India’s Prime Minister Dr Mammohan Singh

“Good health is one of our basic needs” said India’s Prime Minister Dr Mammohan Singh in his speech on the last Independence Day (15 August 2009).

But this basic health need is denied to the millions of those disadvantaged in India. “India is fifth from the bottom in the world if we look at the government expenditure on health,” said Dr Amit Sengupta from People’s Health Movement (PHM) and All India People’s Science Network, at a meeting in Delhi recently. With a battery of vertical health interventions and research, funded by sources other than government, sustainability is undoubtedly of key concern.

Those who are dealing with most preventable causes of diseases, disabilities and deaths on daily basis, are slipping farther away from accessing the existing healthcare services as a direct impact of neo liberalization and globalization policies which India is aggressively pursuing, including and not limited to, the range of free trade agreements (FTAs) India has entered into or negotiating with countries – that in effect – are likely to take away access to seeds, health, livelihood and dignity from the most underserved communities. Is this the way India is going to ensure every citizen has good health?

According to a report by Asian Development Bank (ADB), 41.6% Indians live below poverty line and the income gap between the rich and the poor is widening as a consequence of its “development” paradigm. Growing concentrated populations of people living in extreme poverty and hunger exist in India, in urban and rural areas both. In 19 Asian economies, including the most populous China and India, more than 10% of people live on less than USD 1.25 a day and more than 10% are malnourished.

With appalling health systems left to serve the healthcare needs of an increasing deprived population in urban and rural areas, Mr Prime Minister, how are we going to save these lives that, by the way, form the foundation of our production economy?

The skewed health priorities are obvious. Not to say that vertical health interventions are not adequately funded, but to argue that all health priorities – set by the people – should be optimally funded and addressed to make true the commitment of Manmohan Singh to ensure good health for all.

“There is clear evidence that public financing is critical for good healthcare and health outcomes in any country. Yet in India, only 15% of the Rs 1,500 billion healthcare sector is publicly financed. Investment and expenditure in the public health sector is shrinking” had said Ravi Duggal, in a paper published by Centre for Enquiry into Health and Allied Themes (CEHAT). “In a situation of continuing poverty, this can only lead to increased adversities in health outcomes” further adds Duggal in that paper.

When Mr Manmohan Singh became the Prime Minister of India in 2004, his ascendency to this office also coincided with the release of India Health Report (IHR). IHR was undertaken as a background study for the World Health Organisation (WHO)'s Commission on Macroeconomics and Health. According to the India Health Report, the biggest problems with the health system are the lack of government spending and the inefficiencies and misuse of the meagre resources that are available. It highlighted the importance of investing in health to promote economic development and reduce poverty. Extending the coverage of crucial health services, including a relatively small number of specific interventions, to the world's poor could save millions of lives each year, reduce poverty, spur economic development, and promote global security. Years since then, Mr Singh got the second term as Prime Minister and had made a commitment to achieve good “health for all” (by the way in 1978 India had committed to Alma Ata Declaration to achieve health for all by 2000, and miserably failed to keep the promise), yet the situation for the millions of people haven’t changed much.

No one should die due to entirely preventable causes like hunger, malnutrition, diabetes, chikungunya, malaria, polio, tuberculosis, HIV, diarrhea, dengue, influenza (about 600 die daily due to common flu), swine flu, and a range of other infectious and non-infectious diseases people of India are dealing with on daily basis. Add to this the other direct non-medical conditions that exacerbate the vulnerabilities of people to diseases, disabilities and deaths – poor infection control, lack of safe water, sanitation, and a complex matrix of other development indices.

For instance, the largest ever mass immunization campaign against polio since 2003 (and adequately funded), the war against polio isn’t over. Highest numbers of polio cases get reported from India even today. India not only is failing on polio immunization, it is also failing to provide routine immunization to new born children. According to the National Family Health Survey (NFHS) – III, the all-India average of children getting routine immunization is 43.5 per cent, which is a nominal improvement from the 42 per cent in the NFHS-II in 1998-99. It is clear that India is failing miserably to provide routine immunization to more than 50% of children even after 63 years of Independence.

Infant and maternal mortality rates continue to cloud the tall claims on health in India. There has been an increase in the number of pregnant anaemic women by 8% since the NFHS-II.

Take another example, which is probably as old as Independent India – the fight against TB after discovery of effective powerful anti-TB drugs in 1940s. Despite of global accolades and awards received by India’s Revised National Tuberculosis Control Programme (RNTCP), the number of drug-resistant TB cases is escalating – which according to the WHO is due to poor TB programme performance. According to the recent research published in the Proceedings of the National Academy of Sciences, drug-resistant strains of TB are just as likely to be transmitted between people as drug-sensitive TB, which could make drug-resistant forms of TB "highly prevalent in the next few decades". The study also found that 99% of patients who had anti-TB drug resistance, didn’t contract the drug-resistant strain as a direct result of treatment failure (so stop blaming TB patients) but as a result of transmission of drug-resistant TB from initial TB treatment failure of someone else. Treatment options for those with drug-resistant TB are seriously limited and it costs USD 7000 to treat a single patient. With India’s 1/3 population estimated to be living with latent TB, and alarmingly poor standards of infection control even in healthcare settings, Mr Prime Minister, I am wondering without radical people-centric healthcare reforms how else are we going to realize your statement?

We trust your intentions Mr Prime Minister, however the recent aggressiveness with which your government is pushing the negotiations for FTAs with countries, we honestly doubt the outcome. India is currently negotiating 19 regional trade agreements; four in the pipeline (China, Australia, New Zealand, Indonesia); 10 that have been concluded and at least 17 trade talks at various stages with US, Association of South East Asian Nations (ASEAN), Chile, Korea, among others. Such FTAs commit countries not only to fast-track liberalisation of trade in goods, such as agricultural, and fish products, but bring in new rules for trade in services, workers rights, etc. and stringent intellectual property standards that affect, seed uses, essential medicines and small scale industries. With access to food, livelihood, health and a life of dignity at stake of a large majority of our population, we are left with no clue how is Prime Minister Manmohan Singh going to realize what he has committed us with on the last Independence Day – good health for all?

The provisions on intellectual property rights in FTAs that are legally binding on India will jeopardize generic production of medicines and also the access of those who need these essential life-saving medicines the most. FTAs are also adversely affecting patents – and threatening to undo the gains made earlier by civil society on protecting generic production of essential medicines. Until 2005 India excluded pharmaceutical products from patenting (under 1970 Patents Act). However in 2005, the WTO TRIPS Agreement was fully implemented and medicines become patentable everywhere. India started granting product patents following amendment of the Patents Act in 2005.

“It is crucial for us to stop the FTA negotiations, because our lives are at stake. I know I might get arrested or injured in clashes with police, but we are all willing to face that, because we have more to lose if the [FTA] talks succeed” said a presentation credited to Loon Gangte, President of Delhi Network of people living with HIV (DNP+) and a board member of World Care Council (WCC) in Asia in a meeting recently (Loon was not present, his presentation took place with someone else narrating). “Essential medicines are not luxury goods, to be reserved for the wealthiest of the world but are too often priced like them, causing preventable suffering and death” remarked Loon's slides. The monopoly keeps prices high – essential drugs can be 100 times more expensive due to this monopoly of drug manufacturers.

These corporate led government negotiations in FTAs are further going to exacerbate the health crisis. The patent protection on medicines in developing countries shuts down domestic production of medicines which will clearly make healthcare inaccessible to the population that needs it most.

As per the WHO Global Price Reporting Mechanism, 92% of patients on anti-retroviral drugs (ARVs) in low- and middle-income countries use generic drugs mostly produced in India (2007- 2008). 92% of patients on ARVs in low- and middle-income countries use generic drugs mostly from India (2007- 2008). 67 % of medicines exports from India go to developing countries. Approximately 50% of the essential medicines that UNICEF distributes in developing countries come from India. 75-80% of all medicines distributed by the International Dispensary Association (IDA) are manufactured in India. Lesotho, buys nearly 95% of all ARVs from India. In Zimbabwe, 75% of tenders for medicines for all public sector health facilities come from India. All ARV medications (100%) supplied by India’s National AIDS Control Organization (NACO) come from domestic generic companies. This is clearly under threat if FTA negotiations go forward.

The stakes are high for people living with HIV/AIDS, cancer, heart disease, blood pressure and other chronic conditions whose survival depends on availability of affordable drugs. What happens in India will impact the whole of the developing and least developed world.

Rapid advances that India has reported in healthcare recently, sadly doesn’t reflect the needs of the underserved communities. It rather stinks of capitalism, sorry.

Take for instance, exponential growth of medical tourism – it had a market of USD 310 million in 2005-2006 with 100,000 medical tourists every year which is predicted to grow to USD 2 billion by 2012. India has also become the largest exporter of medical personnel in the globe – 41,000 trained Indian doctors work in the US! “Medical tourism and medical personnel exports are drawing away resources and personnel from providing health care for the Indian people” explains Dr Amit Sengupta. Making India the “basket case” in terms of Health Care in the World – with indicators now worse than that of Bangladesh and Nepal, it is clear that India is slipping further away from achieving what its Prime Minister has committed to weeks ago.