Düşünce ve Kuram Dergisi

Making wealth out of Human Misery

Bhargavi India

Impact and results on the individual and societies of pharmaceutical medicine, commercialization of health (the frame should be generally the commercialization of medicine in capitalist modernism)”

As the number of COVID-19 infections across India cross the 5 million mark, argued by many as very low estimate based on rare testing, what is becoming increasingly clear is 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. When India’s economy was liberalized in the early 1990s, a key concern raised then, and remains, is that the cause of the poor and working classes is not in focus. Health services and infrastructure in India has always been weak, and liberalization weakened it even more by privatizing health services. As a result, about 75% of India’s population which has no means to afford private medical services, suffer. Besides, access to public health services is rare in urban and rural areas, and increasingly so post-liberalisation.

The High Level Expert Group Report on Universal Health Coverage for India 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. 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.”[1]

The manner in which the pandemic is spreading across India is proof that none of these recommendations have been taken seriously, and implemented, 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, Kerala integrated these progressive proviso into its laws. Alongside, there was encouragement for a peoples’ science movement. All these have matured over the decades to provide the critical institutional infrastructure, public awareness and experience necessary to tackle the pandemic. Moreover, various progressive measures have been adopted by the Kerala Government, particularly when it has been led by the Left, and these are about food and other essential supplies are reached to everyone free when there is a public emergency, epidemic or pandemic, so none slept hungry.

For much of the rest of India, the story has been entirely different. The health indicators in the Bimaru states (echoing the Hindi word Bimar, meaning sick) as they are called – Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh, are amongst the worst in the world. Fertility rates are higher than the rest of India, and life expectancy is lower than India’s average. And there are districts within the other Indian states which rank amongst the worst health status of the world, for eg. Raichur in Karnataka state. Besides, in India’s metropolitan areas, the 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.

Aware of this abysmal situation, when Prime Minister Narendra Modi’s in a televised address on 24th March 2020 threw the entire nation into a lockdown, he probably knew that he had thrown the life and livelihoods of millions across India into a terrible chaos. His administration had ignored repeated calls from various public health networks and also the World Health Organisation on the importance of taking the pandemic seriously from January that year – India recorded its first COVID case on 30th January 2020. The Modi instead chose to ignore these warnings and instead focused attention on preparations to receive US President Donald Trump late February. This involved receiving thousands of US officials and international business people, along with large numbers of Non Resident Indians from Europe and USA traveling into Mumbai, Ahmedabad and Delhi to participate in an event called ‘Namaste Trump’.

The neglect did not end there. The Modi administration then focused attention on trying to win the Delhi elections, marked as it was by a brutal pogrom targeting Muslims and killing over 100 in the Delhi region. The administration was also unrelenting on withdrawing the controversial Citizenship Amendment Act, 2019 that treated Muslims as second class citizens, despite nation-wide protests. Instead, it targeted student groups with horrific violence. In addition, Modi’s political party, Bharatiya Janata Party, destablised the Congress party led Madha Pradesh government, causing its collapse, and ensuring BJP took power.

With all this going on, there hardly was any chance of Centre and State Governments focusing on necessary prudent steps that needed to be taken to contain the spread of the pandemic. It is hardly any surprise, therefore, that cities which were affected by these incidences are amongst the worst affected by COVID. Currently, the rates of spread of the disease are spirally, and the overall health situation is deteriorating.

When the lockdown country wide with brutal police force and without any preparedeness, it exposed the scales of unpreparedness and degrees of vulnerability across India. Public health facilities were quickly overburned and yet there was deliberate sheltering of private health care facilities. This has now 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, 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. Alongside, following over 60 days of complete lockdown, the country’s economy is wrecked, and this has sent millions of migrant workers from cities walking home to their villages, merely to survive.

The prevailing situation is terrible. However, it should not be the lens through which the country’s efforts on securing public health should be evaluated. For India has not been completely inattentive of its health needs and demands. Over time, India has been praised for its remarkable achievements in tackling infant and maternal morbidities and mortalities, and has also been incredibly successful in eradicating epidemics such as polio, measles, mumps, tuberculosis, etc. Why the country which managed well through decades of low economic growth in tackling epidemics, has failed so miserably despite recent decades of fast economic growth rates, an outcome of liberalization, needs serious enquiry. The answer may lie in the fact that the wealth creation 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 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 guarantees – be they as 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 chemicals in transit. In a similar way, much of the critically required drug discoveries and manufacture of life saving drugs were heavily dependent on imports at that time.

Noticing this critical lack, India advanced public funded public health research programmes. It also took steps to protect its home grown private pharmaceutical industries, especially by defending the Indian Patent Act 1970 which the transnational corporations wanted repealed, so that international pharmaceutical sector could enter India unhindered. 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. The National Drug Policy, 1978 along with the Price Control Order of 1979 were crucial to providing India’s pharma sector a major ‘directional thrust’ and 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]

Today, India’s public health research institutions are struggling to meet the challenge of developing a COVID vaccine. The reasons for these critical gaps aren’t difficult to deduce. India’s pharmaceutical industry took advantage of liberalization and expanded its innovation and production capacities to make the country a major drug producer. But profit has been a key motive, and this is evident in how the Supreme Court had to intervene in the Novartis case to ensure drugs treating cancer were not put out of reach of patients.

On the health services side, a massive infusion of capital influx into private sector led hospitals has made health care extremely expensive for the much of the middle classes and the poor. Doctors and nurses trained by 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.

That economic disparities and poverty has a direct bearing on health is well tartedat. Well aware of the disastrous consequences of expanding disparities in wealth gained and poverty, particularly in a country that had frequently suffered from famines and chronic persistence of hunger, India in adopting its Constitution in 1950 made a promise to citizens that economic progress should always be addressed in advancing public interest, that private gain and profit should never be prioritized. The structural adjustment policies of the International Monetary Fund and the loan packages of the World Bank, which helped spear-head economic liberalization in India, were undertaken without much debate. There were no safeguards protecting the large informal working sector. Mechanization and technological upgradation threw millions of workers out of jobs, even as labour rights 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 they couldn’t affort, and into economic distress eventually. Unprecedented in world history, farmers are committing suicides due to the prevailing economic distress. From the 1990s till now, over 400000 farmers have killed themselves as per the National Crime Bureau.

It was not as though the country did not see this situation coming. In fact when delivering the Republic Day address in 2000[3], then President of India, Dr. K. R. Narayanan had brought the harsh outcomes of liberalisation, and the following is an excerpt[4]:

“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[5] 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’.”

Economic policies over the past three decades have caused a major shift in health policies and reinforced privatization of healthcare at all levels. These have met with criticisms from the public health[6], farming and environmental movements[7] in the country, the health sector reforms, based on privatization of health care, was promoted by State Governments and the Centre across India. The increasing economic and political power of the growing middle-class population, which gained heavily from the growth and expansion of Information Technology and biotechnology sectors, and whose dreams were oriented by globalization processes, championed these shifts. A new concept evolved of upgrading hospitals in Bangalore, Chennai, Delhi and Mumbai to serve ‘health tourism’. When business interest took over, health sector also became a destination for global financial investment. This was considered as a positive and major contributor to the Indian economy and was even encouraged with subsidies and tax benefits. Public health care suffered, both in investment and attention, private sector health facilities gained massive support. Very soon, the financial methods that secured profits for private health care crawled into public hospitals by the introduction of ‘user fees’ and graded care with substantial technocratic interventions.[8] Such transitions to privatization of health care has happened with very little attention to standards and guidelines that are needed to secure public’s health.

Meanwhile, the restructuring and tartedation of critical public services, such as access to safe drinking water, to waste management, and also in foundational sectors such as energy production and electricity generation continued. With political parties participant in the this privatization epidemic, it was mainly left to civil society organisations and trade unions to raise awareness and concerns of the long term implications and to even fight such privatization ventures across cities and towns of India through rallies and campaigns, even litigations. About this time, concerns emerged about the challenges faced by disabled, queer and others marginalized on caste and religious basis. There remained a huge gap between WHO recommendations and what was implemented in terms of hospital protocols and more.*

With privatization came the public private partnership model of working, which transferred a large chunk of public health delivery into the hands of private players. The government lost focus on core sectors of health that needed attention, such as building Public Health Centres in every town, village and ward of major cities, and instead distracted itself with campaigns to build toilets, to make India open defecation free, packaged as Swachh Bharat Mission[9]. After decades of investing huge amounts of public monies into such campaigns, about 28.7% of rural households across India still lack access to any form of latrines.[10] 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 due to largely unregulated and untreated inflows of industrial and urban effluents.

A critical worry remains in the failure to augment primary health care services through substantial and systemic public funding. This has resulted in the rapid erosion of critical 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 new challenges. For instance, the insertion of intra-uterine devices has been encouraged but has failed due to a variety of infrastructural inadequacies and skills.[11] There are also instances when IUDs have been inserted in women without consent.[12] All this contributes to an erosion in public health centres, and a shift to reliance on private health care facilities, often resulting in a debilitating impact on families’ economic status.

This confusing scenario is enabling private hospitals to profit from trivial procedures to critical services. This is evident in a rapidly evolving health business, commercial surrogacy. Although legal in India, it comes with several challenges. While this has been advocated as a an economic alternative to a poor mother, the weakness in the law, and its weaker regulation of processes involved, allows middlemen and agencies to exploit poor women. During her pregnancy, the surrogate mother typically stays away from her family to avoid social stigma, during which time they also lack insurance and social support. The lack of attention to this growing ‘business’ raises serious concerns about the role of the State, along with various moral and ethical issues.[13]

The prevailing confusion In health sector reforms in India has caused the country to lag behind smaller neighbouring nations such as Maldives, Sri Lanka, Nepal and Bhutan. According to Madan Gopal, a Senior Consultant to India’s Planning body Niti Aayog, the National Health Policy 2017 does recognize increasing disparities in healthcare. In a paper[14] on the state of prevailing health care, he argues that “Quality is also a function of equity.” In an interview to a daily, he has said that “(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,” [15]

Clearly, financialisation 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 equipment and trained human capital from public to private health care. This has also had its impact on values and aspirations of professional staff moving away from the Hippocratic oath. Large health care corporations have strongly influenced the commercialization and turned India’s highly advanced hospitals into health tourism destinations.

The intense commercialization of health care has also brought in industries supplying health care inputs. There has been a surge in pharmaceutical and medical equipment industries. Everything from drug discovery to mass production of generic drugs, and the development of prosthetics and companies supplying orthotics finds a place in India. A number of home-grown pharmaceutical companies of the country today operate at international markets and have turned into multinational companies. With such intense globalization of these health related manufacturing sector, product development 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.[16] 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 scientific resource pool helped build one of the fastest growing and most robust pharma industry of the world. It was a preferred R&D destination for global companies, especially with an increasing demand and competitiveness in generic drugs. India accounts for 20% of global generic drug exports in terms of volume.[17] This talent pool helped build Indian companies, which now are acquiring various other local and foreign companies too. 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.[18]

The commercialization of the health sector has also resulted in the mushrooming of biotech companies, which are largely unregulated, both from the medical ethics perspective and also from economic and environmental impacts. For instance, a growing worry about such expansion of biotech and pharmaceutical companies, is the massive volumes of biomedical waste produced and the lack of systems and capacity to manage it.[19] Although the country enacted strict laws for biomedical waste management, there is little compliance. In addition, the biomedical waste has been commodified like other wastes and its disposal and management has been privatized. Weak environmental regulation raises many worries about the outcomes of disposal of the waste heightening environmental health risks, which is particularly worrying in the context of the COVID-19 outbreak.

With all this frenetic activity underway in the Indian health sector, traditional Indian systems of medicine, which includes Ayurveda, Yoga, Unani, Naturopathy, Siddha and Homeopathy (AYUSH), , has received marginal attention. There has been high volume of rhetorical support indicated by the Indian Ministry of Health and Family Welfare setting up a Dept of AYUSH. In 2014, the BJP led government even elevated it to a separate ministry and also doubled its budget. The number of colleges offering undergraduate and post graduate courses in AYUSH has increased, as have the number of hospitals. Besides, with Prime Minister Modi promoting Yoga, the United Nations has also supported the initiative with an International Yoga Day from 2015.

But the manner in which AYUSH is promoted has received a lot of criticism in the country, especially about the lack of empirical evidence that can be synchronized with prevailing western forms of medical research. There are also serious questions raised about its system of diagnosis and of proof of cure. Scientific and medical community has also dismissed it as pseudo-science, and unsparingly attack it as benefiting from placebo effect. Overall, the government appears to have encouraged the strengthening of such criticisms as 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, largely riding on its innate popularity amongst the India community. This has its risks.

Baba Ramdev, a popular yoga guru, tarted Divya Pharmacy. This was distributing herbal remedies, and with increased popularity rebranded it as an Ayurvedic company – ‘Patanjali’. From its inception in 2005, the company has been mired in controversy.[20] It has been accused of paying workers poorly, using dubious materials in its medicines, money laundering, tax evasion, violations of the country’s biodiversity laws and more. 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. While this received international attention, it also brought to focus Ramdev’s close relationship with Prime Minister Modi. In a matter of days it was revealed that the company had launched product without complying with any drug testing procedure, and risked civil and criminal charges. The narrative quickly shifted with the Union Health Ministry stepping in for Patanjali which now claimed CoroniI was an ‘immunity booster’, even as several State Governments have threatened legal action.[21]

The trivialization of the pandemic and its grievous impact is further evidenced in how country’s main medical and health regulator, Indian Council for Medical Research (ICMR), has claimed a private Indian company, Bharath Biotech, will produce the vaccine by India’s Independence day, 15th August this year. It directed about 18 institutions to ensure all systems are ready, volunteers recruited, human trials undertaken and results are produced for the launch of the vaccine, warning that failure to comply would be viewed ‘seriously’. The very fact that a procedure that takes extraordinary care, careful review of medical ethics, and also a massive and complex collation of financial, human, information and technological resources, which often takes a year or more, is sought to be achieved in a matter of weeks under the threat of penal action, is highly symptomatic of the rot that has 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.

 

Conclusion:

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 public health which demands high levels of rigour and review, transparency and accountability, both in decision making and also 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. Yet, as is discussed above, knowing well the consequences of neglect the Prime Minister led the country in distracting attention away from the impending pandemic earlier this year, and then employed harsh measures to contain the spread, and failed, exposes the problematique of the hollowness 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 now is in 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 recovery, something that most cannot afford. For the poor there the public hospitals which are highly stressed and unable to deal with the demands sick turning up, and forced to turn away those needed critical care. 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.

Meanwhile, the overall health situation in India is taking a huge back step as there is hardly any focus on securing children and mothers who need helps, or elders who need critical care. Public health systems are almost totally oriented to serving the political cause of addressing COVID pandemic and are unable to deal with infant, mothers, general patients and especially the elderly. 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 as they also do from the normative demands of public health of the wide public.

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 essentially of civil society, consumers and trade unions. This demands a return to the overall understanding of the nature of the economy, that capitalist liberalisation lacks humanity, and seeks profit from misery too.

***

 

 

[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]  India celebrates the Republic Day on 26th January every year.
[4]  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.
[5]  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.
[6] 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
[7] 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/
[8] Health care systems in transition III. India, Part I.The Indian experience. Imrana Qadeer, Vol. 22, No. 1, pp. 25–32
[9]  https://pdfs.semanticscholar.org/1ff5/b29efde1a76817b4e092cba1c1a5135a64ae.pdf
[10]  Is rural India 100% open defecation-free like Swachh Bharat data concludes? January 02, 2020 accessible at
 https://www.thehindu.com/data/data-mismatch-is-rural-india-100-open-defecation-free-like-swachh-bharat-data-concludes/article30460909.ece
[11] 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
[12] Prithviraj Mithra, At government hospitals, women being given IUDS without consent, Times of India, 22 Feburary 2018, accessible at: http://timesofindia.indiatimes.com/articleshow/63021211.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst
[13] 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/
[14] 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/
[15] 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
[16] India’s pharmaceutical research problem, Livemint, 15th September 2017 https://www.livemint.com/Opinion/m8uzYstgqiT1rOK1GUOnVI/Indias-pharmaceutical-research-problem.html
[17] http://www.ibef.org
[18] 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
[19] 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
[20] India’s Baba Ramdev Billionaire Is Not Baba Ramdev October 26, 2016
  https://www.forbes.com/sites/meghabahree/2016/10/26/indias-baba-ramdev-billionaire-is-not-baba-ramdev/#7d1d34512d2e
[21] 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

 

 


 

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