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HEALTH
SIR DORABJI TATA TRUST
PROMOTING
HEALTH AND
DEVELOPMENT
IN INDIA
V RAMALINGASWAMI
RANJIT ROY CHAUDHURY
HEALTH
SIR DORABJI TATA TRUST
PROMOTING HEALTH AND DEVELOPMENT IN INDIA
V RAMALINGASWAM1
RANJIT ROY CHAUDHURY
CONTENTS
Preface
5
I.
Introduction
7
II.
The Changing Scenario
8
III.
Principles Of The Strategy
9
IV.
Constraints In The Use of Research
11
V.
Programme Priorities
13
VI.
Conclusion
32
Abbreviations
Note on Authors
© 2003, Sir Dorabji Tata Trust
Published by Sir DorabjiTata Trust
Bombay House, 24 Homi Mody Street, Mumbai 400 001
Tel.: 5665-8282; Fax: 2282-6092/2204-5427.
Email: sdtt@tata.com
34
35-36
----------------------- P r efa c e----------------------Sir Dorabji Tata Trust, since its establishment in 1932, is guided by a deep sense of commitment
towards the country - with a vision for national progress. In 1999, the Trust commissioned a series of
strategy papers to scholars and experts whose mandate was to review the critical needs of the
development sector in India and discern the role a sensitive philanthropic organisation could play. The
process ofproducing these discussion papers was guided by a spirit ofexploration and identification of
what is best to give to the country in the fields of social development. The areas identified were
management ofnatural resources, livelihoods, education, health and social development initiatives.
The last paper included a number of sectors such as civil society initiatives, human rights, family
welfare, the physically/mentally challenged, art and culture and disaster relief. The overarching questions
that each discussion paper was expected to explore were:
®
How are perceptions/concepts in philanthropy changing? What is the perspective for the
future?
•
What, according to the academic and grass-roots perspective, are the needs in the different
fields? And what could be the new fields ofendeavour that could be explored?
•
How does one choose an area offocus from the vast range ofpossibilities within each field?
•
Within the chosen focus, what are the alternative approaches and what is the expected
impact of these approaches? Which type ofinitiatives should be selected for major support
and which should be given token assistance?
A strategic direction for grant making was to be proposed in specific sectors. The experts were also
to offer an opinion on how to respond to thematic issues in urban, rural or tribal areas; and suggest
measures to incorporate equity and gender concerns.
The Trust is happy to present some ofthese papers to a wider audience. Each of the sectors is vast
and although newer concerns will always emerge - because ofthe changing development contextthe papers offer valuable insights and a perspective for the future.
The strategy paper for the health sector was first commissioned to Professor 1/ Ramalingaswami.
He presen ted a draft in 1999, under three broad sections. Unfortunately, Professor Ramalingaswami
passed away before the paper could be finalised and after an interval Professor Ranjit Roy Chaudhury
was approached to assist with the task of finalising the strategy paper on health. His contribution
substantially complementsand brings uptodate the firstdraft ofProfessor Ramalingaswami.
Though the two papers were written separately, they have been integrated into one - co-authored
by two eminent health experts in the country. The bringing together ofthe two papers has necessitated
certain editorial changes.
We gratefully acknowledge the authors and the contributions ofalI who have assisted and enriched
the final publication of the strategy papers; in particular, DrJankiAndharia who put the two papers
together during her tenure at the Trust.
Sir Dorabji Tata Trust
Mumbai, 2003.
0
PROMOTING HEALTH AND DEVELOPMENT IN INDIA
I. INTRODUCTION
The status of health is an important indicator
reflecting social development and the quality
of human life. Further, health care is one of the
most basic human rights, vital for preservation
and promotion of health (Article 25 of the
universal declaration of human rights).
As a result of poor public health facilities
compounded by inadequate allocation, less
than 20 per cent of the population seeking out
patient department services and less than 45
per cent of the people who seek indoor
treatment avail of the services of public health
facilities (National Health Policy - 2002).
Consequently, people are forced to go to private
sector health providers where accountability
systems are weak or non-existent.
structuring, which are continuously being
reviewed and experimented upon by a variety
of civil society organisations.
Public participation, increasing democratisation, the growing awareness of governance
and civil society, the breathtaking advances in
science and technology and pressures to ensure
respect of human rights are important features
of a rapidly-changing world scene. This paper
on health is part of an overall strategy
encompassing many areas.
Several status papers and policy documents
brought out in the last two years have been
taken into consideration when framing a
strategy in 2003.
Some of these documents are:
The regional disparities and the rural-urban
divide in health care outcomes continue and
much remains to be done in the sector, which
from the state perspective, is resource starved.
Health care in a mixed economy is viewed from
two perspectives: Firstly as an industry within
the domain of the private sector. Secondly as a
• The National Health Policy of the country
issued by the Ministry of Health and Family
Welfare-2001.
service within the domain of the government
or the public sector. The meager government
spending is concentrated on secondary and
tertiary sector hospitals in urban areas and rural
• The policy of the Indian Systems of
Medicine in draft form issued by the Ministry of
Health and Family Welfare - 2001.
areas remain largely ignored in the country. A
sensitive grant maker must keep the larger
context of financial allocation to this sector in
mind as well as keep track of developments in
the delivery systems of health care and its
• The Pharmaceutical Policy issued by the
Ministry of Chemicals and Fertilisers - 2002.
• The National Population Policy issued by
the Population Commission of India - 2000.
• The Tenth Five Year Plan document of the
Planning Commission - 2001.
© A document prepared and released by
the Indian Council of Medical Research (ICMR)
titled Priorities in Health Systems Research and
Biomedical Research and Development and the
document Changing the Indian Health System
prepared by the Indian Council for Research
and technology and examine what promise they
hold for health and well-being. The impact
of economic liberalisation and globalisation
on equity and access, especially on marginalised
people; the effects of the forces of
'modernisation' and ill-conceived develop
on International Economic Relations (ICRIER).
mental activities on environmental degradation;
the changes in lifestyle, diet and behaviour; and
o The report of Jeffrey Sachs and the
Commission set up by the World Health
Organisation, in 2002. This is a valuable
the speed of travel and increasing urbanisation
document focusing on the need for more
resources in the field of health in developing
countries. Following the publication of the Sachs
Report, the National Commission on
Macroeconomics and Health was established by
the government of India in October 2003.
One of the authors (Professor Roy
Chaudhury), has been closely involved in
identifying priorities and in the preparation of
each of these documents. This experience has
been put into the writing of this paper.
are some of the factors that impinge upon
human health and are worthy of attention. In
this section, the problems relating to health
arising out of the unprecedented changes
taking place in society are highlighted.This is in
line with the spirit of a 'new social contract for
science'. The integration of natural sciences,
social sciences and the humanities is necessary
to cope with environmental degradation, social
problems, overpopulation, continuing poverty
and inequity.
Demographic Transition
India is in the process of passing through a
The paper is presented under six broad
sections.The first is an Introduction followed by a
brief presentation of the changing scenario.
Principles of the proposed strategy are described
in section III. Constraints in the optimal use of
research carried out in the country are presented
in section IV. Programme priorities are discussed
in section V under several subsections including
a range of diseases and issues of significance such
as medical ethics and leadership development in
the health sector. The paper ends with a few
concluding observations.
II. THE CHANGING SCENARIO
Overview
There is a need to periodically review the
changing socio-economic and cultural scene in
India, the developments taking place in science
0
demographic and health transition, as a
consequence of an increase in life expectancy
and the aging of the population. While some
infectious diseases have been brought under
control (such as polio, guinea worm disease and
leprosy), several existing diseases have shown a
resurgence such as malaria, tuberculosis (TB),
dengue haemorrhagic fever and kalaazar. New
and deadly infections such as HIV/AIDS have
emerged. As the infant and under-five child
mortality rate come down, more and more
people are living longer and the incidence of
non-communicable diseases such as heart
disease, high blood pressure and cancer have
increased. In fact, Asia, including India, is passing
through a hidden epidemic of cardiovascular
diseases.
Cancer has increased in prevalence as the
population ages. Certain types of cancers are
particularly common to India, such as oral cancer
and its relationship to tobacco chewing - an
area that the Tata Memorial Hospital (TMH) has
been addressing over the years.
To sponsor research on factors that promote
healthy aging is a worthy pursuit. It can be
related to diet, nutrition, physical activity,
infectious diseases and susceptibility to cancers.
A proactive approach to efforts that promote
healthy living in the aging population is
recommended. Problems in mental health and
behavioural disturbances could rise in the future.
The focus should be on community mental
health and community psychiatry. The National
Institute of Mental Health and Neuro-Surgery
(NIMHANS), Bangalore, has done pioneering
work in this area. In the area of'disability and
rehabilitation', the focus should be on low-cost
indigenous technology/devices for the
physically handicapped. Leprosy will continue
to need attention for some more time till the
backlog of leprosy-cured patients with
deformities can be rehabilitated.
The Human Genome Project
The Human Genome Project has recently
been completed with many participating
institutions around the world. It provides a
wealth of opportunities to design new
approaches to the study of the role of genetic
factors in diseases. India has considerable
strengths in genomic research and the Indian
Institute of Science (USc) in Bangalore has played
a leading role. The establishment at the USc of
the Centre for Research in Tropical Diseases, the
Tata Institute of Fundamental Research (TIFR)
and other government institutes could play a
critical role in the development, evaluation and
clinical application of advances in genomics.
These developments deserve special attention
so that they may look for strategic
opportunities to pioneer improved policies and
the practice of genetic science and the ethical
aspects thereof.
Surveillance of Diseases
Installing a national surveillance system for
diseases to provide early warning of impending
disease outbreaks and advanced preparedness
can safeguard the future health of humankind.
There is no area more critical for ensuring the
future health of the nation. Although the
government has accepted the report on a national
surveillance and response system prepared by a
group of scientists following the 'plague' outbreak
in 1994, a catalytic role can be played by a sensitive
grant maker in pioneering the development of
such a system in a phased manner on a pilot basis,
developing modules for replication. The Kerala
Initiative is currently in the offing and projects such
as this could be considered for support.
Health Implications of Large-scale
Developmental Activities
Well-intentioned, large-scale developmental
activities such as dams and irrigation systems,
buildings, roads and railways, often leave behind
an environment conducive to proliferation of
disease-carrying vectors unless they are
foreseen and acted upon for prevention. As a
consequence, outbreaks of vector-borne
diseases have taken place in the country. Malaria
is an example. The study of ecological distur
bances induced by developmental activity can
be undertaken by sponsoring pilot projects.
III. PRINCIPLESOFTHESTRATEGY
A strategic approach to grant making in the
health sector may follow a few broad principles,
which are presented in this section.
Build Selectively on the Investments
and Successes of the Past
In the first place, the idea must be timely and
fulfil a deeply-felt need.Then a leader with a vision
0
must be identified to implement the idea. A team
that works in harmony towards the stated goals
must be established. Mid-course corrections,
flexibility and sustainability must be ensured. A
philanthropic organisation has a critical role to
play in planting the seeds of new and innovative
institutions. The Centre for Research in Tropical
Diseases established in conjunction with the lISc
in Bangalore is an example.
Adjust to Contemporary Challenges
and Changing Needs: A New Paradigm in
Research
Any future strategy must make adjustments
to contemporary challenges and changing
needs. The new paradigm of development
research should reflect the following elements:
Focus and Connectivity: Should a
philanthropic organisation disperse its relatively
limited resources to support diverse, small-scale,
unrelated activities or should it focus on a
few development-oriented activities? Focusing
is the desired goal and connectivity of
areas such as health, nutrition, population
and environment should be recognised
in its programme selection (see Pattern
of Grants below). Compartmentalism must
replace integration and synergy for maximum
impact.
Monitoring and Evaluation: End-stage
evaluation and feeding the results to policy
channels, often neglected, are of crucial
importance. In most projects impact analysis is
generally weak including in the public-supported
national research agencies. Research advances
best with interdisciplinary and inter-sectoral
approaches. Social and behavioural sciences
must increasingly interact with biomedical and
health sciences to facilitate application of research
results for human betterment. Monitoring and
evaluation must be an integral part of all projects
supported by a grant.
Community Involvement: In field projects
the community must be actively involved at all
stages including the early stage of goal-setting
right through to the concluding stages
Participatory research is essential for maximising
the outcome of research and its sustainability.
An informed public opinion in matters of health
and disease facilitates the application of
research results. Enhancing public understand
ing of science and community participation in
planning, execution and evaluation of projects
are key to sustainability.
Pattern of Grants
One approach to grant making is to follow a
dual policy of providing medium-sized grants
to a few selected institutions, while the majority
of grants should be small scale, responding to
acutely-felt societal needs over a wide field. An
alternative might be to introduce a different
approach in a phased manner, not all of a
sudden. This would involve setting goals and
priorities, and increasing the size and duration
of the grants to the selected priorities to
demonstrate an impact; and gradually
reducing the number of small grants but not
abolishing them altogether. A philanthropic
organisation should be able to respond to
small but acute needs over a wide front. Such
small grants should not be construed as
'promotional' charity. A formula of 90:10 or
80:20 might be suggested for the relative sizes
of the two types of grants.
Human Capacity Building
Grants for training in new skills and
concepts in India and abroad may be a
continuing feature and contribute in no small
measure to the pool of knowledge, skills and
research capacity in India. Compared to the
government and bilateral agencies, this may
be small but it is critical. Training must be
according to institutional needs and is most
valuable at this time when there is a declining
interest and fall in the number of fellowships
and scholarships available for training abroad
under government auspices. Especially in
areas of cutting-edge science, there is a
continuing need for relatively short-term
training for those mid-career scientists
working in frontier areas.
Role of Philanthropy
There are some unique features of trusts,
foundations and philanthropies, which are
highly relevant to nation-building. These are:
flexibility, innovativeness, risk-taking and
demonstrative action to serve as advance
action for large-scale replication. Scientific
endeavour today, is characterised by 'big
science', vast inputs and infrastructure for
which government funds are being
increasingly devoted to. Nevertheless, there is
a critical role that philanthropies with relatively
small resources can play.
It may be remembered that it was a small
grant from the Rockefeller Foundation that
enabled Florey and Chain to consummate the
original discovery of Fleming and led to one of
the great discoveries of modern science with
great human benefit, viz. penicillin.
Partnership with other Research
Agencies
Co-funding and partnerships with national
and international research agencies are
avenues, which could be explored. After a
choice is made of a worthwhile project to be
funded, it might be of tactical advantage to a
grant-making organisation to enlist other
research agencies in the country to provide
additional resources. This is one way of
leveraging funds for advancing research in
areas, which a philanthropic organisation
considers important.
IV. CONSTRAINTS IN THE USE OF
RESEARCH
Funds available for research in the health
sector are meager and even the results of this
limited research have not been utilised
effectively. A few of the factors preventing the
country's progress in the field of health particularly relevant to research in the countryare described in this section
The Balance between Individual
Research Interests and National
Priorities
One area of concern is that an individual
research worker, a research group or even a
research institute is not easily able to strike a
balance between individual or group research
interests on the one hand and national
priorities on the other. Despite the fact that
national planners in the Planning Commission
and other programme managers have
repeatedly brought out priority areas of
research and work, it is not very often that
research workers look at these priorities or
fashion their research within the framework of
the priorities.
Yet, the research interest of an individual
should not be crushed. As Smt Indira Gandhi
once said (to the Scientific Advisory Board of
the Council of Scientific and Industrial Research
[CSIR] at one of the board meetings), "Let the
dreamer dream." However, it would be more
pertinent to national interest and resources
would be more effectively spent, if the researcher
could dream within the parameters of national
priorities. Otherwise, we have the unfortunate
situation of research areas being at one spot and
the actual research needs of the nation being
somewhere else.
Resources could be earmarked for work in
the priority areas. National awards could be
e
given for work in the areas of research needs.
However, these are marginal mechanisms - the
real challenge is to change the mindset of the
individual researcher in a way that encourages
him or her to work in the priority areas.
The Utilisation of the Results of
Research and Pilot Projects in National
Health Programmes
ministry officials disappear after lunch to the
safe and secure environment of Nirman Bhavan.
This is an issue, which needs to be tackled.
Concerted efforts need to be made to ensure
that national health programmes adequately
use the relevant research, which is being carried
out within the country.
Challenges in Collaborative Efforts
This remains an area of weakness in research
endeavours in the country. So often the
researcher and his or her team spend 10 years
or so on a research project, obtain what he/she
believes are results that should be introduced
into a national programme like nutrition, leprosy
or TB, only to be told by the national programme
managers that the results are not what are
needed! Further, he/she is told - in no uncertain
terms - that there is no way that these results
could be used. This has happened many times
and in important areas. Thus, it is necessary to
take national programme persons into
confidence, even while planning a research
programme. However, this is easier said than
done. Nowadays, researchers and research
institutes usually invite representatives of the
line ministries to their meetings. Very often,
particularly if the meeting is held in New Delhi,
An Experiment
One innovative experiment carried out by the
Department of Family Welfare was to create a
research group in reproductive and child health
within the ministry, but consisting entirely of outside
experts. Some funds, which were earlier used by
the ICMR were earmarked for research
recommended by this committee. This has worked
very satisfactorily and all projects supported are
those marked for support in the ICMR document
Guidelines for Research Support in Reproductive and Child
Health Research, in fact, now the ICMR itself
recommends three-four projects to the committee,
which are funded, when approved, by this
mechanism.
The third issue is of collaborative research or
networking.The common perception regarding
the Indian scientist if he/she could be so profiled,
is that he or she is excellent when carrying out
research in isolation or with his or her team.
Today, however, several things, which need to
be done, cannot be completely carried out by
one group of scientists, such as in the field of
drugs development. There is an absolute
necessity for teamwork with other scientists and
to network with other groups of scientists. And
here the Indian scientist has been found
wanting. Time and again, collaborative ventures
have failed, and not because of science, but
because of ego clashes, a sense of insecurity and
a feeling of competitiveness. These constraints
need to be overcome if we are to carry out good
quality research in the frontier areas.
Challenges in the Development of
Leadership and a Succession Policy
The need for development of leadership and
for creating a transparent succession policy
cannot be overemphasised, and yet this has
hardly ever been done. How many times have
we not seen an outstanding centre of research
under a dynamic charismatic leader wither away
into mediocrity or worse after the leader retires
or goes into a high bureaucratic position or is
whisked away to the comfortable environs of
the United Nations or the World Health
Organisation (WHO)? This has happened
because there has been no succession policy.
The leader has a right to go on to better things,
but he or she also has the responsibility to
create his/her successors. A lot of resources financial, technical and human - are lost when
there is no continuity in the work being carried
out and in the quality of the work being done.
V. PROGRAMME PRIORITIES
Within the context of the strategic principles,
the changes in the scenario and the constraints
in the optimum use of research set out above,
this section deals with programme priorities.The
canvas is vast and the choices are difficult. No listing
of priorities can ever be considered as complete
or final. This section is, therefore, indicative and not
exhaustive. The areas of high priority are given
below and in each area some examples are given
for the type of project that could be considered for
support.
ethionamide, ofloxacin and cycloserine are toxic
drugs. Today, being inflicted with multi-drug
resistant TB is like having a death sentence.
The irony of this entire scenario is that many
of the path breaking discoveries leading to the
directly observed treatment shortcourse (DOTS)
management of TB, which is what the WHO has
advocated all over the world, were first identified
in India.
DOTS treatment, which cures 90 per cent of
TB patients while they remain at home - the
domiciliary concept - was first demonstrated in
Bangalore. The value of carrying out sputum
examination instead of using x-rays was
demonstrated in India. The efficacy of
intermittent treatment with anti-TB drugs,
The DOTS Programme
Tuberculosis
India is committed to the DOTS programme, which
entails that individuals with TB are allocated all the
The scourge of tuberculosis looms over India
which has the largest number of TB patients in
any one country and accounts for one-third of
TB patients all over the world. About 2.2 million
persons are added each year to the existing load
of 15 million active cases.TB is the leading cause
of death among women in the reproductive age
group of 25-44 years. It is expected that the
number of TB cases will shoot up in the presence
of HIV infection. There are some estimates, which
suggest that deaths due to TB, if TB is not
controlled, can go up to four million in the next
decade. In addition, the number of multiple
drug-resistant TB patients has gone up largely
due to irresponsible prescribing of anti-TB
drugs. The cost of treating a multi-drug
resistant case of TB is 250 times more than what
it costs to treat a patient who is not resistant to
the standard anti-TB drugs - rifampicin,
isonicotinic acid hydrazide, pyrazinamide and
ethambutol. In addition, the drugs used in
multi-drug-resistant cases like kanamycin,
medicines and drugs needed for its full treatment.
These are directly given to the patient at the DOTS
centre by a health care worker or some other
responsible person. This total 'package' ensures that,
as far as possible, the patient takes all the anti-TB
drugs needed for a cure and that lack of drugs will
not be a factor in receiving an incomplete course
which could lead to drug resistance.
The five elements which together form this anti-TB
package are:
• Government commitment.
• Diagnosis primarily by microscopy.
• A regular supply of good quality anti-TB drugs.
• The direct observation of the patient taking the
drugs.
• A system of surveillance and monitoring. Four drugs
are given for two months followed by two drugs for
four months for patients who have not been treated
previously for TB. If the drugs are taken regularly, the
cure rate is 90 per cent.
again was demonstrated in India. And yet, we
have not been able to sucessfully meet the
onslaught of this dreaded and insidious disease.
Indeed, a director general of the World Health
Organisation has said, "The whole world has
benefited from the fruits of Indian research - the
whole world, except India."
Studies are needed to find out why doctors
have not been prescribing the anti-TB drugs as
they ought to, since this is well known and why
the patients do not complete the course as they
are supposed to - even when the drugs are
available. In Mumbai alone, 35 different regimens
of anti-TB drugs are being prescribed by doctors.
Multi-drug resistance is largely a man-made
entity. Intervention measures can only be taken
into consideration when we know why there has
been a failure in India of applying and using a
proven technology outside the government TB
programme.
Unfortunately, patients are prescribed a
variety of drug regimens, some of which are
inappropriate, including only a single drug or
two drugs. Private practitioners practising in lowincome areas of India are largely ignorant about
modern advances in the diagnosis and
treatment of TB. It has been shown that about
33 per cent of urban patients and 36 per cent of
rural patients had not been diagnosed as TB
patients even four weeks after they had
approached a practitioner. These irrational
practices, including administration of wrong
drugs, perhaps at wrong doses and wrong
combinations, contribute to the rise of multi
drug-resistant tuberculosis in India. When one
takes into account the fact that about 80 per
cent of all qualified doctors, 75 per cent of all
dispensaries, 60 per cent of hospitals and 75 per
cent of the country's health expenditure are in
the private sector one realises that a DOTS
programme only in a government centre can
never be adequate. Private practitioners need
to be closely involved in the programme and
provide free drugs for the treatment of their
patients with TB. This programme has just begun
but private practitioners, even though they are
equipped with medicines, would naturally like
to be reimbursed for the time they have spent
on their patients. This will have to be worked
out as the patient should not have to pay as he
or she would not have to do so if he or she went
to a government DOTS centre. Organisations
such as the Indian Medical Association would
necessarily have to get closely involved in the
programme and include the treatment of TB
repeatedly in their programmes of continuing
medical education.
Studies should also be carried out whether,
in addition to the DOTS programme, in an effort
to reach all TB patients we should not
complement it with a self administered therapy
(SAT) programme, in which the individual
obtains all the treatment medication initially and
takes them individually without supervision.
TB and HIV
The Revised National TB Control Programme
(RNTCP) and the DOTS programme were initiated I
in India in 1993. By 2001, the DOTS coverage was
40 per cent - enabling about 450 million people to '
have access to DOTS. It is unfortunate that the advent 1
of HIV and AIDS threatens to wipe out to a great
extent the gains accrued so far.
It is estimated that there are about four million
HIV-infested people in India and half of these are
also infected with mycobacterium tuberculosis.
Active tuberculosis will probably develop in seven
per cent of these cases every year, producing
1,40,000 cases of tuberculosis each year, only from
reactivation of a dormant focus of infection. This
represents an approximate 10 per cent increase in
cases even at the current low rate of HIV infection.
TB is the commonest cause of HIV-related death.
TB also has an adverse effect on HIV. There are
studies, which indicate that transcriptional activity
of HIV-1 is enhanced in patients with the two
diseases, which might accelerate the natural
progression of HIV infection.
A challenge for the future is to see how, in
India, the TB programme and the AIDS
programme can work together more closely.
For many years those involved primarily in
tackling TB and those involved primarily in
tackling HIV/AIDS have largely pursued separate
courses. The TB programmes have mainly
concentrated on making sure that all TB patients
have access to the basic essentials of TB control,
while the HIV programmes have formulated their
own strategies.There is a growing recognition
today that there must be much a greater
collaboration between the two. Such an enhanced
endeavour will yield benefits for more effective
use of medicines, the supply system, training and
surveillance.
Studies have shown that prescriptions by
general practitioners are extremely irrational in
Maharashtra and West Bengal. A grant maker
in the health sector could consider organising
a dialogue, in these states, in an attempt to bring
these two health programmes closer and also
to bring government programmes closer to
private practitioners.
HIV/AIDS
The National Health Policy document of the
government of India - 2002 states in paragraph
1.5, "A new and extremely virulent
communicable disease - HIV/AIDS - has
emerged on the health scene since the
declaration of the National Health Policy - 1983.
Since there is no existing cure or vaccine for
this infection, the disease constitutes a serious
threat not merely to public health but to the
economic development of the country."
Surprisingly the only other references to HIV/
AIDS are in Box IV of the document where it has
been stated that the goal of the national
programme is to achieve zero level growth of
HIV/AIDS by the year 2007 and a passing
reference in paragraph 4.3.1 that vertical
programmes like HIV/AIDS would need to be
continued till moderate levels of prevalence have
been reached.
HIV/AIDS was first detected in India in the early
1980s.The disease has had a major impact in the
states of Maharashtra, Tamil Nadu, Pondicherry
and Manipur. According to the figures released
by the WHO in December 2002, India had 12,239
reported cases of AIDS while HIV infection was
present in 3,860,000 persons. The infection rate
was 380 per 100,000 of the population.
In spite of the projection of goals enunciated
in the National Health Policy there is no sign of
abatement in the new cases of HIV/AIDS. HIV
infections are no longer confined to high-risk
behaviour groups such as commercial sex
workers and transport workers, but have spread
to all corners of the country. It is no longer
present only in urban areas. Indeed, because of
this emphasis, the National AIDS Control
Organisation (NACO) has been criticised as it has
confined its activities to sex workers and truck
drivers in addition to setting up a country-wide
network of sentinel centres.
The NACO statistics reveal that unprotected
sexual intercourse accounts for nearly 83 per
cent of the total HIV/AIDS cases. In Manipur and
Nagaland, the predominant route for HIV
transmission is the sharing of needles by
intravenous drug users accounting for about
four per cent. Transmission through blood and
blood products account for another four per
cent, while nearly two per cent of AIDS cases were
due to prenatal infection - from an infected
mother to the child during pregnancy. It would
be wise to consider these figures as only a
fraction of the HIV/AIDS morbidity in the country.
The relationship between TB and AIDS has been
discussed in the tuberculosis section. Some
authorities state that nearly two-thirds of the
opportunistic infections among AIDS patients is
TB, which could lead sometimes to a dual
epidemic of both TB and AIDS.
e
The HIV vaccine and the pricing of drugs:
The extensive research being carried out
a pregnant mother and her newborn should be
globally and in India has not led to any vaccine
being on the anvil. Some vaccines developed
in research laboratories have gone on to clinical
cent of infants born from HIV-positive women
would be free of HIV.
evaluation but have not demonstrated any
beneficial effect. No such development for
public health use can be foreseen in the next
five years.
On the other hand, there has been a
remarkable fall in the prices of drugs for the
treatment of HIV and AIDS. And there are more
drugs available today than before. The National
treated with antiretroviral drugs so that 80 per
After considerable struggle, the Indian
government has recently announced (in
November 2003) that antiretroviral drugs would
be made available free in the country's health
programme to certain segments of HIV carriers.
Pharmaceutical companies have agreed to
lower the prices of these drugs as well.
The conclusion of the committee of the
is no existing cure or vaccine" needs to be
ICRIER on the current AIDS scenario in India in
September 2001 was, "The response in India to
modified. There are medicines today to treat
patients with AIDS. It is up to us to use these
the HIV/AIDS epidemic has been generally slow,
often inadequate, and highly uneven. The
medicines wisely - to determine which category
of patients should be given the drugs, when
epidemic, however, is at an early stage, and this
provides both central and state governments
these drugs should be given, how these drugs
should be distributed and what doses of which
with the opportunity to stabilise it over the next
decade at no more than three per cent of the
adult population."
Health Policy document statement that, "there
drugs should be given.
Unfortunately, although the Indian
pharmaceutical industry has played a leading
role in bringing down the prices of antiretroviral
drugs worldwide, no thought at all - till
recently- was given to the use of anti-HIV drugs
for our patients. The only policy decision that
was being implemented in pilot studies was that
A philanthropic organisation can take a careful
look at the steps outlined to determine where to
support work in spite of several national and
international organisations like the World Bank,
UNAIDS, the WHO and the Department for
International Development, UK (DFID) supporting
AIDS programmes in India. These steps are:
The Pricing of Drugs for the Treatment of AIDS
It would be interesting to look at what has been happening in the pharmaceutical sector in the last two years.
Early in 2001, an Indian firm CIPLA made a dramatic offer, to price a three-drug combination for AIDS treatment
at $350 for a year's supply to the organisation Medicines Sans Frontiers for free distribution for the AIDS
programme in Africa. This price was as little as one-thirtieth to one-fortieth of the price of drugs available in
the Western markets. Leading Western drug companies recently negotiated discount deals with Senegal,
Uganda and Rwanda, which brought the cost down by 90 per cent. However, the price of the Cipla drug
combination was still cheaper. Subsequently, the pharmaceutical house of Glaxo wrote to the drug distributor
in Ghana and to Cipla stating that the sale of the generic version of its drug Combivir was illegal as they were
violating company patents. As a result, the Indian company stopped selling its low-cost version of the
combination. Other pharmaceutical houses have now brought down the prices of antiretroviral drugs to a
fraction of what it cost before. The cost of treating HIV/AIDS patients would come to about Rs15,000 a month.
Twelve antiretroviral drugs have been included in the WHO List of Essential Drugs.
• The development of a reliable database
drawing from different kinds of surveys and
surveillance systems and the mapping out of
high-risk or core transmitter groups.
• The need for stronger political commitment.
• The involvement of the private health
sector.
• The development of HIV/AIDS awareness
and education programmes.
• The development of support services for
those with AIDS.
• The recognition that HIV/AIDS is more
than a health problem, affecting - as it does every facet of human life.
Of these options, it is felt that developing
awareness and education programmes along
with a research base could be considered by a
grant maker. It is the study of human sexual
behaviour that will provide answers to questions
such as why the use of condoms is so low in India.
Whether there is a vaccine or not, it is here that a
philanthropic organisation can make an effective
contribution by bringing social and behavioural
scientists in our country together to work in a
given area and demonstrate how such a change,
viz. behavioural change towards safe sex, can be
brought about.
In view of the unexpected availability of anti
HIV drugs in the country at cheap prices,
a philanthropic organisation could be the
catalyst to organise meetings of clinicians,
clinical pharmacologists, pharmacologists,
toxicologists, health economics specialists,
public health specialists and representatives of
the pharmaceutical industry. The group could
focus on issues like:
• The appropriate stage at which drugs
should be used.
• The optional combination, dosage and
regimen of administration.
• The distribution systems to be established.
• The training of doctors in the use of these
drugs.
• The financial implications of providing
antiretroviral drugs to some categories of HIV/
AIDS patients and carriers.
A grant maker would advance the endeavour
towards containing this dreaded disease if it
supports such meetings.They could perhaps be
organised by the Sir Dorabji Tata Institute of
Tropical Medicine at Bangalore as part of its
ongoing programme.
Malaria
The National Health Policy - 2000 has shown
the epidemiological shift in the number of
malaria cases over the years. There were 75
million cases in 1951, 2.7 million cases in 1981
and 2.2 million cases in 2000. What these figures
do not say, of course, is that soon after India's
malaria eradication programme commenced,
the number of cases had been brought down to
a record low figure of 0.1 million cases before it
started rising again. The reasons for the short
lived success story of the 1960s are many and it
may be useful to take a quick look at some of
these factors.
The anti-malarial teams were disbanded and
shifted to carry out work in the field of family
planning.The use of DDT for spraying was curtailed
as it was found to be toxic. Drug resistance started
appearing. The states did not provide the
assistance that they were supposed to under the
pattern of assistance. And finally, vigilance for
picking up new malaria cases was replaced by a
misplaced sense of euphoric complacency that
malaria was on its way out. In fact, when the Ciba
Research Centre started functioning at
Goregaon, Mumbai in 1962, meetings were held
to determine those areas where new medicines
would be needed so that research programmes
could be initiated by this centre in those areas.
Professor Roy Chaudhury - one of the co
authors of this paper - was privileged to
participate in those discussions. When the
subject of malaria and the development of
anti-malarial drugs was discussed, it was
agreed by ail the scientists that there was no
need for activity in the field of malaria as it
was nearly out. It is ironical that 40 years later,
this paper suggests the need for better antimalarial drugs and possible support for this
activity in cases of chloroquine-resistant
falciparum malaria.
After reaching the record low of 0.1 million
cases, malaria resurfaced and the number of
cases in 1976 were reported at 6.4 million. A
modified plan of operation was launched in
1977 to contain the disease. The three
objectives of the plan of operation were to
prevent deaths, reduce morbidity and
consolidate the gains. The number of malaria
cases was brought down to about 2.14 million
cases annually in 1984 and it has remained at
about that level. Further decrease in the
number of cases could have been achieved,
but again there were constraining factors
such as parasite resistance to conventional
insecticides and anti-malarial drugs in high
endemic areas and environmental changes
caused by development activities which
included rapid unplanned urbanisation and
irrigation projects.
burden. The states in the list include Orissa,
Bihar, Madhya Pradesh, West Bengal, Gujarat,
Assam, Mizoram, Andhra Pradesh, Rajasthan
and UP. Orissa, Madhya Pradesh, Rajasthan,
Bihar and Maharashtra account for over 80
per cent of the total caseload. Madhya
Pradesh and Orissa account for 50 per cent of
the mortality cases.
The current programme involves a special
strategy being implemented under the National
Anti Malaria Programme (NAMP) in 28 towns,
318 districts, 10 per cent of the primary health
centres and about 24,844 villages.These are all
in the high endemic range. A total population
of about 200 million would be covered by NAMP.
In the high endemic areas, 100 per cent central
assistance is provided under the World Bankassisted Malaria Control Project. Funds have
been provided for the provision of synthetic
pyrethroids, impregnated bed nets, rapid
diagnostic tests, artemisinin injections, vehicles,
microscopes and also for advocacy and social
mobilisation campaigns.
It is in this scenario that a philanthropic
organisation needs to consider where its inputs
could make a difference. An increasing cause of
considerable concern is the growing number of
malaria cases caused by plasmodium
falciparum, the strain of malaria which is much
more dangerous than the normally occurring
plasmodium vivax.This type of infection causes
death and is commonly referred to as 'cerebral
malaria'. Particularly worrying is the fact that
these cases are sometimes resistant to the
common anti-malarial chloroquine. The number
of chloroquine-resistant plasmodium falciparum
cases has also increased and the number of
deaths due to malaria has also increased.
It should also be remembered that there
are wide differences in the disease prevalence
between different states in the country. This
needs to be kept in mind if a grant maker
considers
supporting
appropriate
The mainstay of the treatment of
chloroquine-resistant falciparum malaria is
intervention in this field. Ten states in India
account for 93 per cent of the total disease
quinine, but this is a toxic drug and quinine has
to be administered in an injectable form. The
only ray of hope in recent years for treatment
of this entity has been the discovery of
artemisinin from herbal sources. This is, today,
the only powerful non-toxic drug, which can
cure chloroquine-resistant falciparum malaria.
The three compounds artemisinin, artesunate
and arteether were isolated around the year
1972 from the quinghao-su plant, Artemesia
annua by Chinese scientists.
Fortunately cases of resistance to the
artemisinin compounds are, up till now, few.
However, with increasing use of this drug there
is every possibility that resistance may develop.
In that case we would be left with no drug. It
was for this reason that artemisinin was not
released for use for a few years although the
drug was available. When deaths from
chloroquine-resistant falciparum infection
increased in different parts of the country, there
was every reason to make it available. Even
then, it was made absolutely clear that it was
released only for hospital use.
It is important to find and develop at least
one, if not two, other drugs for use in falciparum
malaria. This could be a drug from our plant
sources and from Ayurveda or the Unani system
of medicine. It could also be a synthetic
compound. It is suggested that initiating a
research project, multi-centred to discover an
anti-falciparum drug could be considered by a
philanthropic organisation. It would be a
focused study to prepare for the day when
resistance develops to artemisinin. This would
also fit in with the recommendations of the
ICMR document Priorities in Health Systems
Research and Biomedical Research and
Development - 2001 .They have stated that one
of the priority activities would be to "screen
and develop new anti-malarial, especially
herbal-based products" This is a very broad
mandate.The area being suggested for a grant
maker is more focused. It could be "to develop
an anti-malarial drug for chloroquine-
resistant plasmodium falciparum infection
from plants" This is an important niche that
has not been specifically filled by any donor
or national agency.The possibility of a vaccine
for malaria has not been fulfilled and
laboratory research, primate efficacy and
clinical evaluation would take many years
before such a vaccine, ever if discovered, could
be made available to the public.
Reproductive Health
Problems and issues relating to maternal and
child health and family planning are major
concerns in the country in the field of reproductive
health. In fact, the two cannot be separated. All the
studies carried out till now suggest that population
stabilisation could be achieved within a reasonable
time frame if firstly, there could be an
improvement in the quality of care provided at
the primary health care and referral levels and
secondly, if a wide range of contraceptive
technologies could be made easily available
throughout the country. There are 20 per cent of
women of reproductive age in the country who
Vital Statistics
The National Family Health Survey - 1998-1999
reported that the total fertility rate for India was 2.8
per woman. The crude birth is around 26.1 with an
annual population growth rate of 1.7. The
contraceptive prevalence among married women of
reproductive age (15-49) is 48.2. The extent of unsafe
abortions is not known but the WHO publication,
Health Situation in the South EastAsia Region (1998-2000)
carries a statement which says, "In India during 19901994,11-14 per cent of maternal deaths in rural India
were due to unsafe abortions." Further, 60 per cent of
all abortion deaths in 1994 were of young women in
the 15-24 year age group. The infant mortality rate
(IMR) is around 67.6 per 1000 live births. The IMR is
high when the mother's age is below 20 years, then
declines in the 20-29 age group and rises in the 40-49
age group. Maternal mortality is around 440 maternal
deaths per 100,000 live births.
would like to use contraceptives but who do not
have easy access to these and are therefore, not
using them.These two interventions, together with
other measures, such as enhanced literacy and
empowerment of women, would go a long way in
stabilising our population. In addition, additional
problems are unsafe abortions, high maternal
morbidity and mortality, high infant mortality
including perinatal and neonatal mortality and
sexually-transmitted infections.
It is in this scenario that a foundation needs
to think where the greatest needs are. Giving
high priority to women's issues, such as
reproductive health and the high level of
maternal mortality is important.
Improvement in quality of care: One of the
main focus areas of the national programme, in
its endeavour to reduce the maternal mortality
rate and enhance care of the newborn, is to
increase the number of institutional births. At
present, this is very low. To carry out this
programme successfully and to increase the
quality of care at the primary health care level,
the government needs to enlist the cooperation
and involvement of non-governmental
organisations (NGOs) and practitioners of
obstetrics and gynaecology in the private sector.
Unless all these players act in concert and in
partnership, the results will not be satisfactory.
At the moment, though the government has
been collaborating with NGOs to some extent,
much more needs to be done. For example, there
is no point in turning over the running of
primary health centres to NGOs because they
do not have experience in this. The requisite
training needs to be given first. It is not
necessary to confine this collaboration to NGOs
only in the health field. NGOs with a good track
record in other fields could be entrusted with
this responsibility after some training.
It is proposed that a pilot project be initiated
to see whether in six-eight districts this approach
of partnership in the delivery of health services
is successful. In addition to the private sector,
industry in the area could be asked to participate
in this effort. Already the Population Foundation
of India has initiated highly innovative projects
in reproductive health with active collaboration
from the Tata Group and Ranbaxy. Setting up, at
one or two centres, a model training
programme for doctors from the NGO sector
and for the private sector should be considered.
Training would need to be provided in each of
the following areas: family planning, maternal
and child health, safe abortion techniques,
sexually-transmitted diseases and infertility.
Providing easily accessible contraceptive
methods - reducing the 'unmet need': The Na
tional Family Health Survey (1998-1999) states
that about 40 million women in the country have
an unmet need for contraception. If all these
women (who have said that they would want to
space or limit their births) could have access to
family planning methods, then the current
contraceptive prevalence rate of 48 per cent
would rise to 64 per cent and this one step alone
would begin, according to demographers, to
lower the total fertility rate to replacement levels.
The awareness appears to be there as also the
desire to use contraceptives, but easy access to
a wide range of contraceptive methods is not
prevalent. The National Commission on
Population set up a working group to look
specifically at this aspect and to suggest
strategies to address the unmet need of
contraception.
The Commission recommended that a
"basket of services" should be made available
and that greater emphasis should be placed on
increasing the choices among reversible
contraceptive methods. New methods, such as
the monthly injectable contraceptive for
women and emergency contraception with RU486 or leavonorgestrel should be made available
with proper counselling after the safety, efficacy
and acceptability have been studied among
Indian women in different parts of India.
There are several new methods in the offing,
including one or two technologies for males,
complementing the only methods available
to men today - which are vasectomies and
condoms.
The problem appears to be in reaching these
contraceptives to the potential users
throughout the country. The Commission
suggested that lessons could be taken from the
Delhi model for the selection, procurement and
distribution of drugs including measures to
ensure quality control. It was felt that this model
should be introduced in a few states. Availability
of contraceptives and other medicines could be
markedly improved by means of pooled
procurement of a selected list of essential drugs
and an efficient system of distribution.
It was felt that it was essential to reach out
supplies and services everywhere, quickly and
regularly. It may be necessary, once again, to
reach out to the private sector and the
corporate sector to learn how the products of
the pharmaceutical houses and other
commodities reach the far corners of the
country. A suggestion now being tossed
around in national policy making bodies is
the possibility of actually entrusting
the distribution of contraceptives and
pharmaceuticals to the corporate sector.
Other organisations should also be encouraged
to join this programme. The Gram Panchayats
could play an important role after being
exposed to the issues and the challenges in
the prevailing situation. Finally, selected staff
from the 150 or more medical colleges
scattered throughout the country could
involve themselves much more in the
reproductive health services of the country.This
is being done in cities through the Federation
of Obstetrics and Gynaecology, but more
involvement could come in terms of systems
research and in monitoring the programme at
different levels.
Finally, research in the area of contraceptive
technology needs to be supported because no
country, other than China, is carrying out
research in this vital area. Thus, no answers are
forthcoming from the West. The government,
perhaps, has not realised the tremendous cost
in terms of human resources, materials and time
needed to discover a new contraceptive or any
new drug. The quantum of such long-term
support is never available. One such area,
particularly relevant to this country, is the
development of a herbal contraceptive from our
rich heritage of traditional medicine and
medicinal plants. It is sad to note that this
country which was in the forefront of
international contraceptive research in the
1960s and 1970s, today has very few centres
interested in this work.The centres at New Delhi,
Chandigarh, Lucknow, Hyderabad, Jaipur,
Ludhiana, Mumbai, Chennai, Varanasi and
Bangalore - to mention a few - were at the front
line of contraceptive research. Is it worthwhile
to think of a resurgence in this sphere and is it
something, which a sensitive philanthropic
organisation could consider?
Diabetes
Diabetes mellitus has emerged as a major
health threat, both globally and in India. There
were, according to the World Health
Organisation, 135 million diabetics in the world
in 1995. The figure is expected to grow to 300
million by the year 2025. India, because of its
number, has the largest diabetic population
found in any country and equally alarming is
the increase in the number. The percentage of
population affected by diabetes is the second
highest in India out of all the countries in the
South-East Asia region of the WHO. Only Sri
Lanka appears to have a higher percentage. In
the 1970s, the prevalence of diabetes amongst
urban Indians was at 2.1 per cent. Today, it is
12.1 per cent. In addition, there is a very
large number of Indians who are not yet
diabetics, but who have an impaired glucose
tolerance and many of these will suffer from
diabetes in the future. There were 19.4 million
individuals affected with diabetes in 1995. It is
projected that by 2025 that figure will be at
57.6 million.
Why has there been such an increase in
diabetes in Indians? It is difficult to pinpoint to
one reason, more likely, it is a combination of
several factors. A change in lifestyles - a more
sedentary life with lack of exercise could be one
reason. A change in diet with more intake of
junk food and a diet of high-calorie fat would
add to the risk factors of a person with irregular
exercise. Increased longevity and a familial
genetic background are also reasons, which
need to be considered.
The effects of diabetes are on many organs.
Diabetic patients are 25 times more likely to
develop blindness, 17 times more likely to
develop kidney disease and twice likely to
suffer myocardial infarction or suffer a stroke
than a person without diabetes. The disease,
unless controlled at an early stage, affects the
kidneys, the eyes, the coronary vessels and the
nerves.
A national programme for the prevention
and control of diabetes mellitus is needed and
the government is in the process of developing
such a strategy. The preventive strategy would
be to provide information to the public about
diabetes stressing the need for exercise and
a balanced diet. The other major component
of the strategy would be early diagnosis
and prompt treatment. While diabetes is not
yet a major health threat, the population needs
to be informed more about this disease so
that people can alter their lifestyle and food
habits and avoid the disease. What is
encouraging is that interventions of this
type do lead to beneficial effects and some
of the changes regress. This too, has to be
made clear.
It is a pity that the National Health Policy
statement does not give adequate importance
to diabetes. It has been mentioned just once in
paragraph 1.6, which says,"The period after the
announcement of the National Health Plan - 83
has also seen an increase in mortality through
lifestyle diseases - diabetes, cancer and
cardiovascular diseases." While issues
concerning cancer and cardiovascular diseases
have been in the forefront, diabetes has not.
Support by a grant maker in the vital area of
creating awareness about diabetes through
NGOs or providing support to some selected
organisations would bring rich dividends in the
years to come. No national organisation or
group has taken up diabetes as its priority area
of support.
The occasional disappearance in the market
of insulin and the difference in prices of the
different types of insulin are also areas,
which have to be looked at. Finally, the Indian
Systems of Medicine have several plants,
which are used to treat diabetes both from
Ayurveda and the Unani system of medicine.
Some of these should be scientifically
evaluated. The ICMR, after working on a plant
called viyjayasar (Pterocarpus marsupium)
for the last 12 years, has brought research
to a stage when all the work can be handed
over to a pharmaceutical concern for marketing.
It has been a long and hard journey from the
Madhya Pradesh jungles where it is found
and from traditional medicine - supported
by references in ancient Ayurvedic texts to it becoming a drug. However, it could
perhaps, help many people in India who need a
mild anti-diabetic drug and particularly those
who cannot afford to buy more expensive
medicines.
Cardiovascular Diseases
The hidden epidemic of cardiovascular
diseases in India and its accompaniments stroke, hypertension and cancer - require
intervention at the biological end as well as at
the social end including lifestyle changes.There
are immense opportunities here for highly
relevant research to be undertaken within the
various communities in India with different
lifestyles, food habits and customs. As an
example of an area, which could be funded to
make a difference, is the study of the effects of
yoga, meditation and other natural methods
on the prevalence and control of coronary
artery disease and hypertension. There are
The Delhi Model
The Delhi Model was first established in public
sector teaching hospitals, smaller hospitals and health
centres of the Delhi government. Its success was
recognised and components of the programme are
being implemented by the WHO and DSPRUD in 14
states. The programme, however, has been imple
mented, by and large, only in government or corporate
hospitals. The challenge for the future is to initiate
programmes in the rational use of medicines in the
private sector and also to inform and educate the
public so that they take the drugs prescribed properly
and do not ask for unnecessary drugs.
exciting opportunities in this regard to finding
alternative ways of dealing with the new wave
of non-communicable diseases.
Rational Use of Medicines
The
rational
use
of medicines
is
a
programme, which cuts across all other
programmes and can be used in every sphere
of therapeutic and prophylactic medicine.
The WHO-supported programme, implemented
in India by the Delhi Society for the Promotion
of Rational Use of Drugs (DSPRUD) has
demonstrated unequivocally that, without any
additional expenditure, 90 per cent of the
medicines
being
prescribed
in
Delhi
government hospitals are actually provided free
to the patients. These drugs are of good quality.
Earlier only about 30 per cent of the drugs were
available in the hospitals.
The basis of the concept of the rational
use of medicines is that 90 per cent of diseases
and symptoms of diseases can be treated
by about 300 medicines. This is known as the
List of Essential Drugs. Other components
of the programme, which can only come into
place after an Essential List of Drugs is in
place are:
The Delhi programme has been continuously
assessed by the WHO review committees who are
very positive about its success. The beneficial effects
of the programme are:
• A pooled procurement of medicines.
• The medicines are procured at 30-35 per cent less
than the prices paid for by other government
agencies.
• A transparent two envelope system of
procurement of medicines and effective
distribution of medicines.
• The availability of medicines to the patients has
increased remarkably and 90 per cent of the
prescribed drugs are provided free to the patients.
• The quality of the medicines is good and the fear
of substandard drugs being supplied has
disappeared.
• The quality of prescribing, according to the WHO
criteria, is very good.
• A quantification of the medicines needed.
• The establishment of a system of quality
assurance to ensure that the drugs are of good
quality.
• Rational prescribing.
• Providing objective information to the
doctors and to the public.
Side by side, the programme would need to have
continuous monitoring and evaluation using quan
titative indicators and run training programmes for
all categories of persons dealing with medicines.
Publications such as Standard Treatment Guidelines
and Formularies and mechanisms such as drugs and
therapeutic committees would be effective tools
for this programme.
However, ail the above achievements in the
public sector fade into relative insignificance
when one realises that the use of medicines in
the public sector is only about 15 per cent of the
drugs in use. It is in the private sector that an
effective programme needs to be set up so that
the public and patients do not unnecessarily pay
more for medicines that they do not need or
pay for more expensive medicines when a
cheaper, equally effective medicine is available.
This is not ethical, not economical and not good
therapeutics. Perhaps, a philanthropic
organisation could consider supporting a
dialogue to discuss how this type of programme
could be introduced in a few selected hospitals
in the private sector.
It is heartening to note that while five years
ago the rational use of drugs would not have
found a mention in any policy document, today
no policy document fails to mention its
importance. The National Health Policy - 2002
states clearly in paragraph 4.11, "This policy
emphasises the need for basing treatment
regimens in both the public and private
domain, on a limited number of essential drugs
of a generic nature. This is a prerequisite for
cost-effective public health care." The policy
document very unusually actually mentions
the need for preparing standard treatment
guidelines in paragraph 4.16. "NHP - 2002
envisages the co-option of the non
governmental practitioners in the national
disease control programmes so as to ensure
that standard treatment protocols are followed
in their day to day practice."
e
The Population Policy prepared by the
Population Commission has dealt in depth
with the issue of the rational use of drugs
particularly emphasising the procurement
and distribution of medicines and contra
ceptives and the need for the medicines to
be of good quality. Similar recommenda
tions have been made by the Planning
Commission in the Tenth Five Year Plan, the
ICMR in its 2001 policy document Priorities
in Health Systems Research and Biomedical
Research and Development and by the
ICRIER (2001).
Food, Nutrition, Environment and
Disease
Food security, nutritional security and health
security are an interconnected chain. Foodassociated infections are rampant and have not
received much attention in the country.
Appropriate projects for support in this area
would be those that improve the skills of our
laboratory scientists to detect food-associated
infections and intoxication by prompt and reliable
laboratory investigations to provide inputs for
an appropriate health policy. The recent tragedy
of epidemic dropsy in Delhi due to contamination
of edible oil with Argemone mexicana should
teach the nation a number of lessons in this area.
Environment and Disease: This area offers
opportunities for research and application for
the benefit of the human population in India.
Again, the area is very vast and there are a
number of agencies that are already working in
this field. However, there are problems of acute
concern to the public in which a philanthropic
organisation can make a difference while
working with other research agencies. Examples
where a grant maker could be particularly
effective are the problems of excess arsenic and
fluoride in drinking water. These are well-known
problems, but a recent shocking experience of
the unfolding of the tragic sequelae of excess
fluoride in drinking water in parts of Rajasthan
must open one's eyes to the need for
developing simple and appropriate technology
to bring down the levels of arsenic and fluoride
in drinking water to permissible limits.
There is room for improved technologies to
be developed but equally important is to install
in communities, simple and acceptable
technology that could be maintained by the
communities themselves with technical support
from skilled workers in the area. Pollution of
environmental waters with toxic chemicals
either as industrial effluents or as run off of
insecticides into the waterways are again
problems of vast dimension in need of practical
measures of prevention and control. Modern
methods of measuring atmospheric pollution need
to be spread widely within the country so that the
burden of pollution on humans in different cities
could be quantified objectively and appropriate
methods should be introduced for the reduction
of these hazards. A sensitive philanthropic
organisation could be receptive to projects that are
submitted by competent institutions and
organisations to delve into some of these aspects
of environment, health and diseases.
For example, a grant maker could work
closely with the Centre for Science and
Environment (CSE) to identify priority areas in the
field of environmental health. A sensitive
philanthropic organisation could also avail of the
expertise of organisations like the National
Environmental Engineering Research Institute
(NEERI) at Nagpur and the Council of Scientific and
Industrial Research laboratories in identifying areas
that could be supported in this field.
Traditional Medicine
No background paper on India's health
system can be complete without recognising
the fact that without the support of traditional
medicine practices and the Indian Systems of
Medicine such as Ayurveda, the Unani system,
Sidha and Naturopathy, our health care
structure could not function and would have
collapsed, particularly in rural areas. The
challenge for the future, as delineated in the
National Policy on Indian Systems of Medicine
and Homeopathy (2002), is to see how this
system could be integrated more into the
national health system, how harmonisation
between the systems could occur, how a
scientific base could be brought into the use of
these systems and how more research could be
undertaken to discover new medicines from the
incomparable rich heritage we have been
bestowed with - both within the treasure house
of knowledge of these systems and the rich
biodiversity that is still available to us.
The Indian government policy statement
and the ICRIER report (2001) state that the true
potential of these systems of medicine is still
largely unrealised, despite the creation of a large
and well dispersed infrastructure. It appears that
even in the last 50 years the effect of centuries of
neglect of systems such as Ayurveda has not
been counteracted. Practitioners of these systems
of medicine appear to have lost confidence in
themselves and in the systems. The constantly
recurring question as to whether the scientific
methodology particularly in assessing the safety
and efficacy of medicinal plants and traditional
medicines has any relevance or is appropriate,
has still not been resolved.
Collection
of
authentic
plants,
standardisation of the products and quality
assurance are other areas which need
attention. Even in research, in spite of scores of
laboratories carrying out research on medicinal
plants and despite there being hundreds of
theses written by postgraduate students on
medicinal plants, only one plant has found its
way into the armamentarium of modern or
allopathic medicine. This is gum guggal
(Comnifera mukul) for reducing cholesterol
levels in patients with a high level of
cholesterol. It is hoped that very soon vijayasar
(Pterocarpus marsupium) will be the second
plant. There is a need to take a good look at
the way we have approached research on
traditional medicines.This may then identify the
factors why there has been so little progress in
the discovery of drugs from our herbal sources.
Recently, pharmaceutical houses have begun
working on these plants to bring them out, not
as drugs, but as herbal supplements.
Other issues, again unresolved, relate to the
integration of the different systems - at least at
the primary health care level. Whether
undergraduate medical students in allopathy
should be exposed to the concept and practice
of the other systems of medicine and vice versa
has often been discussed, but no clear-cut
consensus has emerged.
Exports of medicinal plants from India to
other countries are only a fraction of what
percentage they could be at and far below the
export earnings of our neighbour, China. Even
in the area of conservation of plants identified
for their medicinal value we have a long way to
go. Even gum guggal is hardly available. The
following quotation from the ICRIER report
sums up the situation: "There was some
recognition of the Indian Systems of Medicine
(ISM) after independence, but very little was
done by way of follow up. An institutional
framework was indeed established to
standardise education and drugs and to
promote research, but inadequate attention by
policy makers and insufficient financial support
made these initiatives largely ineffective. ISM
continued to be developed as a parallel stream
with no attempt to synthesise or integrate the
systems with modern medicine and assign them
a role in public health." This last fact has also
been brought out in the ISM policy document.
The statement made says, "Although the
government set up an independent department
in 1995 to give focus to these issues, the ISM has
not been able to play a significant role in health
care delivery services for want of their legitimate
involvement in public health programmes."
Studies in alternative medicine for
discovering molecules in plants not known to
science yet and extracting active principles by
scientific research could be supported by a
philanthropic organisation. Dr Dahanukar, an
eminent researcher in traditional medicine, has
said, that in addition to therapeutic substances,
Ayurveda subscribes to the art of living healthy.
Educating people on the usage of home
remedies has a great role to play in self care.
There is need to support valid documentation
of folklore medicine. A panel of experts could be
convened and the entire area could be carefully
explored. In the vast area of traditional medicine,
a philanthropic organisation could profitably
focus on maternal health.
Following these observations one could
identify two major areas where vital inputs and
intervention programmes could be looked at by
a grant giver.The first would be to support an all
round investigation of a traditional remedy or
medicinal plant and help in its development as a
new product.This would involve the collection of
the material, pharmacognostic studies,
toxicology, standardisation and clinical
evaluation. Except for the ICMR, no other
organisation has been willing to support such
studies, not even the pharmaceutical houses who
have chosen the easier route of making a
combination of several plants and putting them
on the market as a herbal health food.
The other area is to encourage and provide
support for a field study to see whether the Indian
System of Medicines could indeed be used in the
health services in one or two districts. A successful
model would go a long way towards the
government initiating more pilot studies. The
districts would have to be chosen carefully with
support from the local Panchayat actively elicited,
support from the state and central governments
would have to be obtained and the support of a
team of public health specialists and Ayurvedic
physicians would be needed. Special legal
exemptions would have to be obtained for
Ayurvedic physicians to use allopathic drugs and
for allopathic physicians to prescribe Ayurvedic
medicines. This should not be a problem as this
would be considered a research project, besides
the medicines could be prescribed jointly which
would cover the legal provisions. It would be a
difficult, but worthwhile study. Other
interventions of a piecemeal nature are
continuing, but have not lead to substantial
progress in the right direction.
The area of traditional medicine needs a
background paper of its own, but we have
presented some of the issues and suggest two
possible areas of support worthy of
consideration by a funding organisation.
Drugs Discovery
scientists may not be able to synthesise a drug
discovered elsewhere by a different route of
extraction or purification and claim its patent. In
order to encourage and help the Indian
pharmaceutical sector to carry out research, the
Pharmaceutical Research and Development
Committee has been set up. This Committee
will help those pharmaceutical houses that
qualify to become a research and development
intensive company. Help would also be
provided to them through another body, which
has been set up - the Pharmaceutical Research
and Development Support Fund. The
Pharmaceutical Policy document of the
government of India has suggested the
following conditions for a pharmaceutical house
to qualify as a research and development
intensive company.
• It should invest at least five per cent of its
turnover per annum
development (R & D).
in
research
and
• It should invest at least Rs 10 crore per
annum in innovative research including drugs
development.
It has often been said that after information
technology, India's next success story could
be in the area of pharmaceutical drugs
development. The reasons for this belief are:
• It must employ at least 100 research
scientists in R & D in India.
• The availability of a competent pool of
scientists capable of discovering drugs.
• It should have been granted at least 10
patents for research done in India.
• The abundance of leads for new drugs
from the biodiversity present in India.
• It should own and operate manufacturing
facilities in India.
• The success story of the pharmaceutical
industry in copying drugs allowed up till now.
The programme has been slow in getting off
the ground and the takers have been few, but it
is still too early to comment on the success or
lack of success of this programme.
• The successful export of drugs in the last
decade.
The government also wishes to encourage
drugs discovery in India. After 2005 when the
provisions of TRIPS come into operation, our
However, one has to be realistic and there
are several serious constraints which would
make it a difficult, if not an almost impossible
task to convert a Rs 5 billion industry to a Rs 25
billion industry by 2020 - as is hoped and
envisaged. Listed below are some of the
constraints:
(1) The regulatory system for new drugs in
India is not in keeping with the new role of Indian
scientists discovering new molecules and trying
to make them into drugs. The mechanisms of
the regulatory body are slow and cumbersome.
Several committees have suggested a major
expansion of the capabilities and strengths of
the office of the Drugs Controller General of
India.There have been repeated calls for setting
up a National Drug Agency. This agency would
have expertise in the different disciplines related
to the assessment of new drug submission. It
would have its own laboratories with an
adequate number of scientists. It would also
have an expanded hand of pharmaceutical/
drug inspectors to look at the market and
keep a watch out for sub-standard drugs.
Unfortunately, in spite of the many
recommendations, this body has not been set
up although some marginal and some
cosmetic changes have been made. The head
of the organisation is no more the Drugs
Controller of India, but the Drugs Controller
and then, instead of carrying out further
toxicological studies and clinical trials in India,
the company sells the molecule to a
pharmaceutical house outside India who would
then arrange for these tests to be carried out.
This is undesirable as drugs which could have
been discovered and developed in India, may
now be developed outside the country. In the
long run this would have an effect on the pricing
of the drug.
(3) There are very few centres where good,
controlled clinical trials are carried out. The
quality of most centres carrying out clinical trials
of medicines is very poor.
(4) There are probably not more than one
or two centres where reliable phase I studies
can be carried out in this vast country.
(5) There is a great paucity of toxicologists
and trained clinical pharmacologists to take
compounds to the development stage.The only
centre in India, which provides training and a
super-specialist degree in clinical pharmacology
is the Postgraduate Institute of Medical
Education and Research, Chandigarh.
General of India.
(2) There are very few centres in this
country capable of carrying out reliable acute
and subacute preclinical toxicology studies in
Ind ia. Th is is a major obstacle. As a result, some
pharmaceuticals have the toxicology carried
out in countries outside India, an essential
prerequisite for drugs development. Several
times the toxicology of compounds
developed in India is carried out in the Czech
Republic and Poland.This is undesirable, as the
quality of work at these laboratories cannot
be verified.
Another unfortunate consequence is that
several leading pharmaceuticals carry out
studies on a potentially new compound in India
These are very serious drawbacks and it is
clear that drugs discovery cannot be successful
in India unless these constraints are removed.
The ICMR has started the development of a
network of toxicology and clinical pharmacology
centres at their existing centres by expanding
the centres and adding to their strength.
However, this will take time and would be
functional in about three to five years time. The
clinical pharmacology centres are being
developed at the KEM Hospital, Mumbai, the Nair
Hospital, Mumbai, the Tuberculosis Research
Centre, Chennai and the Nizam Institute of
Medical Sciences, Hyderabad.Toxicology centres
are being established at the National Institute
of Nutrition, Hyderabad, the National Institute
for Reproductive and Child Health Research,
Mumbai and at the Central Drug Research
reads of instances where doctors have been
beaten up, clinics have been smashed and
Institute, Lucknow.
doctors have been taken into police custody and
kept in jail. These were things one could not
In this endeavour to take India into a different
imagine 20 years ago.
mode and pace of functioning, a philanthropic
organisation would do a great service to the
country if it could consider support for training
people in all aspects of clinical pharmacology
and toxicology relating to drugs development.
There is also a growing feeling in many
persons that they are not being dealt with fairly
by the doctors.The perception is that unnecessary
diagnostic tests have to be carried out and that
these tests have to be carried out at a specific
laboratory or x-ray clinic or Catscan centre, which
Just as the International Clinical Epidemiology
Network (INCLEN) has, for the last 10 years taken
up the cause of training clinical epidemiologists
from all over the world, some organisation is
would then give the doctor a part of the income
from carrying out these tests - the practice
required at this time to provide strength and
support for the training of toxicologists and
commonly described as fee-splitting. The patient
is often not certain why he or she has been asked
clinical pharmacologists at different centres in
India. The pharmaceutical industry needs to
partner the other players in this endeavour, as
eventually they would benefit as a result of good
to stay longer in a nursing home. Is it because he/
she needs to do so or is it because the doctor is
clinical trials being carried out in India. There is
also a precedent here. In the United States of
America, the pharmaceutical house Merck,
Sharpe and Dohme took up this challenge.
Together with the Rockefeller Foundation,
Merck Sharpe and Dohme provided fellowships
to investigators from different parts of the world
but mainly to American doctors at American
centres for training in clinical pharmacology.This
has helped make the USA a leading centre of
clinical pharmacology in the world.
Medical Ethics
There is a great need to teach medical ethics
in the undergraduate medical curriculum as
there has been a growing loss of credibility in
the public about the medical profession. The
increasing number of complaints (for example,
to the Delhi Medical Council) against doctors
for medical negligence, the many cases against
doctors in the consumer courts and the criminal
courts show that many doctors have not
followed the precepts of being a member of a
noble profession. As a result, one hears and
using this as an instrument to enhance the
income of the hospital and his or her own intake?
The patient is uncertain why he/she has to
purchase expensive medicines. Does he/she really
need them? Or is there a nexus between the
pharmaceutical houses and the doctors to
enhance the sale of a particular medicine and
thereby accrue profit to the pharmaceutical
house? The pharmaceutical house, in turn,
provides the doctors who prescribe their drugs
or who are likely prospects to prescribe their
medicines with computers and expensive gifts,
with free trips for him or her and the family in the
garb of attending meetings to places like Goa and
Singapore and other benefits like supporting his
or her research work. This unfortunate, unethical
conduct by doctors has been commented upon
not only in the lay press, but also in professional
journals.
Fresh medical graduates do not even
necessarily know what constitutes ethical or
unethical conduct and when they may end up
being taken to court. In a recent case, we were
told by medical doctors and the owner of a
nursing home that they were not aware that it
was unethical to send out printed circulars to
general practitioners in the neighborhood
The need for this type of activity has been
saying that if they sent patients to this nursing
home, they would be paid 25 per cent of the
recognised in the government's National Health
Policy-2000. Paragraph 4.2.1 states,"NHP-2002
envisages that in order to ensure that
fees as referral charges.
There are several other basic, ethical values
which doctors sometimes violate. One
increasingly common practice is to refuse to take
into a hospital an emergency case such as an
accident victim who is not in a position to pay.
The ethical code of the doctor and the legal
position is quite clear on this point. Providing
information to the patient regarding treatment
and illness is something that should be done if
the patient wants the information. Yet, this is a
very common complaint against doctors at
smaller nursing homes.
There is, therefore, an urgent need in
teaching medical ethics to the younger
generation of would-be doctors. At this stage,
the common patient is not subjected to
irrational or profit-driven medical regimen, a
contemporary code of ethics is to be notified
and rigorously implemented by the Medical
Council of India."
Very closely linked to medical ethics in medical
practice is ethical conduct of research. Here too,
there is a need to teach young doctors what is
considered unacceptable, unethical and illegal
research. In the past few years, we have seen
several cases of clinical trials with new drugs
and a combination of drugs developed outside
this country on patients in this country without
any approval of either the Drugs Controller
General of India or the ICMR. On questioning,
in one case a leading doctor stated that he
medical colleges do not teach this and the state
councils rarely even have a code of conduct.
was not aware that such approval was
necessary. These unethical conduct of trials are
being held at both private and government
medical centres. In another case, an investigator
began clinical trials on a new anti-HIV vaccine
It is proposed that in view of this great gap
and since no organisation has made any
attempt to close the gap, a funding agency
could consider taking the initiative in
introducing courses at a few selected medical
developed outside the country without the
approval of any organisation from within the
country. A hospital in the city collaborated in
the trial. Suddenly, one morning it was found
that the chief investigator and his team had
vanished leaving all their patients in the middle
their minds are fresh and if these concepts are
ingrained in their thinking at such a time, it will
stay with them throughout their lives. The
colleges on medical ethics. The course
curriculum would need to be prepared, tested
in pilot studies and then implemented and its
long-term effect studied. There would be
organisations willing to provide technical help
and there would be medical colleges willing to
undertake this experiment. However, some
resources are needed as well as imaginative
leadership. Besides this, a round-table
discussion could also be organised each year
on the different aspects of medical ethics and
the proceedings could be published and widely
disseminated as a series.
of the trial.
There are very clear guidelines and rules
about sending out tissue samples and blood
specimen outside the country for collaborative
research. These rules are very fair, clear and
transparent. Yet investigators do not follow
these rules and only when something
controversial breaks out, is there an outcry. In a
recent case, the Indian investigator justified the
sending out of samples by saying in an
international scientific journal that she was not
aware of these rules.. • 4.. ... • » ■
Finally, there are cases of fraud in research
where results are reported when the research
This conveys the message that hard work and
dedication go unrewarded, while persons with
has not even been carried out or where the
'other'qualifications can get ahead. This indeed,
number of patients or animals participating in
is one of the main reasons for our doctors
the research has been increased even though
immigrating to the USA, Canada, Australia and
the UK - believing that they would get a better
those numbers did not exist.
and fairer deal in those countries.
It is proposed that a sensitive philanthropic
organisation could take a careful look at ethics
in medical research and consider taking an
initiative in this important area.
Fortunately, there are still - even in this
depressing scenario - a few outstanding
leaders in health in the country, doctors with
vision, dedication and charisma. It would be
Leadership Development in Health
an opportunity lost if an effort was not made
to make use of these dwindling numbers to
There is a need for the development of
leadership in health. Over the years, leadership
create a new wave of emerging leaders in the
health field. No organised programme that
in health has deteriorated to a great extent
and there are various reasons for this. Some
targets the development of leaders in the field
of health has been initiated so far on a
of them are:
national scale - unlike programmes in
leadership development in fields such as
• The mediocrity of teachers in medical
colleges in India.
• An equally depressing lack of leadership
qualities in the health managers of the public
health services at the centre and state level.
• The increasing role of the bureaucracy
and non-medical persons in decision-making
in health matters.
• The erosion of the autonomy of our
leading institutions.
• The marginalisation of those few who
have had the courage to go against the
establishment.
• Political interference, particularly in toplevel appointments and the management of our
health services by persons of modest
attainment who have reached these positions
of power because of their political links or other
reasons - and having reached these positions,
have
---------------
AXCPHE - SOCHAKA
l(c(
Koramanoala
I) I
management sciences and information
technology.
The INCLEN has recently, with support from
the Rockefeller Foundation initiated a wellplanned international programme for the
development of leadership in health. This
programme is being developed in India as well
and this country's experience would be looked
at carefully by the rest of the world.
Amongst other things, two workshops have
been held titled,'Managing Your Programme/
Project More Effectively' and 'Preparing The Next
Generation Of Leaders'. Future workshops will
deal with subjects such as time management,
team and coalition building, conflict resolution,
communication, e - conferencing and strategic
planning. Modules have already been prepared
in each of these areas with examples from health.
A new activity within this programme will be
the Mentorship Programme in India. Potential
leaders between the ages of 30-40 have been
identified and will be classified as 'mentees'.
e
Criteria are being developed for the selection of
the mentors - established leaders who have
much to contribute.The mentor and the mentee
would then be linked together in the hope that
the mentee would gain qualities of leadership
by having a 'hands-on' experience with a leader
make a big difference - a catalytic support
leading to a substantial impact in a neglected,
but vital area. Thus, suggestions for such
support have been made throughout the paper.
Areas, which are important, but have been well
funded such as cancer have not been included.
in the field.
It is suggested that a philanthropic
organisation could take a look at the need for
leadership development in health in this country.
With its financial resources as well as its capacity
to bring leaders from the corporate sector and
the public sector into a programme of leadership
development, a funding organisation could
certainly make a difference.
VI. CONCLUSION
A background paper like this can perforce
deal with certain areas and not deal with others.
No paper on the health status in India can avoid
giving major emphasis on the three diseases tuberculosis, malaria and HIV/AIDS.This is also a
global priority and a $ two billion trust has been
formed called the Global Programme on TB, HIV
and Malaria. A major contribution has been
made by the Bill and Melinda Gates Foundation.
The challenge is to use the funds in the most
cost-effective way. Reproductive health is
another area of concern in India and has been
dealt with at some length. Diabetes is a totally
new field, which has been added on because of
its potential to grow at epidemic-like
proportions and also because it has not received
the attention or priority it deserves, either from
the government and donor agencies or from
NGOs.
Traditional medicine is a subject that
deserves a background paper of its own. A few
areas of possible interest have been brought
out in this background paper. It is hoped that
this will help to stimulate thinking about how
best we can use this unique heritage of
biodiversity and knowledge.
Drugs development and the rational use of
drugs are discussed at length in this paper - the
first subject has been tackled because the
implications of drugs development need to be
appreciated. Why the country has not been
successful in this in the past and why it will not
be successful in the future unless major steps
are taken are important questions to raise. The
rational use of drugs deals with equity, ethics,
good therapeutics and management. It has been
included because it cuts across all sectors. Finally,
no organisation has looked at important
concerns such as medical ethics and leadership
in health and it was felt worthwhile to bring
these to the fore for the attention of a
philanthropic organisation.
In conclusion, a few observations about
primary health care and the development of a
surveillance response system would be in order.
'Health for All' was a concept propounded by
the WHO in 1978, at Alma Ata. This was to be
achieved through primary health care, which is
a combination of preventive and promotive ap
proaches to health as well as with treatment of
endemic disorders in close collaboration with
While identifying areas of discussion, one
factor taken into account is the need for support
in this area of work. More specifically, we have
the communities themselves.There is an urgent
need to rejuvenate the primary health care
earmarked the possibility that there could be a
niche where support from philanthropy could
system in the country and to realise its full
benefits. Any efforts by investigators to develop
appropriate models of primary health care
deserve support. Very little attention has been
paid to this important area by existing research
agencies in the country. The integration
of nutrition effectively into the primary health *
care system is also appropriate for a grant
maker to encourage. Nutrition lies at the
interface between agriculture, health and social
sciences.
A tactical approach by a grant maker that
would make a difference is to develop a protocol
at the primary health centre level - through a
pilot project which would give information to
mothers on weaning foods and on health
promoting activities during the weaning period.
An independent evaluation of the ongoing
government nutrition programme such as the
Integrated Child Development Scheme (ICDS)
can make a valuable contribution. Carefully
designed proposals on home remedies for
maternal health/childcare could be supported
financially with great benefit.
The emphasis in grant giving could shift to
the development of a surveillance/response
system at a national level. Being a method for
disease control through the laboratory system,
it would be the warning, which would activate
the public health system to take action and
control epidemics. The government of Kerala
has taken the initiative and is developing a state
level surveillance system. Dr Jacob John, is a
pioneer in surveillance systems, and has made
a proposal for developing such a system in
Kerala. This can act as the forerunner for a
nationwide system.
In applying science and technology for future
health care, the focus should be on areas where
community participation is part of the process.
After evaluation, valuable knowledge from the
research studies should be made into policy.
Lastly, a grant maker needs to be selective
and identify people in the front line in areas of
interest and solicit proposals from known
individuals or institutions. The interventions need
to be guided by the principles of availability,
accessibility, responsive to the principle of equity,
gender sensitivity, cost-effectiveness and
sustainability.
Abbreviations
AIDS
CSE
CSIR
DFID
: Acquired Immuno Deficiency Syndrome
: Centre for Science and Environment
: Council of Scientific and Industrial Research
: Department for International Development, UK
DOTS
: Directly observed treatment shortcourse
DSPRUD
: Delhi Society for the Promotion of Rational Use of Drugs
HIV
: Human Immuno Deficiency Virus
ICDS
: Integrated Child Development Scheme
ICMR
: Indian Council of Medical Research
ICRIER
: Indian Council for Research on International Economic Relations
USc
: Indian Institute of Science
IMR
: Infant mortality rate
INCLEN
: International Clinical Epidemiology Network
ISM
: Indian Systems of Medicine
KEM
: King Edward Memorial Hospital
NACO
: National AIDS Control Organisation
NAMP
: National Anti Malaria Programme
NEERI
: National Environmental Engineering Research Institute
NGO
: Non-governmental organisation
NHP
: National Health Policy
NIMHANS
: National Institute of Mental Health and Neuro-Surgery
R&D
: Research and development
RNTCP
: Revised NationalTB Control Programme
SAT
: Self administered therapy
TB
: Tuberculosis
TIFR
: Tata Institute of Fundamental Research
™h'
: Tata Memorial Hospital
TRIPS
: Trade Related Intellectual Property Rights System
WHO
: World Health Organisation
Ranjit Roy Chaudhury
Professor Ranjit Roy Chaudhury is one of the leading clinical pharmacologists of the
country. He has been head of the department of pharmacology dean and director at
the Postgraduate Institute of Medical Education and Research, Chandigarh from
1964 till 1981. He has also worked with the World Health Organisation in Geneva,
Bangkok, Alexandria and Myanmar.
Professor Roy Chaudhury is currently an emeritus scientist at the National Institute
of Immunology, New Delhi; the president of the Delhi Medical Council; and the
president of the Delhi Society for the Promotion of Rational Use of Drugs. Since its
inception, he has held the UNESCO Chair in the rational use of drugs at Chulalongkorn
University, Bangkok and is the chairman of the International Clinical Epidemiology
Network.
Professor Roy Chaudhury has written several books including three volumes of
International Experience in the Rational Use of Drugs, Some Aspects of Toxicology,
Herbal Medicine for Human Health, HIV/AIDS and Traditional Medicine and
Enhancing Access of Medicines to the Undeserved. He has also received many
awards. Some of these are the Dr B C Roy Award, the Amrut Mody Award, the S S
Bhatnagar Award, the Chulalongkorn Plaque and the Unitwin Award from UNESCO.
In 1998, he received the prestigious Padma Shri in recognition for his contribution to
the field of medicine.
Sir Dorabji Tata Trust
Sir Dorabji Tata Trust is a philanthropic organisation established in 1932 by
Sir Dorab Tata, son ofJamsetji Tata with a vision for the advancement of the
country. Jamsetji was a man sensitive to the development needs of the nation
and followed a philosophy of
'constructive philanthropy'.
The Trust has
pioneered institutions such as the Tata Institute of Fundamental Research,
Tata Institute of Social Sciences, Tata Memorial Centre and the National Centre
for the Performing Arts - the first oftheir kind in thecoun try.
During the last decade, the Trust has also set up the Sir Dorabji Tata Trust Centre
for Research in Tropical Diseases at the Indian Institute ofScience, Bangalore, the
JRD Tata Ecotechnology Centre at Chennai and the National Institute of
Advanced Studies at Bangalore.
The work initiated by the Trust bears contemporary relevance as it continues to
support innovative enterprises for development of the people of India.
Thoughtful and committed work pioneered by voluntary organisations is
supported in various fields of development.
Need-based educational and
medical grants are given to individuals. The Trust endeavours to uphold the
vision of its founding trustees - that of nation building and of providing
humanitarian assistance to improve the quality of life of the people of India.
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