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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 countrys 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 Indias 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
Indias 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 worlds 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. Indias pharmaceutical exports which the Government is seeking
to expand are of comparable value.
In financial terms Indias 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 worlds wealthiest and healthiest nations.
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, Indias 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 Chinas
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
Source: Office of the Registrar General and Census Commisioner of India, 2011
Receding
pandemics
Increasing NCDs
(lifestyle related)
Delayed NCDs
and emerging
infections
Population
growth
Early
Late
Post
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%
3.0
projected
projected
Ratio of working-age to
non-working population
5
4
3
2
1
1950 1975 2000 2025 2050
ChinaIndia
2.5
2.0
1.5
1.0
1950 1975 2000 2025 2050
ChinaIndia
10
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
11
12
13
14
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)
15
Figure 11: A categorisation of States based on selected healthcare and economic indicators
16
17
18
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
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
19
Doctors
3.1
0.6
Nurses
8.6
0.8
Midwives
0.27*
0.47
Dentists
0.61*
0.06
Pharmacists
0.76*
0.56
20
21
22
23
24
100%
90%
80%
33
53
70%
60%
67
50%
40%
30%
20%
Private
spending
67
47
10%
0%
Public
spending
33
Overcoming barriers
There is a strong Indian public interest case for
supporting the HLEGs 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
26
27
28
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
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
31
32
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 Ashokas 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.
33
34
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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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