are further explored below. But before
this the unusual nature of modern pharmaceuticals as
high technology products is worth emphasis. As Box
9 highlights, they are – although typically difficult and
expensive to develop – once marketed often relatively
inexpensive (especially given adequate scale) to copy.
In the case of the small molecule drugs characteristic of
19 Low imposed prices tend to discourage supply in any sector.
The function of (varying) prices in markets is not to reflect the
abstracted ‘absolute’ value of items, but rather to balance supply
and demand via indicating their relative worth at a given point in
time. Failures to understand this can in the absence of subsidised
production capacity able to operate at a loss or on a non-profit
basis lead to unrealistic expectations that imposing low prices will
ensure cheap supply.
Health and Health Care in India
the years between the beginning of the modern antibiotic
era that started when India gained independence in the
late 1940s and the marketing of innovations such as
trastuzumab (Herceptin) and imatinib mesylate (Glivec or
Gleevec)20 at the end of twentieth century, comparatively
little of their value lies in the direct manufacturing cost of the
substances they contain. It lies rather in the expertise and
investment needed to develop their safe and effective use.
Even with the next generation of typically lower volume
sale ‘stratified medicines’ now emerging this is still
largely the case, albeit that fabrication expertise and
consistency is important in the biological products
context. This combination of factors has made medicines
as high technology products uniquely dependent on the
existence of intellectual property rights (IPRs). Critics of
provisions such as patent laws (brand names can be
taken to represent a different form of intellectual property
protection or IPP, alongside copyrights and exclusivity
rights relating to the regulatory data needed to licence
medicinal drugs) may argue that they make new
medicines too expensive for poor people living without
access to universal health coverage to afford.
To underline points like this, agencies such as the
British and French charities Oxfam and Médecins Sans
Frontières (MSF) have highlighted the important role
that some Indian companies have played in producing
low cost anti-HIV medicines (see below). Yet there is
no evidence based alternative to IP protection and the
temporary periods of exclusive product supply they grant
for incentivising private (and public) spending on high
risk pharmaceutical research (Jacob, 2013). Without
intellectual property ownership rights like those granted
by patents effective AIDS treatments would almost
certainly not have become available as rapidly as proved
to be the case in the last two to three decades. At worst,
the world might still be waiting for such technologies to
emerge.
Policy after the 1962 conflict with China
Despite the courage shown by members of the Indian
Army, the poor level of preparedness revealed by
the 1962 Sino-Indian clash increased awareness of
strategic vulnerabilities like the nation’s dependence on
imported medical supplies. During the first half of the
20th century only very limited progress towards local
production had been made. The most notable examples
include the establishment of the Bengal Chemical and
Pharmaceutical Works in West Bengal and the Alembic
Chemical Works in Gujarat (Chatterjee, 2008). Even
at the start of the 1960s the country was not able to
manufacture most of the medicines it required.
20 Imatinib mesylate was first marketed as a treatment for CML in
2001, about half a century after the Philadelphia chromosome
was initially identified. It provides an early example of ‘rational
design’, and may be taken to serve as a landmark in the transition
of the research based pharmaceutical industry away from its
19th and 20th century origins towards more specifically targeted
approaches to disease treatment.
27
Box 9. The economics of pharmaceutical research, production and supply
Medicines are unique as high technology products.
They are expensive to develop, especially when outlays
on not only clinical trials of successful products but
also the opportunity costs of medicines which fail to
demonstrate safety and efficacy in the later stages of
research are taken into full account. Yet the marginal
costs of their production and supply after they have
been marketed are – even in the case of large molecule
biological products – often comparatively low. This is
why the price of a new medicine during the relatively
short period that it is covered by IP provisions that give
innovators exclusive marketing rights may legitimately
be many times the price at which a generic manufacturer
can subsequently supply.
However, this reality can be difficult for many observers
to accept. Viewed unsympathetically, IPP is seen as
unfairly making new medicines unaffordable in poor
communities. But it is also the case that without
intellectual property rights it is likely that fewer
pharmaceutical innovations would be developed, and
that once IPRs are exhausted pharmaceutical products
are often much more cost effective than labour intensive
approaches to disease prevention, cure and alleviation.
In this context it is important to emphasise that public
and private investments are frequently inter-dependent.
Just as, for example, organisations such as Universities
benefit from royalties on medicines sold by private
companies, the latter may draw on research findings
derived from public spending. Governments could well
be reluctant to authorise the latter without the long
term prospect of not only health improvements but also
financial gains generated via private sector activities.
Pharmaceuticals have a variety of other characteristics
that tend to make them controversial. These encompass
– in addition to their perceived life saving value – the
fact that they are superficially at least relatively easy
to copy or counterfeit as compared to, say, complex
multi-component products like jet engines or electronic
devices such as ‘smart phones’. They also normally
have unusually high value to weight and volume ratios,
especially while under IP protection. This facilitates
both legal trading and illicit movements of goods, albeit
that pharmaceutical manufacture and sale is heavily
regulated as compared with most if not all other sectors.
The most important economic points to highlight in
relation to the emergence of Indian pharmaceutical
manufacturing and the health care challenges the
country is currently facing are linked to the risks of
investing in fundamental therapeutic innovation, as
opposed to researching more cost effective ways of
producing existing proven medicines. Spending on the
latter generates predictable returns. By contrast it is
The shock of the Chinese military advances on the
northern borders led over time to strategic measures
aimed inter alia at assuring better pharmaceutical supplies.
28
much less certain that spending tens or hundreds of
millions of dollars on seeking to discover and licence
radically new ways of preventing or treating disease will
bear fruit. The term ‘risk capital premium’ relates to the
supra-normal returns investors need to anticipate on
successful products for them to continue to channel
funds into areas in which there is a high probability of
project failure.
At present the Indian pharmaceutical industry spends
very little on high risk research and development. Its
main priorities lie in supplying established treatments
at affordable costs, and where possible exporting
such medicines to other nations. In value terms the
US is the single biggest importer of Indian generic
pharmaceuticals, in part because when drugs go off
patent in America new generic suppliers enjoy a six
month period in which they have exclusive marketing
rights. Because of low wages and other advantages
relating to manufacturing capacity (including, as and
when available, State level subsidies) the country is
normally able to produce branded and other generics
at costs well below those presently incurred in regions
such as North America and Western Europe.
Indian companies are therefore unlikely to be
concerned with defending global public interests in
the IP law infrastructure that research based concerns
and many policy makers in countries with stronger
research sectors regard as vital for the continuance of
pharmaceutical innovation. Given the current absence
of insurance based or other financial mechanisms for
protecting Indian citizens in need of newer medicines
from having to meet high costs, patients and the wider
public also have little immediate reason to favour world
standard IP protection for the producers of innovative
treatments.
If the economic position of India strengthens and its
science base and health care system continues to
develop this situation could in time naturally adjust. Yet
for the moment the most probable way forward may
demand an increased international acceptance of the
need for the differential pricing of innovative treatments
in low per capita income countries such as India as
compared to more affluent communities, coupled on the
Indian side with a more sympathetic understanding of
factors such as the cost of the high risk capital required
to sustain ongoing innovation in the bio-pharmaceutical
sphere. Such progress is unlikely to be achieved via
disputes between opposed sectional interests with
rigid views. Rather, it will require flexible dialogue based
wherever possible on common values and an informed
awareness of the processes and demands of worldwide health and health care improvement.
They first took the form of, from 1963 onwards, a series
of Drug Price Control Orders (DPCOs). These were the
progenitors of the current National Pharmaceutical Pricing
Health and Health Care in India
Policy21. The Indian Patent Act of 1970 followed. This
abolished the IP regimen inherited from Britain at the time
of independence. It made only manufacturing processes
(instead of final products) patentable, and reduced patent
term durations to either just five years from the date of
sealing (ie granting) or seven years from the date of filing.
This reform, coupled with measures designed to promote
the local manufacturing of active pharmaceutical
ingredients (APIs) via the imposition of import duties,
created opportunities for Indian companies to ‘reverse
engineer’ new medicines and find progressively more
economic ways of producing them. In the following
decade the Drug Price Competition and Patent
Restoration Act (otherwise known as the 1984 Hatch
Waxman Act) restored patent terms in the US. It also
incentivised and facilitated the introduction of generic
medicines into the American market immediately after
patent expiry. This key reform, along with the subsequent
liberalisation of the Indian economy, helped the Indian
pharmaceutical industry to expand. Its exports increased
significantly from around the middle 1990s onwards.
One recent illustration of the continuing value of the Hatch
Waxman reforms to India was provided by the lipid lowering
medicine atorvastatin (Lipitor). This was by 2010-2011 the
most successful ‘blockbuster’ medicine of all time. It lost
patent protection in November 2011 and Ranbaxy (the
second biggest Indian pharmaceutical company in terms
of revenue, which had been purchased by the Japanese
pharmaceutical company Daiichi Sankyo in 2008), won
approval from the FDA to sell generic atorvastatin in the
American market at about a fifth of the innovator’s price.
The American legislation meant that the Indian company
enjoyed a 180 day exclusivity period, which protected its
sales efforts in the US22.
Twenty first century opportunities
Following a model initially put forward by the WHO in the
1970s, India eventually introduced the first version of its
National List of Essential Medicines (NELM) in 1996. This
today contains some 350 different medicinal entities, all
of which are subject to price controls. In the first decade
of the 21st century additional developments included:
• the marketing by Cipla of a low cost HAART
(highly active antiretroviral therapy) combination,
capable of effectively treating people living with
HIV – see Box 10. Cipla was founded in 1935 and
began bulk pharmaceutical production in the 1960s.
It provides an important example of Indian industrial
21 This in essence controls the prices of essential medicines. Details
relating to disputes over the precise methodologies employed
to determine production cost as opposed to market based
prices are not explored here. However, it is again appropriate to
emphasise that if unrealistically low ceilings are imposed this may
well create supply shortages which can paradoxically help force
poor people to have to purchase relatively high cost treatments
privately.
22 In relation to a separate historical matter, Ranbaxy agreed in May
2013 to pay a fine of $500 million for selling adulterated drugs
in the US market. The company pleaded guilty to seven criminal
counts, including intention to defraud and failing to report that its
drugs did not meet specifications.
Health and Health Care in India
success, despite the fact that its outgoing managing
director Dr Yusuf Hamied was recently quoted as
saying that ‘the time may have come to say goodbye
to India’ (Chatterjee and Balakrishnan, 2013)
• the publication in 2004 by the World Health
Organisation of the first edition of a seminal
report entitled The World Medicines Situation
(WHO, 2004). This publicly criticised the then
limitations in the supply of essential medicines to up
to two thirds of India’s population, and by implication
the country’s domestic pharmaceutical and public
health policy stance; and
• India’s acceptance, effective from 2005, of the
WTO’s Trade-Related Aspects of Intellectual
Property Rights (TRIPS) agreement. This obliged the
country to introduce, in return for continued or enhanced
access to ‘rich’ markets across the globe, a 20 year
patent term for all products, including medicines.
The latter requirement was originally intended to
accelerate progress towards more uniform global
IP provisions. But in the wake of the HIV treatment
crisis discussed in Box 10 the 2001 Doha Declaration
enabled TRIPS participants to take measures to protect
against ‘public health emergencies’, including issuing
compulsory licences (CLs) to permit the production
of patented medicines by third parties (Reichman,
2009). This was widely welcomed, although there are
international disagreements relating to how ‘public
health emergencies’ should be defined and no central
mechanisms for resolving such disputes. India’s 2005
Patent Act can therefore be seen as both introducing
extended product patent provisions and opening the
way to the use of ‘Doha flexibilities’ in ways that, despite
their undoubted popularity within India, some external
authorities believe are inconsistent with the intent and
global social purpose of the TRIPS agreement.
The WHO’s 2004 World Medicines Situation intervention
led in India to the establishment of a Task Force to
investigate improving medicines supply by means
other than price restrictions. This worked under the
chairmanship of a senior Planning Commission member,
Pronab Sen. Its recommendations included increasing
the use of ‘true’ – as opposed to branded – generic
pharmaceutical products; establishing special funds
for meeting medicine costs for patients in need; cutting
excise duties on medicines; and improving State’s
purchasing arrangements for obtaining products to be
supplied via the public sector.
The 2005 Task Force report also called for better public
education about medicines and health care, and an
enhanced role for pharmacies in supplying good quality,
low cost, medicines. This led in 2008 the Jan Aushadhi
initiative, referred to earlier in this analysis.
As discussed above, the latter (unlike an in part similar
‘popular pharmacy’ scheme in Brazil) has not proved
successful, although this is not to say that the health
care role of pharmacists could not in future usefully
be extended in India. The Pronab Sen Task Force’s
conclusions contributed to thinking subsequently taken
29
Box 10. The HIV pandemic and its role in improving access to essential medicines
When the first cases of AIDS were identified in the
US at the start of the 1980s little could be done for
those affected other than offering palliative care. But
following the introduction of AZT (zidovudine) in 1987
and the subsequent development of combination
anti-HIV drugs in 1992, progressively more effective
highly active anti-retroviral treatments (HAARTs) have
emerged. Today, individuals who have access to good
pharmaceutical care and who can take their medicines
as recommended are unlikely to die prematurely as a
result of HIV infection.
Even if the development of a vaccine remains elusive,
drug therapies coupled with public health interventions
might in time – with continuing investment in innovation
and treatment supply – prove capable of eliminating
HIV globally. However, despite the importance of the
successes achieved to date and the future potential
of drug based anti-HIV strategies to contribute further
health gains, the cost of patented HIV treatments has
been a matter of frequent concern in not only the least
developed nations but in emerging economies ranging
from India and Brazil to Russia and South Africa.
In the 1980s US based health activists were driven
by fears that because HIV was regarded as a ‘gay’
disease it would be neglected by both Governments
and pharmaceutical companies. These worries proved
unfounded. But as during the 1990s better drugs were
marketed and in settings from the US White House to
the villages of southern India it became understood
that entire populations were at risk from HIV, questions
about the prices of patent protected anti-retroviral
products became increasingly pressing. At $10,000 or
more per capita per annum their costs were and remain
acceptable in richer communities with robust universal
health care systems. Yet even in America uninsured
people (especially perhaps those in minority group
members) were on occasions unable to get access to
effective care. For most individuals and families in the
developing world it was clearly unaffordable.
In response to this situation, the Indian company Cipla
developed a $1 a day combination therapy. This action
is widely seen as having opened the way to transforming
HIV/AIDS treatment worldwide. It was also at the start
of the twenty first century that the Doha Declaration
made provisions for countries to take action to in
effect override patent protection when confronted with
national health emergencies that required mass access
to high cost pharmaceutical products.
The controversy that has surrounded this area carries
a number of important lessons relating to the need to
recognise health emergencies in a timely and effective
manner. There is now common acceptance that
30
not only pharmaceutical companies but also many
Governments were initially slow to respond to the
AIDS pandemic. One reason for this may be that it
atypically involved the rapid emergence of a need to
supply some of the world’s newest medicines to people
living in very poor communities. Even in the 1980s
many health professionals saw improving sanitation,
nutrition, vaccination and the supply of well established
medicines as the almost exclusive key to achieving
better health in pre and mid transitional settings.
However, health emergencies must be defined
appropriately if the integrity of the global intellectual
property system is to be maintained. In contexts like
cancer care (where the Indian Courts have recently
facilitated the compulsory licensing of a number of
potentially life extending, but not in most instances life
saving, patent protected medicines) there is arguably
little apparent justification for removing the temporary
ability of innovators to generate profit from their
products when the high costs of diagnostic and other
necessary services mean that only the wealthiest are
likely to benefit from low cost access to such ‘cutting
edge’ medicines.
India has made significant progress in preventing and
treating HIV infections in the last decade, albeit that
access to effective therapy could still be significantly
improved – see main text. But as the global population
continues to age and the demand for better treatments
for conditions like the cancers and neurological
disorders increases new challenges relating to
equitable access to new vaccines and medicines will
inevitably arise. This will be so not only in India but in
all emergent economies without UHC. From a worldwide public interest perspective this challenge should
be met in ways that neither neglect the needs of those
who urgently require effective care nor undermine the
ability of the global community to continue investing in
therapeutic innovation.
One possible way forward is through the development of
international mechanisms for funding the development
and supply of new pharmaceutical and allied products.
The GAVI Alliance (originally known as The Global
Alliance for Vaccines and Immunisation) provides
an early illustration of this type of progress. Another
future option might be that world-wide changes in
IP law could serve, through strengthened protection
terms coupled with extended low cost or free supply
obligations in less advantaged communities, to secure
a sustainable balance between protecting long term
public interests in the ongoing evolution of improved
biomedical interventions on the one hand and meeting
the immediate health care needs of vulnerable
individuals and communities on the other.
Health and Health Care in India
forward by the High Level Expert Group on UHC and the
suggested, although now uncertain, goal of extending
free generic medicines supply to half the population by
the year 2017.
As already described, the 12th Five Year Plan had
anticipated that this last will be achievable at the
relatively modest cumulative cost of US $5 billion,
which is equivalent to about 0.3 per cent of India’s
annual GDP. (The 2011 HLEG report had originally
called for an increase in yearly Indian public spending
on medicines from about 0.1 per cent of GDP to 0.5
per cent.) It also supported the introduction of new price
controls applying to an extended essential medicines
list, more transparent drug procurement arrangements,
an enhanced regulatory system and a more effective use
of information technology to track medicines use and
support patient care.
India is now to varying degrees moving forward in all these
areas. There is good reason to believe that over time further
improvements in health will be achieved, notwithstanding
the broader challenges that all countries will in future
have to face in contexts such as climate change and its
impacts in spheres such as food production. Yet it should
also be recognised that there remain problems such as
ill-informed public expectations of medicines in areas
ranging from the use of antibiotics to the effectiveness of
presently available anti-cancer medicines.
Undesirable professional and managerial attitudes and
behaviours also threaten to impede health improvements.
Given the finding that in lost welfare terms disability and
premature deaths due to non-communicable diseases23
alone are already costing India the equivalent of 12.5
per cent of its GDP, and that this total will in future rise
markedly unless appropriate preventive action is taken, it
is arguably vital that the preventive and public health role
of pharmaceuticals in fields such as hypertension, CVD
and diabetes management becomes better understood.
Likewise, realistic approaches to pharmaceutical price
regulation and State level public sector pharmaceutical
purchasing arrangements are needed. In the former
context it ought to be more widely appreciated, for
example, that imposing unduly low prices for essential
products can critically undermine medicines supply. An
undue reliance on supply side price controls when the
root cause problems to be overcome stem from demand
side failures such as corrupted purchasing practices
could inhibit necessary reforms.
With regard to drug procurement systems there is
mounting evidence that ‘arms length’, functionally
independent yet publicly accountable, agency
arrangements like those pioneered in Tamil Nardu
and Kerala can reduce corruption and achieve better
value for money. However, even here technically better
23 As described earlier, infectious diseases currently impose a similar
burden upon the Indian populace. This should continue to fall as
living conditions and health services are enhanced. But there is a
risk that such gains will be more than outweighed by an increased
middle and early later life incidence and prevalence of chronic/
non-communicable conditions such as strokes, CHD, heart failure
and type 2 diabetes.
Health and Health Care in India
systems alone cannot fully counter compromising social
environments (Singh et al, 2013). Achieving ethical
integrity in all aspects of pharmaceutical supply will be
essential for the delivery of optimal care, whether or not
appropriate price control and/or purchasing structures
are in place.
In the medium term the equitable provision of innovative
pharmaceutical products in India and elsewhere may well
demand fresh inter-Governmental agreements on the
principles and application of stratified pricing strategies,
and the extent to which the amounts innovators’ charge
for their products should vary between regions and/or
within communities in accordance with different levels
of (collective) ability to pay. Achieving stratified pricing
in ways which protect the interests of all those in need
of new medicines without undermining the interests
of those willing to invest in the ongoing development
of better therapies is also important. In the immediate
future the issue most likely to cause overt conflicts
between Indian and other national/regional stakeholders,
and which may also impede the development of the
nation’s pharmaceutical sector as it seeks to become
more research oriented, is that of intellectual property
protection.
Intellectual property and the affordable supply of
more effective medicines
At present the domestic Indian pharmaceutical industry
is, like the country’s pharmaceutical market, highly
disparate. There are currently tens of thousands of
competing branded generic medicines, supported on
occasions by questionable marketing practices. Along
with this there are some 300 larger producers/plants
functioning at levels credited as operating in a manner
consistent with the US FDA’s good manufacturing
practice (GMP) standards. (The FDA has a Delhi based
office, which is in communication with State level
inspectorates via the Indian Central Drugs Standards
and Control Organisation.) Beneath this level there
are at any one time as many as 5,000-10,000 small
manufacturers which can open and close fluidly across
India. Such concerns typically make branded goods
that they market themselves and/or supply active
pharmaceutical ingredients (APIs) and other items to
‘higher tier’ companies, although low cost APIs are also
imported in significant volumes from China.
Pharmaceutical production is conventionally regarded as
a capital intensive activity, likely to benefit from savings to
scale. But Indian sources describe the small to medium
sized local companies that the country currently has in
abundance as the mainstay of the domestic industry.
This is because of their flexibility and capacity to keep
costs very low.
Over the past few decades the Indian pharmaceutical
sector has performed robustly. But as compared to
the size of the overall Indian economy and the world
pharmaceutical market as a whole its earnings remain
relatively modest. The extent to which the Indian based
industry’s performance can continue to improve as the
31
global production of generic versions of established
medicines continues to consolidate and become more
efficient is uncertain. Likewise as the world market for
‘biologics’ both expands and matures, this too will
demand changes in the form and functioning of the
Indian and wider international industry.
It is possible that in coming decades the Indian
pharmaceutical sector will rebalance, and move from
concentrating on manufacturing low cost generic
products towards making higher margin ‘biological’
medicines and other innovative forms of treatment. If this
proves to be the case then Indian stakeholders in not only
pharmaceutical research and development but health
improvement more broadly may come to value relevant
forms of intellectual property protection for medicines
and allied products more positively, domestically and in
regions such as North America and Europe.
This is not to imply that important priorities such as
ensuring affordable universal access to (reasonably
defined) essential medicines should be neglected. Nor
ought (or can) resolving urgent challenges such as those
linked to extending the survival chances and quality of life
of less affluent people and groups living with, for instance,
cancer in settings which currently lack adequate public
health care systems be ignored. Yet the above does
mean that recent levels of conflict and misunderstanding
surrounding issues such as the compulsory licensing of
high cost tertiary oncology treatments and events such
as the recent Indian Supreme Court decision not to grant
a patent for imatinib mesylate (Gleevec) are undesirable,
and threaten to undermine both Indian and world-wide
public interests in better care and better medicines.
Unless positive action can be taken to establish an
informed consensus this could lead to defensive
actions which will create long lasting barriers to the
establishment of an optimally equitable and efficient
global pharmaceutical market. This would almost
certainly harm the interests of not only patients and the
wider world public, but all the individual Governments
and companies involved.
The Gleevec case was more complex than is sometimes
assumed. It can only be fully understood within its
particular context and the almost half a century of
research and development which took place between
the discovery of the ‘Philadelphia chromosome’ (the
genetic lesion at the heart of chronic myeloid leukaemia,
for which Gleevec was primarily developed) at the end of
the 1950s and the product’s first approval in 2001. But
from a general perspective it can be argued that current
Indian policies and provisions relating to intellectual
property are in some respects questionable from a
broad international perspective. They at worst threaten
to weaken structures vital to the continuing development
of medicines to prevent or treat conditions such as
cancers or neurological diseases, and a more robustly
knowledge based global health economy. Critics may,
for example, argue that:
• Indian State level powers to grant supply licences for
new medicines when they have been available for sale
32
for only four years can cut across nationally awarded
patent rights. This risk is linked to the fact that no
adequate mechanisms exist for resolving relevant
disputes until after alternative products have been
marketed;
• the granting of compulsory licences (CLs) on
medicines such as sorafenib (Nexavar) on grounds
relating to their not being manufactured in India is
inappropriate; and
• section 3(d) of India’s 2005 Patents (Amendment)
Act is difficult to reconcile with the spirit of the TRIPS
agreement that India accepted for implementation in
that same year.
The latter concern relates to the Doha Declaration issues
noted previously. Section 3(d) seeks to prevent IP ‘ever
greening’ (extension) by curbing innovators’ rights to
patent salts or other derivatives of previously known
substances. However, in the biomedical context the
differences between the properties of such alternative
molecules can be profoundly important. It is also worth
stressing that in normal circumstances it is not in any
jurisdiction possible for such ‘minor’ alterations to be
used to extend an existing patent24. Rather, a new patent
(plus a new product licence) would be required for any
such innovation, leaving – after the expiry of its IPP – the
original product free for generic manufacturers to make
and supply as they wish.
The interests most likely to oppose incremental
pharmaceutical
developments
are
commercial
companies and/or health care funders seeking to
limit market competition or control costs by denying
professionals and/or consumers new, potentially more
effective if also temporarily more costly, choices. For
example, a generic medicine manufacturer might well
want to block the emergence of better alternatives.
It will in the short term be difficult to resolve the
international and intra-industrial conflicts of interest
such observations indicate. It is possible that current
work in areas such as promoting free(r) trade between
India and the EU (and the EU and the US) may foster
closer alignments. However, there is little prospect of a
‘magic bullet’ solution, particularly while Indian public
opinion remains focused falsely on the perception that
reducing innovative medicines prices as distinct from
remedying the nation’s lack of an adequate health care
system is the most important step to be taken towards
achieving better public health. Perhaps the most that
can realistically be hoped for is in the more immediate
future the continuation of high level dialogue about issues
such as medicines price stratification, coupled with the
promotion of greater public understanding of the roles
of established and new medicines alongside lifestyle modifications in disease prevention and treatment – see
Box 11.
24 In the Gleevec case, for instance, it should be noted that although
in other parts of the world a patent designed to protect a range
of possible imatinib presentations had been granted before the
one taken out specifically on imatinib mesolate, only the latter was
applied for in India.
Health and Health Care in India
Box 11. The public health role of medicines use
In the pre-transitional world illness was often regarded
as the result of fate and an absolute lack of choice –
children and adults died because they did not have
enough food or adequate access to clean water, or were
the unlucky victims of unavoidable disease. Medicines
use, to the extent that it existed, was commonly seen as
relieving symptoms and on occasions curing individuals’
complaints, but not as a fundamental way of enhancing
population wide health through human agency.
However, it was recognised at a relatively early stage
in human development that the mass use of psychoactive agents such as alcohol and opium could impact
negatively upon the health of whole communities.
In the modern era tobacco smoking has provided
another example of a form of personal drug use that
can undermine public as well as individual health. The
availability of cigarettes has often been historically
associated with increasing incomes, and hence can be
said to illustrate the fact that with rising affluence the
main causes of death and disability become associated
with the (semi) voluntary selection of hazardous
lifestyle options rather than a total absence of choice.
India contains groups of people at both ends of this
spectrum, from those facing rising rates of obesity at
all ages to those whose children still suffer stunting
because of malnutrition.
Throughout the 20th century immunisation has been
regarded as a public health intervention. It protects
populations via its collective (or ‘herd’) effects, as well
as engendering individual resistance to infectious (and
today some forms of neoplastic) disease. However, it is
only very recently that it has become understood that
medicines used strategically can have similar positive
effects. For instance, the appropriate supply of antiretroviral medicines is now known to reduce disease
transmission within populations. It might even in time
lead to the eradication of HIV/AIDS (see Box 10).
Conclusions
The fundamental tasks facing India in the early 21st
century include completing its delayed demographic
and epidemiological transitions as swiftly as possible,
and building a sustainable post-transitional society with
the material, intellectual and moral resources needed to
provide all its members with an optimal opportunity for
achieving good health in later life. There is no simple way
of guaranteeing progress towards this goal, which will
demand ethical as well as technical competence and
leadership. As the Emperor Ashoka’s Edicts, written
and publicly displayed in the India of over 2,000 years
ago, were in part intended to communicate, excellence
in governance is dependent on not only rationality but
also on characteristics and values such as courage,
generosity, compassion and truthfulness.
Modern India, like the world as a whole, has many
divisions between and within its various communities.
Health and Health Care in India
Water fluoridation has also (despite some vocal
opposition) been shown to be a safe and effective way
of preventing dental caries. Likewise the extended use
of anti-hypertensive and cholesterol lowering agents
has a considerable potential to (along with smoking
cessation) reduce the incidence of cardiovascular
conditions in ageing populations, over and above the
health gains likely to be achievable via dietary and
exercise changes alone (Wald and Misselbrook, 2011).
Such observations have considerable implications for
India, where a quarter of all deaths are already caused
by vascular disease and the incidence and prevalence
of type 2 diabetes is rising rapidly. Some important
research on concepts such as the development of a
safe and effective ‘polypill’ for the primary prevention
of atheroma and events like strokes and myocardial
infarctions has already been undertaken in the country.
But against this the ‘public health’ use of medicines to
reduce average health risks in broad population groups
such as, say, people aged over 50 or 55 is in some
ways threatening to traditional pharmaceutical thinking
and the perceived interests of medical practitioners and
health educators alike. For example, it minimises the
need for individual diagnostic testing and personalised
risk assessments, and can (wrongly) be seen as
obviating requirements for health protecting lifestyles.
At the current stage of India’s progress it may therefore
be that many health professionals, along with regulatory
and allied agencies, will oppose such developments,
regardless of current service limitations and the
strength of the evidence in their favour. Nevertheless,
in the longer term an extended and optimally cost
effective use of medicines to prevent and/or arrest the
progression of NCDs should become more generally
accepted and seen as vital for further extending healthy
life expectation in all communities.
It is also faced with problems like gender related
inequalities and pressing needs in areas ranging from
preventing malnutrition amongst vulnerable children
to enhancing energy production in an environmentally
acceptable manner. However, despite ongoing restraints
and challenges, the emergence of health care and
nationwide health improvement as accepted political
priorities represents an important step forward. It is to be
hoped that the recent work of the Planning Commission
instituted High Level Expert Group on Universal Health
Coverage will lead on to a care system able to serve the
entire 21st century population.
Viewed positively, it is possible that the country’s
established expertise in areas like information technology
and vaccine production will prove useful in recasting
current models of self care and professional care and
opening the way to a unique and potentially world leading
Indian health service model. Likewise, if the lessons of
33
the past relating to, for instance, failures to adequately
support the local implementation of well intended
policies and the repeated twentieth century mistake of
under-investing in primary and community services are
accepted, the current threat from the rising prevalence
of chronic disease in India should prove containable in
ways that permit significant further extension in healthy
life expectancy.
Even if this were to mean raising the total proportion of
GDP devoted to health to, say, 6 per cent in the coming
decade or so, as compared to the current figure of a
little over 4 per cent and an OECD average of around
10 per cent, this could well be a sound, desirable,
investment. Without prompt additional action to prevent
the avoidable losses of wellbeing, skills and abilities
caused by non-communicable conditions in middle
and later life, Indian society will ultimately have to bear
very heavy costs. If not effectively addressed, a growing
NCD burden might undermine the country’s ability to
complete its demographic and allied transitions and
stall its overall economic and social development. Any
such failure would almost certainly have signficant global
repercussions.
Ultimate responsibility for forming India’s health and health
care policies lies with the nation’s elected Government.
Democracy also requires that decisions should be
consistent with the leadership’s vision of the Indian
people’s best interests, alongside more immediate voter
preferences. Given this key understanding, one of the
main recommendations offered here is that alongside the
welcome but still relatively cautious and now apparently
delayed measures recently proposed in the context of
extending access to free generic medicines as part of
the country’s overall journey to universal health coverage,
policy makers may also in the coming decade wish to
consider further reforms relating to intellectual property
law.
It is apparent today that the 1970 Patents Act marked the
start of a new phase of Indian development in relation to
pharmaceutical production and sales. Approaching half
a century later a re-modernised approach to intellectual
property law might mark the beginnings of the country’s
rise as a post transitional community. As India’s capacity
for innovation increases and its health services continue to
improve, ongoing public interests in both the affordability
of health care and the development of better therapies
might best be defended, nationally and internationally,
through strengthening the IPP available to the creators
of more effective treatments in return for new types of
supply guarantee in poor communities.
Such ideas presently conflict with much popular
sentiment. Yet if in future it were supported by nations
like India, such an approach could build on the spirit of
the US Hatch Waxman reforms of the 1980s to deliver
a global intellectual property system better fitted for
meeting 21st century needs.
However, another key message of this analysis is that
achieving better public health requires more than better
medicines supply alone. Similarly, it also needs more
34
than the high technology hospital care that ‘first world
India’ can now offer not only its more affluent citizens
but relatively well-off patients from across the world.
Improving health in ‘third world India’ will centrally
demand enhanced primary care together with significant
advances in areas like communicating the knowledge
and skills needed to prevent disease wherever possible
and access optimally cost effective treatments for
established conditions whenever necessary. Such
solutions need to be understood and ‘owned’ by not
only the medical and other health professionals charged
with providing formal health care, but everyone seeking
to live in ways that protect their health and that of their
families.
One example of an option for enhancing consumer
involvement in health care and balancing more effectively
the power of professional providers against that of
service users could, as noted earlier, involve the use of
SMS messaging to permit patients or others to record
inappropriate restrictions in drug or other forms of public
service provision. For some observers proposals of
this nature may appear controversial. But without such
consumer empowerment measures – coupled with
suitable mechanisms for supporting good practices and
penalising corruption – the pace of health and health
care improvement will be slower than the majority of the
Indian electorate is in future likely to judge acceptable.
In the final analysis, achieving further social and economic
progress in India – with a sixth of the entire human
population – is important for everyone everywhere. In an
interconnected world, India’s policies on everything from
pharmaceutical supply to the provision of comprehensive
and affordable health care in rural villages are likely to
have long term global consequences. The reverse is
also true. This is why policy makers in India should seek
to be well informed about and sensitive to global public
interests along with Indian voters’ (and health service
users’) concerns, and why policy makers and others living
outside the country should also seek to understand and
constructively support efforts to improve the prosperity
and wellbeing of the Indian people. In the 21st century
providing effective and universally accessible and
affordable health care will increasingly become a global
priority, as is building further humanity’s biomedical and
other science based capabilities.
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35
The Emperor Ashoka Maurya ruled most of the Indian subcontinent over 2,300 years ago. He established a health
service and communicated through personally written
edicts about his Buddhist philosophy based approach
to just governance and the maintainance of social unity.
This report was written by Dr Jennifer Gill and Professor David Taylor of the UCL School of
Pharmacy. They gratefully acknowledge the help and advice given by all those interviewed during
the research phase of this project, which was funded via an unconditional grant from the PhRMA,
the US research based pharmaceutical manufacturers association. Dr Gill and Professor Taylor
worked independently, and editorial accountability for its content lies with Professor Taylor.
Copyright © UCL School of Pharmacy, July 2013 ISBN 978-0-902936-27-0 Price £7.50
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