Health and Health Care in IndiaNational opportunities, global
impactsSummaryIndias 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 earths 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,Indiahasexperienceddelayeddemographicandepidemiologicaltransitionsascomparedwith
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.Indiaspopulationof1.2billionisstillrisingbyapproaching1.5percentperannum,orabout18million
peopleayear.Somecommentatorsseethisasastrength.Othersregarditasamajorthreattofuture
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,
includingstrokes,arealoneresponsibleforaquarterofallmortality),chronicrespiratorydisordersand
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 signifcance, 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 signifcant limitations in
areas such as the (free) provision of essential medicines to the
400-600 million poorest Indians. c2Health and Health Care in
IndiaMost 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
accesstoservices.Butthereisevidencethatthecurrentsystemoftenfailstomeetmedicallydefned
need and is ill-suited to meeting the requirements of communities
characterised by increasing chronic/non-communicable 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.ThePrimeMinisteralsoannouncedextensionsinthepubliclyfundedsupplyoffreegenericmedicinesto
the less advantaged half of the Indian population by 2017. A fve
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.About70percentofoverallIndianhealthspendingispresentlymetbyprivateout-of-pocketoutlays.A
similar proportion of this total is accounted for by medicine
costs. These fgures imply that 50 per cent of Indias low health
spending is accounted for by pharmaceutical costs. But the
household survey data from
whichsuchestimatesarederivedmayincludeprofessionalfeesandotheritems,includingthepurchase
oftraditionalremedies.Thecostofallopathic(western)medicinesisatmanufacturerspricesunlikelyto
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.
Measureslikeissuingcompulsorylicensesonsuchproductscanatbestbeneftonlysmallnumbersof
better-off people and some local pharmaceutical companies. The
public as a whole will beneft 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.InfnancialtermsIndiasmostimportantexternalpharmaceuticalmarketsaretheUSandtheEU.Low
costIndianmademedicineshavebeenimportantinextendingaccesstotreatmentsforconditionssuch
asHIVinpoorerpartsoftheworld.However,Indiadoesnotasyethaveastrongrecordinfundamental
pharmaceutical innovation. Critics argue that current Indian
policies are narrowing and limiting intellectual property
protection for products
suchasmedicinesandthatthisisinconsistentwithlongtermIndianaswellasglobalpublicinterestsin
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 stratifed pricing.Another route to further
progress could be through enabling Indian public service users to
report problems
suchasfailurestoprovidepublicservicestowhichpeopleareentitledvia,forexample,SMStextingto
confdentialmonitoringcentres.Thecountryisvulnerabletointernalandexternalchallengesassociated
with,forexample,continuinggenderinequalitiesandglobalwarming.Atworstthereisariskofastalled
demographictransitioncoupledwithincreasedratesofnon-communicableillnesses.ButifIndiainvests
adequatelyinimprovinguniversallyaccessiblehealthcareandpreventingandtreatingnotonlyinfectious
disorders but also NCDs these dangers should prove avoidable. The
country could in time again become one of the worlds wealthiest and
healthiest nations.Health and Health Care in
India3IntroductionIndian commentators have observed that there are
two waysoflookingattheircountryinitsmoderncontext.
Viewedpositively,theinformationpresentedinBox1
underlinesthefactthatIndiahaslongenjoyedcentres
ofwealthandarichsocialdiversity.Seenfromthis
perspective,itistodayintheprocessofrecoveringits position as a
global super-power. Discounting the EU
asacollectiveentityandasmeasuredinpurchasing
powerparity(PPP)basedterms,Indiaseconomyis already the third
largest in the world.
Sincemarketorientedreformsintroducedattheendof the 1980s it has
enjoyed strong growth, driven by success in areas ranging from
pharmaceutical manufacturing and
exportingtoinformationtechnology.AlthoughChinas economic
development from around that time has been
faster(evenin1990thetwocountrieshadroughlythe
samepercapitaGDP)India,whichishometoover1.2 billion people, has
made important progress. For example, average life expectancy at
birth has risen to over 65 years
formenandwomencombined.Thisisabouttwicethe fgure 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 UKs NHS were established at the end
of the 1940s, life expectancy at birth in Western Europe and the US
was atthesamelevelthatIndiaenjoystoday.Sincethenit
hasincreasedinthematureindustrialisedeconomies by another 10 years.
This is only a third of the absolute
gainachievedbyIndiainthesameperiod,albeitthat
enhancingftnessandsurvivalratesinolderpeopleis a fundamentally
different task from that of cutting infant
andchildmortality.ThechallengesfacingIndiatoday
relatetobridgingthetransitionfromfghtinginfections
toreducingtheburdenofchronicdiseaseandliving healthily in later
life.Conventional proponents of the demographic dividend
associatedwithwhentherelativenumbersofchildren
inapopulationfallandtheproportionofpeopleover retirement age has
not yet risen markedly believe that
Indiasstillyoungpopulationisavaluableresourcein 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
isaged35orless.Someauthoritiesarguethatasthe Box 1. Wealth, caste
and class in IndiaIn modern India a little under 20 per cent of the
worlds peopleliveonalittleover2percentofearthsland
surface.Theycollectivelyenjoyanincomeofin
purchasingpoweradjustedtermsbetween5and 6 per cent of global GDP.
However, within that overall picture there are major disparities in
wealth. The country hasabout50billionaireswhosecombinedpersonal
revenues represent in the order of 10 per cent of Indias
totalearnings,andapproaching100millioncitizens with standards of
living comparable to those of affuent people in countries like the
US and Germany. Against this some 400 million Indians live in
severe poverty.Extremesofwealthanddeprivationhavebeenalong
standingcharacteristicofIndiansociety,albeitthat over the millennia
of its existence there have also been
periodsofrelativelyevenlydistributedprosperity.The
countrywasuntilthelastfewcenturiesoneofthe richest on earth. At the
start of the seventeenth century,
atthetimethetermcastewasfrstgainingcurrency,
Indiawasresponsibleforaboutaquarterofallglobal wealth generation.
In the early 1600s only China was of a similar standing. In the
Mughal, Marathan and British dominated periods that followed the
countrys relative prosperity gradually
declined.YetsomeindividualMaharajahs(local
GreatKings)retainedconsiderable(andoftenhighly conspicuous)
personal fortunes into the current era. This pattern of accepted
inequity has been underpinned by Indias unique system of social
stratifcation. 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. 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
betweentodaysIndiaandPakistan.Yetforeignersdid
notcreatetheJati(inessence,noninter-marryingclan 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.Adetailedanalysisofhowcasteandbroadersocio-economicclassbasedvaluesandpracticescontinueto
infuence 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
healthylifeexpectancytoorbeyondthelevelspresently observed in, for
instance, Western Europe and Japan, it is likely that twenty frst
century Indian policy makers will need to fnd ways of further
promoting a communally accepted
commitmenttogreaterequity.Developingbetterfunded and ethically
provided public health services will probably
proveintegraltoachievingthisfundamentalgoal,aswell
astomorespecifcobjectivessuchasimprovingaccess
tomedicinesforthepreventionandtreatmentofnon-communicable
diseases.4Health and Health Care in Indiatwenty frst 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).However,thereisanalternativetothispositivepicture.
Viewedlessfavourably,Indiasnominal(exchangerate
based)GDPpercapitacurrentlystandsatonlyalittle
overUS$1,500($3,700PPPadjusted).Thiscontrasts
withfguresofaboutUS$50,000perheadrecorded
inNorthAmericaandWesternEurope,andacurrent Chinese real per capita
income of over twice the Indian
level.AlthougharelativelysmallminorityintheIndian
populationenjoystandardsoflivingaboveEUandUS
norms,400millionormoreofthenationscitizenslive in severe poverty.
In rural areas, where two thirds of the
nationspeoplearestilllocated,themedianhousehold income is little
more than US $500 a year. Such fgures help to explain why a quarter
of the current global total
ofchilddeathsoccursinIndia,alongwithasimilar proportion of the
worlds maternal deaths. ConcernedIndianobserversmightalsoregardthe
nationslarge,youngandmainlypoorpopulationasa
potentialsocialtimebomb,ratherthananunalloyed
economicasset.Theymayinadditionpointtothe
sometimesunder-estimatedstrengthsofcommunities 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 byincreasesinhealthylifeexpectancyandextended
workingandactivesociallives.AsFigure2indicates, healthy life
expectancy in India is about 15 years less than that recorded in
Japan (Salomon et al,
2012).Furthermore,despiteitsreputationforpluralityand 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 as an independent republic large sections of the Indian
populationdonotasyethavereliableandaffordable
accesstogoodqualityhealthcare(HighLevelExpert Group on Universal
Health Coverage, 2011). Comprehensiveprivatehealthinsurancecovering
chronicaswellasacutehealthneedsisnotasyet
generallyavailable,whilereportedpublicspendingon health care in
India is presently only a little above 1 per
centofGDP.Notwithstandingtheincreaseto2.5per
centofGDPby2017anticipatedinthecountrys12th
FiveYearPlan,thisisoneofthelowestproportions
recordedanywhereintheworld.Recentfguresfrom sources such as the
OECD and the World Bank put total
Indianhealthspendingatjustover4percentofGDP,
comparedwithabout5percentinBRICSlikeChina
andRussiaand9percentinBrazilandSouthAfrica.
IntheUSsome18percentofGDPisnowspenton
healthcare.InIndiaout-of-pocketpersonalandfamily
paymentsprovidethelargestreportedelement(about 70 percent) of
health care funding.Indian health service users are already facing
increasing diffculties with regard to the prevention and treatment
of non-communicableconditions(IMS2012;Reddyetal, 2005).This
threatens health in middle life and beyond.
Atthesametimethereisasignifcantresidualburden of infectious
disorders. Diarrhoeal diseases, for example, still represent along
with pneumonia a major threat to infants in less advantaged rural
and urban communities
livingwithoutadequatecleanwatersupplies.Ratesof TB related
mortality and morbidity remain high in
adults.Intheareaofpharmaceuticalcarethelowpricesand
generallygoodqualityofIndianmanufacturedgeneric
productsoughttohavefacilitatedthesupplyofessential
medicinesandvaccinesforall.Yettheexistenceofan
oftenapparentlydysfunctionalprivatemarketfornon-patented branded
medicines, coupled with problems such
asstockoutsandcorruptionaffectingthepublicsector pharmaceutical
supply chain, has meant that standards of
treatmentarenotashighascouldotherwisehavebeen attained. Some
observers interviewed during research for Figure 1: Crude birth and
death rates and population size, India
1901-2011Source:OffceoftheRegistrarGeneralandCensus Commisioner of
India, various yearsFigure 2: Healthy life expectancy, selected
countries, circa 2010Source: (Salomon et al., 2012)Health and
Health Care in
India5thisanalysis1fearthatcontroversiesabout,forinstance,
thepricesofpatentprotectedmedicinesdevelopedby
multinationalsforconditionslikecancer(andthatinthe main have at
least to date limited life extending rather
thansavingapplications)haveservedtoconcealmuch more important
public health questions about the supply of basic established
treatments to the mass of the population.
ItisunderstandablethattheIndianpublicisconcerned about the cost of
pharmaceutical products. On a day-to-day basis many people
experience outlays on drugs (which
tovaryingdegreesalsoencompassprofessionaland 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.
Yettheavailabledatacanbediffculttointerpret.Itis
concludedherethatspendingonallopathic(western science based as
opposed to other traditional) medicines
expressedinmanufacturersprices(netofmark-upsby 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 fgures reported
elsewhere. What has been
moreatypicalisIndiastodatelowoveralllevelofhealth
investment.Itisalsoworthstressingthattragediessuch
asfamiliesbeingdrivenintopovertybecauseofhealth
carecostscaninlargepartbeseenasresultingfroma 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
sharingfnancialarrangementsforenablinguniversal
healthcareaccesscould,despitetherecenteffortsof bodies such as the
High Level Expert Group (HLEG) on
UniversalHealthCoverageestablishedbythePlanning Commission for
India, have perpetuated an absence of
wellgroundedpoliticalandwiderpublicdebateabout health
improvement.Against this background, the central goal of this
analysis is to inform in a balanced and welfare oriented manner
European andNorthAmericanstakeholdersunderstandingsof
thechallengesandopportunitiesfacingIndiaandher
people.Asalreadyindicated,itisparticularlyconcerned with the
growing burden of long-term non-communicable conditions (NCDs)
being recorded in India, along with other
emergenteconomiessuchas,forinstance,Chinaand Turkey. (See, for
example, Carter et al, 2012).
TheexperienceofcountrieslikeRussiawhere,despite
relativelylowinfantmortalityandarelativelyhighper capita GDP, male
life expectancy has in recent decades
beensimilartoorevenbelowtheIndianaverage,
underlinestheimportanceofaddressingthethreatof
risingNCDandlifestylelinkedmortalityandmorbidity
intimelyandeffectiveways.Thatis,bycombinations
ofhealthbehaviourchangeandthejudicioususeof
medicinesandotherhealthcareinterventionsforthe 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
researchanddevelopment,aswellasfacilitating
affordableworld-wideaccesstomedicines.Itbegins
withanoverviewofdemographicandepidemiological
transitioninIndia,followedbyadiscussionofthe
presentprovisionofhealthcareandthepotential importance of recently
proposed reforms. It then turns to issues relating to the ongoing
development of better medicinesandIndiasambitionstobethepharmacy of
the world. Continuing concerns surrounding TRIPS (the Agreement on
Trade Related Aspects of Intellectual Property Rights) are
explored, alongside the signifcance of recent Indian decisions to
issue compulsory licenses (CLs) for a number of patented medicines.
Such actions which are clearly
popularwiththeIndianpublichavebeenapplauded
bysomeobservers.Buttheyareseenbyothersas
threateningnotonlyindustrialbutglobalpublichealth
improvementrelatedinterests.Asecondaryobjective
ofthisreportistoexplorewhythisisthecase,andto suggest ways of
reducing the potential for
damage.However,therearetwomoreintroductorypoints
thatfrstrequireemphasis.Itisimportantinitiallyto
emphasisethat,forsuccessfulimplementation,public
healthinitiativesofalltypesneedtobeconsistent
withthebeliefs,values,resourcesandneedsofthe
communitiestheyareintendedtobeneft.Theycannot
normallybeimposedwithoutmeaningfulconsultation, or be copied
uncritically across from one cultural setting
toanother.Academicandothercommentatorsshould
beawarethatsolutionstoproblemsthathaveproven
effectiveincountriessuchas,say,theUS,theUKor
BrazilmaynotworkinIndiassocialandeconomic
context.Likewise,withinacountrythesizeofIndiait should not be
assumed that approaches that are viable and demonstrably cost
effective in one State will prove equally desirable in
another.Followingonfromthis,todaysIndiacoverslessthan
2.5percentoftheworldslandsurface.Yetasecond
pointtostressisthatthe28Statesincludedinits Federal structure
(along with the 7 centrally administered
Unionterritories)typicallyhavepopulationsthatare
comparableinsizeto,orlargerthan,thoseofnations
suchas,forinstance,SpainorCanada.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.
1In 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. 2Sources 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.6Health and Health Care in
IndiaIndiastotalpopulationisovertwicethatoftheentire European Union
and four times that of the US. Within the
countryStatesdiffergreatlyinrespectof,forinstance, 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
betweenelitesinDelhiandtheleadershipsofnational 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 diffcult and/or
potentially misleadingtoattempttounderstandIndiaasasingle entity.
Parts of the country are much more resistant than
otherstochange,andtoconceptssuchasuniversal 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 propertyprotectionaretobeequitablyresolved,the
wider global community will need to be sensitively aware of the
immediate physical needs of Indias people. Those
seekingtosupportthecountrysongoingdevelopment
willalsoneedtounderstandthefundamentalsocial
driversbeneathcurrentpatternsofnationalandlocal
governance,andthehistoricallydefnedconceptsof status and justice
underpinning the modern day working of the worlds most populace
democracy.Figure 3: Population and literacy per Indian state,
2011Source: Offce of the Registrar General and Census Commisioner
of India, 2011Population trends and changing patterns of disease
health in India in the early 21st
CenturyThetermsdemographicandepidemiologicaltransition
relatetothecloselyintertwinedpopulationand
diseaseincidenceandprevalencechangesthathave
characterisedtheglobalhumandevelopmentprocess of the last two
centuries. These accompany movements from rural subsistence living
towards more urbanised and affuent ways of life. The nature and
timing of the shifts
involved,whichincludebothindividuallifeexpectancy
gainsandpopulationageing,areoutlinedinFigures4 and 5.
Beforetheearly1800sthatis,200yearsafterthe 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 earthhadanaveragelifeexpectancyofmuchover40
years.Thiswasfrstandforemostaconsequenceof high typically up to 20
per cent annual infant mortality
rates.Butbecauseofthebeneftsoflowpressure
demographicsystems3,coupledwithagricultural 3There 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
India7advancesandearlystageindustrialisation,peoplein
EnglandandTheNetherlandswerebytheendofthe Napoleonic wars (in 1815)
a little wealthier and healthier than populations elsewhere.
Thetechnicalprogresssuchcountriesmadeintime
helpedtoopenthewaytotheglobaldevelopments
takingplacetoday.Butthiswasatthepriceofthe
colonialisminitiallyfacilitatedbythedemographic,
technicalandmaterialadvantagesenjoyedbyWestern
Europeascomparedtotherestoftheworld.Global average life expectancy
at birth remained under 35 years
throughoutthenineteenthcentury.InbothIndiaand China, for example,
it did not rise much above this level
untilthesecondhalfofthetwentiethcentury.Itisstill
(inpartduetotheonlypartiallycontained,ifdeclining, HIV pandemic, as
well as ongoing military conficts) little more than 40 years in
parts of Africa today.However,oncecommenceddemographictransition
despiteexceptionalexperiences,mostnotablylike
thatofFrancetendstofollowthesamebasicpath
everywhere.Asenvironmentalconditionsandfood
suppliesstarttoimprove,deathratesamongyounger
adultsbegingraduallytofall.Thisisatfrstbecauseof reduced risks from
infectious diseases. Better sanitation, for example, cuts the
spread of water borne conditions.
Sotoodoesanimprovedimmunestatusinindividuals
andacrosspopulations.Enhancedimmuneresponses resulting from
improved nutrition (coupled in the modern era with access to
pharmaceutical products like vaccines
andantibioticandanti-parasiticdrugs)boostrecovery
ratesandclassicallyfacilitatefurtherproductivitygains. Child and
then infant survival rates also rise, as conditions become still
more favourable.Althoughculturesvaryinthespeedatwhichreligious
andothervariablesinhibitorencouragebehavioural
andsocietaladaptations,declinesinbirthratesand increases in the
status of women follow the achievement
ofloweredinfantmortality.Protectionfrommalnutrition
anddebilitatingparasiticandotherinfectiousillnesses
ininfancyandchildhoodcoupledwiththeadditional benefts of smaller
families, better child care and changed
patternsofeducationleadontoothergains.These include a 15-20 point
rise in average IQ, as between pre- and post transitional
communities (Flynn, 2009).
Suchadvancesenhanceworkforceparticipationand reduce the ratio of
dependents to working age adults,
partlybyallowingolderpeopletousetheirskillsfor longer. This
supports continued economic and societal
development,includingimprovedhealthandsocial
careprovision.Thesocialprocessesthathelpresult
intheestablishmentofuniversalhealthcoverageand care (UHC) systems
have been termed care transition
(TaylorandBury,2007).Fromtheperspectiveof
thisanalysistheachievementofUHCisacommon
characteristicofallmaturepost-transitionalsocieties.
(See,forexample,RodinanddeFerranti,2012.)Yet
asthecontrastingpatternsofhealthserviceprovision in, say, the US
and the UK illustrate, this end point can
beachievedindifferentwaysandwithdifferinglevels of effciency.
Figure 4: Stages of demographic and epidemiological
transitionSource: The authorsStages of epidemiological
transitionPestilence and famineReceding pandemicsIncreasing
NCDs(lifestyle related)Delayed NCDsand emerging infectionsPre Early
Late PostCrude death rate Crude birth rateStages of demographic
transitionPopulationgrowthFigure 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 nations1860 1880 1900 1920 1940
1960 1980 2000 2020 204014%7%Percentage of populationaged
65+FranceSwedenUKUSAJapanRep. of
KoreaChinaThailandBrazil2060IndiaSource: The authors adapted from
WHO, 20128Health and Health Care in
IndiaThereisevidencethat,whenpoorlyplannedand
regulated,marketbasedsolutionsare(atleastinthe
lateinfectiousdiseasetransitionalphase)morecostly and less
benefcial to the health of populations than well planned,
effectively regulated, tax funded health services.
Butinordertoenhancepublic(health)interestsand 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
sometimesrecognised4.Theymaythereforebevery
diffcult,ifnotimpossible,tointroducesuccessfullyin
heterogeneousnationsinthemid-transitionphase. Russian history might
be taken to illustrate the price that may have to be paid for
attempts to force cohesion
and/orchangebeforecommunitiesarereadynaturallyto accept
it.IntheIndiancontextcontinuingeconomicandsocial development will
demand intensifed efforts to introduce
UHC.However,despitetherecentfndingsoftheHigh
LevelWorkingGrouponUniversalHealthCoverage
institutedbythePlanningCommissionofIndia(see
below)itcouldprovecounter-productivetoprescribe
asingletheoreticallyoptimalnationalmodel.Many
commentatorsbelievethatintheforeseeablefuturea
fexiblemixofpublicandprivatesystemsdesignedto
facilitatebetterhealthservicefundingandprovisionis
likelytoemerge,albeitthatinthecaseofthepoorer segments of the
Indian population better medicines and care provision will very
probably require
free-at-the-point-of-usesupply.Tobeviable,suchmeasuresmustbe
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 Indias demographic
developmentThe 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 frst called the dominions
ofIndiaandEastandWestPakistan.Withsubsequent support from the
Republic of India the latter became the
fullyindependentPeoplesRepublicofBangladeshin
1971.Atthestartofthe1970sIndiawasarguablyahead
ofChinaintermsofitseconomicdevelopment.The nations GDP per capita
was still marginally higher than
thatrecordedintheChinesePeoplesRepublic.Yetit
wasalsoaroundthattimethattheCulturalRevolution
heraldeddramaticdeclinesinthelatternationsfertility rate. The one
child policy introduced in China in 1979
canbeseenassecuringtheinitialfallsinbirthrate triggered by the
painful social upheaval of the late 1960s
andearly1970s.UntilthatpointmostConfucians,
likemanybelieversintheothermonotheisticreligions
foundedaround2,500to1,500yearsago5,had
espousedtheviewthatwomenshouldbesubservient 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
ascomplexanddeeprootedasgenderrelationships should not be
exaggerated. By contrast, in the Indian democracy of the early
1970s Ghandiadministrationledattemptstocurbpopulation
growthbymeasuressuchasencouragingmen(and
oftenforcingpoorermales)tohavevasectomieswere
notsuccessful.Thisstrategywasrejectedbythe
IndiandemocracyseeBox2.Reactionsagainstit,
somecommentatorsbelieve,setbackattemptsto
extendfamilyplanninginIndiabyseveraldecades. Figures 6a and 6b
describe relevant trends, and from a demographic perspective cast
light on the core reasons whyChinaseconomicperformancehasinrecent
decades outstripped that of
India.Insummary,Indiacanbesaidtobeintheprocessof 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 refects the strengths of Indias
traditions and the fact that its domestic population has not been
directlyvictimtoamajorwarinlivingmemory.Yetthe
slownessofIndiasdemographicandepidemiological
adaptationmeansthatatthebeginningofthe21st
centurythenationspopulationisstillchallengedbya
highprevalenceofinfectiousdisease,alongsidean
alreadylargeandgrowingnon-communicableillness burden. The next
section of this brief UCL School of Pharmacy report considers the
part that public health interventions 4It was not a coincidence
that the establishment of the UK NHS took place at the end of the
1939-45 confict, close to what can be regarded as the fnal stage of
Western Europes 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.5The frst 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 confict 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 India9Box 2: Family planning in
IndiaThe frst 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,
thelatterwasstill40per1000populationatthetime
ofindependence.In1951thefrstFiveYearPlanfor
thethennewnationhighlightedfamilyplanningand
welfare.Thesetopicshavebeenexplicitlyaddressed
inallsubsequentFiveYearPlans.Yetitwasnotuntil the start of the
1970s that India moved to adopt a
pro-activefamilyplanningprogramme.Atthattimeonly
aboutoneintenmarriedwomenwasusingmodern contraceptive methods
(including female sterilisation). It is claimed that Sanjay Gandhi
infuenced his mother, thethenPrimeMinisterIndiraGandhi,tointroduce
aradicallynewapproachtobirthcontrol(Mukhuti, 2010). As well as
seeking to incentivise men who had
hadtwoormorechildrentoacceptavasectomy,the
approachheandthewiderGhandiadministration
promulgatedsoughttoabolishthedowryandcaste systems and to focus
increased national effort on goals
suchasprotectingthenaturalenvironment.Viewed sympathetically, this
initiative can be seen as an attempt to enhance per capita
prosperity in a self-suffcient 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.Itinfactturnedintolittlemorethanaforced
sterilisationcampaign.Localoffcials,policeoffcers
anddoctorsreportedlybehavedinauthoritarianways in order to meet
vasectomy and allied quotas, in some
casessterilisingbothyoungmenandwomenagainst their will. It was in
particular feared that unmarried males
oflowsocioeconomicstatusorwithanti-Congress
politicalviewswerebeingtargetedandinvoluntarily sterilised. Such
concerns have been widely blamed for
settingbacktheuptakeoffamilyplanninginIndiafor 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 economicandsomeotherrespectsout-performed India since the
mid 1970s see main text.Currently,aboutahalfofallmarriedwomenare
usingcontraception,includingsterilisation.However,
thereremainlargeregionalvariations.Uptakerates
in,forinstanceBihar,SikkimandAssamhavebeen
lowerthaninStatessuchasthePunjab,Karnataka, Gujarat, Andhra Pradesh
and Maharashtra. The latter,
forinstance,introducedin2010aschemewhereby couples are paid a
little over US $100 if they wait two years after marriage to have
their frst child. The current
fertilityrateinIndiaisabout2.5childrenperwoman,
comparedwith3.4inPakistanand1.6(belowthe 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
percentperannum,whichisadding18millionextra people a year to the
Indian population. Figures 6a and 6b: Demographic changes in India
and China, 1950-2050anduniversallyaccessiblehealthcarecouldplayin
further reducing factors like infant mortality and maternal
deaths,andextendinghealthylifeexpectancyinIndia. Before this,
however, the remainder of this section offers an overview of the
disease specifc issues and trends of particular relevance to
achieving better health in India. 19501975200020252050
19501975200020252050Ratio of working-age to non-working
populationChildren per woman76543213.02.52.01.51.0ChinaIndia
ChinaIndiaP R OJ E C T E D P R OJ E C T E DSource: Bloom,
201110Health and Health Care in IndiaParasitic, bacterial and viral
disordersPoorstandardsofreproductiveandchildhealthare associated
with inadequate maternal and infant nutrition
inalllessadvantagedcommunities.Relevanthealth 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 inIndiasufferingfromstuntedgrowth.Femaleinfants
appear to be at greater risk of malnutrition than males.
Likewise,unlikethecaseinanyotherworldregion, women in India are at
greater risk of death from causes such as burns than men.
Alongwithassociatedindicatorssuchastherelatively
highreportedprevalenceofacidattacksbymenon women and data revealing
the selective medical abortion of female foetuses, this suggests a
community that has notasyetuniversallyundergonethesocialtransitions
needed to sustain post transitional health development.
Highlevelsofinfectionmayinadditionberelatedto problems such as the
fact that microbial pathogens tend
nottoberecognisedastherootcauseofinfectionsin traditionally based
forms of medicine7. This may help to explain why, for instance,
open-feld defecation continues
tobewidespreadinpoorruralcommunities.Coupled with the inadequate
sewage removal problems that have been compounded by rapid
urbanisation, this can lead
tothecontaminationofwatersuppliesanddomestic environments alike
(John et al., 2011). Figures 7a and 7b illustrate the fact that
diarrhoeal illness remainsamajorcauseofchildmorbidityandmortality
inIndia,alongsiderespiratorytractinfections.Around
aquarterofallchilddeathsareduetopneumonia. Infectious conditions
ranging from tuberculosis and HIV
infectionthroughtoparasiticcomplaintslikelymphatic
flariasisandvisceralleishmaniasisarealsorelatively
prevalent,whileDenguefeverisanimportantexample
ofapotentiallylifethreateningviralinfectionwhich,like malaria, is
spread via mosquitoes.In aggregate, infections still cause some 40
per cent of deathsinIndia,ascomparedwithabout60percent
in1990.(GlobalBurdenofDiseaseStudy,2012).In
thecaseofTB,forinstance,2millionnewcaseswere
recordedin2009,alongwithcloseto300,000deaths
(Johnetal,2011).Despitetheestablishmentofa
NationalTuberculosisControlProgammeinthe1960s, 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,
asmayalsobetruewithmalariainIndia,iswidely under-recorded.Published
fgures, based on laboratory confrmed infections identifed in public
hospitals, fall far short of the 30 million cases that probably
occur annually (Harris,2012).Someauthoritiesarguethattracking
hospitalconfrmeddatagivesaconsistentbasisfor
diseasemonitoring.YettherealityremainsthatIndiais suffering a large
Dengue fever epidemic which is being poorly recorded.
Alackofthelocal(State)levelpublichealthresources
neededtogeneratediseasesurveillanceinformation
requiredtoinformspecifceffortstocontrolinfections and when possible
eliminate their sources has impaired
thenationscapacitytorespondtosuchchallenges
effcientlyandeffectively.Indianobservershavenoted that the fact
that the British inspired 1897 Public Health
Actremainedun-amendedforoveracenturyimplies
thatthisareahasnotreceivedalevelofattention 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., 20116India 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
0.47.7Such 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.Health and Health
Care in India11commensurate with public interests in health
protection andimprovement.Onesuggestedreasonforthishas
beenaninappropriatedivisionofFederalandState 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
levelscarryresponsibilityforservicedelivery(Reddyet al,
2011).Havingsaidthis,malariacontrolnationalprevention
andtreatmentpoliciesappeartohavebeenrelatively
successful.However,eveninthisfeldmortalityunder-recordingisacontroversialtopic.Theratioofthe
actualnumberofdeathsoccurringtothoseoffcially acknowledged may, as
with Dengue fever, be over 100:1.
ThetotalnumberofrecognisedmalariacasesinIndia was 1.6 million in
2009, with a steadily rising proportion being due to Plasmodium
falciparum. Treatment failures
duetodrugresistancealsoappeartobeincreasing. This underlines the
need for good access to high quality anti-malarial medicines, and
suffcient strategic and feld
professionalsupporttofacilitatetheirappropriateuse and preserve
their effectiveness.HIV/AIDSratesprovideafurtherexampleofinfectious
disease related controversy and partial success in India. It is
presently estimated that there are about 2.5 million
peoplewiththisinfection.Itsprevalenceishighestin
southernpeninsulaStateslikeAndhraPradeshand
Karnatakaandalsointheextremenortheast,where viral transmission has
been associated with drug use see Figure 8. Yet overall the
nationally reported incidence
ofHIVisfalling.Theavailabledataindicatethatthere
arenowover300,000individualsinreceiptofpublicly funded frst line
anti-retroviral treatment.TheestablishmentoftheNationalAidsControl
Programme in 1987 and the subsequent launch with fnancial support
from agencies such as the World Bank
oftheNationalAidsControlOrganisation(NACO)
has,togetherwithprogrammesinareassuchasthe
preventionofmother-to-child-transmissionandsex worker and other at
risk group education, been credited
withthecountryssuccessinthisarea.By2009over 13 million Indian
citizens had, for instance, been tested
forHIVinfectioninintegratedcounsellingandtesting centres (ICTCs)
dedicated to this purpose. However,theWHOhasclaimedthatonlyabouta
quarter of the Indian citizens infected with HIV/AIDS who could
beneft from antiretroviral medicines are receiving
them.AboutahalfofthoselivingwithHIVaresaidto
beunawareoftheirdiagnosis.Accesstosecondand third line treatment
also appears very limited. In the order
of150,000peopleayeardiefromHIVlinkedcauses (Sinha,
2012).AcombinationofastrongemphasisinStatessuchas
TamilNaduonpreventingviraltransmissionamongst sex workers and other
groups at high risk, coupled with
thelimitedbutimportantnationallysupportedaccess
tolifesavinganti-retroviraldrugsavailable,helpsto explain falling
prevalence rates. Given the Indian based
pharmaceuticalindustryscapacitytosupplylowcost anti-HIV medicines
in areas such as sub-Saharan Africa
itisperhapsdisappointingthatbetterdomesticsupply
hasnotasyetbeenachieved,albeitthatasinother care contexts providing
low cost drugs alone does not in itself ensure that effective care
is affordable.FurtherimprovementsinIndiasHIV/AIDSprevention
andtreatmentrecordisagainlikelytodependon strengthening local
capacity to understand and respond
torelevantaspectsofthediseasesepidemiology
andtransmission,whilealsosuccessfullyintegrating
thisaspectofhealthprotectionandcareintoamore
unifedoverallsystem.Aswithmanyotherconditions,
theestablishmentofnationallyledtop-down,vertically
oriented,specialistInstitutesandprogrammeshas brought benefts. But
achieving greater health gain in the
futuremaywelldemandhorizontalintegrationandan enhanced emphasis on
the robust provision of generalist primary and community services,
backed by specialists only when genuinely needed.
Afnalpointtomakeintheinfectiousdiseasecontext
isthatalthoughinthepastIndiasdeliveryofvaccines
tochildreninruralandpoorurbancommunitieshas
beenvariable,performanceisalsoimprovinginthis
area.Thereisgoodreasontohope,forinstance,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 ofsouthIndiaover60percentofinfantsagedunder
twoyearsnowreceivefullimmunisationcourses,as defned by national
protocols. However, in the so-called
BIMARU(whichtranslatesfromHindiassick)States of Bihar, Madhya
Pradesh, Rajasthan and Uttar Pradesh
theequivalentproportionwasstillunder50percent
in2007/08.Thelowestunder-twoimmunisationrate Figure 8: Estimated
adult HIV/AIDS prevalence in the States of India, 2007Source: John
et al., 2011Andhra PradeshArunachal
PradeshAssamBiharChhattisgarhGoaGujaratHaryanaHimachal PradeshJammu
and KashmirJharkhandKarnatakaKeralaMadhya
PradeshMaharashtraManipurMeghalayaMizoramNagalandOrissaPunjabRajasthanSikkimTamil
NaduTripuraUttar PradeshUttarakhandWest BengalAndaman and Nicobar
IslandsChandigarhDadra andNagar HaveliDaman and
DiuLakshadweepDelhiPondicherryHIV/AIDS prevalence1.00%12Health and
Health Care in Indiashouldbenotedtherearesignifcantdiffcultiesin
accuratelyascribingcauseandeffect.Vestedinterests may also infuence
the appreciation of the extent of the relative harm due to
commercially supplied goods such
astobaccoproducts.Prolongedsmokingkills50per
centofallsmokers,andcontributestodisablingthe great majority of the
remainder.Posttransitionalcommunitieshaveproportionately
moreolderpeoplethanthoseatearlierstagesinthe
developmentcycle,andsonormallyhavetocarry
increasedabsolutechronicdiseaseburdens.Yetthe 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.Overandabovecareaccessvariables,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.
Thismayleadontonon-communicablecomplaintsin later life, as too may
problems such as foetal and child
malnutrition.Thethriftyphenotypehypothesis(Hales
andBarker,1992;Barker,1997)couldhelptoexplain
whyIndiaalreadysuffersanunusuallyhighlossof
potentiallyproductiveyearsoflifeduetodeathsfrom cardiovascular
disease in people aged 35-64 years.By 2030 the volume of premature
disability and loss of
lifesufferedbyIndiansofworkingageisprojectedto 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
aboutthree-quartersofalldeathsinIndia(Pateletal.,
2011).Estimatesfromdifferentsourcesvary,butapproaching
60millionIndiansarealreadybelievedtohavetype2
diabetes(Shetty,2012).Thisfgureisalsoprojectedto 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,orperhapsbecauseofimmutableinheritable
variances.InpopulationsofEuropeanethnicitytype2 diabetes is
relatively unusual below the age of 50. But in Figure 9: Estimated
percentages of deaths in India attributable to the major chronic
disease risk factorsSource: Patel et al., 2011recorded at that time
was 30 per cent in Uttar Pradesh, Indias most populace State (Paul
et al, 2011).Giventhenationsprovencapacitytodevelopand manufacture
vaccines, there is good reason to hope that in future well managed
immunisation programmes using
anexpandedrangeofproductswillfacilitatefurther
healthgainsinareassuchasreducingthetollofchild
deathscausedbyrespiratorytractinfections.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,viralandparasiticconditions.Alongside
progressinareassuchasimprovingtheheatstability
ofvaccinesand,whenandwhereneeded,morerapid
andaccuratediagnostictestingandbettercurative
treatment,Indianchildrenandadultshaveasmuch
ormoretogainfromcontinuinginvestmentinbetter
pharmaceuticalproductsforinfectiousindicationsas 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
thanforfemales.Butnowthatbothwomenandmen are enjoying longer lives,
the burdens imposed by
non-communicablediseasesuchasheartdisease,stroke and the physical
and sensory problems associated with
type2diabetesarebecomingmoreapparent.Sotoo are the impacts of
respiratory conditions such as COPD
andmentalhealthdisorders.Box3describesissues
relatingtotheverylimitedprovisionofpsychiatricand other forms of
mental health care in India.
Atonestageitwasbelievedthatatanygivenagethe
harmcausedbyconditionslikeCHD/ischaemicheart
diseaseandotherconsequencesofraisedblood
pressureandhighlowdensitylipoprotein(LDL)lipid levels rises as
countries grow more affuent, and people
canaffordmorefattyfoodsandsedentarylifestyles
aswellastheuseof(more)tobacco,alcoholand/or
otherharmfulleisuredrugs.Butthefullpictureismore
complex,notleastbecauseintodaysglobalsociety
agespecifcdeathratesfromvasculardiseasesofall types are (as with
COPD) typically greater in low income
countriesthantheyareinmoreaffuentnations(WHO,
2012).Thisispartlyduetothefactthatpoorerpopulations are often
exposed to multiple risk factors like untreated
hypertensionandindoorcookingsmoke.Figure9
providesanoutlineoftherelativelevelsofmortality
associatedwithsuchvariablesinIndia,althoughit 8For example,
Sabchareon et al (2012) recently reported a Thai trial of a Dengue
vaccine produced by the French company Sanof 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.Health and Health Care in India13India it often
occurs one or two decades earlier (Mohan
etal,2007).SomesouthernIndiancitiesarealready 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.AsdiscussedinBox4,attachingvalideconomiccosts
tolossesoflifeand/ordisabilityadjustedlifeyearsis
problematic.Nevertheless,inwelfaretermstheharm
causedbynon-communicablediseasescanalready
reasonablybesaidtorepresentintheorderof12.5per cent of Indian GDP
foregone. In currency equivalent terms 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
ofIndiaspeopleand,potentiallyatleast,theabilityof
thenationseconomytocompetewithothersunless
promptandeffectiveactionistakentopreventand/or
treatconditionssuchassuchaCHD,COPDandtype
2diabetes.TherecentestablishmentoftheNational
ProgrammeofPreventionandControlofCancer,
DiabetesandCardiovascularDiseaseandStroke Box 3: Mental health care
in IndiaAs with other NCDs, mental illnesses tend to be better
recognised as societies develop and infectious disease
burdensfall,sorevealingotherformsofdistress.
Communitiestypicallybecomemoreableandwilling
tofundservicesfortheirmostvulnerablemembers
astheyprogressonfromsubsistenceagricultureas
theirmainmeansofproduction.Withdevelopment, people become less
likely to ascribe religious or other
supernaturalcausestopsychiatricandpsychological
phenomena.Stigmaagainstindividualslivingwith
mentalillnessdrivenbycombinationsofignorance,
superstition,prejudiceandexcludingbehaviours
alsotendstodeclineaspopulationsbecomebetter 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
signifcantvariancesintheestimatedincidenceand
prevalenceratesformentalhealthproblemsinIndia.
Butanumberofstudiessuggestthatroughlysixper
centofthecurrentIndianpopulationhavesignifcant
mentalillnesses.Thisimpliesthatintheorderof70
millionpeoplecoulddirectlybeneftfromappropriate
treatmentandsupport(Chatterjee,2012).Theglobal
epidemiologicalevidencesuggeststhatabouttwice
thatnumberarelikelytobeexperiencinglessserious emotional and allied
problems like anxiety states at any
onetime,aburdenwhichcouldalsoberelievedby more effective
services.Oneindicatorofthescaleofpotentialdemand
formentalhealthcareisthefactthatthereare
approaching140,000recordedsuicideseachyearin
India.Notwithstandingdifferencesinpopulationage structures, such
data imply a rate at least equivalent to
orabovethoserecordedinposttransitionalsocieties like, for example,
the UK and France. Some challenges,
suchasincreasesintheriskofsuicideamongst
poorIndianfarmers,mayonoccasionshavebeen
exaggerated.Butininternationaltermsthereisclear
evidencethatyoungerwomenareatparticularlyhigh risk of suicide and
other forms of violent death in
India.Despitethefactthatthecountrywasin1982oneof the frst in the
developing world to initiate a high level National Mental Health
Programme (NMHP - Sinha and Kaur, 2011), access to effective
publicly funded mental healthcareremainsverylimited.In1996aDistrict
Mental Health Programme (DMHP) was launched under the umbrella of
the NMHP. It was intended to focus on
areaslikeearlydetectionandtreatment,rapidtraining for primary care
doctors on the diagnosis and treatment
ofcommonmentalillnesses,raisingpublicawareness
ofmentalhealthissuesandmonitoringtrendsinthe occurrence of mental
health problems. By the end of the ninth Five Year Plan the
programme was established in 27 of Indias 600 plus districts. Yet
its overall impact has been judged disappointing (Patel et al.,
2011). In2009arevisedNMHPwasapproved,partlyinthe face of a
recognised national shortage of psychiatrists.
Withonlyonesuchmedicallyqualifedindividual
forevery500,000peopleandonepubliclyfunded psychiatric hospital bed
for every 50,000 persons, India
hasamongstthelowestlevelsofmedicalpsychiatric
careprovisionintheworld.Accesstopsychiatric nursing, clinical
psychology and specialised psychiatric pharmaceutical care appears
to be even more limited. The2009NMHPaimedtoincreasepsychiatric
manpower, upgrade mental health hospitals and de-stigmatise mental
illness via interventions such as public
advertisingcampaigns.Primaryhealthcaredoctors working in villages
were also to receive additional mental health training (Sinha,
2009; Sinha and Kaur, 2011). Suchattemptstoimproveprovisionaretobe
welcomed,particularlywhentheycanbebackedby
adequatefnancialinvestment.Butthereareclearly
majorchallengesstilltobeovercomeinthisareaof 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
healthinIndia(UCLCulturalConsultationService,
2012).Assuggestedabove,forexample,thediffcult
situationformanywomeninIndiacanexacerbate
mentalhealthproblems(Basu,2012).Membersof
marginalisedpopulationssuchasDalits(oncetermed
untouchables)mayalsosufferparticularformsof
mentaldistressthatmightberelievedbyappropriate
formsofcareandsupport,alongsidewidersocial interventions.14Health
and Health Care in
India(NPCDCS)indicatesnationallevelrecognitionofthe
importanceofthistask.Keywaysforwardrangefrom curbing tobacco use
and promoting increased physical
activitythroughtoextendingtheuseofmedicinesthat
canlowerriskfactorssuchashighbloodpressure, hyper-glycaemia and/or
hyper-cholesterolaemia.Cancer in modern
IndiaReportedcancerincidenceandmortalitylevelsvary
signifcantlywithinthecountry.Forinstance,relatively recent reports
show the age adjusted male cancer death rate in Delhi is
121/100,000, compared with 44/100,000
inruralMaharashtra.Theprobablereasonsforsuch
observationsincludedifferingpatternsofalcoholand
tobaccouse,togetherperhapswithvaryingratesof access to diagnostic
testing. Smoking and other forms of tobacco use is associated with
about a half of all male and approaching a ffth of female cancers
in India, which isgloballythethirdlargestproducerandconsumerof
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).
Dietaryandenvironmentalfactorssuchaslowfruit
andvegetableconsumptionamongstsomegroups
andexposuretopollutantsalsoimpactoncancer
incidence.Indiahasunusuallyhighratesoforaland
cervicalcancer,theoccurrenceofwhichisinpart
relatedtoHPVinfections(whichcouldifaffordedbe
preventedbyimmunisation)andasubsequentlackof screening services.
Nevertheless, because cancer is an
acquiredgeneticdiseaseassociatedwithbreakdowns
intheintegrityofcelldivisionregulation,individualand
populationageingisthesinglemostimportantdriver
ofitsoccurrence.Thishelpstoexplaintheacrossthe board rise in
projected cancer case numbers shown in Figure
10.ForacountrywithayoungpopulationIndiawas
unusuallyadvancedwhentheNationalCancerControl Programme (NCCP) was
established in 1975, shortly after Box 4. The costs of acute and
chronic illness in
IndiaAttachingmeaningfuleconomiccoststolossesoflife
and/ortheimpactsofavoidabledisabilityinIndiais inherently diffcult,
as it is in all other environments. This is not least because it is
debateable from a theoretical
perspectiveastowhetherornotthelivesofpeople
livinginpoorcommunitiesshouldbevaluedanyless than those of people
in richer ones. Important questions
alsoexistastowhetherornotfuturehealthgains should be discounted in
the same way as other forms of investment beneft, and about the
extent to which in countriesthathavelargelaboursurplusespremature
lossesoflifeand/orfunctionalcapacityhavenegative impacts for people
other than those directly involved.
However,itcanbroadlybeestimatedthatnon-communicableconditions(includingmentalhealth
problems)andinfectiousandalliedformsofharm
(includinginjuries)presentlyeachcostIndiansociety about 150 million
Disability Adjusted Life Years (DALYs)
perannum.This300millionlostDALYmilliontotal
impliesagrosswelfarelossequivalenttosome25 per cent of the countrys
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/externalcauses(Pateletal,2011).Assuminga
presentgrossnationalproductofalittleunderUS$2 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 $250billionayearatexchangeratevalues.When
expressedinpurchasingpowerparity(PPP)adjusted terms this fgure
rises to some $500 billion. Overthenext20yearsthelossesduetochronic
non-communicablediseasearepresentlyprojected
toremainconstantintermsoflostDALYs,whilethe infectious disease
burden should halve. However, such estimates (which are set against
an anticipated further riseinIndiaspopulationofsome250millionpeople
between2010and2030)aresubjecttoanumber
ofcaveats.Ifeitherorbothinfectiousandchronic
illnessesmortalityandmorbidityratesweretofallat
anacceleratedrate,considerableadditionalwelfare
gainswouldbegenerated.Toillustratethis,ifhealthy life expectancy in
India could be enhanced by 10 years
(thatis,tothelevelChinaiscurrentlyreportingsee
Figure2,page4)byreducingthecurrentlygrowing
burdenofdisabilityassociatedwithvasculardisease
andtype2diabetes,thenaconservativeviewisthat this would lead to
annual welfare gains similar to Indias
totalinvestmentinhealthcare.Thatis,some4-5per cent of GDP. Figure
10: Projected cancer incidence rates in India to 2020Note: 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., 2010Health and Health Care in
India15thethenUSPresidentRichardNixonsdeclarationofa war against
cancer. There was an understanding at that
timethatcancersaffectpoorpeopleinlargenumbers, primarily because
the less affuent 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 inspecialisthospitalcareandtheenhancedsupplyof
medicines(otherthananalgesicslikemorphine,which are currently
inadequately available to many less affuent Indians) for later
stage cancer treatment. Recentdevelopmentssuchastheactualorproposed
grantingbytheIndianCourtsofCompulsoryLicences for some oncology
products should be understood from
thisperspective.However,theNCCPhashighlighted the importance of
primary prevention, and Indian policy
makersarenowtakingactivestepstodiscourage 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
andtreatmentservicesremainsverylimitedinmuch
ofthecountry.Raisingtherateofearlystagecancer identifcation is a
vital frst 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
IndiaIn2012theagencyIMS,withresearchbased
pharmaceuticalindustryfunding,conductednearly 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
thatover90percentofrespondentssaidtheyfeltable to get medical help
when they are ill, albeit that this was less often the case in
rural areas than in urban localities.
Thisresearchalsoconfrmedthatthecostofmedicines 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 Ministers
initiativeThe Indian Prime Minister Manmohan Singh announced on the
countrys 66th Independence Day in August 2012
thathisGovernmentsNationalCommonMinimum
Programmewouldbeextended,startinglaterinthat 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 ffth in 2013) that
includes a comprehensive range of essential generic medicines
supplied via the countrys 160,000 sub-centres, 23,000 primary
health centres, 5000 community health centres
and600-plusdistricthospitals.Itwasproposedthat
theFederalGovernmentwoulddirectlyfund75per
centoftherelativelylimitedcostofextendingpublic health service
generic medicines supply.This important, although now postponed or
abandoned, policy initiative also envisaged that doctors working in
the publicserviceshouldceaseprescribingbrandeddrugs and that the
National List of Essential Medicines (NLEM),
whichpresentlyincludessome350treatmentsranging
fromanti-HIVmedicinestoanalgesics,wastobeused by States as a guide
to what should be supplied free of
chargetoallthoseentitledtopubliclyfundedtreatment (Munshi, 2012).
It is of note that a number of States, such
as,forexample,Chhattisgarh,arealreadyseekingto introduce extended
free medicines supply
arrangements.AproposaltosetupaCentralProcurementAgency
forthebulkorderingofdrugswasalsoapprovedby
theUPAGovernmentCabinet,albeitthatthistoo
maynowhavebeenabandoned.Statesshouldstill,
however,berequiredtoprocuremedicinaldrugs
directlyfromtheirmanufacturersorimportersthrough
anopentendersystem,andshouldprovidestate-of-the-artwarehousesfordrugstorageanddistribution
(Dutta, 2012). Such actions help to address criticisms made by
agencies such as the WHO to the effect that,
althoughIndiahasrapidlydevelopedpharmaceutical
manufacturingcapabilitiesandachievedarelatively strong exporting
record, its health policy makers have
nottodatebeenaseffectiveastheirindustrialpolicy
equivalentsinensuringthatfreeorlowcost,good
quality,medicinesareconsistentlyavailabletothe poorer half to two
thirds of the domestic population. The countrys future success in
this area will in large part depend on reducing levels of corrupt
and allied perverse behavioursamongstprescribersandpubliclyfunded
medicinessuppliersandpurchasers.Onepossible way forward in this
context could be the development
ofenhancedmechanismsforconsumerreportingof public health service
failures to supply free medicines,
throughforexampletheanonymoususeofSMS
(shortmessageservice)textingtoindependentlyrun national health
service quality surveillance centres (see main text
conclusions).Todate,localIndianpharmaceuticalmanufacturers
havehadlittleornoneedforintellectualproperty
protectionotherthantheuseoftradenames.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 signifcantly extended progressive Indian
companies maybecomemoremotivatedtoinvestindeveloping new, more
effective, products. It is by no means certain this will prove
possible. But if it can be achieved they will
consequentlybecomemoredependentonprovisions other than brand name
protection, including patents or alternatives such as periods of
regulatory exclusivity, for the successful continuation of their
businesses.16Health and Health Care in
IndiaInthecaseofoutpatient(ieprimaryandcommunity
care)services,privatefacilitiesaretodaytypicallymore accessible in
the sense that most people fnd it easier to travel to them than
publicly provided services. This
wasnotfoundtobesowithhospitalcare.Peoplein
ruralandpoorerurbanareasare,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.Yetitisofnotethatotherobservershavereported
recurrentdrugshortagesinpublicservicesettings.
Thereisevidencethatpatientsforreasonsoften
relatedtoprovidersidecorruption,andinappropriate 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).Improvingperceptionsoftheadequacy,integrityand responsiveness
of public services is therefore an important
goal,iftheyareinfuturetoplayamoreextensiverole. Presently, the
Indian health care system is, in urban areas
especially,largelyprivateproviderdominated.Taking
thefndingsofthisresearchintheround,theyhelpto
explainwhytheprovisionofhealthcarehasnotbeena high profle political
issue in India. In essence, the majority
ofintervieweessaidthattheyfeelsubjectivelythatthey
havesatisfactoryaccesstoservices.Theymayalso value looking to their
families rather than publicly funded agencies for help when in
particular need.Becausemedicinecostsareaclearpublicconcernthe
abovefndingsmayalsobetakentoconfrmthatitis
understandablethatpoliticalandmediaattentionhas 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
informedobserveroftheIndiansituationwouldargue that the recent (but
now postponed or abandoned) Indian
FederalGovernmentannouncementofaUS$5billion nationwide programme
aimed at improving the provision of good quality, free to the
consumer, generic medicines
viathepublichealthsysteminthefveyearsto2017
wasanythinglessthantimelyandappropriate(Box5).
Freepubliclyfundedmedicinessupplyhasfundamental advantages for poor
and vulnerable service
users.Potentiallydistortingfactorssuchasthefactthat 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 bestressedthattheIMSresearchreferredtoabove
didnotinvestigatetheextenttowhichrespondents were receiving good
quality care as defned in terms of evidence based medical, nursing
and/or pharmaceutical best practice. In a country where a
signifcant proportion of practitioners
donothavethequalifcationstheymayormaynot
claim,andinwhichtheimportanceofpreventingand
managingchronicillnessesasopposedtotreating
acuteconditionsisasyetinadequatelyappreciated,
evidenceofsubjectivepublicsatisfactiondoesnot confrm 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
typicallyhigherthanitisincountriessuchastheUS, despite a plethora
of epidemiological evidence showing that the inverse is true (Sen,
2002).Figure11,takenfromtheIMSanalysis,highlightsthe
factthatIndianStatesdiffersignifcantlywithregardto the longevity of
their populations and their health policy Figure 11: A
categorisation of States based on selected healthcare and economic
indicatorsSource: IMS, 2012Health and Health Care in India17related
competencies. Its categorisation of, for instance, Uttar Pradesh as
a middling rather than a lagging State
mayonthebasisofrecordedlifeexpectanciesand 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.
ThecentralbandofBIMARUStatesfacesspecial
challengeslinkedtofactorssuchasilliteracyandhigh population
density, as compared to the relative success
ofexamplessuchasPunjabandHimachalPradesh9
tothenorthandtheDravidiantraditionStatesofTamil Nadu and Kerala to
the south. In Kerala there is a long
standingandinternationallycelebratedcombinationof
femaleeducation,nearuniversalliteracyandlowinfant mortality. Kerala
also enjoys relatively high spending on health and low levels of
corruption as compared to the rest of the country.Early
originsIndia has, in the shape of the knowledge and practices like
those embodied in Ayurvedic medicine, health care
traditionsdatingbackasfarasthosefoundanywhere else in the world.
For instance, over 2,300 years ago in
AshokasMauryanEmpire10(Ashokalivedshortlyafter Hippocrates was
alive in Greece, and ruled over almost
thewholeIndiansub-continent)therewasarelatively sophisticated
health system. It included public hospitals and the allocation of
physicians to serve rural areas.
Somecommentatorsarguethatconceptslikethatof humoral balance, which
existed in the Galenical beliefs of medieval Europe and in related
forms survive in Indian
traditionalmedicineinitsvariousmanifestationstoday, 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 lifestylemoderation, 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
medicineadaptedtoaccommodatetheuseofopiates and other drugs
associated with the introduction of Islamic medicinal expertise
into India. They were able, as was so
inthecaseofEuropeanmedicalpracticeataboutthe
sametime,toaccommodatenewknowledgeandskills 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 populations care. Some new facilities
andserviceswereestablishedandimportantindividual
contributionsweremade,notleastinareassuchas
understandingtheepidemiologyandcausationof infectious diseases, by
European physicians. Yet it is fair
tosaythattheBritishwereprincipallyconcernedwith 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,includingconceptsofantisepsisandeffective
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
anywhereotherthantheUKhighly,anddoingvirtually
nothingtosupportIndianbasedmanufacturing(Thum Bonanno et al,
2012).IntheperiodbetweentheendofthefrstWorldWar
(inwhichPunjabiandotherIndianArmydivisionswere extensively
involved) and Indias independence after the
1939-46confict,progressindevelopinghealthcare
facilitiesforthemassofthepopulationremainedslow.
Followingverylimitedconstitutionalchangesin1919
whichsomeIndianandBritishreformershadoriginally
hopedwouldopenapainlesspathtoindependence
andthesubsequentand(inWinstonChurchills
contemporarywords)deeplyshamefulmassacre
perpetratedbyBritishoffcerledGurkharifemenon
PunjabiciviliansinAmritsar,healthimprovementwas
furtherimpededbythedelegationofkeypublichealth related duties to
what were then termed the Provinces.
Thefailingsofthislastmeasurewererelatedtoalack
oftheeffortandinvestmentneededtoensurethe competent execution of
delegated responsibilities in local
settings.AscommentatorssuchasProfessorSrinath
ReddyofthePublicHealthFoundationforIndiahave observed, kindred
problems have lived on into modern
India.Nevertheless,intherunuptoindependencethe
thenIndianGovernmentin194312recognisedaneed
toimprovethepublichealthsystem.AHealthSurvey
andDevelopmentCommittee(HSDC)wasformedand charged with making
recommendations for future health service reform and improvement.
TheBhorereport(asitbecameknownaftertheHSDCs civil servant chairman)
noted in 1946 that if it were possible
toevaluatethelosswhichthiscountryannuallysuffers
throughtheavoidablewasteofvaluablehumanmaterial 9Himachal 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 traffcking of young women from other poorer parts of India.
Such observations underline the complexity of the current Indian
situation.10Ashoka 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 signifcant 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. 11Ayurveda,
Yoga and Naturopathy, Unani, Siddha and Homoeopathy12Immediately
after the publication of the Beveridge Report in the UK. This
heralded the establishment of the British welfare state.18Health
and Health Care in Indiaand the lowering of human efciency through
malnutrition and preventable morbidity, we feel that the result
would be so startling that the whole country would be aroused and
wouldnotrestuntilaradicalchangehadbeenbrought
about(HealthSurveyandDevelopmentCommittee, 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).Thereportalsostated,inlinewiththesubsequently
establishedIndianRepublicsConstitution,thataccess to primary care
is a basic right to be respected regardless of an individuals
socioeconomic standing. It saw primary
careasthefoundationofanimprovednationalhealth
caresystemandproposedathreetieredsystemof
primaryhealthcentresandlocalsub-centres,served
bycommunitycentresanddistricthospitalstowhich
patientscouldbereferred.ThestructureoftheIndian public health
service of today (see Figure 12) still partly refects that early
vision.The Bhore Committee in addition introduced the concept
offveyearplanningtothehealtharena.Thelatter chimed well with the
overall approach to economic and
socialdevelopmentplanninginstitutedbyJawaharlal Nehru soon after
the establishment of India as a newly independent State (Box 6).
Improvingthepublicshealthwasfromtheinceptionof modern India
accepted as an important end. Yet despite the good will of the
Government of the newly independent India
andthefactthatthenationsleaderswantedtoaddress health inequalities,
the 1959 Mudaliar Committee was able to report only very limited
success. Established to evaluate the health progress made during
Indias frst two Five Year
Plans,itfoundthatwhileepidemicdiseasemanagement was working
relatively well too little importance was being
assignedtoassuringexcellenceatthePrimaryHealth 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
startofthe1980stheadoptionofthecountrysfrstfree
standingNationalHealthPolicy.Butprogressremained
patchy,andproblemsofunevendevelopmentwere arguably compounded by
the increasing reliance on private
investmentengenderedbytheinmanyrespectshighly benefcial
liberalisation of the Indian economy in the 1990s. Private
resources have tended to fow more towards States with higher levels
of social and material infrastructure, like for example
Maharashtra, Gujarat, Tamil Nadu, Karnataka
andAndraPradesh.PoorerStateshavefaredlesswellin Box 6: Planning in
IndiaWhen India gained independence on August 15th 1947 its leaders
sought to establish governance mechanisms
capableofpromotingrobusteconomicgrowthand
defendingthewidersocialinterestsofthecountrys citizens. The then
Prime Minister, Jawaharlal Nehru, had witnessed the rapid
industrialisation of the Soviet Union
inthepre-warera.JosephStalinadoptedasystem
basedonFiveYearPlansintheUSSRin1928.Nehru believed notwithstanding
the disadvantages of Stalins autocratic and murderous rule that
this had contributed signifcantlytoSovietadvancement(Maheshwariet
al.,2008).Buildingonmeasuresfrstintroducedin India during the 1930s
and early 1940s, Nehru and his
colleaguesdecidedtoincorporateasimilarplanning
functionintoIndiasmuchmoredemocraticpolitical
system.TheIndianleadershipofthelate1940stried
tocreateanalternativetoextremeversionsofboth 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 hadveryrecentlyplayedadecisiveroleindefeating Nazi Germany.
Further, its economy (as symbolised by
thelaunchofSputnik1)wastogrowfasterthanthat
oftheUSthroughoutthe1950s.Itwasnotuntilthe 1960s that Soviet
progress began to falter, and the life
expectancyofRussianworkingagemeninparticular began to gradually to
decline. In1950thePlanningCommissionwasformedasan expert advisory
organisation. It was (and is) positioned in parallel with the
directly elected organs of State, with
Nehru(byrightasPrimeMinister)asitschairman.Its
rolewasthen,asitistoday,toassessthephysical, capital and human
resources available within India, and to prepare plans for their
optimally effective utilisation.
ThePlanningCommissionseekstoadvisecentral
governmentandtheStateadministrationsonpriority issues as they
arise, to evaluate policy successes and failures, and to identify
barriers to continuing economic and social development. The frst
Five Year Plan (1951-1956) was primarily focused on raising the
standard of living of the nations at that time
300millionpeoplethroughstrengtheningagricultural
output.SincethenthestructureoftheCommission
anditslinkswithotherbranchesofgovernmenthas been substantially
reformed. Yet its underlying purpose
remainsdespitetrendssuchasindustrialisationand
thecountrysshifttoalessregulated,freermarket
oriented,economicapproachessentiallysimilarto that envisaged in the
1950s. The demise of the original
Sovietmodelwasrelatedtothefactthatalthoughin the health context it
had contained infectious disease it
provedunabletorespondtosubsequentchronic/non-communicable 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 thelongtermdynamicsof(healthy)populationageing.
Effectively responding to this transition will be as or more
criticaltothesuccessoftwentyfrstcenturyIndiaas improving
agricultural practices was to the nation at the start of the
1950s.Health and Health Care in
India19termsofattractingbothinwardfnancialinvestmentand
skilledpeople,soperpetuatingthehealthieriswealthier cycle within
the Indian environment (Bloom, 2011).
Injectionsofmoneyfromorganisationssuchasthe World Bank and USAID
may also have meant that Indian
Governmentfundsandattentionwereonoccasions
(paradoxically)divertedawayfromhealthtoother priorities. This
opened the way to a greater reliance on
theprivatesectorforhealthdevelopmentresources
(MaandSood,2008),whileatFederalleveltheIndian
Governmentcontinuedtoconcentratemoreonareas
likedefenceandthedevelopmentofanenhanced transport system. 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
careimprovement,successiveIndianadministrations
couldwellhavemissedimportantopportunitiesto
promotedemographicandepidemiologicaltransition and fundamentally
enhance welfare and productivity. In relation to this key issues
include:1.An over-reliance on vertically organised, single
condition, programmesSuch initiatives can be very attractive to
politicians and policymakersseekinghighlyvisiblesuccesseswithin
aspecifctimeframe.Theyalsotendtobepopular
amongstspecialistmedicalandalliedprofessional
interests,andwithexternalfundingagencies.Inareas
rangingfrommalariaandHIVcontroltorecentactions aimed at eradicating
polio in India and elsewhere, there
isevidencefromacrosstheworldofpositivevertical
programmeachievements.Yetbecauseoftheneed
forindependentstaffngforeachseparatedisease
programmetheyarerelativelyexpensivetosustain (Ministry of Health
and Family Welfare, 2002). Over and
abovethistheyarenormallyill-fttedtosupportingthe 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
usersAsnotedpreviously,totalpublicspendingonhealth
inIndiaisatpresentlylittlemorethat1.2percentof GDP unusually low in
international terms. At the same time private spending frequently
takes the form of direct
personalpaymentsratherthaninsurancecontributions.
Thiscombinationcan,amongstotherthings,serve
tomakeexpenditureonmedicinesseemaparticular
problem,despitethefactthatabsolutepharmaceutical
outlaysinIndiaarelow(Figures13aand13b).Infact, recorded overall
Indian spending on medicines is average
fortheBRICnationswhenexpressedasapercentage
ofGDP(WHO-EMP,2012),despitethefactthat(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 healthservicescanbedefnedbythedemonstrable
effcacy,safetyandepidemiologicalrationaloftheir provisiontoget