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