Thank you to the FMES Managing Committee, the working editors of IJME and the core organising team of the 10th National Bioethics Conference, for felicitating me for the work I have been doing. I am overwhelmed by your gesture! I am just one of the scores of health activists in India trying to raise issues from a pro-people perspective in health and healthcare, and to forge a humane and ethical alternative to the dominant Indian healthcare system. I consider this as a felicitation of the spirit and the work being done by this community of activists. It is in this spirit that I humbly accept this honour. I was able to give more time to this work, thanks to my wife, Sandhya, who has been the family breadwinner.
While accepting this, I must also share my sense of sadness that despite our best efforts, for decades, we are nowhere near our cherished goals. Today, in this globalised world, advancements in medical and other technology, and in the economy, have the capacity to realise the goal of health and healthcare for all. However, in India and in most parts of the world, the overall situation in the field of health and healthcare is only deteriorating, as is the overall socio-economic and political situation. The relentless march of global warming and prospects of climate catastrophe darken this picture further. Despite the range of pro-people initiatives by collectives I have been involved in, I see that we are nowhere near making the desired impact. We continue to be on the margins. In the current almost hopeless situation, one can only keep trying and keep hoping! Let me explain why I feel this way.
In the first thirty years of Independence, India achieved some milestones in health indicators compared to the colonial period. A nationwide network of public health facilities was built, including the much-needed primary health centres in rural areas, a major achievement though inadequate in coverage and quality of care. However, the public health system was mainly preoccupied with the “Family Planning Programme” which had become almost an obsession, and also with vertically managed disease control programmes. Despite these limitations, various health and healthcare indicators improved. Secondly, thanks to the Indian Patent Act 1970, and to the technical capacity built up in the National research laboratories in India, production of much cheaper generic formulations boomed in the eighties and beyond. Compared to those in other developing countries, Indian citizens started getting access to a whole range of relatively cheaper generic medicines.
After the 1990s, the Indian government more or less abandoned the limited attempt to build an Indian variety of welfare capitalism. Those who had amassed wealth and political clout through the three decades of post-Independence development either buckled under the pressure of Western financial institutions, or willingly joined hands with them to adopt a new path of “market dictated development”. In healthcare, four industries prospered under this new policy of liberalisation, privatisation and globalisation (LPG) pushed by the World Bank. These profit-driven sectors are — the pharmaceutical industry, the medical laboratories industry, the hospital industry and private medical colleges. The government’s regulation as regards quality and price in these four areas is almost non-existent, leaving the field open almost entirely to market forces. The results have been disastrous for the common people. Let me explain briefly.
About half the medical colleges in India are privately owned, with little effective regulation of the fees they charge. As a result, parents of an undergraduate MBBS student spend around Rs 1 crore for graduation, and later, about Rs 2 crores for post-graduation in a private medical college. Doctors graduating from these private medical colleges are obliged to earn high incomes by hook or by crook. Hence, they tend to indulge in unnecessary interventions, accept commissions from the pharma industry, commercial and corporate pathology laboratories, and even from fellow doctors for referring patients to them. In these colleges, exposure to clinical work is very limited as the hospitals attached to them have few patients and rely far more on investigations than on clinical understanding. Further, since the majority of these students want to go in for post-graduation, they focus more on practising multiple choice questions (MCQs) for the NEET-PG exam, rather than on getting clinical experience and skills during their internship. This has been the bitter experience of my medical teacher friends. This debasement of clinical medicine is common among government medical college graduates who also focus on their preparation for NEET-PG. Patients have to pay the price of these unhealthy developments.
The pharma industry has benefited tremendously from this neoliberal policy in the economy and in medical education. In the nineties, price control over medicines was mostly withdrawn. Due to a public interest case in the Supreme Court by the All-India Drug Action Network (AIDAN), the government was forced to regulate the prices of essential medicines from 2013 onwards. However, its Drug Price Control Order, 2013, was designed to maintain high margins for the pharma companies; hence, it has hardly reduced the burden on patients. I am a trustee of the Lowcost Standard Therapeutics (LOCOST) Trust, Vadodara, and we manufacture and sell, with a 20% margin, more than 100 essential generic medicines to non-profit health organisations. Since we are a small-scale manufacturer, our cost of production is high and yet our prices range from half to one-fifth of market prices. Overall, unrestricted profiteering by the pharma industry is a big burden on hapless patients. Besides, irrational Fixed Dose Combinations (FDCs) continue to be a big problem, exposing the unfortunate patients to unnecessary medications, unnecessary side-effects and unaffordable high prices. FDCs constitute only 7% of the WHO List of Essential Medicines list which includes only rational FDCs. Whereas in India, FDCs constitute 40% of the market, as all kinds of irrational FDCs are allowed to be marketed. Even the modest recommendations of the Nilima Kshirsagar Expert Subcommittee, to ban a list of irrational FDCs, have not been implemented. Overall, this has meant that, in India, medicine prices are around four to ten times higher than they should be. Medicines alone account for 29% of inpatient and 60% of outpatient expenses, respectively, and every year 3% (ie about 5 crore) Indians are pushed below the poverty line because of over-priced healthcare.
Till the 1990s, doctors were, by and large, general practitioners. Consultants, hospitals, and laboratories played a secondary role. Commission practice was not rampant, except in some metropolises. The situation has changed radically during the last 35 years. Not only the pharma industry but corporate pathological laboratories, the corporate imaging industry and corporate hospital chains have overwhelmed medical practice, making over-investigation and unnecessary interventions the norm. The hapless patient is at the receiving end.
Since the 1990s, the government has systematically underfunded and neglected the already inadequate public health services. Central and State government healthcare expenses have stagnated for the last 40 years, constituting a mere 1.3% of the GDP, far below the recommended 2.5% of GDP by the present government’s Niti Aayog, and the 5% and 3% of GDP respectively, by the WHO and the High-Level Expert Group of the Planning Commission. Huge numbers of posts in public health services are vacant, especially at higher levels, and barring the exception of some states, the under-funded, under-staffed public health system is leaderless, dispirited and dysfunctional. Moreover, nowadays, in the guise of public private partnership, several public healthcare institutions are being handed over to profit-centred corporates. Poor people suffer the terrible consequences of all this.
The various health-groups I have been involved with, during the last 50 years, have opposed all these unhealthy policies. We have worked to educate the public on issues of healthcare policy through writings in the popular press, public programmes, signature campaigns, etc, and tried policy-level interventions at different levels. These groups have also suggested and tried to practise and foster alternatives of various kinds. However, most of the policy improvements which we have tried in different parts of India, and national level attempts by the Jan Swasthya Abhiyaan, the all-India coalition of health-activists, continue to be ignored. The policy-makers are wedded to the prosperity of the rich and powerful lobbies. What is more worrying — the strength of all the pro-people groups remains marginal and the impact far short of what is needed. What is the way ahead? The only remedy is that those who feel strongly that health and healthcare need to be transformed need to give more time, more energy, more money, to push for better policies. Unfortunately, the People’s Health Movement is very short of volunteer-time and donations. This situation can and must change and I would appeal to all, to try to chip in as much as possible. Only a strong people’s health movement can change the situation. Those who want this change to happen need to make it their priority. Voluntary NGO work can help to push the pro-people agenda; but funded NGO work cannot solve the problem of paucity of voluntary time and material resources. We need these to build a broad-based strong movement, from below, to demand policies for achieving the goal of health and healthcare for all.
Thank you again for this felicitation and thank you all for a patient hearing.
Author: Anant Phadke (anant.phadke@gmail.com) Co-convenor, Jan Arogya Abhiyan; Trustee, LOCOST; Member, Lok Vidnyaan Sanghatana, Medico Friends Circle and All India Drug Action Network, INDIA.
Conflict of Interest: None declared
To cite: Phadke A. FMES-IJME Ethics Award 2025 acceptance speech: Anant Phadke. Indian J Med Ethics. 2025 Apr-Jun; 10(2) NS:171-172. DOI: 10.20529/IJME.2025.033
Copyright and license
©Indian Journal of Medical Ethics 2025: Open Access and Distributed under the Creative Commons license (CC BY-NC-ND 4.0), which permits only noncommercial and non-modified sharing in any medium, provided the original author(s) and source are credited.