As the number of COVID-19 infections across India cross the 5 million mark, argued by many as very low estimates based on insufficient testing, the yawning gap between the demands of a billion plus people for good health and the abysmal support and health infrastructure extended by the Government is becoming evident. When India’s economy was liberalized in the early 1990s, a key concern raised was that it would not address the needs of poor and working classes. The pandemic has confirmed that. Health services and infrastructure in India has always been weak, and liberalization weakened it even more, particularly by privatizing health services. As a result, about 75% of India’s population have no means to afford private medical services, as access to public health services is rare both in urban and rural areas. They suffer the lack chronically, and particularly in emergencies as is being caused by the pandemic.
The High Level Expert Group Report on Universal Health Coverage for India (1) instituted by Planning Commission of India reveals that Government (Central government and states combined) as of 2015 invest a very low 1.2% of GDP in health. The Commission argued that budgetary allocation needs to increase 2.5% of GDP by the end of the 12th plan (2017), and to at least 3% by 2022 towards securing the goal of health for all. To guarantee equitable health access it is necessary, the report argues, “for all Indian citizens, resident in any part of the country, regardless of income level, social status, gender, caste or religion, to affordable, accountable, appropriate health services of assured quality (promotive, preventive, curative and rehabilitative) as well as public health services addressing the wider determinants of health delivered to individuals and populations, with the government being the guarantor and enabler, although not necessarily the only provider, of health and related services”. It then goes on to illustrate the principles that have guided formulation of recommendations towards introducing a system of Universal Health Care in India. These are: “(i) universality; (ii) equity; (iii) non-exclusion and non-discrimination; (iv) comprehensive care that is rational and of good quality; (v) financial protection; (vi) protection of patients’ rights that guarantee appropriateness of care, patient choice, portability and continuity of care; (vii) consolidated and strengthened public health provisioning; (viii) accountability and transparency; (ix) community participation; and (x) putting health in people’s hands.”
The manner in which the pandemic is spreading across India is proof that none of these recommendations have been taken seriously by the Central and State governments, barring worthy exceptions such as the State of Kerala. A close scrutiny of how Kerala kept its infections and mortalities low reveals that it is the outcome of work that started in the 1980s. At this time the State introduced deep decentralization of rural and municipal services, which included public health, education, farming extension, etc. It also did this with citizen focus, and by strengthening local governments. When the Constitutional 73rd Amendment (Panchayat Raj) Act, 1992 (for rural areas), and Constitutional 74th Amendment (Nagarpalika) Act, 1992 (for urban areas) was enacted by the Indian Parliament guaranteeing constitutional status to local governments, Kerala integrated several of its progressive provisos into its laws. Alongside, there was encouragement for a peoples’ science movement. All these matured over the decades to provide critical institutional infrastructure that supported heightening public awareness in dealing with regular governance challenges and this experience has served immensely critical in tackling the pandemic. Various progressive governance measures adopted by the Kerala Government, particularly when it has been led by the Left, and these are about reaching health and other essential services, food and other essential supplies, free when there is a public emergency, epidemic or pandemic – so none slept hungry, have borne fruit during the pandemic.
For much of the rest of India, the story has been starkly different. The health indicators in Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh, Bimaru states as they are called (echoing the Hindi word Bimar, meaning sick), are amongst the worst in the world. Fertility rates are higher than the rest of India, and literacy and life expectancy is lower than India’s average. And there are districts within the other Indian states which rank amongst the worst in health when compared with the world, eg. Raichur district in Karnataka state. Besides, in India’s metropolitan areas, poor and working classes who constitute close to half the population have little or no access to primary health care. Studies over decades have revealed that a critical health event in a poor family destroys its economic capacity irreversibly.
Prime Minister Narendra Modi was intensely aware of this situation. Yet in a televised address at 8 pm on 24th March 2020, he threw the entire nation into a lockdown from that very midnight. He knew well that the barely 4 hour notice that he gave would throw the life and livelihoods of millions across India into a terrible chaos. Yet he did it. That when his administration had ignored repeated calls from various public health networks, and also the World Health Organisation, on the critical importance of taking the pandemic seriously and organizing preparedness from January this year – India recorded its first COVID case on 30th January 2020. Modi instead chose to ignore these warnings and focused his and the entire administration’s attention on preparations to receive US President Donald Trump late February. This involved receiving thousands of US officials and international business travelers, along with large numbers of Non Resident Indians from Europe and USA, who brought the virus with them as they travelled into Mumbai, Ahmedabad and Delhi to participate in an event called ‘Namaste Trump’.
The gross neglect did not end there. Modi administration then focused attention on trying to win the Delhi elections. India’ Home Minister Amit Shah, Modi’s right hand, and several other cabinet members, are alleged to have orchestrated a brutal pogrom targeting Muslims, killing over 100 in the Delhi region alone, to polarize communities to win the elections. They lost. But the administration was unrelenting. It had brutally tried to suppress nation-wide opposition to the controversial Citizenship Amendment Act, 2019 that brackets Muslims as second class citizens. It intensified this repression it targeting student groups with horrific violence. Modi’s political party, Bharatiya Janata Party, also worked hard in destabilising the Congress party led Madha Pradesh government, causing its collapse, and ensuring BJP took power. All this when covid-19 spread across India.
This disturbing political situation contributed to Central and State administrations becoming inattentive to the critical necessity of taking prudent steps to contain the spread of the virus. It is no surprise, therefore, that cities which were affected by the pandemic the most are also those which were directly impacted by these political disturbances. In fact, the spiraling rates of the disease is in these very metropolises, and this is also contributing to overall deterioration of health in the surrounding regions. The brutal country lockdown without any preparedness, has exposed not merely the scales of systemic unpreparedness, but also the gross disparities in vulnerabilities across India. Public health facilities have been over-burdened very quickly, and yet there have been deliberate efforts by the State in sheltering interests of private health care facilities. Initially this was by channeling all COVID related relief to Government hospitals and then opening up private sector to also treat, but at huge costs to patients.
All this has contributed to a surge in cases. Between the third week of May to the third week of June, COVID infections in India have quadrupled, death rates are spiraling up, and there is story after story from across the country of how villages, districts and cities are completely unprepared in dealing with the pandemic. Horrific events of bodies of victims being dumped in pits are surfacing from across the country. Meanwhile, over 100 days of complete lockdown has wrecked the country’s economy, sent millions of migrant workers from cities walking home to their villages, merely to survive, and left millions without livelihoods.
Historic building of health care holding India in a pandemic:
The prevailing situation is terrible. However, it should not be the only lens through which the country’s efforts in securing public health need to be evaluated. For India has not been completely inattentive of its health needs and demands. Over time, India has been heralded globally for its remarkable achievements in various public health fronts: bringing down infant and maternal morbidities, and mortalities, successfully; successfully eradicating epidemics such as polio, measles, mumps, tuberculosis; substantially addressing the HIV/AIDS epidemic; etc. Why the country which managed well through decades of low economic growth in tackling epidemics is failing so miserably in tackling the pandemic, that despite recent decades of fast economic growth rates, needs serious enquiry.
The answer may lie in the fact that wealth creation in the past two decades has largely concentrated in the hands of the super-rich, which in India also means an industrial class embedded in feudal histories and political patronages. As a result, the wealth disparities in India of today are amongst the worst in the world, with over 78% of India’s wealth held by the super-rich who constitute less than 1% of its population. In fact, if the income of the top 10% of Indians is accounted for, it would be over 90% of the total wealth of the country. These disparities have a shocking impact on a population where over 90% of wage earners are in the informal sector, and thus without any safeguards – be they in the form of housing, health and insurance.
Another major factor determining India’s health sector is the capacity and capability of pharmaceutical sector to extend health security for all. I came to understand the precariousness of this situation as a researcher in the Department of Microbiology and Cell Biology at the Indian Institute of Science in the early 1990s. Our team was then tasked to develop a vaccine for Rotavirus as part of a Indo-US joint venture. The research required a variety of reagents that were unavailable in India. Our Professor and team leader had to fly to other countries to purchase these reagents and big worry was securing the stability of the reagents in transit. Even today, much of the critically required drug discoveries and manufacture of life saving drugs were heavily dependent on imports at that time.
But India noticed this lack and advanced a variety of public funded public health research programmes. It took steps to protect its home grown private pharmaceutical industries, especially by defending the Indian Patent Act 1970 which the transnational corporations wanted repealed. Defending the Patent Act against various threats of international action, including from World Trade Organisation, was crucial in sheltering India’s private and public pharmaceutical industries so they could produce a variety of life saving drugs and make it accessible at highly affordable rates. This also helped stave of pressures to open up India’s pharmaceutical sector to foreign direct investment. The 1978 National Drug Policy and the Price Control Order of 1979 were crucial to providing India’s pharma sector a major ‘directional thrust’ as these policies supported maximization of “production of bulk drugs locally, providing leadership to public sector undertakings, reduction of import bulk drugs, encouragement for growth of local industry, reduction in selling prices of essential drugs and their formulations”. (2)
Losing the public health advantage due to liberalization:
However, in the decades when liberalization of India’s economy took hold, India’s public sector health research institutions were neglected and are today struggling to meet the challenge of developing a COVID vaccine. The reasons for these critical gaps aren’t difficult to deduce. India’s private pharmaceutical industry took advantage of liberalization and expanded its innovation and production capacities, to make the country a major drug producer. Profit has been a key motive. And this was most clearly evident in how the Supreme Court had to intervene to ensure cancer drugs were made accessible by Novartis.*** This growth story of India’s pharmaceutical sector has been at the cost of public sector enterprises.
On the health services side, massive infusions of capital into private sector led hospitals has made health care extremely expensive for much of the middle classes, and unaffordable for the poor. Doctors and nurses trained in public health medical systems have shifted their patronage to private hospitals, due to higher salaries and financial gains, leaving public hospitals in tatters. Central Government’s measly allocation for public health has ensured such gaps can’t be closed. In a pandemic they are all too visible.
Economic disparities and poverty have a direct bearing on public health. The framers of India’s Constitution were well aware of the disastrous consequences of such expanding economic and social disparities, and thus promised through Article 39 that economic progress would always be advanced ensuring public interest would override private profit. But when due to serious economic collapse India was forced to accept structural adjustment policies of the International Monetary Fund and loan packages from the World Bank, the opportunity was employed by international capital and western powers to spear-head economic liberalization in India. This was undertaken without much debate, and some argue without much choice. There were no safeguards protecting the large informal working sector.
When foreign direct investment was infused into India’s industrial and commercial sectors, and the country tuned to forces of globalization, mechanization and technological upgradation followed which threw millions of workers out of jobs. Labour, social and environmental standards were weakened. In the farming sector, which provides a majority of adults with gainful employment, low purchase price for farm products combined with high input costs pushed millions of farmers to take loans that they could not afford. This pushed them very quickly into economic distress and in an unprecedented turn in human history, farmers began committing suicides. Over 400,000 farmers have committed suicide in India since its economy was liberalized and the country integrated with forces of globalization. It is now feared India will become the suicide centre of the world. (4)
It was not as though the country had not seen this situation coming. In 2000, then President of India late Dr. K. R. Narayanan delivering the Republic Day (5) address brought to focus the harsh outcomes of liberalisation. The following is an excerpt (6):
“Fifty years into our life in the Republic we find that Justice – social, economic and political – remains an unrealized dream for millions of our fellow citizens. The benefits of our economic growth are yet to reach them. We have one of the world’s largest reservoirs of technical personnel, but also the world’s largest number of illiterates; the world’s largest middle class, but also the largest number of people below the poverty line, and the largest number of children suffering from malnutrition. Our giant factories rise from out of squalor; our satellites shoot up from the midst of the hovels of the poor. Not surprisingly, there is sullen resentment among the masses against their condition erupting often in violent forms in several parts of the country. Tragically, the growth in our economy has not been uniform. It has been accompanied by great regional and social inequalities. Many a social upheaval can be traced to the neglect of the lowest tier of society, whose discontent moves towards the path of violence. Dalits (7) and tribals are the worst affected by all this.”
And he added:
“The unabashed, vulgar indulgence in conspicuous consumption by the noveau-riche has left the underclass seething in frustration. One half of our society guzzles aerated beverages while the other has to make do with palmfuls of muddied water. Our three-way fast-lane of liberalization, privatisation and globalisation must provide safe pedestrian crossings for the unempowered India also so that it too can move towards ‘Equality of Status and Opportunity’.”
Privatisation of health care in India:
Economic policies over the past three decades have caused a major shift in health policies, and reinforced privatization of healthcare at all levels. These policies have met with wide-ranging criticisms from the public health movements, (8) from farming and environmental movements, (9)and trade unions in the country. In contrast, the Indian middle class which has substantially gained economically with the emergence and growth of information technology and biotechnology sectors, transformed this new found power into political power and championed the cause of globalization.
About this time, a new concept emerged in the health sector – health services. This involved upgrading hospitals in major metropolises such as Bangalore, Chennai, Delhi and Mumbai to serve the needs of the middle and rich classes and also to cater to ‘health tourism’ – particularly from Europe and Gulf countries. When such business interests gained control of the health narrative, the private health sector in India began to reorient itself into becoming a major destination for global financial investment. This was considered as a positive contributor to the Indian economy and was encouraged with various subsidies and tax benefits. Public health care suffered, both in investment and attention, while private sector health facilities gained massive support. Very soon, the financial methods that secured profits for private health became quite common in major cities, and this trend crept into even public hospitals where highly financialized concepts such as ‘user fees’ began to make entry and gain acceptance. (10) Such transitions to privatization of health care happened with very little attention to standards and guidelines which are critical to securing the public’s health.
Meanwhile, the restructuring and commercialization of critical public services, such as access to safe drinking water, to waste management, and in foundational sectors such as energy production and electricity generation, continued unabated. With political parties participant in this privatization epidemic, it was essentially left to civil society organisations and trade unions to raise awareness about the long term adverse implications of such policies and to even organize resistance through rallies and campaigns, even public interest litigations. The challenges faced by disabled, queer communities and others marginalized on caste and religious basis, also had to be addressed. Many a time these challenges ended up before the Supreme Court, with mixed results. The lack of a coherent approach from the Government to promote public health for all mean that the gap between World Health Organisation recommendations of One Health and what was implemented in India’s hospitals and public health services, widened.
Public Private Participation, and its implications:
With privatization came the promotion of public private partnership models, which were extensively employed in transferring large chunks of public health delivery systems into the hands of private players. The government, meanwhile, forgot to focus on core sectors of health such as building Public Health Centres in every town, village and ward of major cities. Instead it distracted itself with campaigns to build toilets, to make India open defecation free, packaged, as it was, as Swachh Bharat Mission (11). After decades of investing massive amounts of public monies into such campaigns, about 28.7% of rural households across India still lack access to any form of latrines. (12) A fairly large proportion of India’s population still does not have access to clean drinking water, sanitation and hygiene. Most rivers and streams across India, and also the ground water, has been contaminated with chemicals and pathogens from unregulated and untreated inflows of industrial and urban effluents.
A critical worry is the failure to augment primary health care services through substantial and systemic public funding. This has resulted in rapid erosion of critical health delivery skills that were available everywhere, say of traditional birth attendants who played a significant role in reducing maternal and infant mortalities. Even though India has made substantial progress in reducing maternal and infant mortality, the aggressive encouragement, even incentivization, of population control through institutional births has created its own challenges. For instance, the insertion of intra-uterine devices has been encouraged but has failed due to a variety of social stigmas and infrastructural inadequacies, even skills. There are instances when IUDs have been inserted in women without consent because there are incentives extended for promoting such birth control methods, especially by some foundations. (14) All this contributes to an erosion of confidence in public health centres, and a shift to reliance on private health care facilities, often resulting in debilitating impacts on the economic status of affected families.
This confusing scenario is enabling private hospitals to profit from trivial procedures all the way across into critical services. This is evident in a rapidly evolving business – commercial surrogacy. Although legal in India, it comes with several challenges – it is being advocated as a an economic alternative to poor women. The weakness in law and regulation allows middlemen and agencies to exploit poor women. During her pregnancy, the surrogate mother typically stays away from her family to avoid social stigma, when she also lacks insurance and social support. The lack of serious attention by the State to this growing ‘business’ raises various moral and ethical concerns. (15)
Such persistent confusion prevailing in the health sector of India has caused the country to lag behind smaller neighbouring nations such as Maldives, Sri Lanka, Nepal and Bhutan. According to Madan Gopal (16), a Senior Consultant to India’s Planning body Niti Aayog, while the National Health Policy 2017 recognizes increasing disparities in healthcare, it has also created serious concerns over the quality of care. Arguing that “Quality is also a function of equity”, he explains how “(w)hile one would expect private sector care to have higher quality, there is increasing evidence suggesting poor quality. Problems with the public and private health setup are largely the same—gulf of difference between the reported and actual diagnostic and treatment facilities, the tendency of over-prescribing and subjecting patients to unnecessary interventions, lack of efficient monitoring mechanisms, and poor implementation of regulatory controls,” (17)
Clearly, financialization and commercialization of health care has only helped accommodate private interests and shift much of the resources of the public health sector to the private health sector. There has been a huge shift in investments of both health care assets and trained human capital from public to private health care. Besides values and aspirations of professional staff has been impacted with most moving away from working for the health of all, a core component of the Hippocratic oath, to extend medical support as a component of a commercialized service. Large health care corporations have strongly influenced this commercialization and turned India’s highly advanced hospitals into health tourism destinations.
Manufacturing health as a commodity:
The intense commercialization of health care has attracted into India a range of industries and technology companies supplying health care machinery. There has been a surge in pharmaceutical and medical equipment industries as well. Everything from drug discovery to mass production of generic drugs, and the development of prosthetics and companies supplying orthotics, now finds a place in India. A number of home-grown pharmaceutical companies of India operate globally and have turned into multinational companies in their own right.
India is a preferred R&D destination for global companies, especially with an increasing demand and competitiveness to capture the generic drugs market, and the country accounts for 20% of global generic drug exports in terms of volume. (18) Indian pharma market is amongst the fastest growing in the world and is considered a massive recipient of foreign direct investment in India. Controversially, such growth is also because India offers a massive and varied patient pool for drug trials, and at costs far cheaper than most developed countries. A large number of trials, especially the non-communicable diseases, are being conducted in India. This contributes to global health research even though it may not benefit the population of the country. (19)
With intense globalization, product development in health related manufacturing sector is increasingly oriented towards the highly profitable western market. While premier scientific research institutes, and public sector pharma and bioscience companies have faced barriers, and also lack investment in research and development, the private sector is roaring away with investments and expanding business growth opportunities. Many a public scientist have agitated demands for more allocations of public funds. But their voices are barely heard. As a result, India ranks very low in investing in public science research. (20) The large pool of highly qualified and competent scientists and doctors are therefore forced to move to the private sector or leave the country for better opportunities. This is a travesty as India’s large public sector science pool helped build one of the fastest growing and most robust pharma industrial sectors of the world.
The commercialization of the health sector has also resulted in the mushrooming of biotech companies. However, they are largely unregulated in the praxis of medical ethics, and in their financial viability and environmental impacts. A growing worry also is about how such expansion of biotech and pharmaceutical companies is creating massive volumes of biomedical waste produced, and causing a host of problems due to the lack of systems and capacity to manage it. (21) Although the country has enacted strict laws for biomedical waste management, there is patchy compliance. Biomedical waste has been commodified like other wastes and its disposal and management has also been privatized. Weak environmental regulation and monitoring raises serious worries about environmental health risks, particularly in the context of the COVID-19 outbreak.
Neglect of AYUSH:
With such frenetic activity underway in the allopathic component of the Indian health sector, traditional Indian systems of medicine, which include Ayurveda, Yoga, Unani, Naturopathy, Siddha and Homeopathy (AYUSH), has received marginal attention. There has been high volume of rhetorical support for AYUSH, indicative in the Indian Ministry of Health and Family Welfare setting up a separate Department of AYUSH. On becoming Prime Minister in 2014, Narendra Modi elevated the AYUSH department to a separate ministry and doubled its budget. The number of colleges offering undergraduate and post graduate courses in AYUSH also increased, as did the number of hospitals. Besides, with Modi promoting Yoga, the United Nations stepped into to declare an International Yoga Day from 2015.
But the manner in which AYUSH is promoted has received a lot of criticism in the country. There has been a particular lack of rigour in conducting AYUSH research. As they systems involved are differ from the empirical evidence based western forms of medical research, there is also an impediment in its acceptance abroad. As a result there are serious criticism raised about its system of diagnosis and of proof of cure. Western science and medical fraternity has dismissed AYUSH as pseudo-science, and have unsparingly attacked it as benefiting from placebo effect. Overall, the government appears to have encouraged the strengthening of such criticisms for it has failed to establish fool proof systems of review of the efficacy of such traditional medicinal systems. In fact, it has allowed for the massive expansion of the Ayurvedic based pharmaceutical companies, often without rigorous verification, riding largely on faith in the systems amongst the India community. This has its risks.
Controversies mire India’s COVID battle:
Baba Ramdev, a popular yoga guru, started Divya Pharmacy. This company was distributing herbal remedies for a while and when its popularity increased, the company was rebranded as an Ayurvedic company – ‘Patanjali’. From its inception in 2005, the company has been mired in controversy. (22) It has been accused of paying workers poorly, using dubious materials in its medicines, of money laundering and tax evasion, and also violating country’s biodiversity laws in accessing bioresources. Such criticisms notwithstanding, the profits of the company have soared and it is amongst the fastest growing FMCG (fast moving consumer goods) retailers today.
On 23rd June 2020, Baba Ramdev and his associate claimed their drug Coronil cured Covid-19. In a matter of days the company had launched its product, and without complying with any drug testing procedure, risking civil and criminal charges. The narrative quickly shifted with the Union Health Ministry stepping in for Patanjali, which now changed the narrative and claimed CoroniI was an ‘immunity booster’. (23) All of this received international attention as it brought into focus Ramdev’s close relationship with Prime Minister Modi and his Bharatiya Janata Party. It has been argued that anyone else would now have been in prison.
Such trivializations of the pandemic, and its grievous impact, is further evidenced in how India’s main medical and health regulator, Indian Council for Medical Research (ICMR), has claimed a private Indian company, Bharath Biotech, has a vaccine for COVID-19 and that it will be ready after human trials on India’s Independence day, 15th August this year. (24) ICMR was so driven in its pursuit that it directed about 18 health institutions to ensure volunteers are recruited, human trials undertaken and results produced to the launch a vaccination drive on Independence Day. Failure to comply would be viewed ‘seriously’, ICMR warned.
The very fact that a procedure that takes extraordinary care, careful review of medical ethics, enormous investment in finding the right candidates for trials and recruiting them ethically, and the massive and complex collation of financial, human, information and technological resources that it demands, and following which it could take upto a year or more to test the vaccine, was completely lost on ICRMR. That it directed all this to be achieved in a matter of weeks, and that under the threat of penal action, is highly symptomatic of the rot that has now set into the public health sector of India. How this controversy plays out will determine in large measure what happens to India’s ability to ensure health for all.
The Patanjali Coronil episode and ICRM COVID vaccine decision are highly indicative of the vulnerability of India’s health sector decision making to the machinations of power politics. This does not bode well for any public administration system, and most especially not for public health which demands high levels of rigour and review, transparency and accountability in decision making and health delivery. The fact that India’s public health delivery systems have been caught totally unprepared in dealing with the COVID pandemic shouldn’t come as a surprise. In fact this prevailing chaos was meant to happen. When the Prime Minister distracted attention away from the impending pandemic earlier this year, and then employed harsh measures to contain its spread, and failed, it exposes the problematique in India’s health delivery systems.
Post liberalisation, India’s health delivery has been a victim of financialisaton, commercialisation and profiteering, and this is evident in how the focus of the government is now institutionalising relief and recovery by setting up, rather belatedly, massive COVID treatment facilities. Here too it has been recorded that the approach is in monetising from the recovery of the sick, and at costs most cannot afford. For the poor there are public hospitals. But these are over-stretched in dealing with the pandemic and are often turning the those who need critical care away. As a result, there are many instances of the really sick dying at the gates of hospitals, whilst private care institutions are selectively taking those with mild symptoms, even asymptomatic patients, possibly with the intent of increasing their revenue streams.
Such factors are constraining the overall health situation in India, which is taking a huge back step. There is hardly any focus on securing the health of children and mothers who, or elders who need critical care. Public health systems are almost totally oriented to serving the political optics of addressing the COVID pandemic, even as they are unable to deal with the sick streaming in. Doctors and nurses are overstretched, under paid and highly exposed to risk in public hospitals. Meanwhile, those who serve in the profit making private health sector tend to gain from the pandemic, without stepping up to the challenge.
Given how the larger political set up has largely not focused attention on key deliverables of public health delivery, with many leading politicians heavily invested in profit making from private health care, the task of retuning India to the health for all focus remains a daunting task. This is now essentially become a cause of civil society, consumers and trade unions, not of Governments and public sector. This demands a return to the overall understanding of the nature of the economy, and is a clear indicator that capitalist liberalisation lacks humanity, and seeks to profit from human misery.
1 – High Level Expert Group Report on Universal Health Coverage for India, instituted by Planning Commission of India, accessible at: http://phmindia.org/wp-content/uploads/2015/09/Plg-Commission-HLEG-Report-on-Health-for-12th-Planrep_uhc0812.pdf
2 – The Indian Pharmaceutical Industry: Pride and Growth Lever of India, Express Pharma News Bureau, 17 December 2019, accessible at: https://www.expresspharma.in/business-strategies/the-indian-pharmaceutical-industry-pride-and-growth-lever-of-india/
3 – Gabble R, Kohler JC, “To patent or not to patent? the case of Novartis’ cancer drug Glivec in India”. Global Health. 2014;10:3. Published 2014 Jan 6. doi:10.1186/1744-8603-10-3 accessible at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3884017/
4 – Shemin Joy, India may become farmer suicide capital: Agri Adviser. Deccan Herald Nov 032019. Accessible at https://www.deccanherald.com/national/india-may-become-farmer-suicide-capital-agri-adviser-773068.html
5 – India celebrates the Republic Day on 26th January every year. The day is marked with military and cultural parades. On its eve, the President of India speaks to the nation through a televised address.
6 – The full text of the speech delivered by late President K. R. Narayanan on the eve of India’s Republic Day, on 25 January 2000, can be accessed at: http://www.indiatogether.org/opinions/speeches/krn2000.htm, accessed on 18 January 2010.
7 – Dalit is a generic description of quite a few communities that have been suppressed socially, economically and culturally by the highly structured and discriminatory Caste system of India. All those castes and communities that have been thus discriminated are called Dalits.
8 – The 2004 Mumbai Declaration of the People’s Health Movement staunchly criticized liberalization and globalization as contributing to public health distress in India. See, The People’s Health Movement, Ravi Narayan, Claudio Schuftan, and Brendan Donegan, in Global Public Health, accessible at: https://oxfordre.com/publichealth/view/10.1093/acrefore/9780190632366.001.0001/acrefore-9780190632366-e-54
9 – See Grievances of Communities Affected by Environmental Decision Making on Development Projects, organised by Campaign for Environmental Justice in India, 13th November 2005, accessible at: https://esgindia.org/new/campaigns/index-of-submissions-for-moef-suno-and-moef-chalo-13-14-november-2005/
10 – Health care systems in transition III. India, Part I.The Indian experience. Imrana Qadeer, Vol. 22, No. 1, pp. 25–32
11 – https://pdfs.semanticscholar.org/1ff5/b29efde1a76817b4e092cba1c1a5135a64ae.pdf
12 – Is rural India 100% open defecation-free like Swachh Bharat data concludes?, The Hindu, January 02, 2020 accessible at
13 – Dinsa Sachan, Contraceptive chaos: Copper-T better in emergency, but doctors do not encourage its use, Down to Earth, 17 September 2015, accessible at: https://www.downtoearth.org.in/news/contraceptive-chaos-38437
14 – Prithviraj Mithra, At government hospitals, women being given IUDS without consent, Times of India, 22 February 2018, accessible at: http://timesofindia.indiatimes.com/articleshow/63021211.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst
15 – Saxena P, Mishra A, Malik S. Surrogacy: ethical and legal issues. Indian J Community Med. 2012;37(4):211-213. doi:10.4103/0970-0218.103466 accessible at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3531011/
16 – Gopal KM. Strategies for Ensuring Quality Health Care in India: Experiences From the Field. Indian J Community Med. 2019;44(1):1-3. doi:10.4103/ijcm.IJCM_65_19, accessible at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6437796/
17 – Lack of infra, access, quality key hurdles for national health policy. Live Mint, 19 March 2019 accessible at https://www.livemint.com/politics/policy/lack-of-infra-access-quality-key-hurdles-for-national-health-policy-1553018075376.html
18 – http://www.ibef.org
19 – Clinical trials and healthcare needs in India: A difficult balancing act but opportunities abound! Sanish Davis Year : 2017 | Volume : 8 | Issue : 4 | Page : 159-161 http://www.picronline.org/article.asp?issn=2229-3485;year=2017;volume=8;issue=4;spage=159;epage=161;aulast=Davis
20 – India’s pharmaceutical research problem, Livemint, 15th September 2017 https://www.livemint.com/Opinion/m8uzYstgqiT1rOK1GUOnVI/Indias-pharmaceutical-research-problem.html
21 – India’s medical waste growing at 7% annually: ASSOCHAM Jaideep Shenoy TNN Mar 22, 2018 https://timesofindia.indiatimes.com/business/india-business/indias-medical-waste-growing-at-7-annually-assocham/articleshow/63415511.cms
22 – India’s Baba Ramdev Billionaire Is Not Baba Ramdev October 26, 2016
23 – Uttarakhand govt issues notice to Patanjali’s Divya Pharmacy over Covid-19 ‘medicine’ Neeraj Santoshi June 24, 2020 https://www.hindustantimes.com/india-news/uttarakhand-govt-issues-notice-to-patanjali-s-divya-pharmacy-over-covid-19-medicine/story-B6j599c7tUkS7yNM7j2RYP.html
24 – Sohini Das, India to launch Covid-19 vaccine by August 15:ICMR chief Bhargava July 4, 2020 accessible at https://www.business-standard.com/article/current-affairs/india-to-launch-covid-19-vaccine-by-august-15-says-icmr-chief-120070300634_1.html