Geneva Health Forum Archive

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Primary Healthcare Before the Alma Ata Declaration: A Case Study in Asia

Author(s): A. C. Y. Kok1

1History of Economy, University of Geneva; Hong Kong SAR, Hong Kong Special Administrative Region of China Keywords:  primary healthcare

Keywords: Primary healthcare

Lessons learnt from a pilot project decades before the Alma Ata Declaration on primary healthcare could be useful for today’s health programs. Three books and a website have been consulted, including a personal account of one of the person-in-charge, Dr. C.C. Chen. Chen worked in the pilot Ding Xian project from 1932 to 1938. Chen is a PUMC graduate and obtained his MPH degree in North America and is a faculty member of PUMC (Zhang, Da Qing, A Social History of Diseases in Modern China (in Chinese), Jinan: Shandong Education Publishing House, 2006, p. 176). Chen joined the Ding Xian project and lived there upon the persuasion of his former professor at PUMC, Dr. John B. Grant (Taylor-Ide, Daniel & Taylor, Carl. E., et al., Just and Lasting Change: When Communities Own Their Futures, Baltimore: Johns Hopkins U. Press, 2002, p.  96-97). Chen first met Grant, who was Professor of Public Health at PUMC, when he was a student there in 1926 (Chen, C.C., in collaboration with Frederica M. Bunge, Medicine in Rural China: a Personal Account, Berkeley: U. of California Press, 1989, p. 37). Grant had been head of the department of public health at PUMC for nearly fifteen years till his departure in 1934. John B. Grant, MD, MPH (1890-1962) was born in China to missionary parents. After having finished his education in medicine and public health in North America, he returned to Beijing to become the first head of the Department of Hygiene and Public Health of PUMC. Grant, of PUMC, had once been assigned to work on the incidence of hookworm in China and he concluded that a program with measures of prevention and treatment was needed. Grant organized rural and urban demonstraion areas for teaching and research and he joined the pilot primary healthcare project in Ding Xian in 1928. However, this project was discontinued due to the outbreak of armed conflict from 1937.


A research group affiliated with Jin Ling University conducted an ongoing socio-economic survey project in this modest county, Dingxian. Survey reports showed that there were 400,000 inhabitants. Chen organised a local health survey of a sample population of about 45,000 persons. Survey results showed crude birth and death rates and infant mortality rate. Communicable diseases were the main causes of the illness. Epidemics are caused by abnormal climate, according to the Chinese classics The Spring and Autumn [Annals] of Master Lu by Lu Pu-wei (d. 235 BC)(Zhang, 2006, p. 55). More than one-third of the deaths could be prevented, out of more than two thousand deaths reported in this survey. Another survey showed that nearly ten percent of the school children were regularly absent from classes. The second most common reason cited was preventable diseases.


In this pilot project, a three-tier primary healthcare system had been established. Some communicable diseases were eliminated; common health problems of children and newborns were reduced; level of health knowledge was improved; safe drinking water became available; vaccination was implemented. Since local people were recruited to be trained as lay health workers, the annual health expenses of the whole project is low (Zhang, 2006, p. 183).

Lessons learned:

Local universities had participated in this pilot project in providing technical support. This included needs assessment, recruitment and training of local lay health workers, evidence-based evaluation and a proposal of a sustainable system of low health expenditure. Primary healthcare programmes today could possibly learn from the experience of this pilot project of the 1930s.

What Ever Happened to Alma Ata? A Discussion Paper

Author(s): A. Hemmerling*1

1Women’s Global Health Imperative, University of California, San Francisco, USA

Keywords: Alma Ata, primary healthcare, brain drain, WHO

Editorials are in preparation as we approach another anniversary of the 1978 Alma Ata health conference. After 30 years, will this conference now be portrayed as a charming historical footnote or a revolutionary declaration still awaiting a road map into the 21st century?


After the WHO called for ‘Health for all by the year 2000’ in 1976, the Alma Ata conference in 1978 took place at the height of the Cold War, and the situation was shaped by, among other influences, the discussion of social and economic human rights, the unsuccessful malaria eradication programs as well as the experiences of the Chinese barefoot doctor movement. The conference was set as a response to un-addressed healthcare needs of developing nations as they emerged from colonialism. The new strategy was Primary Health Care (PHC) and aimed at the socio-economic root causes of illness. However, the enthusiastic consensus for a sustainable grassroots healthcare delivery system empowering people to be part of addressing their own healthcare needs was quickly narrowed down again to the oldfashioned vertical approach - donor driven and focused on tangible outcomes such as growth monitoring, oral rehydration, breast feeding and immunization. Was the rapid nosedive of the PHC agenda into policy oblivion a result of the worldwide implosion of leftist ideologies, due to paradigm shifts within organizations or turf wars within medical hierarchies, or because of widespread failures in the field? In the past, pilot projects as well as large-scale national efforts have successfully implemented primary healthcare strategies by including lower level cadres of health workers. Tens of thousands of village health workers have been trained in basic sanitation, to diagnose the most common communicable diseases and to provide essential medicines to treat them. Traditional birth attendants as the only healthcare workers able to reach the majority of women in rural areas were trained to provide family planning and basic obstetric care. Some countries even went ahead and implemented systems using surgical officers to perform common abdominal and obstetrical procedures. Where such efforts failed, it was usually not as a result of the ineffectiveness of these strategies, but rather the lack of political will to sustain financial and policy support for such programs At the outset of the 21st century we are facing a global healthcare crisis of new proportions. Governments and donors are committed to giving millions of people access to antiretroviral drugs, malaria treatment and anti TBC drugs. Additionally, the Millennium Development Goals call for a significant reduction in child and maternal mortality. But who will be on the forefront implementing these goals, when at the same time we witness a drain of the global health workforce away from where it is most urgently needed? Do we as politicians and health policy makers truly believe that this health crisis can be solved with continuing to focus on shiny new hospitals and installing highly trained doctors and nurses in every village on the planet? Why do we continue to plot the best medical care as the enemy of the good and sufficient medical care? And isn’t it cynical to use ethical arguments as a front to keep pushing for the unattainable highest level of care for everyone, when this strategy does little more than deprive the majority of people of any kind of medical care at all?


Thirty years after Alma Ata and in the midst of a growing global healthcare crisis, it is time to re-evaluate the old WHO goals and the merits of PHC. We need a thorough scientific and political analysis and discussion of what has worked and what has failed to fully understand the potential of PHC for reaching the Millennium Development Goals.

Lessons learned:

Let’s not have this anniversary pass by with more of the same friendly epilogues, but instead work on a road map to rejuvenate the Alma Ata strategies for the 21st century. We have lost enough time already.

Quality of Medical Training and Emigration of Physicians from India

Author(s): M. Kaushik*1, A. A. Bang2, A. Mahal3

1Nutrition and Epidemiology, Harvard School of Public Health, Boston, USA, 2Nutrition and Epidemiology, SEARCH, Gadchiroli, India, 3Population and International Health, Boston, USA

Keywords: India, physician, migration, medical education, quality.

‘Brain drain’ has been recognized since the 1950s but the renewed attention on physician emigration has uncovered little new ground and most of the new literature has focused either on measuring the absolute number of persons who leave native countries or their impact on health system performance in the native countries. However, there is little research on the systematic factors that influence emigration such as medical schools where these physicians are trained. This has hampered development of strategies to lower the rates of physician emigration.


The objective of this paper is to examine the relationship between the quality of medical training and rate of migration to the United States and the United Kingdom among Indian physicians who were graduates of Indian medical colleges over the period 1955-2002. Methods: Data on the number of seats in different Indian medical colleges was collected from public sources, along with information on university affiliation and year of establishment. Colleges and universities were ranked, by quintile, according to three indicators of the quality of medical education: (a) student choices in a nation-wide competitive exam, (b) academic publications by medical college/university; and (c) availability of specialty and sub-specialty medical education. For each quintile, we calculated the fraction of medical graduates who emigrated to the United States and the United Kingdom. The data were analysed using 2x2 contingency tables and Mantel-Haenszel chi-square tests.


Medical college graduates from the top quintile of universities and medical colleges were 2 to 4 times more likely to emigrate to the United States and the United Kingdom than graduates from the bottom quintile colleges and universities over the period 1955-2002. These results did not change by the method of ranking used, or the time period considered.

Lessons learned:

Conclusions and policy implications: Ours is the first study to use nation-wide data to establish that graduates of institutions with better quality medical training have a greater likelihood of emigrating. Interventions designed to counter loss of physician leaders, teachers and managers, should focus on physicians who graduate from top quality institutions and who contribute disproportionately to ranks of emigrating physicians.

Recruitment of Health Workers: Towards Global Solidarity

Author(s): A. Sanne*1, J. Espelid1
Affiliation(s): 1Secretariat for International Cooperation, the Norwegian Directorate for Health and Social Affairs, Oslo, Norway
Keywords: Recruitment, health workers, global solidarity.

The global community is facing a grave health crisis. Much of the developing world is experiencing high mortality rates and low life expectancy. An acute shortage of health workers hinders a solution to the crisis. There is also a great need for health workers in developed countries. Ageing populations and medical advances create a demand for healthcare that many countries choose to meet by recruiting trained health workers from developing countries. This aggravates the often desperate situation in the ceding countries. A more sustainable solution needs to be found for both developing and developed countries. Developed countries have a moral responsibility to ensure that meeting their own needs does not entail draining health workers from developing countries.
The Norwegian Government has therefore committed itself to actions that contribute to stemming this flow. In the report ‘Recruitment of Health Workers: Towards Global Solidarity’, the Norwegian Directorate for Health and Social Affairs proposes a policy foundation for this commitment. This report was handed over to the Norwegian Ministry of Health in the third quarter of 2007.


The report proposes actions in three areas. Together this will help reduce the factors that ‘push’ health workers from their home countries and ‘pull’ them to certain developed countries. First, a better balance must be found domestically between the need for health workers and supply of health workers. The need for new health workers can be reduced by improving the utilisation of existing human resources within the health and care services. Also, the domestic capacity for training health workers should be adjusted to ensure that supply fits the need. Secondly, a larger part of the Norwegian development assistance given to developing countries should be targeted at measures that increase not only the receiving countries’ capacity to train health workers, but also conditions for those already employed in the sector. Thirdly, it is neither a goal nor a realistic expectation to expect a full stop to the migration of health workers from developing countries. One cannot force individuals to stay in their native countries. Also, migration is not one-sidedly negative – it can have many positive effects for the ceding countries. The Norwegian Directorate for Health and Social Affairs therefore proposes the creation of both national and international guidelines with mechanisms for compensation to ensure that developing countries are not at loss when health workers are recruited to jobs in developed countries.


The proposals of the report will be considered for implementation by the Norwegian Government. This process will probably finish by the end of 2008.

In Search of a Better Life: The Migration of Healthcare Workers from Developing Countries

Author(s): S. M. Kabene*1, R. W. Leduc2, J. M. Howard3

1Management and Organizational Studies and School of Nursing, 2Management and Organizational Studies, 3Schulich School of Medicine, The University of Western Ontario, Canada


Migration, healthcare, developed countries, developing countries, foreign trained, Sub-Saharan Africa, brain drain, human resources, push factors, pull factors, financial capital, social capital, educational knowledge, capital flight, educated immigrants, industrialized nations, healthcare systems.


With an increasing need for healthcare professionals in developed countries, the aging population has created a growing reliance on foreign-trained healthcare professionals, many of whom tend to come from Sub-Saharan African nations. As a result of this phenomenon, known as brain drain, Sub-Saharan African nations have been faced with a human resources crisis in the healthcare sector. Workers who are thus leaving to meet these increased demands from developed countries are further depleting the limited sup- ply of healthcare professionals currently in Sub-Saharan African nations.


The objective of this paper is to identify the issues related to brain drain and offer potential remedies to minimize effects of brain drain. Brain drain is occurring in Sub-Saharan African nations and this is contributing to the further depletion of their healthcare systems. While evident that these source countries need to implement policies and address the push factors encouraging migration, ethical considerations need to be addressed when developing potential remedies. Through the use of secondary sources, data and information were collected and analysed that demonstrated the migration patterns of healthcare professionals, the push and pull factors of migration, and its resulting costs and benefits.


Recent statistics show that an estimated 1.5 million professionals from developing countries were working in industrialized nations. With the population of Sub-Saharan Africa totalling over 660 million, a ratio of fewer than 13 physicians per 100,000 individuals exists. Research demonstrated that poor compensation and wages, lack of further career development and education, poor working conditions and the risk of contracting deadly diseases such as HIV/AIDS, tuberculosis or cholera are push factors that contribute to the reasons for which health professionals migrate to developed countries. The opportunities for significantly higher wages, substantially safer and cleaner working conditions and more manageable workloads are some of the pull factors that make recipient countries attractive destinations.

Lessons learned:

One of the most serious problems associated with brain drain is the outflow of financial capital, social capital, and educational knowledge out of the source country and into a host country. This phenomenon is also known as ‘capital flight’. The result is a win-lose situation, where the host country reaps the benefits of educated immigrants, while the source country loses a portion of its skilled population. Recent statistics show that an estimated 1.5 million professionals from developing countries were working in industrialized nations, which causes further harm to the existing healthcare systems of the source countries.

GHF2008 – Opening Ceremony

Session Outline

Sunday, May 25  2008, 17:30-19:00, Room 2
Welcome adresses: 
Chair(s): Louis Loutan, President of the Organizing Committee, Geneva Health Forum, Switzerland & Brigitte Pittet-Cuenod, Vice-Dean, Faculty of Medicine, University of Geneva, Switzerland
Prof. Louis Loutan, President of the Organizing Committee, Geneva Health Forum, Switzerland
Mr. Bernard Gruson, Director General, University Hospitals of Geneva, Switzerland  
Prof. Jean-Louis Carpentier, Dean, Faculty of Medicine, University of Geneva, Switzerland 
Mr Manuel Tornare, Vice-President, Administrative Council, City of Geneva, Switzerland 
Mr Jacques Martin, Counsellor, Health and Development, Swiss Permanent Mission to the UN, Swiss Confederation
Key Note Addresses:
Primary Healthcare For The New Century
Dr Mirta Roses Periago, Director,  Pan American Health Organization, Presence of Dr Anarfi Asamoah-Baah, Deputy Director-General, World Health Organization, Switzerland 
Strengthening Health Systems: A Vision For Africa
His Excellency Prof. Gilbert Balibaseka Bukenya, Vice-President of the Republic of Uganda  

Session Video

GHF2010 – PS13 – Neglecting Neglected Diseases: More of the Same?

Session Outline

Parallel session PS13, Tuesday, April 20 20120, 14:00-15:30, Room 3
Chair(s): Ole Olesen, Scientific Officer for Neglected Infectious Diseases, Directorate for Health Research, European Commission, Belgium
Implications of Global Health Strategies on Neglected Tropical Diseases: Perspective from the Field
Abiy Tamrat, Medical Director, Médecins sans frontières, Switzerland
Obstacles to the Reintegration of Sleeping Sickness Control Activities in Primary Health Care Facilities, DRC
François Chappuis, Associate Professor, Division of International and Humanitarian Medicine, University Hospitals of Geneva & Medical Advisor, Médecins sans frontières, Switzerland
Leishmaniasis Control in Kenya: Current Challenges and Future Strategies
Joseph Njau Gatuna, Ministry of Health, Kenya
DNDi R&D Model: Innovation through Collaboration Instead of Competition 
Shing Chang, Research and Development Director, DNDi, Switzerland

Session Documents

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Session Report

Submitted by: Maushami Kabra (ICVolunteers); Contributors: Anne Descours (ICVolunteers), Christoph Wirth (ICVolunteers)

Photo by John Brownlee,

The huge range of tropical diseases, which come under the umbrella of 'Neglected Diseases', are often masked by malaria, TB and HIV/AIDS in developing countries. Human African trypanosomiasis (HAT/sleeping sickness), Viseral Leishmaniasis (VL), primary health care (PHC) in regions of sub-Saharan Africa, particularly Democratic Republic of Congo (DRC) and Kenya, were some of the main issues discussed in this session.

Abiy Tamrat, Medical Director from Médecins sans Frontières (MSF), Switzerland, began the session with his insights on Implications of Global Health Strategies on Neglected Tropical Diseases: Perspectives from the Field.

Neglected Tropical Diseases (NTD) affect more than 1 billion people and are responsible for more than 500,000 deaths per year. Mr. Tamrat shed light on the necessity to introduce a new classification of NTDs to better tackle these very different diseases. Depending on the organisation classifying them, the number of NTDs varies drastically from 3 to 45. Instead of the usual classification that separates simple (widespread, mass treatment, low cost) from complex diseases (endemic, needing individual medical care, high cost), he proposes to range NTDs among three overlapping classes of diseases, namely those with:

  • Existing effective treatments and control strategy.
  • Social or economic implications such as stigmatisation;
  • Complex management or tool deficiency.

This grouping would help in developing adapted health care strategies and orientating funding mechanisms. No competition between the various diseases should occur and an integration of funding mechanisms at all stages should be put in place. This would foster a better optimisation of resources, a more holistic approach to patients and a better lead optimisation. The speaker concluded that one should absolutely avoid continued neglect of NTDs.

François Chappuis, Associate Professor, Division of International and Humanitarian Medicine, University Hospitals Geneva and Medical Advisor for Médecins sans Frontières, stood in for Ole Olesen, Scientific Officer for Neglected Infectious Diseases at the Directorate for Health Research at the European Commission. Prof. Chappuis show photographic images of screening processes which have not changed in 84 years.

Sleeping sickness in Africa, also known as Human African Trypanosomiasis (HAT), is transmitted by the tsetse fly. The disease presents two phases: before and after Central Nervous System infection. Whereas the first stage can be easily treated by pentamidine, the second one needs treatment by infusion, which is not well suited to field conditions. Like most NTDs, HAT occurs in poor areas in low-income countries (Central Africa in this case). There is limited global impact of this disease and thus there has been a lack of diagnosis and treatments. Thanks to WHO-Sanofi Aventis agreements and better controls, the disease has stepped back in the last decade. However, a lack of sophisticated diagnostic and treatment tools and the weakness of Primary Health Care structures are still big hurdles to a long-lasting decrease in the number of cases. Furthermore, there is a lack of adequate numbers of properly trained health care workers and irregular drug supplies to contend with. There are considerable difficulties simply in reaching remote populations and the region suffers from political instability. There is an urgent need for more simple tools (diagnostics and treatments) and a vertical approach for HAT control cannot be avoided.

François Chappuis also presented on behalf of Joseph Njau Gatuna, Ministry of Health, Kenya, on Leishmaniasis Control in Kenya: Current Challenges and Future Strategies.

Leishmaniasis (also known as kala-azar) is a chronic vector borne disease and exists in two forms as visceral leishmaniasis and cutaneous leishmaniasis. Kenya alone reports 600 cases annually of patients suffering with the disease. VL is prevalent in arid areas characterised by ant hills and deep crevices in the ground. Rainfall is the only remedy. The main challenges facing this NTD include limited knowledge of the disease among health workers and a lack of diagnostic facilities. A revision of the 2001 guideline for control of VL is due to be published, but has been delayed due to lack of resources. Supplies of the effective treatment, Pentostam, SSG/Sodium Stibogluconate (from Albert Davis, India), are available in Kenya. Research questions to be addressed include vector identification, drug assessments and diagnostics tests. Funding problems arise due to a limited overall budget, a lack of a specific budget to control the disease and a lack of stakeholders providing funds. Key players, such as KEMRI, MSF, Merlin, UNICEF and WHO, have been collaborative however. The speaker presented a strategy for the elimination of leishmaniasis which a participant in the meeting contended was far from realistic.

Shing Chang, Research and Development Director from DNDi, Switzerland, presented DNDi R&D Model: Innovation through Collaboration Instead of Competition, and discussed his organisation’s promising R&D product portfolio.

DNDi was established in 2003 with a mission to collaborate with partners in order to address the needs of patients suffering from neglected diseases. Their objective is to deliver 6-8 new treatments for neglected tropical diseases (NTD) by 2014 and build an overall robust pipeline. Successful pharmaceutical drug development comes at a high cost and usually patent busting approaches and competitive innovation are the routes pharmaceutical companies take to generate revenue. DNDi’s model is to innovate for the patient’s benefit and develop cost effective drugs through successful partnerships with public sector, humanitarian and international organisations. A vital part of DNDi’s success comes from its collaborative approach at an early stage conducting compound mining and biological screening with pharmaceutical and research institutions. Clinical trials, registration and good manufacturing practices are developed in association with partners such as Médecins sans Frontières and Sanofi Aventis. In conclusion, despite limited spending, DNDi has been able to add two anti-malaria drugs and one anti-HAT drug to its portfolio, and has promising new Chagas and HAT fixed-dosed combination products under development.

Violence Against Women in Selected Nigerian Video Films and Novels

Author(s): C. L. Enwerem1
Affiliation(s): 1English and Women Studies, Imo state University, Owerri, Nigeria
Keywords: Women’s rights and health; violence against women, Nigeria, Africa

Women and girls in Nigeria are still subjected to various culturally based forms of abuse, exploitation and discrimination, the most common of which include wife battering, rape and other forms of sexual violence, female genital mutilation, trafficking in women, and inhuman widowhood practices. One of the primary concerns of the Millennium Development Goals is to ‘promote gender equality and empower women’.


The paper examines how certain forms of violence against women are portrayed in selected Nigerian video films and novels. It discusses how Nigerian dramatists and novelists present or misrepresent gender related violence in their works. It also tries to relate the prevailing negative gender attitudes in the country to the local socio-cultural contexts in which these writings and films are set and to the wider global discussion of gender justice and human rights. The paper focuses on a representative selection of video films and novels which portray the Nigerian woman burdened in various ways with patriarchal prejudices and at times very obnoxious native laws and customs that flagrantly violate her human rights and dignity.


It concludes with some comments on the adverse social consequences of violence against women, and the relevant international conventions, local legislation and other social responses that seek to redress these gender related anomalies in Nigeria. It also considers how home videos which are now widely used to dramatize these social ills can more creatively be used to promote the campaign to eliminate all forms of discrimination, abuse and violence against women.

Lessons learned:

Analysis of Price Components of Essential Medicines in India: Policy Options for Improving Access to Medicines

Author(s): A. Kotwani*1, L. Levison2
Affiliation(s): 1Department of Pharmacology, Vallabhbhai Patel Chest Institute, Delhi, India, 2Public health consultant, Boston, USA
Key messages:

1 – Government to increase transparency in manufacturer set, Maximum Retail Price printed on all medicines.
2 – Establish a working group (from ministries involved in health policy, private sector, academia and NGOs) to explore ways to bring all essential medicines under price control and remove all tariffs on medicines.
3 -  All public procurement bodies to enforce reliable delivery from suppliers.

Summary (max 100 words):

The study was conducted to investigate the relationship between medicine prices, price composition and pricing policy. A medicine price component survey utilizing the WHO-HAI (Health Action International) methodology was used to collect and analyse price components along the supply chain in the public and private sectors in New Delhi, India, February-March, 2007. Eight target medicines were surveyed: amoxi- cillin250mg, atorvastatin10mg, ciprofloxacin500mg, diazepam5mg, omeprazole20mg, ranitidine150mg, salbutamol syrup and ceftriaxone injection. Interviews were conducted with key informants in the Ministry of Health & Family Welfare, Ministry of Chemicals & Fertilizers, Drug Controller General of India, National Capital Territory (NCT) of Delhi, Municipal Corporation of Delhi (MCD) and New Delhi Municipal Corporation (NDMC). Data on public sector procurement systems was collected from 4 public healthcare providers: Central Government (CG), NCT Delhi, MCD and NDMC. In the private sector data was collected from 3 manufacturers, 1 super-stockist, 4 wholesalers and 7 retailers. Results: Public sector: NCT Delhi, MCD and NDMC have functioning procurement systems. Procurement for the central government is handled by outside entities who charge a processing fee, taken from the drug budget. However, NCT and CG tertiary units reported erratic supply resulting in more expensive local purchases of medicines. NDMC prices are higher, perhaps due to its technical qualification restricting the bidding pool. The CG dispensaries use significant amounts of proprietary medicines, which results in large expenditures. Private sector: All strips/boxes of medicines are printed with the MRP (Maximum Retail Price) by the manufacturer. Trade schemes between manufacturer, wholesaler, and retailer are common, and take the form of “buy 7 get 3 free” (30% discount). Trade schemes savings are not passed on to patients. Retail markups were found to be higher than the established margin; wholesale markups matched the established rates more closely. Price variations in the manufacturer’s selling price between popular trade names (‘branded’) and generic equivalents suggest that popular ‘brand’ medicines are priced well above their true manufacturing cost; prices are set at what the market will bear. For a few generics retailer margins were greater than 400%. Taxes: Various taxes levied include VAT, excise tax and an education tariff. All public procurement systems pay 4% VAT.

Conclusion (max 400 words):

India has a prolific generic industry with hundreds of generic equivalents, but with medicines known by their trade name and brand loyalty affecting the market. Several public sector departments provide health care to citizens. Responsibility for medicine pricing and access to essential medicines is fragmented and distributed across different ministries. There is much that the government, the public and the private sectors can do to increase access to essential medicines.

Lessons learned: Only 74 medicines are mentioned in schedule that is under price control. Most of the essential medicines (over 350) are not under price control. No control of government on fixing the price of non-scheduled medicines. Trade schemes are common and huge margins for retailers on branded-generic medicines.  Replication of efforts among public sector procurement offices. Unreliable delivery from suppliers in public sector leads to local purchase of medicines.