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Oppi Commemorative Publication Improving Access Innovation And Reach Of Healthcare In India


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Oppi Commemorative Publication Improving Access Innovation And Reach Of Healthcare In India

  1. 1. Commemorative PublicationImproving Access, Innovation & Reach of Healthcare in India July 27, 2012, Mumbai. Knowledge Partner India’s Strategy Boutique
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  3. 3. ConclaveImproving Access, Innovation & Reach ofHealthcare in IndiaInaugural SessionWelcome & Opening Remarks Mr. Tapan Ray, Director General, OPPIInaugural Address Mr. Ranjit Shahani, President, OPPI and Vice Chairman & Managing Director, Novartis India Ltd.Address by Chief Guest Mr. Dilsher Singh Kalha, Secretary, Department of Pharmaceuticals, Government of IndiaWHO Perspective Dr. (Ms.) Nata Menabde, WHO – India RepresentativeKeynote Address Dr. K. Srinath Reddy, President, Public Health Foundation of IndiaSession 1Improving Access to HealthcareOpening Remarks by the Chairman Dr. Shailesh Ayyangar, Managing Director, India & Vice President, South Asia, Sanofi India Ltd.Improving Access to Healthcare: Hospital Chains Mr. Anil Kamath, Founder Chairman Esemcee AdvisorsImproving Access through Affordable Healthcare Dr. K. Venkatesham, CEO, Rajiv Gandhi Jeevandayee Arogya Yojana 3
  4. 4. Session 2Moving Ahead in the ‘Decade of Innovation’Opening Remarks by the Chairman Mr. Kewal Handa, Managing Director, Pfizer Ltd.Making India a Global Hub for R&D Mr. Bart Jannsens, Partner and Director, The Boston Consulting GroupSession 3Improving Reach of HealthcareOpening Remarks by the Chairman Mr. Rajan Tejuja, President and Executive Director, Janssen, Johnson & Johnson Ltd.Improving Reach of Healthcare: Health Insurance Mr. Anil Varma, President, Howden Insurance Brokers IndiaImproving Reach of Healthcare: Use of Technology Dr. Rohit Shetty, Vice Chairman, Narayana Nethralaya Postgraduate Institute of OphthalmologyPanel Discussion, Summing up and Vote of Thanks Moderator – Mr. K.G. Ananthakrishnan, Managing Director, MSD Pharmaceuticals Pvt. Ltd. Mr. Sudarshan Jain, Managing Director, Healthcare Solutions, Abbott Healthcare Pvt. Ltd. Mr. Rakesh Bhargava, Chairman, Fresenius Kabi Oncology Ltd. 4
  5. 5. Foreword The conclave on Improving Access, Innovation & Reach of Healthcare in India held in Mumbai on 27th July, 2012 organized by the Organisation of Pharmaceutical Producers in India (OPPI) is very timely as it provides an excellent opportunity for policy makers and various stakeholders including the industry experts to present their views on diverse aspects of growth of the healthcare sector in India. OPPI has always attempted to facilitate greater access and has encouraged research and development to provide quality healthcare solutions. The presentations in the symposium highlighted the need to increase India’s healthcare expenditure from 1.2% of GDP, reduce the burden of out of pocket expenses which is as high as ~70%, drastically improve healthcare infrastructure on a globally comparable level, form a collaborative approach involving all stakeholders and focus on a few Mr. Tapan Ray Director General, OPPI specific areas within innovation to create an R&D centric base. The eminent speakers at this conclave range from policy makers at thegovernment level, World Health Organization, pharmaceutical industry, Industry associations,Insurance bodies, reputed consulting firms and healthcare facilities. Their thought provoking views,outlook and brainstorming sessions on the pertinent matter has definitely enriched the members at theconclave and will facilitate improvements in the healthcare sector.We hope that you will find this publication informative and useful.Tapan RayDirector GeneralOPPI 5
  6. 6. Executive SummaryIndia is currently ranked the world’s 11th largest economy by nominal GDP and third largest byPurchasing Power Parity (PPP) and has seen strong economic growth and rising per capita income inthe last decade. However, India’s continued economic growth will be at risk unless quick action istaken to improve the health of its growing population.Although India has made substantial progress in key healthcare indicators such as, infant mortalityand maternal mortality, our distinguished speakers have highlighted a set of key challenges that mustbe overcome to improve access and reach in an equitable manner across states, urban and ruralareas, income groups and education, gender and caste strata. The most frequently spoken of at theconclave were the following:Poor public health services - The government provides only a part of actual healthcare services, thequality of care varies significantly across states and there are real challenges in providing basichealthcare in rural areas.Inadequate healthcare financing - Insufficient government funding for healthcare which at 1.2% ofGDP ranks India 178 out of 190, countries coupled with low insurance penetration that does not coveroutpatient care and medicines leads to ~70% of healthcare expenditures being borne out of pocketand even drives people into poverty.Dual disease burden - India’s infectious disease burden is inadequately controlled while there is anemerging epidemic of chronic diseases.Shortage of healthcare human resources - A shortage of close to 20,000 doctors and 13,000nurses at primary health centers and community health centers has significantly impacted the quality,efficiency and cost of treatment, this is further compounded by imbalances caused by 80% of India’smedical personnel based in urban areas.Poor healthcare infrastructure - India has only 0.9 beds per 1000 population versus a minimumrequirement of 2 beds per 1000 population, countries like Sri Lanka and China have close to 3 bedsper 1000 population.Among the priorities and aims for improvement in healthcare access and reach, the following themeswere highlighted by the eminent speakers who comprised a mix of policy makers at the governmentlevel, WHO, pharmaceutical industry, industry associations, insurance bodies, reputed consulting firmsand healthcare facilities.Improving access to medicines - The governments intent to spend INR 26,000 over a 5 year periodon a free medicines scheme was welcomed, which will increase public expenditure on medicines from0.1% of GDP to 0.5% of GDP, by increasing the public procurement of medicines through an efficientstocking and distributing based central procurement system at a state level, similar to that in TamilNadu.Increased government expenditure on healthcare - The government intends on increasing publicexpenditure on healthcare from the current level of 1.2% of GDP to at least 2.5 % of GDP by the end 6
  7. 7. of 12th five year plan and eventually increases it to 3% of GDP by 2022 to universalize healthcareservices. It was proposed that the government should ensure the even distribution of healthcareexpenditure between states by allocating state proportional budgets.Creation of healthcare infrastructure - Initiatives spoken of were the upgradation of primary healthcenters and making them available 24x7, upgradation of community health centers to bring them atpar with the Indian health standards, and mass recruitment of ASHA workers, doctors and nurses.India also needs to open ~600 medical colleges and ~1,500 nursing colleges to meet the globalaverage of doctors and nurses.Support the Universal Health Coverage (UHC) agenda - The UHC proposed a basic healthpackage with no user fee that will focus on ensuring that expenditures on primary healthcare shouldaccount for at least 70% of all healthcare expenditure. This will ensure that the demand for secondaryand tertiary healthcare services and correspondingly healthcare costs reduce substantially.Focus on innovation in healthcare – There is an urgent need is to facilitate the adoption ofinnovative technologies and products in the Indian healthcare system to improve access and reach.A range of initiatives were spoken of ranging from eco-friendly toilets known as Bio-digesters createdby DRDO for the rural poor, thus improving sanitation to leveraging technologies such as a phonebased screener, which uses a needle free system which does not pierce the patient to detect anemiaand other technologies like Tele-ophthalmology and Tele-mentoring that, with the advent of the tablet,handhelds and other mobile devices equipped with 3G facilities are gaining strong momentum.Improve health insurance penetration - There is a strong need to bring all state specific schemesunder the UHC and bringing improvements to the government health insurance scheme RSBY. Onesuch example discussed was the Rajiv Gandhi Jeevandaye Arogya Yojana in Maharashtra which builton the learnings gained from the Rashtrya Swasthya Bima Yojana and the Andhra PradeshArogyasari. The RGJAY has focused on improving the monitoring systems, reserved certainprocedures for only government hospitals to ensure flow of money in the system and put in placevarious efforts to keep the administration cost low, eg: where unclaimed amount has to be returned tothe scheme.It was also suggested to improve penetration of insurance in the tier 3 cities and semi urban areas,companies should leverage bank branch network, post office and micro finance entities.Focus on preventive measures rather than curative practices - Drawing from internationalexperiences to reduce the burden of healthcare on the state which indicate that India must focus onbuilding a preventive healthcare approach and outlook. Programs must be devised paying lots ofattention to health checkups that incentivize people to keep up to the standards of wellness thusdiminishing the need for medical treatment.There was a unanimous view that the key to improving healthcare access and reach will be whereGovernment, Non-Governmental Organizations, Corporate sector, Pharmaceutical companies,doctors, policy makers and various other stake holders collaborate and enhance their knowledge levelin finding innovative ways to improve access to healthcare. 7
  8. 8. In summary, many of the speakers echoed the quotation cited by Dr. Srinath Reddy, “If we want tocreate a future, we cannot extend the present”.The agenda with regard to innovation at the conclave was focused around how India could become aglobal hub for R&D and how it could become a potential leader in Biotechnology.With regard to India as a centre for R&D it was felt that while India has made some steps forwardswith the % of global R&D invested in India increasing from 0.1% to 1.1%, the main driver for thisincrease has been labour cost arbitrage which may not really count as innovation and is not somethingthat may be a sustainable proposition.Asking the question of what India is good at and where it can build competitive advantage BartJannsens, a Partner at BCG spoke of India’s advantages in the form of a large, diverse andrepresentative patient population and key areas where India is strong such as Information Technology(IT), Engineering and Clinical Research.With regard to India becoming a potential leader in Biotechnology it was suggested that the industryhas been short sighted and is unable to think ahead of the success gained in the generic space.It was felt that a step in the right direction and the creation of a new paradigm for pharmaceutical R&Dinnovation was the Indian government’s approval of Ranbaxy’s anti-malarial drug, a drug developedwith cost-efficiencies at a price that’s affordable. It showcases how an emerging country can play akey role in developing drugs for neglected diseases.A series of recommendations were made which would allow India to become a global R&D hub and aleader in Biotechnology. It was suggested that India should focus where it can build a competitiveadvantage and focus on the convergence of life sciences with the three disciplines India is strong atnamely IT, Engineering and Clinical research. This could throw up opportunities in areas such asBioinformatics, Bio-nanotechnology, genomic databases and translational research.A general thought on overcoming the hurdles that derail progress and of creating a businessenvironment that is conducive to investment, particularly innovation by reducing uncertainty as well asreducing policy delays and policy paralysis. An example cited was how as a result of India not creatinga conducive environment for clinical development its share in new started trials dropped from ~ 36% in2005 to ~ 20% in 2011.Finally they suggested India needs to move beyond the legacy of success derived from the genericsindustry, focus more specifically on local needs and public health issues, learn to coordinate andcollaborate with other Indian firms to take advantage of scale and pooling of resources and capitaliseon the spirit of entrepreneurship. There has been consensus that the Indian Government hasrecognized the fact that there is a great opportunity for innovation in India and is working towards thisin its 12th 5 year plan. 8
  9. 9. Inaugural Session Knowledge Partner India’s Strategy Boutique 9
  10. 10. Welcome and Opening Remarks Mr. Tapan Ray* Director General, OPPI Good Morning Ladies and Government to make medicines available in Gentlemen the country at a price, which is cheaper than even Pakistan, Bangladesh and Sri Lanka, on Welcome to you all at the the other, the fact still remains, a large ‘OPPI Conclave’ for a day percentage of Indian population does not have long deliberation on Access, access to affordable modern medicines, asInnovation and Reach of Healthcare in general compared to just 15% in China and 22% inand Pharmaceuticals in particular by the Africa.national and international experts. The moot question therefore arises, despite allOur special welcome to the Chief Guest, Shri stringent price regulatory measures by theDilsher Singh Kalha, Secretary , Department of Government and prolonged public debatesPharmaceuticals for carving out some time over nearly four decades to ensure betterfrom his busy schedule to address us this ‘affordability of medicines’, why then access tomorning. modern medicines has remained so abysmal to a vast majority of the population of India,Our hearty welcome goes to one of the key even after sixty five years of Independence ofarchitects of the healthcare reform initiatives in the country?India, Dr. K. Srinath Reddy, world renownedcardiologist and the President of Public Health While India is making reasonable strides in itsFoundation of India (PHFI). We are honored to economic growth, the country is increasinglyhave you with us Sir. facing constraints in providing healthcare benefits to a vast majority of its population withWe are privileged to have with us the ballooning ‘Out of Pocket (OoP)’ expenditurerepresentative of the World Health of around 78 per cent of its population.Organization (WHO) in India, Dr. NataMenabde. We cordially welcome you madam This is mainly because of the following keyto this Conclave and eagerly look forward to reasons:listening and taking note of the WHO  Low public spending on health at aroundperspective on healthcare access in India. just 1.1 percent of the GDPI welcome all our speakers of the conclave and  Fragile healthcare infrastructurethe vibrant media of our country and all the  Very low penetration of health insurancemembers of OPPI for your kind presence.  Poor healthcare delivery system  Absence of ‘Universal Health Coverage’Our Inaugural and the first BusinessSession is on ‘Access to Healthcare’. As we know access to healthcare comprisesDespite so much of stringent Government not just medicines but more importantly thecontrol, debate and activism on the healthcare infrastructure like, doctors,affordability of modern medicines in India, on paramedics, diagnostics, and healththe one hand, and the success of the centers/hospitals. In India the demand for 10
  11. 11. these services has outstripped supply. innovator to make the innovation sustainable.However, the key focus of the government has Moreover, pharmaceutical innovation is a verystill remained primarily on access to expensive process and grant of patents to themedicines. There is an urgent need to have a innovators is an incentive of the government toholistic approach in developing adequate them for making necessary investmentshealthcare infrastructure, efficient delivery towards R&D projects to meet unmet needs ofsystems for medical supplies and creation of a the patients. The system of patent grants alsotalent pool of healthcare professionals and contributes to society significantly by makingparamedics, to ensure access to healthcare for freely available patented information to otherall the citizens of the country. scientists to improve upon the existing innovation through non-infringing means. ByOPPI has undertaken an important study on unleashing the power of innovation, India will‘Enhancing Healthcare Access in India’. The also be able to create socio - economicStudy aims to identify the key barriers in transformation, which is a critical step towardsaccessing healthcare today, what needs to be developing India as a knowledge economy.done to eliminate these barriers and develop aroadmap for improving healthcare access in Thus, innovation being one of the key growthIndia. drivers for the knowledge economy, creation of innovation friendly ecosystem in the countryThe second Business Session is on calls for a radical change in the mind set-fromInnovation. Healthcare industry in general and ‘process innovation’ to ‘product innovation’,the pharmaceutical sector in particular, across from ‘replicating a molecule’ to ‘creating athe world, have been experiencing a plethora molecule’. A robust ecosystem for innovation isof innovations not only to cure and effectively the wheel of progress of any nation.manage ailments to improve the quality of life,but also to help increasing overall disease-free Considering all these, our Prime Minister haslife expectancy of the population with various very aptly declared 2010-2020 as the “Decadetypes of treatment and disease management of Innovation”.options. Unfortunately despite all these, overhalf the global population is still denied of basic The third Business Session before thehealthcare needs and support. Panel discussion will be on ‘Reach of Healthcare’. While India is making reasonableIt is encouraging to hear that the Government strides in its economic growth, the country isof India is working towards this direction in a increasingly facing constraints in providingmore elaborate manner in its 12th Five Year healthcare benefits to a vast majority of itsPlan. population.In business session II, titled: Moving Ahead We find some good initiatives though,in the ‘Decade of Innovation’, two global especially for population below the poverty lineexperts will enlighten the august audience on (BPL) with Rashtriya Swasthya Bima Yojana‘Making India a Global Hub for R&D and (RSBY) and other health insurance schemesMaking India a Leader in Biotechnology’. through micro health insurance units, mostly in rural India. It has been reported that currentlyInnovation, as is widely acknowledged, is the around 40 such schemes are active in thewheel of progress of any nation. This wheel country.should move on and on with the fuel of IPR,which is an economic necessity of the 11
  12. 12. As the disease pattern is undergoing a shift Manufacturers & Associations (IFPMA),from acute to non-infectious chronic illness, the Geneva. He represents various Committees ofreach of treatment is becoming even more the Government and Industry Associationschallenging. like, FICCI and CII. He is also a Member of the Governing Board of Institute of IntellectualCurrently, health insurance schemes only Property Studies (IIPS) and is a visiting facultycover expenses towards hospitalization. in India’s top Management Institutes.However, medical insurance schemes shouldalso cover domiciliary or inpatient treatment Mr. Ray holds a B.Sc. (Honors) and a Master’scosts and perhaps loss of income along with Degree in Geology from the University ofhospitalization costs, as well. Calcutta and was a National Scholar. He is an Alumnus of the Indian Institute of ManagementWe shall know much more about it from the (IIM), Ahmedabad.experts during their deliberations. .OPPI Conclave will conclude with astimulating ‘Panel Discussion’ on thetheme of the Conclave: ‘Improving Access,Innovation & Reach of Healthcare in India’,which will help us charting the Way Forward.I am sure you all will enjoy the Conclave andfind it very useful… but do not miss theopportunity of interacting with the galaxy ofspeakers to enrich ourselves with theirperspectives on this important subject.Thank you.* Mr. Tapan RayMr. Tapan Ray is the Director General of theOrganisation of Pharmaceutical Producers ofIndia (OPPI).Mr. Ray has over 30 years’ experience in thePharmaceutical and Life Science Industry andhas held various senior positions in India andabroad like Global Commercial StrategyManager, Glaxo plc. U.K.; Director in theBoard of Glaxo India Limited and ManagingDirector, Abbott Laboratories India Limited;Chairman of the Board of Shasun PharmaSolutions Ltd., Northumberland, England, U.K.He was also the President of OPPI.Mr. Ray is Member of the Council,International Federation of Pharmaceutical 12
  13. 13. Inaugural Address Mr. Ranjit Shahani* President, OPPI Mr. Kalha, Dr. Reddy, Dr. back that we have contributed to life Menabde and my dear expectancy. friends from the industry. It is always a pleasure to be here with you.Improving Access, Innovation and Reach ofHealthcare in India is the key to achievingUniversal Healthcare for all and has manydimensions. Today’s agenda will hopefully helpbring out these dimensions and point us in thedirection of some solutions. The question thatis often asked is what is access? Onedefinition by Parker explains access as: “Theability to reach, obtain or afford entrance toservices.”Today, health is not uni-dimensional; health is However, despite these improvements, therea state of complete physical, mental and social are huge disparities. Today, a girl born inwellbeing and not merely the absence of Germany is destined to live a 100 years, but adisease or infirmity. girl born in Botswana may live to be only 35. This has to do with a multitude of factors asWe have to look at the context in totality. As there are huge challenges at play population is growing, the diseaseburden due to non-communicable diseases is The complexity of their causes of poverty asalso growing at a fast rate, especially in the well as the inter dependencies with healthpoor income segments. This has become a deficits make “simple” solutions impossible.cause for great concern in India. In addition, So, whilst there is general agreement thatthe burden of communicable diseases, though health matters and that good health is certainlyon the decline, remains a concern. desirable for all, there is a pronounced pluralism of opinions with regard to what oughtLife expectancy has more than doubled in the to be done and by whom to ensure poorlast century; however, the quality of life has not people’s health. And the rhetorical question Iincreased. In the 19th century, life expectancy ask here is, “are the poor the wards of thewas on an average, 31 years of age, by that state, or of the pharma industry, or of thecount, none of us here in this room would be hospital?”alive today. By developing access to cleandrinking water life expectancy rose to 48 years. I think multiple stakeholders need to comeWith the advent of an advanced Pharma together to solve this very difficult problem,industry, life expectancy has risen to 68 years. particularly when we have such a largeSo, we must pat ourselves a little bit on our population living on an income of USD 2 or 13
  14. 14. less; there are issues of basic needs, such as There are differences in the factors leading tofood, health comes much later. So, there are disease, disability or death between thebig challenges as we go ahead. developing and developed world. The inter- relationship between poverty and health isPoverty and health we all know create a reinforced when you notice that factors such asvicious cycle, and there is a fundamental inter unsafe water, sanitation, and hygiene and ironrelationship between the ‘state of poverty’ and deficiency are negligible causes for concern inthe ‘state of health’ of a nation and its citizens. developed countries, yet they are the chiefPoor health is not only a component and reasons for the atrocities in poor countries. Forconsequence of poverty but is also the cause iron deficiency there is a low cost interventionof it. An individual’s state of health determines which could dramatically change the lives ofthe person’s ability to work and therefore earn. thousands of people but access is an issue.For poor people the health of their bodies and India bears the highest burden of diseases asminds is a critically important asset, and often we all know, both in terms of mortality andtheir only asset. morbidity, and also in terms of the lowest investments in healthcare.Men and women were sick because they werepoor; they became poorer because they were Clearly, there are many choices, butsick and sicker because they were poorer: we developing new, scalable and high impactall know this vicious cycle. The state of health approaches are important. We hear a lot aboutdepends not only on having a sense of good tele-medicine, chip in the pill and many otherpersonal hygiene, safe drinking water, devices, but to make an impact these need toadequate food and lifestyle choices, but also reach the huge population that currently has noon a host of other factors which shows that access.multiple stakeholders need to come together tomanage this stark reality. Millions of patients benefit from what the pharmaceutical industry does, we are not justOf course, the developing world suffers the talking of providing medicine at a cost andmost. The reality check is sobering: The marketing it, but also a lot of differential,human cost of 2.5 billion people facing a daily innovative pricing for expensive medicines,struggle for survival is high in terms of mortality donation programs, vast research andand morbidity. This can be easily development investments in tropical diseasesdemonstrated by two of the most significant and the tremendous support for broader healthhealth indicators which are infant mortality and and development goals across the world.maternal mortality. Nearly 10 million childrendie before they reach their fifth birthday and Just by improving access to vaccines, up to500,000 women succumb to preventable 10.5 million lives could be saved every yearillnesses during pregnancy and complications worldwide. In India, we all know the availabilityduring childbirth. Low-cost interventions are of vaccines is at a very low cost and yet theavailable that could prevent at least two-thirds penetration is very, very dismal.of these deaths but access to these facilities ispoor. 14
  15. 15. This continuous battle for the fulfillment of the As prosperity increases health will increase soright to health has to be fought on many fronts. life expectancy will also increase.The right to health goes much beyond access: During the course of today we will discuss theBesides safe drinking water, sanitation and multiple barriers to access which affect globalfamily education, it is also about delivering health. We will also talk about solutions as wemedical interventions and cost effective go forward, for we certainly need more andtreatments, to go not only to the better off but more stakeholder management andto the poorest and well into the interiors of partnerships. A lot of it has to be trulyIndia, and many non-medical health collaborative, and involves partners such asinterventions which includes the training of the World Health Organization, United Nationsmedical staff where simple foot soldiers can agencies and Non-Governmentalmake a big difference. Organizations. We all have to come together; there cannot just be a single or oneThere is a clear correlation between per capita dimensional approach to this.spend on health and GDP. As our GDPincreases, the expenditure on healthcare will Just to summarize, what I have said andgo up and therefore access should also strongly feel is:improve. So, there is hope on the horizon thatIndia with its current GDP growth is Access to healthcare has three fronts anddirectionally headed in the right direction. these can be summed up as find new andIncome levels which you see from 2005-2025, better treatment, make these treatmentsis an example of the growing middle and available and more importantly create anbottom segments of the population pyramid – adequate healthcare infrastructure. 15
  16. 16. Research-based companies have a long success in creating sustainable shareholderlegacy of corporate responsibility in India, with value within local and internationallycountless contributions to the improvement of competitive environments, covering a range of industries, including Pharmaceuticals,health outcomes in the country. We are Petrochemicals, Synthetic Fibers, Specialtyworking every day around the clock to find new Chemicals, Dyes and Intermediates, he hastreatments and cures for society’s greatest extensive functional knowledge of Mergers andhealth problems. The way forward is really Acquisitions, Off shoring and Outsourcingthrough the creation of infrastructure, ventures and Research & Developmentexpanding awareness of healthcare and Processes. Mr. Shahani is President,greater use of technology. Organization of Pharmaceutical Producers of India (OPPI), President of Swiss-Indian“We are getting there, we are not there yet, but Chamber of Commerce (SICC) and past President of the Bombay Chamber ofI am confident that with the support and help of commerce and Industry.all stakeholders, we will manage it!”Thank you for your time.* Mr. Ranjit ShahaniMr. Ranjit Shahani is Country Presidentresponsible for the overall operations of theNovartis Group of Companies in India. He isalso the Vice Chairman & Managing Director ofNovartis India Limited. A Mechanical Engineerfrom IIT Kanpur and MBA from JBIMS,Mumbai, with over three decades of distinctivesenior managerial experience in national andglobal MNCs and a proven track record of 16
  17. 17. Address by Chief Guest Mr. Dilsher Singh Kalha* Secretary, Department of Pharmaceuticals, Government of India OPPI president, OPPI I agree with Mr. Shahani that health and members and my dear healthcare do not just include medicines and colleagues, it gives me hospitals. One has to critically recognize other immense pleasure to aspects such as safe drinking water, adequate address this gathering supply of nutrition and food, improved sanitation and above all education. Some ofOn my way to the conclave, I was told that the barriers to access are closely related to theusually there are not many government issues just stated above. I do not regard myselfrepresentatives addressing the conclave. as a “guest” in this conclave; in fact myHowever, I realized this is not the case this concerns are in unison with all of you presentyear. Several of my colleagues were here. Keeping in mind the emphasis given byscheduled to speak later in the day. I was keen the Prime minister on inclusive growth, Ito understand, why this is the case this year. I believe that the healthcare sector displays awas informed that to have a meaningful stark rural urban disparity.discussion on the pertinent issues stronggovernment participation is imperative. I am When we talk about the indicators affectingglad to share this platform. healthcare or about the barriers to access, we find that the crux of the problem lies inAccess, Innovation and reach are three critical delivering primary health care. These problemsissues that outline the agenda of this conclave. though present in urban areas become moreI presume the discussion on access would be prevalent in rural areas because of lack ofan independent one whereas the role of geographical access. When trying to answerinnovation in bridging the gaps in access to the question as to whose wards these poorhealthcare would be dealt in the latter people are, I can say that they are not asessions. particular company’s or the pharmaceutical Industry’s wards rather they are the wards ofWe know that access to healthcare is a major the nation.issue gripping the nation today. Our newpresident in his inaugural address to the nation There are a number of problems that we face.pointed out hunger as a major problem that our There is lack of even the most primitive meanscountry faces today. I feel that hunger of communication in some parts of India. Thererepresents just not an empty belly but a whole are some places in India where even thelot of things which include poverty, under armed forces would not go. So making surenourishment, death and loss of earnings. The that health facilities reach the population inconsequences of hunger are much larger than such areas is a mammoth task. Even in areasthe above-mentioned; it deprives a person of where there is adequate access to healthcare,his basic needs and that gets reflected in lack there isn’t much statistics to show whether theof education and opportunities. The gravity of population can afford it. In urban areas, onethe issue of access can be very well may have to travel for a shorter distance thanunderstood in the context that India is still someone in a rural area, but does accessibilitystruggling to cope with the issue of hunger. guarantee affordability is a question that 17
  18. 18. remains unanswered. Hence the issue of right to healthcare, development of humanaccess cannot be looked upon as a standalone resource is the need to focus on improvingissue; instead it should be looked upon as a access to education and health. This is evident thmeans to evaluate the progress that the from the draft proposal of the 12 five yearcountry has made. plan, whose emphasis is largely in the sectors of health and education.I would also like to take this opportunity toclear some of the misconceptions in the public There is never a straight forward answer as toabout the working of the government in the how much government expenditure is sufficienthealthcare sector. I often hear people say that to meet the healthcare needs of the country.the government is sleeping. Let me assure you The current expenditure of the government onthat this is not the case. Although I concede healthcare sector is close to 1% of GDP. Anthe argument, put forth by many, that the increase in the allocation of resources from thegovernment could have done better, allocated government may not be the answer to themore resources to the health and education dismal state of healthcare in India. In spite ofsector and improved upon the inefficiencies in criticism, initiatives like NRHM (National Ruralthe system, It is not that the government has Health Mission) continue to meet their desirednot tried and this is evident from the fact that objectives. But there is a need to focus onthe health profile in general has improved over preventive care and promote it on a largerthe last decade. The Government has put in scale in rural areas.considerable efforts ranging from health policyinitiatives in the year 2002 – 2003 to coming up There is a shortage of talent in the Indianwith schemes like National Rural Health healthcare sector. Currently India needs closeMission (NHRM) targeted specifically at to 20000 doctors and 13,000 nurses. One ofimproving healthcare in the rural population. the objectives of schemes like NRHM is toIndia’s IMR (Infant Mortality Rate) and MMR involve local communities to be a part of the(Maternal Mortality Rate) figures still portray a healthcare system. At this point I want to sharehorrific story as the ratios are worse than those one of my personal experiences. As part of theof the sub Saharan region. But the efforts put work related to the planning commission, Iforth by government have significantly arrested visited some of the states and got anthis trend. The government has repeatedly opportunity to see the ground realities of somemissed the target goals and may continue to of the schemes implemented by themiss it in future but that does not stop it from government. In spite of the fact that many aputting in the desired effort. An example of the times resources were scare and the processesabove mentioned scenario is the improvement were inefficient because of the presence ofin the IMR and MMR figures over the past numerous departments, there was no dearth ofdecade. The Infant Mortality Rate has come motivated ASHA (Accredited Social Healthdown from 64.9 per 1000 in 2000 to 47.57 per Activist) workers. Another worrying issue is1000 in 2010 whereas the Maternal Mortality that, despite greater prevalence of non-rate has come down from 32.7 in 2000 to 24.0 communicable diseases, Tuberculosis, malariain 2010. Also the program to provide clean and cholera are still prevalent in India. Thoughdrinking water has ensured that most of the architectural correction of the health sector iscountry has access to drinking water. the key objective of the NRHM, it is to be carried out through integration of verticalThe crux of the entire talks and discussions on programs and structures.right to education, right to food and nutrition, 18
  19. 19. Whether the impact of health policies or the promoting institutional delivery among theresults of government efforts has truly been as poor pregnant women. Many still believedesired, is debatable. I stand here today not that it is safer to have a delivery at homeonly representing the government but also than in a hospitalassuring the pharmaceutical fraternity that thegovernment is aware of the realities. Further, I strongly believe that education is the key tothe government interventions go beyond just increasing awareness. Education andlowering the price of medicine. The improved reach would result in an increase ingovernment has adopted a more holistic awareness and as a result the rural healthapproach. However, let me concede that we mission would stand a better chance ofwould love the results to be better than what delivering the desired results.appears to be generally on paper. Another barrier to increasing the access ofI would now like to draw your attention towards healthcare has been the diagnostics ability andsome of the barriers that the industry faces the positive will of the person who There are some indications suggesting an undesired scenario of over prescription of bothEducation and awareness are major concerns diagnostics and treatment. There also existsand are interrelated. It is possible to get the the underutilization of the widely availablephysical infrastructure in place but to make diagnostic tools. Increase in awareness amongpeople aware of its presence becomes a the users about these tools can go a long waychallenging task. There are enough statistics in helping overcome the barriers to access.available to prove this. The importance ofeducation was very well emphasized by Dr. Without going into the statistical details, thereShahani, in his speech. I would like to quote exists an uneven distribution of healthcaresome of the statistical data provided earlier by expenditure between urban and rural areas. Inhim which brings out a stark reality in India this context, I would like to share a personaltoday. experience. I come from Punjab. The economic conditions of Punjab are considered Infant Mortality Rate (IMR) is 50% higher in better than several other states. CMIE has rural areas than in urban areas continuously rated Punjab’s infrastructure as the best in the country. Despite the economic Children whose mothers have at least 10 well-being, the need for affordable healthcare years of education are twice as likely to remains an issue. I once enquired with a survive than children whose mothers are commission agent, also known as RTI agent, uneducated responsible for marketing of agro-produce, what has he experienced with farmers. His Only 23% of women take folic acid, which response was, farmers having greater than 10 incidentally is available for free acres don’t come to him, while farmers owning less than 5 acres line-up outside his house. Significant number of deliveries takes place These small acreage farmers come to him to at home despite having schemes like get their children treated in hospitals. They Janani Surakhsha Yojna, a safe have limited options when somebody falls ill in motherhood intervention under the National their family. Rural Health Mission (NRHM) being implemented with the objective of reducing maternal and neo-natal mortality by 19
  20. 20. The out of Pocket expenditure on health in the weighing all possible scenarios and is likely tocountry is close to 75% of the total healthcare come up with a decision on low cost drugs. Inexpenditure. According to NSSO, one out of order to ensure a happy and healthy India,three people who are hospitalized are forced to essential medicines should be made availableborrow money or sell assets to pay for the to the poor and vulnerable section at anexpenditure. The survey also points out that affordable price. The formula for pricing thatbecause of high OOP expenditure; 20 million the government comes up with would beIndians are pushed below poverty line every balanced keeping in mind the interest of theyear because of loans. An even graver industry and the concerns of healthcare inconcern is the unreported ones who can’t even India.borrow money. Not many people would bewilling to lend to these people. In addition to I recognize the efforts put in by many of youthis there is prevalence of gender bias, where here in order to ensure that innovativewomen and girl children may not be given the products drugs reach the poor at an affordablesame priority in a family when it comes to cost. My request to you would be to enhancehealthcare. the initiatives such as differential pricing in areas with no accessibility, ensuring reach ofThese are some of the major barriers impeding innovative products in the interiors of thethe access of healthcare in India. In order to country, improving clinical awareness,overcome these barriers, I feel that everyone, improving reach of basic primary healthcare byboth government and private, should work utilizing the qualified manpower, increasingtogether and contribute towards improving the awareness through use of multimedia likehealthcare in the country. television and radio. Some of the initiatives like the programs aimed at improving medicalThe government understands the need to education and capacity building areimprove the infrastructure in NRHM and commendable.realizes that the initiatives may not lead todramatic changes in improving access in a Another pressing issue that has come to ourshort span of time. Some of the initiatives notice is the presence of large number ofinclude - up gradation of the PHCs (Primary unnecessary drugs variants available in theHealth Centers) to make them 24x7, up country. This seems to be an issue gaininggradation of CHCs (Community Health prominence and which is quite evident from theCenters) in order to bring them at par with the fact that one finds this concern documented onIndian Health Standards, recruitment of ASHA the approach paper of the planning(Accredited Social Health Activist) workers, commission.doctors and nurses and proper utilization of thereferral units. There are an increasing number of innovations related to healthcare and sanitation that oneI feel that apart from the initiatives of the comes across. Although these innovativegovernment bodies there is a lot that can be products are sometimes cheap there is anachieved by innovation. Innovation in issue related to the adaptability of thesetechnologies and pharmaceuticals and products. A recent example being the Bio-innovation in administering of drugs can help digesters, eco-friendly toilets designed bylower cost. Although low cost generics are not DRDO (Defense Research and Developmentthe only solution to improving access, but this Organization) for the rural poor, which convertis a sensitive issue. Hence the government is human waste into usable water and gases in 20
  21. 21. an eco-friendly manner. The effluent from Gurdaspur, Commissioner, Patiala Division,these bio-digesters is odorless and harmless Director of Industries, Member (Finance) of theand can be used for gardening and irrigation. State Electricity Board, State Excise andThese are mostly pre-fabricated structures and Taxation Commissioner, Secretary (Science &are easy to install in any terrain. As a pilot Technology) and Finance Secretary of theproject these bio digesters would be launched State of Punjab. He has also served as Seniorin 300 gram panchayats this year. I feel that, Adviser in the Planning Commission betweenIndia needs millions of these systems in order 2008-2010 where he was in charge of theto improve sanitation. Another interesting Industry Division and of Development Plans ofinnovation is the phone based screener, a the States of Jammu & Kashmir, Himachalprick free system for detecting and reporting Pradesh and Uttarakhand. This exposed himanemia, costing around USD 20. Dr. Reddy in not only to the issues involved in developmenthis speech has pointed out many such of industrial sector, including pharmaceuticals.examples. There is a need to facilitate the He was appointed Secretary, Department ofadoption of these innovative technologies and Pharmaceuticals in the Government of India inproducts in the healthcare system. Even the January, 2012.flagship programs of the government like theNRHM need to evaluate and incorporate theusage of such tools in our country.Going forward, I hope the initiatives by thegovernment succeed and the targets areachieved. The government plans to spend INR27,000 crore on free medicines and increasethe expenditure on health sector to 2% of theGDP. The department of Pharmaceutical isplanning to re-launch the Janashudi scheme.DOP is committed to work in collaboration withthe industry and strive to move in a direction ofbetter health and better sanitation for thecountry.*Mr. Dilsher Singh KalhaMr. Dilsher Singh Kalha is an Officer of theIndian Administrative Service. He received hisschooling at the Doon School, Dehradun, andobtained Masters degree in History from St.Stephens College, University of Delhi. He wassponsored by the Government of India toAustralia to pursue Masters degree inBusiness Administration (MBA).Mr. Kalha has worked in various capacities inGovernment of Punjab and Government ofIndia. These include District Magistrate, 21
  22. 22. World Health Organization Perspective Dr. (Ms.) Nata Menabde* World Health Organization – India Representative I am very pleased to have aspects that can and should be improved an opportunity to speak within the health system itself. before you today. The topics that we are We need to take a balanced approach. On one discussing today are not hand let’s properly deliver from within thenew; they are strongly emerging and taking health sector and on the other, use the toolsgreat importance in the public debate, both in and mechanisms of governance to reach out tomedia and very importantly, at various levels of those other sectors which can contribute andthe government. Today, this conclave brings add value to the progress in health systemmuch closer the views of the private sector, outcomes.public sector, government and service I want to briefly share with you the Worldproviders across this country. Health Organization’s framework for the healthI have taken up my job in India less than 2 systemyears ago and indeed I have seen manygatherings which were, perhaps, less inclusivein terms of representation of different sectors,public and private.The previous speaker, the Secretary of theDepartment of Pharmaceuticals, hasappropriately pointed out the presence of alarger representation of government membersin this conclave. I think the reason for so manygovernment and/or public sectorrepresentatives being present today is acommon understanding that governancematters; and it matters increasingly as What it shows is that, there are a number ofgovernment takes seriously its role in looking inputs which need to go in the health systeminto issues such as access and reach. for it to perform its core functions. The WorldThere is the issue of a holistic approach to Health Organization considers four aspects:access and health improvements and it goes governing the system, generating necessaryfar beyond the health sector itself. We are resources at various levels to run the system,increasingly trying to reach out to other sectors producing services with the use of thosewith implications on health outcomes. resources and, very importantly, financing theHowever, I think it is premature to conclude sector. Financing does not only mean makingthat unless other sectors do their job, the money available but also managing that moneyhealth sector cannot improve its own in a way that can produce good qualitydeliverables and outputs, for there are multiple services. Then, through various issues and intermediate systems outcomes such as 22
  23. 23. improved access, improved continuity of care response initiatives many of which areand improved quality of care, we can achieve currently taking place in India.the main outcomes of the health system. It is only with a combination of the necessaryAlthough “improved health for all people” is a resources, technology, staff, and difficult policymajor goal of any health system, there are two decisions that the performance of the systemother aspects which are equally important if not will improve. This should hopefully bring aboutmore important. One is: “Responsiveness of easier access to services, better quality ofthe system to people’s needs”. This is a very services and an important emphasis on equity,important non-medical dimension of health which is another fundamental cross-cuttingsystem outcomes which is not always looked principle of the World Health Organizationsat very carefully. This is evident from the health system framework along with theexamples highlighted earlier today that those dimension of higher system efficiency. Thisissues should not be underestimated and, chain of interrelated activities will have thealthough we have to build awareness, we also greatest impact on health.have to hear and understand what is it thatpeople need? And how can we improve their There are various dimensions of access, and Iinteraction with the health system, so as to would like to highlight some:meet their expectations. As far as the World Health Organization is concerned, effective and equitable “populationThe other goal is “financial protection”. And coverage” is a single most effective strategicthat is, in the World Health Organization’s intervention, since it derives from human rightsview, protecting people from catastrophic and equity principles, which are fundamentalexpenditure and from falling into poverty when for the functioning of any modern society.they get sick. Financial protection is not just ameans to health improvement, but it is put in its Indeed, the breakthrough report on Universalown right as one almost equal objective of the Health Coverage (UHC) led by Dr. Srinathhealth system. So improving just health Reddy has made a historical shift in India’sindicators is not good enough - financial thinking in this area. Although we are still a bitprotection also must be improved. And that far from achieving the UHC goals, havingshould be done, amongst other things, also framed such an explicit analysis of challengesthrough “efficiency improvement”. that we face and possible solutions is already helping in organizing and mobilizingIf we translate it into the Indian context, the communities, systems and sectors to think howgovernment has to look at not only how to they can best contribute to this important goal.provide financing but also at how to make thefinancing effective in reaching desired health There are several factors that influencerelated and other goals of health system. access, such as “geographical factors”, “cost sharing arrangements” and others, and, as Dr.The finances should not only be used to Devi Shetty often says, even if governmentdeliver necessary services to people who need financing is increased, it may not be able tothem, but also to ensure that those service pay for all what Indian people need, thereforeenvironments are fairly regulated and that they “low cost-sharing arrangements” have beenare supported by solid planning and not just proposed as a solution. But given diversity ofemergence of some brilliant, but often adhoc India, this needs to be debated as various arrangements could be considered in various 23
  24. 24. contexts within India. Also, adequate choices There is therefore vast scope to increasebetween the providers need to be made public financing for health and we are hopeful thavailable - this requires an adequate regulation that this impetus will come during the 12 fiveand enforcement of the service quality and is year plan and in further governmentlargely a role of a government. plans. Already, there has been quite a strong commitment expressed by the governmentThere are various “organizational barriers” to regarding increased public allocation foraccess and there are “preferences” of the health, but let us also be aware that thepopulation, who choose where they go and inspiring, almost double digit economic growthseek services - markets develop along with of India over the last decade, which hasthose preferred choices. So on one hand, brought India to one of the 10 largestsystem has to respond to these choices and, economies of the world needs to be sustainedon the other hand, one has to think whether and there are challenges to overcome such asthese choices are the most rationale, efficient, lack of infrastructure, lack of humanof best quality and how to influence the resources, bigger macro-economic issues thatbehavior and choices of the consumers while need to be addressed through effectivemeeting their expectations. government policies. However, increased public financing will not solve all the problems immediately, since making money available is not the only solution, there are many other interventions that are necessary. If we look again at India’s total health expenditure, as a percentage of GDP (which includes public and private expenditure), it is not too low in absolute terms. So, we are not talking about India not spending money on health; we are talking about this expenditure largely falling on the patients in a form of anIf we look at India’s public spending on health out-of-pocket expenditure. But, the challengeamong 190 countries for which data are is, at present, that these out-of-pocketavailable, it ranks low by any angle you want to expenses correspond to nearly 80% of India’slook at it (World Health Statistics 2012, WHO); total health expenditure. General government expenditure on health Although the public expenditure on health is as % of GDP: 1.3% (Rank 178); increasing and developments are happening Total expenditure on health as % of GDP: through various government initiatives (I very 4.2% (Rank 168); much agree that the government is actively driving in many directions today), still there are General government health expenditure as issues which are challenging and have great % of total health expenditure: 30.3% (Rank impact on health, such as some primary health 174); care centers and sub centers having Per capita government expenditure on inaccessible roads, shortages of electricity, health: 38 PPP int. $ (Rank 160); 24
  25. 25. irregular supply of water and lack of telephone Norway, not a member of European Union,and computer facilities. had its own policies and until few years back had only about 2000 products authorized on itsThere is also a shortage in the number of market. This was achieved through applying ahealth personnel available at primary health so called “need” clause (so that each time acenters and community health centers. We can pharmaceutical company applies fortalk about these numbers at length, but we marketing authorization, the regulatoryultimately need to see the impact of authorities would assess whether the productimplementing some major policy decisions, is really required or not - are there alreadysuch as establishing medical colleges, and other products with similar effect on the marketthese cannot be simply left to the private sector or noted.). So Norway would not have, forto address. Having said that, there are some example, 50 brands of Paracetamolpolicies which are encouraging, for example, authorized on its market, This used to be adevelopments in tackling health personnel very powerful clause and health of Norwegiansissues - this is one of the crucial factors which was not less good when compared to Frenchwill have a great impact on the future of India’s or Danish populations where such limitationspopulation and their health. for market entry did not apply. Evidence shows that there is no direct correlation between theIt is that in India we are facing a double number of products circulating in the marketepidemiological burden of communicable and and the number of medicines prescribed pernon-communicable diseases (NCDs). NCDs patient and corresponding health outcomes.have now become a serious challenge and So, one can look at all the possible strategiesnumbers are growing not only in urban areas to reduce the number of products in thebut also in the rural sector. Many of these are market, without causing direct effect on diseases and we are very much At the same time we must be careful inlooking at how to address these through both interpreting such evidence as health outcomespharmacological and non-pharmacological are not just a result of use of pharmaceuticals,therapies, and, very importantly, through but we have to look also at other determinantseffective disease prevention policies in India, of health. Furthermore, there is a scope ofwhich, at first sight, may not always be in the looking into drug use practices, such asinterest of pharmaceutical manufacturers. whether medicines are prescribed properly,But pharmaceutical manufacturers also want to whether antibiotic resistance is growing etc.have a healthy nation and environment to In any case, unfortunately for all of us, healthoperate in. I think this requires very close promotion will not solve all issues very quicklycollaboration, common understanding and a – it will take time. Pharmaceutical markets indialogue on how to advance health promotion emerging countries are growing now and willand disease prevention measures. be growing in the years to come. So there isAs has been mentioned today, a long list of going to be higher consumption, but it will alsopharmaceutical products is available on the increase the burden in terms of cost of healthmarket in India. In this context, I would like to system while we still need to find answers todraw your attention to some other several issues: hunger, malnutrition, routinepharmaceutical markets, for example, of immunization coverage of children etc.Norway. Furthermore, there are multiple additional barriers in terms of access to medicines: 25
  26. 26. pricing, financing mechanisms, neglected greater than 50% savings can be achieved bydiseases for which necessary medicines do not using generic alternatives. However, our studyexist but also the irrational use of medicines, has several limitations and is notlack of adequate regulations and guidelines comprehensive. Nonetheless, explicit genericand lack of properly functioning bodies in terms policy is important to ensure a better access toof accreditation of services or ensuring proper essential pharmaceuticals.prescribing practices. Barriers also includeunreliable supply systems, inadequate So, there are various mechanisms, whichinfrastructure and logistics for supply of could be used for reaching universal healthpharmaceuticals. coverage, and as Dr. Reddy and his team have highlighted, the first winner could be inYou would agree that India is the world’s pharmaceuticals area.generics pharmacy. In fact, within the WorldHealth Organization’s “Pre-qualified” product Then there is also the issue of Foreign Directlists (which are supplied through international Investment in the pharmaceutical sector. I amdevelopment assistance mechanisms) Indian sure you will be discussing this somewhereHIV medicines have largest share (72%). today because there has been a recent rulingSimilarly, India keeps a rather large share of on this, and I know that the Organization ofTB products in WHO’s prequalification Pharmaceutical Producers of India has notprogramme (35%). been very welcoming this decision for a variety of reasons, but we have to also assess whatWhat this indicates however, is that there is a are the benefits and risks here and there arelarger scope yet to be reached in many other hopefully some benefits too, in terms ofareas, such as non-communicable diseases, in protecting India’s generic manufacturers. Butwhich India could step in within years ahead? one has to look very carefully how this rulingThere is a large scope for generic markets not will be applied because it will be dealt with on aonly in India but worldwide - in the US, rate of case by case basis.generics coverage is as high as 78%, in Brazil:63% and in South Africa: 71%. However, the And then there are issues of price control andtime to market for generic product after the regulation - we have heard already today aboutpatent expires varies from country to country. the ongoing debate. It is not clear as to whereSo, whereas in the US it would take 6 months, it will end up, but it has to end up in the areain many European countries for most products where the reasonable compromises are beingit will take much longer before the generic made, so that Industry is not put in conditionsproducts reach the market. Market after patent where it cannot anymore operate, cannot doexpiry varies greatly with high priced branded research, cannot make investments in itsgenerics often taking market share. This development but also such policies shouldpresents a great opportunity for Indian generic ensure that people do not die because theymanufacturers to export if they meet cannot afford necessary medicines. Andinternational quality specifications consistently. sometimes this is a choice between death, impoverishment or survival. So it is not and itAccording to a study we have conducted in 17 cannot be looked at only from the perspectivecountries, where we surveyed some of the of profit margins for pharmaceutical industry.products to estimate what would be the We have to recognize that this high out-of-economic impact of switching from the pocket expenditure on health care andoriginator brands to generic alternatives, medicines is a very prominent characteristic of 26
  27. 27. middle and low income countries. The Now, more has to be done, it has to be done incountries that are economically affluent do not a better way. However, this is not so simpleaccept that people have to make such choices; and we all bear the responsibility to contributeinstead they regulate, reimburse, have and help in this very important agenda for thegovernment systems, have Universal Health benefit of India’s people.Coverage schemes and protect their peoplethrough various mechanisms. So, in a way, low Thank you very much.and middle income countries actually puthigher economic burden on their populations *Dr. (Ms.) Nata Menabdefor health care. This is a general trend whichhopefully will be improving in India as it moves Dr. Nata Menabde is WHO representative toon with Universal Health Coverage. India. Prior to taking up her current job Dr. Menabde has worked as Deputy RegionalMoney availability alone is not going to resolve Director of the WHO Regional Office forthe hurdles of Universal Health Coverage. It Europe. She has led WHO Regional Officeshas to be supplemented by various health work on Health Systems and their relationshipssystem interventions as highlighted in the with health and wealth which culminated in adoption of Tallinn Charter on health systems.beginning of my speech, but also through Dr. Menabde has successfully partnered withaddressing social determinants and other key stakeholders such as the Council ofhealth determinants such as environmental Europe, the European Union, the Europeanones and others. Commission, UNICEF, the, World Bank, OECD, the Global Fund, the EuropeanWe have recently launched with the Investment Bank and others to increase theGovernment of India, the World Health effectiveness of WHOs work.Organization’s new country corporationstrategy for the next 6 years through which wewill be very closely focused on supporting theUniversal Health Coverage agenda. The WorldHealth Organization will provide support onstrengthening information systems, evidencegeneration, policy analysis, linking private andpublic sector contributions, facilitating andconvening various stakeholders and severalother selected areas such as quality andaccreditation of health services.Despite all the challenges I spoke of andhighlighted today, I want to mention that theIndian government has made very impressive,historical health policy and political decisions inthe recent past. The government is doingextremely well in terms of pushing healthagenda across other sectors and has alreadyimplemented several major successfulinitiatives such as the National Rural HealthMission and many others. 27
  28. 28. Keynote Address Dr. K. Srinath Reddy* President, Public Health Foundation of India Good morning ladies and century, when the Bismarckian reforms took gentlemen. It a pleasure place in Germany, principally propelled by and a privilege to be here, some of the social ferment that was unleashed particularly to have been by the work of Rudolph Virchow and others. preceded by three eminent Chancellor Bismarck, a smart strategist,speakers, who have already detailed the need recognized that the protection of the health offor focusing on improving access to healthcare the people was integral for growth of theas well as the quality of healthcare in India. economy in Germany. It was important fromPart of my presentation will be repetitive but the point of view of not only the industrialnevertheless may help to underscore the key production but also the army. Hence, apartmessages that have already been from some of the social ferments that wascommunicated. taking place in Germany, the economic and the imperial aspirations of Germany were amongClearly, it is important that OPPI devotes its the principal reasons to start the movementattention and efforts to improve access and towards Universal Health Coverage.reach of healthcare and also promoteinnovation in healthcare so that the health The Beveridge model that came in United thindicators in India improve and improve across Kingdom in the 20 century led to theall sections of our society. But as Mr. Kalha formation of the National Health Service. Sinceand Dr. Menabde have clearly emphasized then several countries have embarked uponthat we need to think of health beyond the path to the universal health coverage. Wehealthcare. Since multiple determinants of now have varying models across the world tohealth exist, we need to try and address each pick from and to choose some of the betterof these determinants. I am in unison with Dr. elements to see how best we can craft themMenabde that if we look upon this as a nation into our own model as we develop it. Severalbuilding effort rather than just the task of an low and middle income countries have nowindustry to advance its own objectives, then I moved swiftly towards Universal Healththink OPPI would find it very convenient to also Coverage, having already accomplished 100%enter this space of health promotion and look coverage or reaching very close to it. Forupon it as part of extended responsibility for example, Mexico announced at the end of lastimproving healthcare in this country. year that they had attained 100% universalNevertheless, I will focus this presentation on coverage. China has attained 96% coveragehealthcare because this will detail some of the and is proceeding to attain 100% coverage thisrecommendations that we have made to the year and South Africa too is well on its way. InGovernment of India (GOI) and the planning our region Thailand and Sri Lanka have beencommission in our report on Universal Health among the important leaders in this segment.Coverage (UCH). At the time of Independence, India started off with a vision of Universal health coverage,The path to universal health coverage opened spelt out very clearly in the Bhore report and thup at least two centuries ago in the 19 also adopted the egalitarian objective. The 28
  29. 29. Indian government and the Indian constitution community-based caregivers. This ishave subsequently faltered to some extend in underscoring the huge health workforcedelivering on that promise but they are now crises that we are now experiencing not justrededicating itself to that vision and in India but in many parts of the world.commitment this year. Pharmaceutical products do have a veryIt has now become imperative for global policy important role to play in this journey towardsmakers, not only within the health sector but Universal health coverage because people dofrom other sectors to look at the need for need medicines at some stage of their life.addressing universal health coverage. Laurie Mexico, as I mentioned earlier, has alreadyGarrett in the introductory section of the report achieved Universal Health Coverage. In termsrecently released by the Council on Foreign of the coverage part of it, the Mexican HealthRelations of the United States, on Universal Minister declared a few months ago that by thehealth coverage talks of global health’s three end of the previous year every single Mexican would have access to the medical care and more than 106 million Mexicans would be receiving healthcare through public financing. But the interesting part is that the Health Minister said that government is investing 3.5% of the GDP or 32 billion USP spending in the public health sector in the fiscal year of 2011-2012, of which 30% would be used exclusively for medicines given free of charge. So the interesting part is that, although there is a clear emphasis on public financing as a goal of universal health coverage, there is also a great emphasis on the supply of essential medicines free of cost as an integral first stepoverreaching needs: at achieving universal health coverage. At the same time Spain, which was on the brink of a Health financing schemes that cover the major financial crises, which unfortunately costs of care without putting health continues even now, announced that they were consumers, governments, or providers at shifting to a policy of complete prescription of risk of bankruptcy or severe economic generic drugs only across the country and hardship estimated that they would save 2.5 billion Euros by shifting to that particular policy. So Systems of health-care delivery that can there is a clear understanding by the global absorb the many now-fragmented services policy makers that in terms of the economic and provide accessible treatment and environment one has to look at healthcare cost prevention universally to those in need and within the context of healthcare cost one A health-care workforce worldwide that has to look at the availability and pricing of should be at a minimum five million persons pharmaceutical products. larger than it is currently, that displays a India has had much to be proud about in terms deeper range of skills, and that features of its health gains since independence. As the greater attention to health management and health secretary has pointed out in recent 29
  30. 30. years we have accelerated that progress. - Tobacco related deaths are at least 1Nevertheless, there are still several areas of plus in million and is currently estimatedconcern which we must remind ourselves of, if to be about 1.2 in a million. These arewe have to really look at the appropriate likely to rise to 2.4 million by and implement them effectively. If wecompare ourselves with our own neighbors, Sri Some of these deaths due to chronic diseasesLanka and Thailand, our Infant Mortality Rate are occurring because a variety of risk factors(IMR) was 50 when Sri Lanka’s was 13 and are combining to kill Indians much earlier asThailand’s was 12. Even the under-5 mortality compared to the western population. Forrate in India compares very poorly with Sri example, the first heart attack occurs about 10-Lanka and Thailand. When we look at the 15 years earlier in Indian population aspercentage of children fully immunized, it was compared to western populations. and since a66% in India when Sri Lanka, even at the large number of deaths occur below the age ofheight of its civil conflict achieved 99%. 64 years, if you consider the age range of 35 to 64 and look at the number of prematureIn terms of the current health scenario, we cardiovascular deaths that have occurred, andhave recently recorded in a major survey that- are likely to occur, India lost about 9.2 million potentially productive years of life due to 42% of our children under-5 years are premature cardio vascular disease in the year underweight, which the Prime Minster 2000. And we will lose close to 18 million by termed as a national shame. year 2030. This is about 570% more than the United States in year 2000, and will be 900 The current infant mortality rate is 47 per percent than the U.S. for that age band in the thousand which has certainly started year 2030. No country which aspires for declining since NRLM(National Rural accelerated economic development and Livelihoods mission) but still needs to positions itself as a potential economic power accelerate in terms of its further decline of the 21st century can afford such a hemorrhaging of human resources in the Maternal mortality ration (MMR) is about productive prime of midlife. 212 per 100000 live births and there is a challenge to meet the national goals that The health inequities that exist in India are also th we have set for ourselves in the 12 plan appalling. A girl baby born in Kerala is 6 times period by 2017. We have to achieve an IMR less likely to die before her first birthday than a of 27 and an MMR of 100. girl baby born in Madhya Pradesh. Similarly, neonatal mortality rate varies from 11 per 1000 We have multiple burdens of disease that in Kerala to 53 per 1000 in Odisha. Same are competently challenging an under country but different fate! This health inequality resourced health system. is reflected not only across states, but within - In 2011 it was estimated that we have states between urban and rural areas, across about 61 million persons with diabetes income strata, education strata and across and is estimated to rise to about 101 gender and caste strata. million by 2030. If we want to look for a compelling reason for - Clinical Hypertension was about 130 why Universal Health Coverage urgently million in 2011 and likely to rise to 240 required by India, we can look at the data from million by 2030. 30
  31. 31. the National Sample Survey, published in2006. 28% or rural residents and 20% of urban residents had no funds for healthcare Over 40% of hospitalized persons had to borrow money or sell assets to pay for their care Over 30% of hospitalized persons fell below the poverty line because of hospital expense There are also large interstate differentials inPart of this, is because of the low priority public spending. In terms of public spending onaccessed to health in our overall envelope of health, Kerala spends about 3 times more thanpublic financing. Our public financing is fairly Bihar. And it is not surprising to see that wehigh when compared to other countries, but the find this reflective in the different levels ofproportion allocated to health has been immunization in these states. Tamil Nadu doesconsistently low, and therefore as a percent of a little better than the projected amount itGDP, we compare poorly with Sri Lanka, China spends because it has a sturdy system forand Thailand. This is also reflected if one looks delivery, whereas UP does even worse in itsat per capita expenditure on health; there is a allocation for health because of poorsubstantially lower expenditure on health in governance. So there are a number of factorsterms of total expenditure. When one looks at but public financing of health does matter.per capita public expenditure on health, wherethe government is contributing, there again onesees a huge disparity that occurs betweencountries like Sri Lanka and Thailand, andIndia. Our expenditure on health lacks farbehind. If one looks at the high burden of out of pocket expenditures, India has a very high burden, variably estimated from 70% to 80% over the years. The planning commission currently says it is 78% but nevertheless, it is outrageously high compared to many other countries. If you look at the contributors to out of pocket 31