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Despite the recent policy impetus for age-friendly cities, there is still scope for more geographical insights into ageing in low- and middle-income countries (LMICs). Cities in LMICs, such as Bengaluru (India), are witnessing an increase in the size of the older population in their peripheral urban regions, but there is relatively little understanding of the risks of exclusion in later age in these liminal zones. This study, set in a peripheral ward of Bengaluru, focuses on the experiences of exclusion/inclusion of socio-economically marginalised older adults and their access to work, health care and leisure. The research uses a multidimensional old-age exclusion framework to highlight how the domains of neighbourhood, material resources, mobility infrastructure and social relations influence the risks for social exclusion. We use a qualitative approach by combining behavioural mapping and in-depth interviews. Our findings highlight some ways in which institutionalised exclusion from civic infrastructure accentuates the precariousness of ageing. The rigidity of traditional hierarchies in peri-urban regions has meant that older adults who were poor, women and belonged to marginalised castes experience constrained mobilities to access labour markets, health care and social life, compounding their place-based exclusion. Despite social networks and solidarities, older adults on the periphery faced individualisation of risks while trying to access the basic amenities, thereby falling between the gap of the urban–rural milieu and governance. Age-friendly cities need to accommodate such hybrid transitionary urban processes, in the absence of which, active ageing in these rising peripheries can be impeded.
The hypermobile cities of India stood still with the onset of COVID-19-induced lockdowns. Public transport services were the first to be suspended, and older adults in particular were instructed not to leave their homes (Press Information Bureau (PIB), 2020). Even with the easing of lockdown and the resumption of limited public transport, older adults were ‘restricted’ from using services as per the pandemic-related advisories issued by the state. Mobility, which is central to active aging, health status, and well-being (World Health Organization (WHO), 2007) of older adults, was affected by this exclusion in the public transport system. The short-and medium-term implications of such lockdown protocols towards the (im)mobility of older adults requires attention. Given the Indian urban transport scenario, the dependence of older adults (particularly those from low-income groups) on public transport and the inadequate public transport infrastructure is relevant to contextualize the pandemic advisories.
This chapter uses the case of Bengaluru city in southern India to highlight how transport protocols issued during the COVID-19 pandemic impacted older adults’ (im)mobility. Even before the lockdown was rolled out on March 24, 2020, Bengaluru's public transport system had been struggling to cater to passenger demand. With physical distancing norms in place, which reduced ridership and trip number, it has become more difficult for passengers in general, and older adult passengers in particular, to access public transport. In Bengaluru, a large proportion of older adults are mobile, work in the informal sector, and earn a low income. They cannot afford private transportation and are therefore dependent on public transport (Baindur and Rao, 2016). The exclusion of this group from the public transport system will have implications for their access to work, social life, and essentials such as banking, health care, and groceries.
In this chapter, we take an intersectional perspective, where we examine how events such as the COVID-19 pandemic further accentuated the already disadvantageous position of older adults in the absence of age-friendly interventions. The chapter reviews the literature, government circulars, and social media communication to understand the state's major transport-related decisions. We use data from our online survey (conducted between June 9 and June 30, 2020), in which we focused on the impact of COVID-19 lockdowns on older adults’ mobility in urban India.
This chapter attempts to understand the medical innovation landscape of India in detail by specifically focussing on the pharmaceutical, biopharmaceutical and medical technology sectors. The first part of the chapter overviews the performance of these sectors with a special focus on research and development (R&D). The second part attempts to unearth the institutional co-production of medical R&D. This section of the chapter examines the formal and informal actors and processes in the network of production, the institutional network of funding and product development. The data presented in the chapter are drawn from secondary sources and published literature on medical innovations in India and other countries. The data on industry performance are obtained mainly from CMIE Prowess, reports of the Association of Biotechnology Led Enterprises (ABLE) and the published reports of the Department of Science and Technology, the Department of Biotechnology and the Ministry of Chemicals and Fertilisers. The data on funding are compiled from various sources including CMIE Prowess for private and public Indian and foreign companies, the Department of Science and Technology, the Biotechnology Industry Research Assistance Council (BIRAC), Government of India (GOI), for funding of research institutions and websites of the companies and service aggregators for the funding of start-ups. The data on clinical trials across companies and disease and participating hospitals are compiled from the Clinical Trial Registry of the Indian Council of Medical Research (ICMR).
The Indian pharmaceutical industry: sales, export and R&D
Studies have already shown that the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPs) regime provided an impetus for the industry to change its direction and destination and become more export oriented in its production activities (Dhar and Gopakumar 2006). Concerns were raised that imports would increase in the product patent regime and unfavourably affect the balance of trade. However, the Indian pharmaceutical industry could achieve a positive balance of trade mainly due to the export of formulations (Joseph 2009). Studies further revealed that the compound annual growth rates (CAGR) of exports of formulations are greater than those of bulk drugs in the TRIPs era, a trend opposite to one observed in pre-TRIPs era. These trends showed that imports also increased though the leading importers are multinational companies (MNCs), which was attributed to the removal of restrictions in the post-reform period.
Medical expenditure constitutes a significant component of out-of-pocket health spending in India. Recent research has shown that catastrophic household health expenditure has increased in India (Brinda et al. 2015; Pandey et al. 2018). Studies have found several policy interventions that are responsible for the increase in the cost of medical expenditure. These include structural adjustment policies and the resultant rapid privatisation of healthcare (Ghosh 2011), non-regulation of the private sector (Bonu et al. 2009; Bandameedi et al. 2016), irrational prescription practices of doctors (Bhaskarabhatla and Chatterjee 2017), poor health financial protection (Devadasan et al. 2007; Selvaraj and Karan 2012), market-based pricing policies of drugs (Narula 2015) and, above all, the higher cost of medicine. Development of new branded generics and biosimilars has contributed immensely to the treatment of several infectious and non-communicable diseases in India. However, with the adoption of a market-based pricing policy, it is not clear whether new drugs that are coming to the market are affordable to people. This chapter critically examines the question of affordability due to considerable variations in the prices of newly approved branded generics in the light of the market-based pricing policy of drugs in India. It also offers a discussion on various policy initiatives across the globe on pharmaceutical pricing and its relationship with affordability.
The chapter has used secondary data sources to examine the financial burden of medicines and prices of formulations of drugs. Data on prices of medicines for inpatient and outpatient treatment presented in the chapter are drawn from the nationally representative data of India – social consumption – health survey of the National Sample Survey Organisation (NSSO), Ministry of Statistics and Programme Implementation, Government of India, collected from January to June 2014. Medical expenditure is provided for a reference period of 365 days for inpatient care and 15 days of outpatient care for items including doctor's fee, diagnostic tests, bed charges, cost of medicine and other medical as well as non-medical expenditure. The data on the prices of formulation and brands of selected drugs discussed in the study are obtained from the web portal of Pharma Sahi Dam of the National Pharmaceutical Pricing Authority, Ministry of Chemicals and Fertilizers, Government of India.
The Coronavirus disease 2019 (COVID 19) pandemic has posed fresh challenges pertaining to the prevention, control and management of infectious diseases in the medical innovation landscape all over the world. Although the emergence and resurgence of communicable diseases have been serious health concerns, especially for poor regions and populations across the globe, these diseases did not receive adequate attention in medical innovations due to various political economy reasons and their confinement to limited (poor) regions. For instance, we have seen outbreaks of Ebola haemorrhagic fever in African countries, cholera in African and Asian countries, dengue haemorrhagic fever in India and other South Asian countries, Japanese encephalitis in India and Nepal, and influenza and malaria in African and South Asian countries in the recent past that perhaps did not receive sufficient attention of the vaccine, drug or medical equipment industry. Similarly, the worldwide severe acute respiratory syndrome (SARS) outbreak in 2002 and the Zika virus epidemic in 2016 also did not significantly change the priorities of medical innovations, which are mostly concerned with non-communicable diseases. However, the COVID 19 pandemic has exposed the lack of preparedness to emerging communicable disease problems across the world and compelled us to revisit the threat of communicable diseases in a globalised world since the infection changed the prevailing risk perceptions by crossing the binaries of rich and poor and exposing the entire humanity to infection. The COVID 19 pandemic thus poses certain questions on the epistemological base of the present organisation of medical innovation, which is built around the principles of techno-scientific capitalism and setting of priorities in medical innovation. This book attempts to discuss the mismatch between public health priorities and medical innovations which can have implications for the health of the global population in the future.
The last four decades have witnessed several path-breaking innovations in healthcare, particularly in drugs, vaccines and medical technologies. Advancements made in the research in health and life sciences across the world have played a conspicuous role in medical innovations. The proliferation of biotechnology and its associated streams of biomedicine, bioinformatics, genomics and advancements made in the field of synthetic biology have widened the scope of medical innovations to the next level.
Striking the right balance between healthcare priorities and pharmaceutical policies is a critical public health challenge for India given their mutually conflicting nature and interests. On the one hand, the country has an expanding pharmaceutical and biopharmaceutical sector with a strong presence of domestic and multinational private companies. The sector, with significant state facilitation, could effectively position itself as the future engine of economic growth by reorienting itself to the new intellectual property and trade regimes. The dominant discourse now is that ‘all publicly funded research should be translated into private entrepreneurial activities because technological innovations contribute to nation's economic growth’ (Lehoux et al. 2016b: 115). The most important outcome of this discourse is the domination of the financial logic in all matters pertaining to state facilitation, research and development (R&D), dissemination, trade and market expansion of the industry over population health. On the other hand, India has a huge burden of diseases stemming from a gamut of public health problems, including the uneven distribution of demographic and epidemiological transition, increasing privatisation of healthcare, insufficiently regulated pharmaceutical market, low affordability of life-saving medicines and, most importantly, the escalating out-of-pocket healthcare expenditure coupled with poor financial risk protection. Public health relevance of R&D in healthcare is to be assessed in the context of these conflicting concerns of health and industrial policies in India.
Challenges of responsive medical innovation
What should be the focus and priorities of medical innovations in countries like India? The simple answer should be the diverse epidemiological needs of the country across regions, income groups, age groups and gender. Unsurprisingly, what is strongly emerging from the data of growth, expansion and the disease focus of R&D across the globe in general and India in particular is the mismatch between the priorities of industry and public health. We identified five overriding patterns in the product innovations in the drug, vaccine and medical technology sectors that illustrate these mismatches in India. First is the near-complete dominance of ‘me too drugs’ (including branded generics and biosimilars) in the R&D in drug development in the pharmaceutical and biopharmaceutical sectors.
The Indian pharmaceutical industry has played an important role in the development of generic medicines (Farmer 2001). However, whether those who are heavily dependent on the public sector benefit from this advancement made by the industry is a critical question for several reasons. First, as is well known, the bulk of these generic drugs are exported to international markets and are inaccessible in India (Swain et al. 2014). Second, the market is dominated by branded generics, which are usually priced higher than their corresponding generics (Mathew 2015). The quality of essential generic medicines that are available in the public sector has been also under question (Bate et al. 2009). The prospect of drug development in India assumes paramount significance for public health in this context. This chapter discusses in detail whether drug and vaccine development in India is responsive to the disease burden of the population, epidemiological changes and accessibility of services. To begin with, we present the data on disease burden in the country from 2000 to 2015 and juxtapose the therapeutic focus of the drugs approved for marketing, the new chemical entities (NCEs) in the pipeline and vaccines. The data on disease-specific mortality are collected from the mortality database of health statistics and information systems of the World Health Organization (WHO) for the years 2000, 2005, 2010 and 2015. These data are further disaggregated across four age groups. Data on morbidity are extracted from the National Sample Survey Organisation (NSSO) 71st round on health in India (2014). Data on drugs approved for marketing are compiled from the Central Drugs Standard Control Organisation (CDSCO), Government of India.
Causes of deaths in India: a detailed analysis
We have extracted the data of causes of deaths for the years 2000, 2005, 2010 and 2015. As Table 3.1 shows, non-communicable diseases (NCDs) constituted the highest cause of deaths in all these years as compared to communicable diseases (CDs). Furthermore, there is a steady increase in deaths due to NCDs along with a decline in mortality due to CDs in general in the line of the trend of epidemiological transition. For instance, the share of NCDs in total deaths increased to nearly 61 per cent in 2015 from 46 per cent in 2000. Similarly, share of NCDs was reduced to nearly 21 per cent in 2015 from 30 per cent in 2000. The share of injuries and accidents in the causes of death also marginally increased during this period. Table 3.1 presents the causes of death for males and females. As the table shows, the trend of dominance of NCDs was true for both males and females. However, the burden of CDs was found to be more on females than males.
The previous chapter illustrated that innovation is a process of co-production in which several institutions and interest groups involve actively. This process of knowledge production essentially is not value neutral. What is, hence, important to understand is the nature of the institutions which are involved in the co-production of innovation and their priorities. This is important in medical innovations given the mutually conflicting priorities of public health and industrial interests. As is well known, research and development (R&D), especially in the pharmaceutical sector, in its initial period was supported by government institutions, public laboratories and government grants. However, with the new patent regime the private players have started participating increasingly in drug, vaccine and medical technology development. Studies have shown that the pharmaceutical industry is one of the sectors that have high R&D spending levels (Dhar and Gopakumar 2006, Abrol et al. 2011). Studies also showed that availability of medicines and medical technology products in the market has increased significantly in India with the expansion of domestic and multinational private companies, which benefited from a facilitating industrial policy environment (Joseph 2016). However, most of the R&D activities in India remain merely a small part of the large global value chain emphasising on contract manufacturing and contract research. The focus of research in the industry, therefore, has been predominantly guided by the consideration of the Western markets (the United States and the European Union), leaving less focus on neglected tropical diseases and population (see Viergever 2013). Studies showed that only 10 per cent of domestic firms’ investment on R&D is spent on the needs of developing countries (Rowden 2013). It is, hence, not clear whether the change in the policy design, though it has increased research activity, has taken care of the public health needs of the country.
This chapter attempts to understand the disease focus of health R&D in India. It specifically examines the drugs, vaccines, medical devices and diagnostic technology R&D of private and public sector firms/institutions in India. We have extracted the data on drugs approved for marketing in India from 2001 to 2017 from the Central Drugs Standard Control Organisation (CDSCO), Government of India, to understand the therapeutic focus of drugs R&D.
Striking the right balance between public health priorities and health innovation is a critical policy challenge for India given their mutually conflicting nature and interests. India has a huge burden of diseases implicated by a gamut of health problems including the uneven distribution of demographic and epidemiological transition, threat of new infectious disease pandemic like COVID 19, increasing privatisation of healthcare, low affordability to life saving medicines and most importantly the escalating healthcare expenditure coupled with poor financial risk protection. The central question that the book addresses is whether health innovation in India is sensitive to the public health needs and priorities. It unearths the overriding issues related to responsiveness and equity in India's health innovation. The book highlights the need for a responsible innovation framework for India that balances the priorities of public health and the industry goals.
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