Juices for PMS, patches for cramps: Period care gets padded up

There are 336 million menstruating women in India, and 36% use disposable sanitary napkins, according to Menstrual Hygiene Alliance of India (MHAI). That’s 121 million women.

It’s no surprise then that the menstrual products market is growing. And fast.

Valued at $340 million by market research provider Euromonitor in 2017, the sanitary products market in India is predicted to grow to $522 million by next year. It is dominated by international FMCG (fast moving consumer goods) companies such as Procter & Gamble’s Whisper and Johnson & Johnson’s Stayfree, which, according to Euromonitor, have a retail market share of 50.4% and 24%, respectively. Their products are priced low to ensure maximum reach, especially in a country like India.

But not everyone is price-sensitive. Those who can afford it tend to seek quality alternatives. As in any industry.

So, despite the FMCG dominance in sanitary products, there’s been a flurry of menstrual products focused on health and comfort. From pain-relief patches to PMS-friendly juices to anti-rash creams to ‘naturally’ made pads, the Indian sanitary products market has, in the past few years, grown to accommodate more than just a basic need. Much like skincare, haircare, or even dental care, period care is a growing option available online.

And it’s catering to women who’d be happy to spend that extra buck for a comfortable period.

“It is a convenience-conscious market. There is a large audience that is not happy with their brands. They want value for money, but they want better products,” says Deep Bajaj, founder of Sirona, a Delhi-based online hygiene products company which offers tampons, cups and other products.

“It’s how [cab aggregator] Uber bettered the market from [competition] Meru. Now, even if it costs a little more, you are willing to take an Uber for the convenience,” he adds.

This shift is particularly interesting in the sanitary products space for it’s one marred with societal shame. Even today, sanitary pads are often wrapped in their trademark black plastic bags—to be used but not seen. Over the past few years though, India has seen its cultural mainstream, Bollywood, take on the subject with films like Pad Man and Phullu. Just a few months ago, the documentary Period. End of Sentence., which spoke about India’s menstrual taboos, won an Academy Award.

“It’s time we stopped whispering about periods”

Gauri Singhal, Founder, Floh

“About three decades ago, Whisper was the first brand to show a sanitary pad and mention the word ‘periods’, in our advertising. At the time, when we wanted to advertise on primetime, TV channels thought it was an inappropriate product to advertise,” says a spokesperson at Whisper, P&G which claims a double-digit percentage growth this year. Whisper’s iconic ‘Touch the Pickle’ campaign in 2014 was well received for taking on period superstitions.

Of course, a lot has also changed. Enough to make period care products marketable if not popular. EcoFemme, a social business which makes washable cloth pads in Tamil Nadu’s Auroville, claims 44.63% growth since 2015, which was also the year it started its online store. ‘Chemical-free pads’ brand Azah, launched as recently as November 2018, claims 40-50% growth each month. And while these companies are still fairly small, they’re reaching their customers in ways FMCG companies aren’t. They have one-on-one channels between the buyer and the company via social media and monthly subscription programmes, eliminating the need for women to settle for a product that’s just about okay.

Comfort and environment, but not cost

A fair share of these period care companies, interestingly, started with providing sustainable alternatives to the FMCG companies’ sanitary napkins. A DownToEarth article, based on MHAI data, calculates that India alone generates 12.3 billion disposable sanitary napkins a year, most of which are not biodegradable.

EcoFemme launched in 2010 to aid menstrual education and provide a livelihood to the rural women of Tamil Nadu, and due to the philanthropic efforts of those who liked its washable cloth product, it grew as a business. “I began a small production with the idea of making the products available to women in Auroville. Some were inspired to start selling the products in their home countries (mostly in Europe). Within a few years, I had a small ‘business’ that had grown completely organically,” says EcoFemme founder, Kathy Walking. The company now sells five different sizes of reusable pads priced at Rs 230-275 each ($3-4).

The menstrual cup, also known as the moon cup, made of silicone, is possibly the most sustainable sanitary product. One cup lasts close to a decade, is reusable, washable. All it takes is a one-time payment.

However, that one-time payment can seem daunting to many. “Newer products such as menstrual cups are niche offerings as of now, since the numbers are small and unit prices are higher than what the vast majority of Indian customers may be willing to pay,” says Devangshu Dutta, founder-chief executive of Third Eyesight, a consulting firm in the consumer products and retail sector. “There is, no doubt, a case to be made for lifetime value comparison between menstrual cups and pads as well as the obvious environmental impact, but the first barrier in many consumers’ minds across product categories is unit price,” he adds.

The moon cup came to India in 2016, with Sirona launching it at under Rs 400 ($6), followed by Boondh, a Bangalore-based social enterprise focussed on sustainable menstrual health practices, which currently sells it at Rs 700 ($10).

Sirona had previously found success in launching the disposable female urination device ‘PeeBuddy’ in 2015 (Rs 20/$0.30 a pop). While this wasn’t a menstrual product, it marked disruption in the feminine hygiene market, having sold over 2 million units to date. Soon, Sirona was selling pain relief patches (Rs 290/$4 for five patches that last 12 hours each), anti-chafing rash cream (Rs 375/$5), disposal bags, tampons and panty-liners.

Another brand Carmesi, which takes its name from the colour ‘crimson’, launched its pads in November 2017, with the promise of both comfort and being “chemical-free, environmentally friendly”. Its products cost Rs 200 ($3) upwards while the FMCG alternatives start at as low as Rs 40 ($0.5), for a pack of 10.

The Carmesi website

“We…made this industry care for a woman’s experience with her period products at a time when the conversation was restricted only to affordability. While we acknowledge the problem of affordability of sanitary pads, we don’t dismiss the need for better products. The personal care industry has advanced so much. Then, why not menstrual hygiene?” asks founder Tanvi Johri.

Being Juliet, meanwhile, saw an opportunity in playing concierge for menstrual needs. With as many as 18,000 regular customers, the service solves the delivery problem by sending a box of menstrual hygiene products (and goodies) to one’s doorstep for Rs 500-900 a month ($10-12). Which is a bit steep.

Being Juliet’s subscription plan

“As a society, we are conditioned to see women as selfless beings who don’t spend on themselves. That’s how the affordability pitch comes in,” argues Ankur Goyal, the founder and CEO of &Me, India’s first ‘period drink’. The &Me drinks come in different flavours, for women with PMS (premenstrual syndrome) and PCOS (polycystic ovary syndrome), costing Rs 320 ($4.5) for a pack of four. It aims to bring the focus back to menstrual health, targeting nutritional deficiencies and symptoms like mood swings and night sweats.

When India’s first menstrual drink was launched last year, it was called Rhythm. “We decided to put the words PMS directly on the bottle and it made no difference in our sales. The time for hidden words and sentences to signal menstruation are over,” says Goyal.

Comfort and cost, but not the environment

Shashwat Diesh overheard his sister complaining about rashes from pads. He couldn’t understand why women with her income didn’t have access to better products. He along with Aqib Mohammed (both co-founders of Azah) conducted a survey with a sample size of 300, and over 50% had suffered period rashes. “We looked at the products in the market and realised they used a lot of cheap raw material and harmful chemicals that caused skin irritation,” he says. After some material research and time spent on design, they launched Azah, a pad with a soft, organic cotton top layer. Azah, priced at Rs 240 ($3.5) for a box of 12 pads, has over 12,000 regular customers, and while it isn’t biodegradable, it promises to be in two months.

Azah’s website

Pads are far from the ideal sanitary product, but it’s what the market demands. “We thought of sanitary pads first because Indian and other South Asian women still don’t want to use invasive products. It is more cultural conditioning than anything else, but it is difficult to change,” says Swathi Kulkarni, co-founder and CMO of Mumbai-based chemical-free sanitary brand Nua. Launched in May 2018, it claims to have acquired 60,000 unique customers with 50% residing in tier-II and tier-III cities.

Then there’s the minority of tampon users in India. Globally, the tampon market share is predicted to attain an overall value of $6.34 billion by the end of 2025, according to market researcher Transparency, and some companies have seen the opportunity in India. While Sirona sells tampons, Floh, also a digital-first market entrant, launched in May 2018 as ‘India’s leading tampon brand’.

Floh claims a 40% monthly growth, with founder Gauri Singhal stating that 50% of its orders come from tier-II and tier-III cities. Early this year, Floh introduced an ‘all-natural, cramp-free’ period patch. “Besides, sanitary napkin is a monopolistic category,” says Singhal. A view Sirona’s Bajaj echoes when he says pads aren’t conducive to much innovation.

Most women still favour the pad, and in a comfort-led market, they’re only willing to be environmentally-conscious if the product ticks all the other boxes. “The environmental impact of disposable sanitary pads, or for that matter of any other product, is not yet a big purchase influencer for most Indian consumers,” says Dutta of Third Eyesight.

The P&G vow

P&G aims to be able to recycle absorbent hygiene products (AHP) in 10 cities by 2030, according to its latest sustainability agenda. In the long term, it hopes to use 100% renewable or recycled materials for all products and packaging. Mostly because it contributes to the problem. Quite a bit.

However, there are a few brands in the market that sell biodegradable sanitary pads, often at steep prices. These promise women an eco-friendly solution without the hassle of adapting. Laura O’Connell, communications officer at EcoFemme, though is quick to caution. “We are concerned about this type of product because often ‘biodegradable’ or ‘compostable’ menstrual products need very specific conditions in order to be broken down. If you dispose of them in a plastic bag [they] cause just as much harm as conventional disposable menstrual products,” she says.

As such, FMCGs producing disposable sanitary pads are also making an attempt to recycle the waste they add to the landfills. “We have committed to establish an Absorbent Hygiene Products Recycling facility… India will be the first country outside of Europe where we will launch this,” promises the Whisper spokesperson. “The technology upcycles sanitary waste to deliver high-quality secondary raw materials such as recycled cellulose, recycled plastic, and recycled superabsorbent.”

The rural question

While FMCGs are quick to promise waste-management solutions, they’re less keen for a change of tack.

“In reducing the margins between sustainability and affordability, it is important to consider that a large percentage of the population still do not use the right products to manage their menstrual hygiene—which can pose significant health hazards in the long run,” says Manoj Gadgil, Marketing Director, Johnson & Johnson.

For the newer brands, rural markets, which FMCGs have access to, are still a distant dream. “Distribution and dialogue are a challenge and something that small brands will only be able to address with investor funding and government support,” says Bajaj of Sirona who also admits that he has written several letters requesting the government to switch to cups in its awareness programmes. “If we are proposing a sanitary pad solution to these women, we will face the additional problem of them landing up in our landfills in the next 10-15 years. Besides, a cup does away with buying stocks every month,” he adds.

More options in the offing

Boondh is also working on a reusable menstrual disk. “It’s similar to a diaphragm (female contraceptive) and will be easier to use,” says Kannan.

So far, at the policy level, the cup is barely acknowledged. The GST exemption in 2018 was a singular effort aimed only at sanitary pads. “Most menstrual cup sellers refer to US FDA guidelines. They are not categorised as a drug or medical device and hence do not fall under any standardising or regulatory body,” explains Bharti Kannan, Founder, Boondh, who has filed an RTI with the Central Drugs Standard Control Organisation to understand the status of menstrual cup regulation in India.

The industry, especially the kind demanding policy change, has a long way to go. But entrepreneurs aren’t giving up yet and believe the solution to all menstrual health problems ultimately lies in the tenets of awareness and reuse. “We hope to see a lot of change in the next five years. But, one thing is certain, the future will not be a pad-only story,” says Bajaj.

The urban shift

While Bajaj appeals to the government, Singhal of Floh is happy to have started a conversation with the slogan “Have a bloody good period”. What Carmesi does with its name, Floh does with its use of blood red ink in its campaigns instead of the usual cerulean blue.

“It’s time we stopped whispering about periods,” says Singhal, aware of the pun.

Kulkarni of Nua sees a promising trend in eliminating taboo—free and open two-way communication. “We receive several messages seeking advice and product details on our social media as public comments, not private messages. These aren’t restricted to tier-I cities either,” she says.

Kannan of Boondh admits the boom is heartening but is careful in her analysis of the situation. “The emergence of new players and the rise of feminist politics have indeed played a role in dismantling taboos, but it is not like there is no shame. We still have a long way to go,” she adds.

Reusable methods are also “a means to avoid the synthetic ingredients in pads and tampons”

Dr. Geeta Komar, Consultant-Obstetrics and Gynaecology, Columbia Asia Hospital

Both P&G and J&J declined to comment on these new players. There is a lack of formal data to establish the period care companies’ presence or growth story, but the stakeholders aren’t too concerned yet. “It is essentially a new category and it is too early to talk in percentage terms. It holds value mainly for the disruption it is causing. When we sell 7,000 menstrual cups a month we are ensuring these women stop buying sanitary pads altogether,” explains Bajaj. “More players only mean more options for women,” he adds.

Azah’s Mohammed suggests there’s one other thing that keeps them going. “Catering to a niche, comfort-driven market is not an incentive for traditional players yet.”


Edited by Durga M Sengupta.

Clarification: An earlier version of this copy carried a typo in place of Swathi Kulkarni’s name and missed Shashwat Diesh’s name altogether. These errors have been rectified. We regret the same.

A digital cure for India’s mental health crisis

Just two months into the existence of Juno Clinic, it was evident the company’s business model wasn’t going to cut it. Founded in January 2016 by Davman Technology Services, Juno was meant to meet a pressing and widespread health need—that of accessible, affordable psychotherapy.

To do this, it aggregated independent mental health professionals—psychologists and psychiatrists—on an online platform, making them accessible both offline and online. With $2.4 million in funding from individual investors including Atul Nishar, the founder of Hexaware Technologies & Aptech Computers, Juno was one of the first chains of its kind in the country.

The opportunity couldn’t have been more apparent. Conservative government estimates state that nearly 15% of India’s adults need active interventions for one or more mental health issues. The World Health Organisation (WHO), meanwhile, states that one in four people globally may be affected by mental disorders.

And while a huge market of potential patients awaits these mental health interventions, the supply side of the equation is horribly skewed. In 2017, Anupriya Patel, minister of state for health and family welfare, painted a grim picture of the mental health care situation in the country. In response to a question asked by a minister in India’s lower house of Parliament, the Lok Sabha, Patel stated there were just 3,827 psychiatrists and only around 898 clinical psychologists in the country. As against a requirement of 13,500 and 20,250, respectively.

According to the WHO, access to treatment is grim with a treatment gap of up to 95.7% for depression in India

Depression treatment gap

According to the WHO, access to treatment is grim with a treatment gap of up to 95.7% for depression in India

Set against a backdrop so stark, Juno seemed destined to succeed. It saw itself as a solution, not just to access, but to a critical factor preventing people from seeking mental health care in India. The stigma around mental illness. By allowing people to seek help remotely and discreetly, mental health issues could finally be addressed.

But Juno, and other startups such as HealthEminds and ePsyClinic which began with similar marketplace-based models, have been forced to rethink their approach entirely, scale down considerably, or become bootstrapped, respectively. They underestimated just how ingrained the stigma dogging mental illness is. Indians are still reluctant to take the plunge and get diagnosed, find a professional therapist, and open up to a stranger, however qualified. At least not en masse. Not yet.

The struggles of these startups are indicative of the prevailing attitudes in the country regarding mental health issues and the difficulties in controlling the quality of therapy in a marketplace. But this isn’t to say there isn’t a market for mental health care in India at present. Bengaluru-based Cadabams Mental Healthcare Services and 1to1Help, for example, have steadily grown to annual revenues of Rs 22.5 crore ($3.2 million) and 12.1 crore ($1.7 million), respectively, for the year ended March 2018.

Both 1to1Help and Cadabams have very different models. The former, started in 2001, provides psychologists for wellness programmes run by large Indian and multinational companies. Founded in 1992, Cadabams, on the other hand, operates an inpatient psycho-social rehabilitation centre for various mental health issues like alcohol de-addiction and drug abuse. In both cases, patients can avoid paying out of pocket—through insurance, in the case of Cadabams, while employers pay for 1to1’s services. The other obvious commonality is that both are strictly offline.

It would be easy to simply chalk this down to an online versus offline battle, but it’s more complicated. A number of app-based mental health startups have popped up over the last few years, rapidly gaining popularity. They do not just offer therapy as a service but as a product, too. Apps like Touchkin’s Wysa and Mindcrescent’s InnerHour, which are seeing thousands of downloads each day, with Wysa claiming a user base of over 1 million.

Different strokes

Most accepted modern treatment options for mental disorders are pharmacotherapy or medication; physical activity; activity therapies like occupational therapy; expressive therapies like music, art and dance therapy; and psychotherapy

It may still be early days, but what accounts for these wildly differing fortunes that have seen apps become ubiquitous while marketplaces have struggled?

Juno’s journey

Two months in, Juno went from aggregating independent therapists to hiring them. A senior executive with Davman points to various quality issues the company faced with its original approach. At the service level, doctors would show up late, not take electronic notes, and their training wasn’t standardised.

While psychiatrists, he adds, are trained in medical colleges, psychologists simply hold a master’s degree in psychology, with no standard levels of quality. He had other concerns, too, like ensuring the privacy of the patients was protected since therapy is very sensitive. He asked not to be named as the company is currently planning to raise a new round of funding.

As of May 2018, in its quest for growth, the company had hired around 50 therapists, opened four physical centres, and was conducting 4,500 sessions a month till May last year. This wasn’t Juno’s redemption story though. This was it finding its feet.

Juno’s expenses for the year ended March 2018 stood at Rs 9.25 crore ($1.3 million), while its revenue for the same period stood at just Rs 1.6 crore ($229,146). Realising its cash burn was unsustainable, the business shut down all but one of its physical centres, shifting all of its sessions online today. While Juno is today down to just 1,600 sessions a month, the senior executive claims that the company is now operationally break even, with revenue remaining at around last year’s levels. The Ken could not independently ascertain this as the company hasn’t filed its results for the year ended March 2019.

Learning from mistakes

Juno’s journey is a decent example of what works and what definitely doesn’t when it comes to mental health care businesses built primarily on providing access to experts. For one, the common startup practice of burning cash in the quest for growth simply doesn’t work in a space this nascent and with as little societal acceptance.

Cricketer Robin Uthappa-backed HealthEminds, for example, which followed a similar model to Juno’s original curated marketplace approach also struggled to grow. One of its investors and advisors, Vishal Pereira, director of CreedCap Asia, said that two challenges for HealthEminds were the pressure from VC backers to grow too much too soon. While it struggled to meet its targets in terms of sessions, growing the supply in a country starved of mental health professionals also proved difficult.

Unlike Juno, which decided to scale down and grow organically, HealthEminds gave up the ghost. Earlier this year, it shut down commercial operations, although it is still run on a very small scale by its co-founder, Dr Sunita Maheshwari.

Pereira and the senior Davman executive both agree that online counselling removes the stigma associated with therapy. Additionally, says Pereira, if a company ends up empanelling therapists—psychiatrists, psychologists and counsellors—with vernacular language capabilities, the market for online therapy is big.

While Davman has survived, there are still obstacles in its journey. First, psychotropic drugs a psychiatrist would prescribe to a majority of her patients cannot be prescribed online. This takes away from the legitimacy of the service.

Then there’s the unwillingness to pay out-of-pocket for therapy. This is high in a primary care setting among patients who can afford it. While patients at an organisation like Cadabams usually have acute mental disorders and paid inpatient care is imperative, this isn’t the case for online services. Earlier this year, the insurance regulator asked insurers to cover inpatient mental healthcare, meaning centres like Cadabams are likely to gain further impetus. Meanwhile, 1to1Help sees traction as organisations are far more willing to pay for these services than individuals.

Investment in inpatient mental healthcare

In October last year, Rangsons Healthcare tapped into the inpatient mental healthcare market by inaugurating India’s first chain of super specialised neurocare centres for treating depression—‘Mindful TMS Neurocare’

An app a day

Even as the likes of Juno buckle down for a slow, uphill trudge forward, a series of app-based mental health startups are rapidly gaining traction. Healthtech startup Touchkin claims to have 1.2 million users for its mental health app Wysa, and says it is adding between 2,000 to 3,000 people every day. Mindcrescent, meanwhile, claimed to have 350,000 downloads of its Inner Hour app in a year, averaging out to roughly 1,000 sign-ups a day. Both apps are free and are used both within and outside India.

According to Ramakant Vempati, co-founder of Touchkin, apps that offer therapy as a product as well as service have a better chance of getting used because the demand for therapy alone is very limited in India.

Founder of Tata Trusts-funded app Trust Circle, Sachin Chaudhry recalls his brother’s schizophrenia diagnosis at the age of 12. The first obstacle in getting treatment, he believes, is awareness, the second is screening and the third is diagnosis. Treatment of the mental disorder comes after. Apps, therefore, are a great tool. They can be downloaded for free, and users can gauge their mental health based on some rudimentary in-app tests.

The focus, says Chaudhury, is on prevention and early intervention for all, not just those who are sick. It is through the layers of products—called tests, smiles and connect on the app—that one finally gets to the paid feature to access therapy—care. Between tests and care, is a spectrum of tools that help the user become more aware of their emotions and then connect with a group.

“Once people see how stressed, depressed or anxious they are, they can decide what to do with that information. Emotional graphs and mood monitors create awareness of emotions,” says Chaudhry, explaining the Trust Circle’s functioning. This awareness could, one day, lead to treatment.

Wysa, on the other hand, is promoted as a 4 AM friend and an artificial intelligence life coach. A bot where one can ask questions and receive suggestions. For instance, says Smriti Joshi, even though Wysa’s model is not very precise as it is still evolving, the bot is based on cognitive behaviour therapy (CBT), dialectical behaviour therapy (DBT) and motivational interviewing that have all proven to be effective in a wide range of disorders. Joshi is the chief psychologist at Wysa. Wysa also has tools targeted to curbing other negative feelings and thoughts. Mostly audio-based, these are usually less than 15-minutes-long.

A screenshot of Wysa app

In the first study to assess the effectiveness of Wysa app, researchers concluded the app helped in average mood improvement. However, more research is required to validate these initial findings in much larger samples and across longer periods.

Inner Hour, on the other hand, has developed programmes like a 28-day plan for management of anger, stress, worry, etc. This includes certain activities along with a chatbot meant for immediate support.

Two screenshots of InnerHour app

Support systems, not solutions

Joshi believes that online tools could indeed play a part in treating mental disorders. However, she is quick to admit that no tool on Touchkin’s Wysa can guarantee treatment or management of these mental disorders. However, using these tools regularly can help build positive coping skills to help manage difficult thoughts or emotions. It can offer wellness to those who do not have any mental disorders, but for those with mental health issues, it serves as a support to weekly sessions with a trained therapist.

Joshi says that once Wysa is downloaded, it first assesses the user’s mental health. Based on this, the app may suggest the person seek professional medical help instead. Unfortunately, says Joshi, most people do not heed this advice. Instead, they choose self-help tools on the app alone or in combination with text-based access to psychologists.

However, Wysa’s approach of suggesting offline therapy is not the norm in India. In January 2019, National Institute of Mental Health and Neuro Sciences (NIMHANS) reviewed 278 free apps for depression. A little over a third of these encouraged users to seek professional help.

Joshi talks to between 40-50 people every day via the app. “We ask them if they are professionally diagnosed, what are the barriers in them accessing professional help, and if we feel they need it, we encourage them to seek professional help,” says Joshi. By her estimates, about 75% of people she speaks to do not realise the intensity of their condition, lack social support or cannot afford therapy.

The appeal of these product-driven apps lies in the fact that they are constantly available and largely free to use. More importantly, they also get rid of the awkwardness of opening up about one’s issues with another person—mental health professional or otherwise. Most people that Joshi talks to do not talk about their emotions even with friends or family because they feel judged.

The fear of judgement, says Joshi, is a major reason many patients including Wysa users find it hard to seek daily therapy. An app, however, can create build trust and help people get used to sharing emotions. It can break barriers of loneliness and circumvent stigma.

Filling in

According to Amit Malik, who practised as a psychiatrist in the UK before founding Mumbai-based Mindcrescent, apps can also help mitigate the shortfall of mental health professionals. Online self-care programmes, says Malik, can develop scale and impact for a large sub-segment of this population early in their illnesses.

With the therapist-patient ratio askew, Malik believes that online products or tools intelligent enough to personalise therapy programmes can provide high-quality help and convince people of the value of therapy. All the while keeping costs low and providing help to millions of people who would never otherwise get it.

Touchkin, for instance, despite its vast reach, has hired only 7 psychologists for their ‘life coaching’ subscription service. It is a text-based chat service with a psychologist, who replies within a day.

But can these online services—either apps or e-clinics like Juno—replace the need for offline therapy entirely, though?

Mumbai-based clinical psychologist Dhruvita Mehta, who practices independently and with Juno Clinic, does prescribe some self-help tools that are offered by Wysa as well to her patients. But she says they aren’t enough on their own. “I would not want to use all the tools for all people. Some I would suggest becoming part of a group, some to try a new hobby or get a new job. Therapy is customised according to people,” she says.

Still, Mehta feels that platforms like Juno Clinic that offer professional therapy via audio-visual means online can be effective when the mental disorder is in the mild to moderate range. At Mehta’s clinic, however, 90% of patients are on medication prescribed by psychiatrists. This means they have acute mental health issues and need offline therapy sessions. Self-help tools or even online sessions can only do so much for them. “All of this helps, but mostly after people have been in therapy for two to three months,” she adds.

Still, the demand for Juno’s online sessions is organically growing between 10-15% every month, says the senior Davman executive quoted earlier. This executive hopes an inflexion point will come someday, exponentially growing the demand for therapy and allowing for a business with an offline and online presence to be built. Until that time comes though, a faceless world of self-help chatbots, audio programmes and tools will have to do.

India’s crops are feeling the heat in a warming world

Jagtar Singh lost his cotton crop twice. In just over two weeks. First, it was the rains that lashed Chaina village in Punjab’s Faridkot district in the first week of May, just after sowing. The unseasonal rains killed them before they could even germinate.

On second sowing, the seeds did germinate. But the crop couldn’t withstand the severe heatwave around 15-20 May, which again, was “extremely uncharacteristic” Singh says over the phone.

“Hundreds of farmers lost their entire crop in the village, which has never happened before.”

Earlier this year, a similar story played out with wheat. Kashmir Singh, a farmer from Gurdaspur, also in Punjab, says yields fell by 100 kg per acre across his 50-acre farm, leading to a loss of close to Rs 1 lakh. Wheat yields declined about 20% this year in the Malwa belt of Punjab due to warmer winter nights, says Umendra Dutt, executive director of Kheti Virasat Mission, a non-profit, though detailed data is sparse.

According to the Global Climate Risk Index 2019, India is the 14th most vulnerable nation in the world to the impacts of climate change, in between Niger (15th) and Antigua and Barbuda (13th).

With every increase in temperature of 1 degree Celsius, global wheat production is estimated to fall by 6%. India’s mean land surface air temperature in 2018 was 0.41 degrees Celsius above the 1981-2010 average, according to the Meteorological Department.

And agriculture in India, where six in 10 farmers rely on rains to water their crops, is becoming trickier every season as extreme weather events become more frequent. Warmer weather is altering crop seasons and harvest areas and also improving conditions for pests. Erratic rainfall is causing droughts across vast swathes of agricultural land and flooding in many other parts of the country.

All of this is changing just how everything from rice to apples is being grown—in the process threatening livelihoods and food security for decades to come.

Wheat feels the heat

The worst hit by changes in weather are the rabi or winter crops and fruits, say experts. Rising temperatures and warmer winter nights are causing a condition known as terminal heat stress which is hurting wheat production from Punjab in the north to Bihar in the east.

The wheat cycle is getting delayed due to a late harvest of rice as a result of the late onset of the monsoon. When it gets to the grain filling stage (when dry matter accumulates in the plant and ends up splitting into the grain, determining the grain weight), nights start getting warmer, which stunts the growth of the kernel, resulting in lower yields.

On the edge

61% of farmers in India rely on rain-fed agriculture and 55% of the gross cropped area is rainfed, making farming more vulnerable as the seasons grow more erratic

“Wheat is also facing frequent cases of frost-like conditions,” says S.K. Chaudhary, assistant director general (soil and water management), Indian Council of Agricultural Research, a state-run agency. “Even though wheat is a winter crop, if the temperature falls below 4 degrees Celsius and stays there for a week, it can damage the crop seriously,” Chaudhary says.

Changes in climate are expected to reduce the yields of irrigated wheat sown on time by about 6% in 2020, according to projections by the Indian Agricultural Research Institute (IARI). However, if you have to take into account late sowing, yields may fall by as much as 18% in the next year, and 23% by 2050.

Shuffling rice

Rising temperatures are also putting pressure on rice—a kharif or summer crop and one of India’s two staple grains, along with wheat.

In the east—West Bengal, Bihar, eastern Uttar Pradesh—farmers are facing frequent delays in the onset of monsoon rains which decreases productivity. (On Wednesday, India Meteorological Department declared that the onset of monsoon this year might be delayed by a week.)

“If the sowing window of rice is delayed by two weeks, the production might fall by up to 20%,” says an agronomist working in the private sector, requesting anonymity since she is not authorised to talk to the media.

IARI projections predict that irrigated rice yields are likely to fall 4% by next year, and 7% by 2050. Rainfed rice yields are estimated to decline by 6% in 2020, though improved productivity is expected to narrow that to 2.5% by 2050.

On the other hand, global warming has opened new areas for rice cultivation “We were never producing rice, traditionally,” says Kartar Singh, a farmer from Punjab. “The rising temperatures made it possible for us to grow rice.” Punjab today accounts for almost 10% of the country’s overall rice output—11 million tonnes out of the total 104.32 million tonnes in 2015-16.

The increasing concern with the crop, though, is that the wheat-rice agriculture system in Punjab is resulting in an alarming rate of ground water depletion. And farmers continue to grow rice because they get more subsidies from the government.

Bad apples

Warmer climes have seen the apple belt in the mountainous state of Himachal Pradesh to higher altitudes, according to Pramod Aggarwal, who leads the South Asia division of the CGIAR Research Program on Climate Change, Agriculture and Food Security. (CGIAR is an global organisation focused on food security, formerly called the Consultative Group for International Agricultural Research.) A decade ago, apple cultivation would have started at 1,250 metres above mean sea level—today, it’s been pushed to 2,500 metres.

Local apple varieties require “chilling”, or a period of cooler weather, to mature. And most of the traditional apple-growing areas are witnessing temperatures in the upper 20s as against the optimum 22-24 degrees Celsius. The changing patterns of rainfall and higher temperatures are altering the fruit’s development stage and resulting in sunburn and cracking.

On the other hand, though, newer technologies are being deployed to help “farmers grow low-chill varieties of apples, which don’t need much chilling,” says the agronomist quoted above. If these work out, apple production may end up shifting back to the lower hills.

Saffron burn

About 90% of the world’s saffron is grown in Iran. Another 7.3% is produced in the Indian state of Jammu and Kashmir. Or at least it used to be.

In the last few years, saffron cultivation there is under threat in the Pampore area and its neighbouring regions, which grow most of the state’s saffron. “Saffron is one of the most delicate plants and depends entirely on snowmelt,” says Shresth Tayal, a fellow at the Centre for Himalayan Ecology in The Energy and Resources Institute, who has studied glaciers and snowmelt in Kashmir.

“So if the snowfall is more or less, the productivity gets hurt. And with the weather in the region getting increasingly unpredictable, it is one of the worst affected crops,” Tayal says.

The land under saffron cultivation has decreased from around 5,800 hectares in the 1980s to below 3,700 hectares in 2016. In its glory days, the state would produce as much as 16 tonnes of saffron a year. (It takes around 150,000 flowers to produce 1 kg of the spice.) In the last few years, according to news reports, output has fallen to less than 1 tonne a year.

And the winner is, chickpea?

One of the rare beneficiaries of the changing climatic conditions in India is the chickpea. Originally a winter crop that was produced in the northern plains and central India, it lost favour to wheat after the Green Revolution—the modernisation of Indian agriculture in the 1960s—and the area under chickpea cultivation reduced drastically.

However, in the last couple of decades, cultivation picked up in states in the south and the west, such as Andhra Pradesh, Maharashtra and Karnataka. Which led to the development of short-duration (90-110 days) varieties that can withstand warmer, harsher weather conditions, with resistance against multiple diseases too.

As temperatures across the country rose, these hardier varieties have gained ground—production rose to 11.2 million tonnes in the 2017-18 crop season from 3.8 million tonnes in 2000-01.

“The potential in chickpea is huge, especially with the technological advancements. I won’t be surprised if production crosses 20 million tonnes by 2050,” says the agronomist quoted above.

The missing picture

“I doubt numbers will explain what is really happening in agriculture in India. All the examples are anecdotal,” says Chandra Bhushan, deputy director general of Centre for Science and Environment.

He is right. Despite similar stories of declining output from different parts of the country, overall agricultural output in India is increasing. Total foodgrain production, for instance, rose to 285 million tonnes in 2017-18 from 217 million tonnes in 2006-07.

The biggest reason behind the confusing statistics is the fact that India is divided into 127 different agro-climatic zones with different patterns of agriculture. The effects of extreme weather are localised and the decline in production in those areas is mitigated by the increase in production elsewhere.

“The yield potential of many crops, including pulses and cereals, is as high as four-five times their current output,” says Arabinda Kumar Padhee, director, country relations and business affairs, International Crops Research Institute for the Semi-Arid Tropics, or ICRISAT. “So yields may rise overall despite damage due to weather conditions.”

Productivity, he adds, shouldn’t be the only monitorable parameter to look at the impact of climate change.

Fragmented landscape

Over 80% of Indian farmers are smallholders, according to the Agriculture Census, who farm on less than two hectares of land, making data sampling extremely difficult

Irrigational water, for example, is a big variable. “Whenever we talk about the future production, we assume that the water level will be at the current level, which is not possible,” Padhee says. “Average annual rainfall might not have changed drastically but there are extreme patterns. Rains are getting heavier when they fall. Moderate rainfall days are decreasing and there are prolonged drier spells.”

“I have been asking scientists how the increase in temperature is affecting soil moisture but I haven’t yet got a satisfactory answer,” says the agronomist quoted earlier. “People are telling me that even if we don’t have enough moisture in the soil, we are providing for that through irrigation. But that is hurting profits and putting more stress on farmers.”

More localised research and more extensive data sets are some of the first steps towards getting Indian agriculture ready for a climate crisis. And prepare we must.

Bracing for the storm

The rise in temperature by 1 degree Celsius can result in farmers’ income declining by about 6% in unirrigated districts, according to the Economic Survey of India for 2017-18. The survey also predicts that temperatures in India are likely to rise by 3-4 degrees Celsius by the end of the 21st century.

India could face an agricultural loss of over $7 billion by 2030, according to the Intergovernmental Panel on Climate Change. But if climate resilience measures in the form adaptive strategies are implemented, 80% of the losses could be averted.

One very valuable tool would be real-time weather and crop advisories to mitigate risks. Take rice, for example, which is an important but extremely water-intensive kharif or summer crop. If the farmer misses out on the sowing window, which is increasingly becoming the norm due to the delayed onset of the monsoon rains, yields may decline by 20-25%.

“Farmers should know that even if they have missed the sowing window, there still are some variants that they can cultivate without impacting yields much,” says the agronomist quoted above. The crop advisories that farmers get right now—mostly issued by the government—are obsolete and based on decades-old practices.

In April this year, the Meteorological Department said it is working at a brisk pace to issue localised weather forecasting to all 6,500 blocks across 660 districts in the country by 2020.

Farmers also need to adjust their cropping, switching to more heat-resistant varieties of the same plants, shifting sowing dates to avoid the hottest months of the year, or changing crops entirely.

“In the semi-arid areas, farmers are adopting crops such as cotton instead of more weather resilient cereals, anticipating higher results but also facing a high risk of failure,” says Anthony Whitbread, a research programme director at ICRISAT. “They should be educated to adapt to sorghum, millets or pulses to mitigate the risks.”

Simultaneously, scientists are looking at developing more stress-tolerant variants of crops. Between 2006 and 2018, for instance, close to 550 high-yielding climate-resilient crop varieties were developed by ICAR and notified for commercial cultivation.

“We are also developing short duration crops to help farmers against the shorter sowing windows,” says ICAR’s S.K. Chaudhary. “Moong (green gram), for example, takes about 80-90 days from sowing to harvest. We are now trying to develop cultivars that take only 50 days to harvest.”

Back in Faridkot, Jagtar Singh has sown cotton for the third time in the last week of May. “There was still some sowing window left for the crop. But if this gets destroyed again, then I will have to drop the plan entirely,” he says. In that case, Singh says, he will switch to growing cowpea.

For now though, the cotton plants are doing fine and Singh is keeping his fingers crossed.

Much ado about India’s health insurance 2.0 *conditions apply

The Narendra Modi-led government has made a comeback in India. For healthcare, its second-term return greenlights an ambitious health insurance scheme—Ayushman Bharat. The government, over the next five years, intends to provide health insurance cover to the 500 million poorest in the country. Meanwhile, private insurers have a plan of their own. To boost the most profitable kind of health insurance—the one that individuals buy.

There is tremendous scope for health insurance in general to grow, but individually-bought health insurance is the most unpenetrated market right now. Indians with disposable incomes have opened their wallets for fast-growing industries such as e-commerce and fintech over the past five years. Investors are now betting that the next five will be the right time for insurance, especially health, to become a want. Not just a need that corporations and the government traditionally provide.

Divya Sehgal, an investor, goes as far as using American psychologist Abraham Maslow’s ‘hierarchy of needs’ pyramid theory to explain the motivation behind investing in health insurance. Sehgal is a partner with the PE firm True North which bought a 51% stake in insurer Max Bupa in February this year.

Now, according to Maslow’s theory, once the human needs for food, shelter and clothing are met, safety comes next. “Every person would spend more on premium to cover themselves from basic risks,” Sehgal says. Insurance, particularly health, may have been a low priority for Indians up until now (as it is an evolved need), but this would change as purchasing power rises, he expects. The evidence supports the hypothesis. Life, motor and other general insurances are not as high a priority on Maslow’s pyramid, and so, they’re seeing relatively slower growth.

This vision isn’t limited to Sehgal either. A consortium, led by Mauritius-based investment firm WestBridge Capital and Indian billionaire Rakesh Jhunjhunwala, got approval from the government’s statutory body Competition Commission of India (CCI) to buy over 90% stake in health insurer Star Health in April this year. Similarly, private equity TPG-backed hospital chain Manipal Hospitals bought out the 31.5% stake of Indian business group TTK from Cigna TTK health insurance, resulting in a name change to Manipal Cigna in the first week of this month. HDFC Ergo general insurance, meanwhile, has been in discussion to buy a stake in health insurer Apollo Munich over the last few months, said an employee of the insurance company. Reliance Capital got approval for a health insurance company back in October 2018. According to two persons in the know, the Mumbai-based conglomerate Bajaj Group (that operates Bajaj Allianz General Insurance) has, since 2001, been planning to launch a standalone health insurance company. However, the company itself hasn’t confirmed this.

All of them expect younger Indians to fall sick more often as time progresses. They realise the importance of health insurance—inpatient and outpatient. California-based fitness technology venture GOQii that manufacturers wearable fitness band indicated that 38.3% of people between the age group of 20-45 suffer from at least one lifestyle disease ranging from diabetes, high blood pressure, cardiac issues to thyroid, acute gastrointestinal issues and acidity; and this number could go up by another 15%, as per India Fit Report 2019. The health insurers plan on aggressively getting Indians to buy health insurance and incentivising fitness by offering discounts on premiums.

However, as one of the former senior executives of a leading health insurer put it, “Insurance is neither e-commerce nor fintech. It is hard to sell the promise of security for risk one cannot imagine and even harder to make it profitable when it reaches high scale.” He requested anonymity as he is bound by a non-disclosure agreement.

FDI limit deters growth

Many foreign investors are wary of investing in Indian insurance because only 49% foreign direct investment is allowed. It means the investor would have to take more risk with less operational control

Even with plans for aggressive growth, health insurers are nowhere close to the finish line. Let’s look at hard numbers. True North plans to grow Max Bupa by 5X in the next six-eight years by focusing on providing health insurance to individuals. Similarly, health insurers that The Ken spoke to expect the individual insurance business to grow from the current 33 million users to 150 million over the next five years. Now, both individual and group businesses have about doubled during the last five year period; with the optimistic 5X growth expectation, for both group and individuals, 600 million (450 million group health insurance users) would be insured. Add this to Ayushman Bharat’s targeted 500 million. Together, the projected 1.1 billion insured would cover about three-fourths of the expected Indian population of 1.4 billion in 2024.

Sounds great. But these are optimistic targets. In reality, the health insurers plan to grow not just by adding more users but, in part, by adding more value-added services to their current users’ schemes and focusing on the profitable individual business rather than the loss-making group business.

Aiming for high cover, low claims

The most profitable business is the individual business, but it is the hardest to scale. Group business and government schemes bring in scale, but since the premiums are negotiated, they often result in losses. Which is why Sehgal sees a growth story “overwhelmingly higher than other health insurers” in Max Bupa, as over 97% of its business comes from individuals, which keeps the claims ratio under control. Sehgal believes now is the time to boost individual health insurance sales and increase True North’s value of Rs 1,001 crore ($144 million) to over Rs 5,000 crore ($719.6 million) in the next six to eight years.

To achieve that, he plans to digitise more processes and start innovation in a new category—outpatient (OPD) insurance, which would be an uphill climb for True North.

Indirect foreign investment in OPD

Aetna, American-managed healthcare company that also sells health insurance, entered India in 2016 by making its first investment of Rs 100 crore to expand an OPD subscription product. The product was developed by the Indian Health Organisation (IHO) which offers primary care, discounts on pharmacy and diagnostic bills and most importantly, medical advice. Aetna had acquired IHO in 2011.

The apprehension around promoting new innovation is low in insurance because of the probability of high claims ratio, points out Prashant Tandon, co-founder and CEO of e-pharmacy 1mg that has tied up with Max Bupa and general insurer ICICI Lombard to manage their new OPD insurance products. Health insurance has faced high claims ratios in the past; the OPD is more susceptible to overuse, high claims and high payouts once patients start to demand regular doctor appointments and diagnostic tests. Which is why insurers are still testing the waters. Tandon does not share any numbers but says it is only recently that those who have bought the OPD policy have started filing claims at 1mg for medicines and diagnostics.

For now, the insurers are just trying to upgrade existing users to higher-value products, said an ex-senior executive with a health insurance company, who requested anonymity due to a non-disclosure agreement. Although almost all insurers have applied for approval for OPD insurance products with the insurance regulator, none have started marketing these products to the masses, he added. The Ken has previously reported that Max Bupa, Apollo Munich and ICICI Lombard had launched their products and that the PolicyBazaar Group had planned to start marketing its OPD product by the end of last year. They’re all yet to advertise their products. Once they do, it would mean developing a distribution network to expand coverage as the online direct sale of health insurance is still low in India. True North plans to expand from its current metro cities focus to every city with 2 million+ population.

A person, not a car

Vaidyanathan Ramani, head of product and innovation with PolicyBazaar, believes that even though the opportunity in health insurance has been evident for about a decade, there has also been a lot of apprehension about selling it.

Star Health—the first and the largest standalone health insurer, founded in 2006—did prove that health insurance was a big market, provided you knew how to sell it – but the general thinking was that health is more difficult than motor, fire, etc to underwrite and to sell, Ramani said. Everyone expected health insurance to grow faster than motor insurance as health is a basic need, not a car or a two-wheeler, he added. The prediction has come true despite motor insurance being mandatory in India. And about half a dozen standalone health insurers have made all the difference by expanding health insurance coverage faster than about a dozen general insurers that sell motor, fire and other forms of insurance in addition to health. If any players can expand health insurance coverage while controlling claims ratio, the best bet are standalone health insurers such as Max Bupa, Manipal Cigna and Star Health, believe investors.

General insurance companies, which are allowed to sell various non-life insurance products, have been unable to grow as fast as standalone health insurance companies (SAHIs) such as Apollo Munich and Max Bupa. Ramani, who was head of strategy with Royal Sundaram General Insurance before he joined PolicyBazaar, says that the reason is that travel, home, motor, etc insurances are managed in one way and health in another.

For instance, a motor insurance premium can be estimated based on the quality of the car and how one drives it, but not health insurance. “I am burdened with you for 365 days till you come for renewal next year. If I feel I have made a wrong call with you, I price you correctly next year. In health insurance, you are with me till you die and I can’t leave you and I know you are only going to grow old and fall ill more often. I will price thinking what will happen to you for the next 25 years,” Ramani explained. The variables in health insurance are very high as one can be affected by mild to severe communicable, non-communicable and lifestyle diseases; healthcare costs can increase more than expected and one can fall ill anytime between the first or the 25th year, he added.

In health insurance, you are with me till you die and I can’t leave you

Vaidyanathan Ramani, PolicyBazaar

These are the few reasons why general insurers have focused on providing group insurance to companies that make a promise of one year and bring in a large customer base to grow, but they have now realised that these are very competitive and are often unprofitable. A former senior executive with a third-party administrator (TPA) (which administers policies for health insurers) said that these factors led health insurers to harden premiums about two years ago. When the premiums almost tripled in some cases, for instance from a Rs 700 ($10) premium for a basic Rs 1 lakh ($1,439) policy, the average premium rose to above Rs 3,000 ($43), she added.

She also pointed out that one of the reasons SAHIs have grown faster than general insurers in the health segment is because they carry brand names of hospitals such Max, Apollo and Religare (which belongs to the same group as Fortis Hospitals). Going forward though they may have it rough as True North plans to phase out the hospital brand name Max. Inversely, if the insurance regulator allows HDFC Bank’s joint venture with Germany based insurance group Ergo to acquire India’s largest hospital chain Apollo’s stake in Apollo Munich, it would suffer from a loss of branding.

No one recognises Apollo Munich, they just recognise Apollo. It grew due to the brand. Further, Apollo experimented a few products and initiatives in hospitals before taking them to the market

Former employee with Apollo Munich

The former senior executive with a health insurance company, quoted above, calls it a chicken and egg situation. (The executive recently left the company to build a chronic disease management company that could work with health insurers in the future.) Traditionally, insurance has been driven by TPAs, agents and banks;  health insurers don’t believe in grand marketing, as it is rare for anyone to go buy insurance. People would much rather put it off for another day. It is a market that requires patient capital, he adds. PEs are buying into these companies, he says, adding that they will soon realise “selling anything in India is hard but selling insurance is the hardest”.

Correction: An earlier version of this story inadvertently attributed quotes by Divya Sehgal of True North to Ashish Chandra (of True Cover). Additionally, the word Group has been added to PolicyBazaar with regard to its OPD plans, for greater clarity. We regret the errors.

Local with solar: As China goes cheap, India loses the beat

When China sneezes, as the (modified) adage goes, the world catches a cold. And India, at least when we’re talking about solar power, is today the first to start sniffling.

The year 2018-19 was a special one for India’s solar industry. For the first time since 2014, new installations of solar power declined, by about 10%. To put that in context, installations had roughly doubled in each of the two previous years.

The obvious reason was a set of safeguard duties imposed on imports of solar equipment starting July 2018. Intended to insulate domestic manufacturers from cheaper Chinese solar modules, the move drove developers to halt plans for new solar plants.

A seemingly straightforward tale of a protectionist policy that backfired. But behind it lies a complex interplay that results in Chinese policy effectively dictating the dynamics of the Indian solar industry.

And with Indian policymakers unable to put together anything more than a piecemeal response, the country’s vaunted National Solar Mission—with an ambitious goal of 100 GW of solar power generating capacity by 2022—is lumbering along, far short of its targets.

The China shadow

The Chinese government, over the past two decades, has progressively increased support to expand both renewable energy generation and equipment manufacturing.

By 2012, China-based solar module makers had enough capacity to supply the entire world’s solar panel needs. The resulting glut in the early 2010s led to the collapse of several Chinese—as well as American and European—manufacturers. Both the US and the European Union had slapped anti-dumping and anti-subsidy tariffs on Chinese solar cells and modules by the end of 2014. Undeterred, Chinese companies set their sights on a new, rapidly growing market—India.

The Narendra Modi government in 2015 raised the country’s solar capacity target to the current 100 GW from the earlier 20 GW. (As part of a bigger renewable energy target of 175 GW from solar, wind and small hydropower projects by 2022.) India rose to become China’s biggest solar export market in 2017, accounting for about 30% of shipments by Chinese manufacturers.

Full house

Nine of the top 10 manufacturers in the world are based in China; the sole exception is South Korean company Hanwha Q-Cells

Much as in the US and Europe before, cheap Chinese equipment drove down costs for developers, giving India some of the lowest prices for solar-based electricity tariffs in the world. Tariffs fell to less than Rs 3 ($0.04) per kilowatt-hour as companies bid furiously for projects in 2016 and 2017, as imports accounted for about 90% of module sales.

But last year, something happened. China sneezed.

In May 2018, the Chinese government abruptly announced that it was ending all subsidies for solar power. Any new solar plants would have to make do without aid from the state. Chinese solar equipment makers, which accounted for 70% of global solar module shipments in 2018, rushed to the international markets.

Prices plummeted, and this could have been a godsend for Indian power producers and a nightmare for local panel makers already unable to match Chinese prices. But, at the same time, Indian trade authorities, which had been investigating the effect of Chinese solar imports since 2017, announced a 25% safeguard duty to protect local manufacturers.

We already know what happened next. Power producers, already struggling with the record low tariffs as a result of bidding wars in previous years, decided to wait out the safeguard duty. Imports more than halved in 2018-19 to $1.7 billion from $3.42 billion the previous fiscal year.

But that figure doesn’t tell us everything. Lower prices meant that even though imports, in terms of value, declined steeply, volumes fell only by a modest 9.6%. And therein lies the rub for India’s dreams of local manufacturing.

Weak sauce

While prices of locally-made solar modules have steadily dropped over the past four years, Indian manufacturers are still far short of Chinese economies of scale. While Indian modules cost an average of about $0.26-0.27 (Rs 18-19) per watt, imported modules average $0.20-0.22 (Rs 13-15) per watt. Even with a 25% safeguard duty, Indian companies are barely able to match prices.

One reason is that most modules made in India are simply assembled from solar cells imported from, well, China.

The solar power supply chain goes something like this: First come wafers or ingots of silicon, which are used to make cells, which are put together to make a module or panel. Few Indian manufacturers produce solar cells (the basic unit of a panel), and even those that do ultimately use wafers (the raw material) from China.

“Paradoxically, the duties on imported modules is much lower than those on glass, EVA and most of the other raw materials that go into manufacturing a module. Without enough of domestic production of EVA and other raw materials in the country to meet module manufacturers’ demand, this will only increase the cost and hurt businesses as well as customers,” says Hitesh Doshi, a founding member of All India Solar Industries Association.

With India’s safeguard duty falling to 20% next month, and 15% next year, Indian manufacturers may soon find themselves back at square one. “Many developers now are just postponing their purchases till the safeguard duty drops to 15%, or phases out entirely,” says Kanika Chawla, director of the centre for energy finance at the Council on Energy, Environment and Water (CEEW).

Which brings us back to China. Earlier this year, the Chinese government moved to reinstate some of its solar subsidies and phase them out over time. How this plays out will dictate, in large part, what happens to Indian industry.

“The biggest variable, or unpredictable element, is China. Even today, it’s not really clear what the Chinese programme is, over what period of time it will be spaced out, etc.,” says Vinay Rustagi, managing director of renewable energy consultancy Bridge to India. Chinese capacity addition is expected to rise this year, he says, with module prices remaining largely stable.

“But if Chinese demand undershoots, it will have a direct and immediate impact. Prices could easily drop by up to $0.02 (Rs 1.40),” Rustagi adds.

And in the first three months of 2019, Chinese capacity addition has been sluggish, at 5.2 GW, down 40% from about 9.6 GW in the same period last year.


“Tariffs in India are currently not viable,” says CEEW’s Chawla. Price ceilings set by the government have resulted in tepid response at recent auctions and tenders. One auction for solar and wind projects last month saw only two bidders. And in total, while the central and state governments in 2018 had put up tenders to build over 50 GW of solar plants, only 13 GW of projects were actually awarded, according to a CEEW paper co-authored by Chawla.

Power producers will continue to wait out the safeguard duty, and manufacturers are unlikely to be able to pick up the slack in the meantime, Chawla adds. “China developed its manufacturing base first, then built demand.” The Chinese government provided support from low-cost loans to infrastructure to even electricity prices.

Chinese companies were able to develop both scale and capability. Indian manufacturers’ total manufacturing capacity is a little less than 9 GW of solar modules a year (far short of the 20 GW of annual targeted capacity addition), according to CEEW. Chinese manufacturers produced nearly 40 GW of modules in the first half of 2018 alone.

Nevertheless, solar installations will pick up again in 2019 and over the next few years, according to projections from Mercom India, a clean energy consulting firm. But tellingly, its estimates put India’s total solar power generating capacity at about 70 GW of the 100 GW target by 2022. (Utility-scale solar projects, though, aren’t going to get back to 2017’s peak for the next three years at least, according to Mercom’s forecasts.)

The government continues to trumpet its renewable energy programme, with power minister R K Singh saying on Tuesday that it’s on track to meet its 175 GW clean energy target (including the 100 GW from solar) by 2022.

To be fair, the state has also announced initiatives such as a viability gap funding scheme in February, which would allot Rs 8,580 crore ($1.23 billion).

Government-owned enterprises can use the funding to set up 12 GW of solar power using Indian-made panels, between 2019-20 and 2022-23. This is apart from existing incentives for electronics manufacturing and a plan to link solar power tenders to manufacturing.

Line of credit

Chinese manufacturers get cheap debt at 3-4%, a source of competitive advantage against Indian firms who pay rates as high as 11-12%

The solar industry and analysts, though, largely remain sceptical about these schemes. Setting up manufacturing, it goes without saying, is a capital-intensive process, and uncertainty over India’s solar policies make long-term investments tough to swallow.

The manufacture of photovoltaics—electricity-generating solar cells and panels—in India “suffers from a range of competitive disadvantages… These include inferior terms of debt capital, higher electricity prices, lower-scale operations, lack of vertical integration, outdated technology, and lack of demand visibility,” according to the CEEW paper cited earlier.

In the end, India’s solar march goes on. But unless local manufacturing policies get a radical overhaul, it will still be to China’s drumbeat.

With inputs from Pranav Balakrishnan and Pranav Shankar.

Biomedical waste could be India’s ticking bomb—or a thriving market

Uttar Pradesh, India’s most populous state and one of its poorest, hasn’t had the best track record in terms of medical facilities. Most infamously, 30 children died in the main government hospital in the district of Gorakhpur in 2017 due to a lack of oxygen cylinders. In January, the same hospital, Baba Raghav Das Medical College, was fined Rs 5 crore ($720,000) by the National Green Tribunal for improper disposal and burning of biomedical waste this January.

The problem of biomedical waste disposal isn’t new to Gorakhpur, nor limited to it. In 2016, Gaurav Srivastava filed a Right to Information, or RTI, request to find out how many biomedical waste treatment facilities existed in Gorakhpur and three nearby districts. 34-year-old Srivastava, who formerly worked on climate change issues and as an environmental auditor in the state, received a damning response—zero.

Little has changed since. Uttar Pradesh, as on 25 July 2018, had 525 violations of the Biomedical Waste Management Rules by healthcare facilities and treatment facilities. And while it may be one of the worst offenders, biomedical waste disposal is a nationwide issue.

India has a problem—it generates more biomedical waste than it can process. According to 2017 data from the Central Pollution Control Board (CPCB), India generates 559 tonnes of biomedical waste a day. The CPCB says that 92.84% of this waste is processed properly, either incinerated or sterilised and buried by independent treatment facilities or by hospitals.

The remaining 7% or so, however, goes untreated—that’s 41 tonnes of waste a day, or nearly 15,000 tonnes a year. Without proper treatment, and with reports aplenty of biomedical waste being mixed in with municipal garbage, India is staring at a potential biohazard crisis.

Among the types of infections caused by biomedical waste are gastrointestinal transmitted by faeces or vomit, respiratory infections caused by saliva and mucous, and eye infections caused by infected eye secretions. Inadequate waste management, apart from causing environmental pollution may lead to transmission of diseases like typhoid, cholera, hepatitis and AIDS through needles contaminated with infected blood.   

Poor management of medical waste risks polluting water, air and soil.  

The environment ministry in February this year updated the 2016 biomedical waste regulations. The idea was to improve compliance and strengthen implementation as healthcare facilities are not segregating medical waste diligently and handing it over to facilities.

But there are no punishments, not even heavy fines, under the current regulations. Only a show-cause notice or suspension of licence by the district magistrate. The lack of stringent punishments is one of the reasons why these rules have been criticised as ineffective.

On the flip side, market research firm Novonous forecasts that as India’s hospital capacity expands, the biomedical waste management market will grow at an annualised 8.41% till 2025. And it will grow on the backs of Srivastava and a slew of entrepreneurs and companies across the country who have made biomedical waste disposal their business.

After the response to his RTI, Srivastava registered a startup called Gorakhpur BioSerV Energy Pvt. Ltd to cater to Gorakhpur’s district hospital, a railway hospital and, of course, Baba Raghav Das Medical College. In addition, he would also cater to smaller nursing homes and clinics that have nowhere else to treat their waste.

But for the past three years though, he has been running from pillar to post to get his business off the ground. And even as Srivastava struggles, the number of waste treatment facilities in India has remained largely stagnant. In fact, it’s been that way since 2010. Inconsistently enforced and often-amended regulations, lack of governmental support, and healthcare centres that bend the rules threaten to derail whatever opportunity the market presents, while simultaneously creating a health and environment crisis.

Little fish, big fish

“In my opinion, except for the big players, setting up facilities is extremely difficult,” says Seshi Reddy, assistant general manager at Hyderabad-based Medicare Environmental Management, India’s largest biomedical waste management company.

Owned by the Ramky Group, a conglomerate that also has interests in infrastructure, real estate and pharmaceuticals, Medicare is over two decades old and has over 50,000 clients across India. Its clientele spans government, corporate, diagnostic and pathology clinics, dental and veterinary labs, and its 18 facilities across 12 states can process 200 tonnes of waste a day.

But Medicare is an outlier. Biomedical waste management is a cutthroat business, with compliance and competition among the main challenges, says Reddy. With every change in rules and specifications, costs go up. For hospitals, clinics and labs, however, it’s just another expense to be minimised—and the lowest bidder wins. Consequently, returns on investment are low; Medicare, which was incorporated in 1997, broke even in 2005, says Reddy.

The government does offer financial aid to make it easier for companies—especially small-scale entrepreneurs—to set up common treatment facilities for biomedical waste. The environment ministry funds 25% of the total project cost—up to Rs 1 crore ($144,000). (The north-eastern states are a special category, where the central and state governments together cover up to 75% of project costs.)

But before all that, another huge hurdle—and perhaps the reason why the number of waste treatment facilities hasn’t grown in nearly a decade—is land.

No man’s land

“The most critical aspect for setting up such a facility is land availability because according to the rules, it should be far from the population and no water body should be near the plant,” says Srivastava. These facilities come under the hazardous industries category and require environmental clearance.

The regulations say that state governments have to identify appropriate land and allot it either free of cost or at a concessional rate. The bureaucratic maze, though, ensures this doesn’t happen.

To start with, project proposals go to the hazardous substances management division of the environment ministry, which decides on financial aid. Once that’s cleared, though, the buck passes to the respective state government land-owning agency. With no real coordination between the environment ministry, the CPCB and the state-level agency, many projects get stuck waiting for land.

“The procedure to acquire land to set up new facilities is so long drawn out that private companies become tired and bow out finally,” complains Vinod P, president of the Common Biomedical Waste Treatment Facilities Association of India (CBWTFAI).

But to cap it all off, what may be the biggest hurdle to the growth of the waste management industry is the simple fact that most of their potential clients just don’t follow the rules. And the government has so far done little to change that at scale.

What compliance?

The government set a deadline of 27 March this year to phase out chlorinated plastic bags and gloves, establish a barcode system for waste generators and operators, install Global Positioning System (GPS) units in vehicles transporting waste to treatment facilities, and ensure pre-treatment of unsanitary waste water through disinfection. None of this has been implemented on the ground, according to executives of waste management companies and government officials.

Additionally, before 2016, if any healthcare facility was not treating more than 1,000 patients per month, they weren’t required to get authorisation from pollution control boards. With the new rules, every waste generator had to be registered with their respective state pollution control boards.

“60% of healthcare facilities are non-bedded and previously only bedded facilities were required to take authorisation but now everybody is required to take one,” says Vinod. And according to the rules, a healthcare facility also cannot get registered or obtain licences from state authorities without tying up with common biomedical waste treatment facilities.

However, in March, the National Green Tribunal noted that non-compliance was widespread and asked states to give status reports by 30 April, or be forced to deposit Rs 1 crore every month with the CPCB. Sample this: Out of 2.38 lakh healthcare facilities in the country, only 30% have authorisation.

The application for authorisation is exhaustive and provides the authorities with all information like the treatment facility a hospital has tied up with and the waste it generates etc. A CPCB scientist said that they are yet to get data from 1.51 lakh non-bedded facilities in the country and have no idea where their waste is going.

CPCB member secretary Prashant Gargava did not respond to repeated calls from The Ken on whether the tribunal’s ruling has been enforced.

Medicare’s Reddy points out that most of his clients still haven’t been authorised by their respective state pollution control boards. “For example, 5,200 are registered as my customers in Bangalore alone and they are taking my services, but 80% have not taken authorisation from state pollution control board,” he says.

And about half of non-hospital healthcare facilities—the thousands of polyclinics and diagnostic centres across India—have not tied up with waste treatment facilities, adds Medicare’s Reddy. “Veterinary centres are worse, only 2% or 3% have tie-ups with waste treatment facilities.”

A senior environment officer from Karnataka State Pollution Control Board said that AYUSH facilities are reluctant to take authorisation as they argue that they don’t generate as much biomedical waste as allopathic ones do.

This is a particularly sticky point for waste management: The larger hospitals and healthcare facilities either work with separate treatment companies or have their own in-house treatment centres. But the smaller clinics and pathology labs continue to either dump medical waste along with other garbage or bury it without proper sterilisation.

Bad as all this is, the likes of Medicare aren’t stopping.

New prospects and a troubled future

One of the biggest potential shifts that waste treatment firms see today is residential medical waste. “All these days, we were focussing only on medical waste from healthcare facilities,” Reddy says.

“Residential sector is generating more medical waste than the healthcare sector.”

Seshi Reddy, Assistant General Manager, Medicare

A few years ago, Medicare started a pilot project in Bengaluru, which has a population of 12 million, to collect household medical waste from two zones in the city—Yelahanka and the West Zone. In these two zones alone, the company is collecting 2.5 tonnes medical waste from residences per day.

The medical waste from houses includes sanitary napkins, earbuds and nails, and objects contaminated with blood and body fluid contaminated which are otherwise mixed with solid waste. Medicare is focusing on gated communities and apartments, and is charging Rs 35 ($0.5) per house per month. The company has signed on 500,000 households, and estimates that it will get 750 grams of medical waste from one family per month on an average. (Families with diaper-wearing children generate 2.5 kg of waste per day for two children. Without children, sanitary napkins account for 500 grams of waste per month per family.)

More recently in May this year, the Bruhat Bengaluru Mahanagara Palike (BBMP) put out a tender to process biomedical waste for 9.6 million houses in the city—an estimated 40 tonnes of medical waste. Similar initiatives have also been started in Pune and Indore.

“We are submitting our bid for the tender,” Reddy said.

CBWTFAI’s Vinod, however, is more cautious about the market potential of the biomedical waste sector in India. “Day by day the rules are being tightened by the government. It wants to have limited facilities so that it can have a control,” he says.

Vinod owns a facility in Gujarat. Of 33 districts in the state, seven districts do not have more than 200 healthcare facilities. “When our investment is Rs 5 crore ($720,000) to Rs 7 crore ($1 million) and I have to spend on transportation, it is not viable.” Without scale—about 10,000 hospital beds worth of clients, by most estimates—the unit economics just don’t work for a standalone treatment plant.

Most of the facilities are not running to their full capacity and only 70% to 80% of their capacity is being utilised. “If the facilities are run to their full capacity then they will start getting a return on investment of 8-10%. Now they are either just breaking even or getting an ROI of 5-7%,” says Vinod.

Back in Gorakhpur, Srivastava and his team of four are still pushing for their planned treatment plant. “Our plan is to make this economically viable and generate additional sources of revenue apart from disposal charges from healthcare facilities so others can replicate as well,” he says.

Which brings us to India’s fundamental problem—the medical waste we produce is ballooning. By 2022, the country is projected to hit 775 tonnes of medical waste per day, up almost 40% from today. At least. Because the real numbers may be even worse.

According to a scientist working with the CPCB, the board is struggling to measure the waste generated by non-bedded hospitals—healthcare facilities that don’t have in-patient departments. “The quantity of waste generated will increase significantly once we get this data,” he said, asking not to be named.

Our insufficient supply side isn’t prepared for this, because it just isn’t a viable business. Without the government actually enforcing biomedical waste regulations, and forcing healthcare facilities of all hues to get on board, the waste treatment sector is unlikely to grow beyond the big hospitals it already covers. 

Zomato, Swiggy and food delivery in the age of plastics

Deep in the recesses of GPRA Complex, New Moti Bagh—an upscale, gated colony for civil servants—lies a sewage treatment and waste management plant. This is Delhi’s first zero-waste area, run by Green Planet Waste Management (GPWM).

Smack dab between GPWM’s wastewater treatment and composting centres is a shed where non-recyclable plastic herded from GPRA Complex is turned to oil. This is done through a process called pyrolysis. It’s where the dankest plastic goes to die: milk packets, water bottle labels, torn, oil-stained styrofoam, and dust-laden carry bags. 

About 10% of the daily 50-odd kilos of plastic fed to this pyrolysis plant are disposable trays, food pouches, and cutlery, the kind Rajesh Mittal has seen more of in recent years thanks to food delivery.

“It’s only around 10% here because this is a high-end colony and every household has a cook,” says a bespectacled Mittal, GPWM’s managing director. “You’ll see more food containers in places like Noida, or places with a relatively higher younger, unmarried demographic. The kind of plastic generated varies from area to area and the local demographic.”

You probably know this now: we’re living in what environmentalists dub ‘The Plasticene’ (Age of plastic). Plastic, relative to metal and paper, is a young material, first finding form as Bakelite in 1907 and gaining ground because of the exigencies of war. Its affordability, portability, and disposability, once our boons, are now banes bar none. As of 2017, the world produced 350 million tonnes of plastic (excluding PET or Polyethylene Terephthalate—reusable packaging mostly for liquids).

And in an increasingly-tired world, where longer working hours marry technology and birth convenience, food containers are the new delinquents. As per a 2018 study published in science journal Elsevier, door-to-door food delivery in China accounted for a nearly-eightfold jump in packaging waste in just two years, from 0.2 million tonnes (2015) to 1.5 million tonnes (2017). Closer home, in India, we don’t know how much plastic we generate. That’s because the Central Pollution Control Board (CPCB) underreports such data. But we can hazard some guesses with food delivery.

In October 2018, restaurant discovery and food delivery service Zomato claimed to fulfil 23 million monthly food orders. Its rival Swiggy, which does not disclose monthly order numbers, is believed to fulfil up to 28 million orders as of March 2019. This amounts to thousands and thousands of tonnes of food container and cutlery waste, at the least. 

Small wonder then that Bruhat Bengaluru Mahanagara Palike (BBMP), Bengaluru’s civic body, wants to ban plastic food containers. Bans on single-use plastics in Maharashtra and Tamil Nadu, meanwhile, are ineffectual due to inconsistent implementation. In a bid to seem self-aware, Zomato introduced an opt-out feature for customers to avoid plastic cutlery. Swiggy, on the other hand, put the ball in the court of restaurants with its Swiggy Packaging Assist (SPA) platform, which aims to offer more eco-friendly packaging options.

For all its cheapness, plastic is a complex material. To understand how culpable food delivery is or isn’t in its propagation, we need to enter the proverbial ant farm to observe how aggregation, customer ratings, policy blindness, waste monetisation, and plastic colouring come together to create an endless maze of muck.

Sit tight.

Touch and go

Launched in September 2018, SPA is a marketplace where restaurants can bulk-buy food containers, cutlery, and bags. At the time, media pegged it as a move to encourage sustainable packaging, including trays made from bagasse and corn starch. Eateries buying eco-friendly or recyclable items from vendors on SPA get a 5% discount on these purchases. Virtuosity in itself needn’t be questioned. But gilded virtuosity should. And that’s because plastic containers and trays are not just available, but more visible on SPA.

SPA is available in seven of 200 cities Swiggy operates in, meaning any eco-friendly benefits are considerably limited in geographic scope. The argument can be made that packaging vendors may not be present in all 44 cities to facilitate SPAs mission. Also, it makes business sense to focus on metros. But this brings another hiccup to the fore: price.

Plastic trays and containers on SPA range from Rs 2-10 (approximately) per unit. Paper boxes, Rs 3-7 per unit. A ream of parchment paper costs Rs 2,138. A 300ml glass bottle is Rs 11.50. At the time of last checking the SPA site, bagasse-based packaging was only available in one location—Chennai—while corn starch trays weren’t available at all.

Swiggy Packaging Assist’s landing page offers different packaging options for partner restaurants to chose from

Now, consider Swiggy’s most-ordered items. The company’s 2018 StatEASTistics report, which analyses food trends among its orders, revealed that Indian food, specifically, biryani, is most popular. Apart from biryani, this consists mostly of gravies, often oily and spice-laden, which are usually delivered in plastic containers since they hold up better against these culinary elements. South Indian breakfasts, often with accompaniments packaged in thin, non-recyclable pouches, are also popular. 

Paper boxes, meanwhile, are used for pizzas, sandwiches, and burgers, none of which surface among the most popular foods on Swiggy. Zomato reports similar numbers. North Indian food accounts for 50% of the total order volume. South Indian food another 15%, followed by Chinese at 10-15%. Stacked up, 75% of orders favour cuisines prone to spillage and served piping hot.

One Bengaluru-based founder of an inventory management platform said that managing costs was a higher priority than being eco-friendly. “Packaging alone can account for 10% per unit food cost,” he explained, adding that returns, cancellations and discounts offered by platforms leave little margin for an eatery to buy expensive eco-friendly material. 

“India currently uses 14 million tons [of plastic] annually which will grow to 25 million tons by 2025. Packaging is a fast growing segment for foods, industry, and pharma packaging. This will remain; there’s no alternative here”

Hiten Bheda, Former President, AIPMA

“There’s no sense paying premiums [for eco-friendly alternatives] if few customers care for packaging in lieu of convenience,” he adds. Having run a cloud kitchen, he requested anonymity to avoid upsetting peers in the food delivery business.

Swiggy declined to respond to The Ken’s questionnaire on SPA. Instead, a spokesperson said Swiggy was working to improve the design and recyclability of packaging solutions. Hundreds of restaurant partners across cities (with or without the plastic ban), the spokesperson added, have started using greener packaging solutions when possible. Like Zomato, Swiggy is introducing an opt-out feature for disposable cutlery.

Supporting a switch

The Bengaluru entrepreneur had a point about customers prioritising convenience over eco-friendliness. Eateries will only use non-plastic packaging if it’s more accessible and can withstand heat and messiness. Without this, customers won’t care. If anything, Indian food delivery services have been in a bind due to fevered complaints about spillage and food tampering.

Cue more tape, Ziploc bags, and containers.

There’s much to be said about the average Indian customer on food delivery platforms. Plastic is an eyesore, and while the clogging of our rivers or choking marine life causes distress, we don’t hesitate to ask for an extra plastic fork or spoon. Some even ask for extra containers. Because eateries providing more plastic cutlery are perceived as offering more value. “The opt-out choice for plastic cutlery was a fight against this ‘extra is good’ mentality,” says Rakesh Ranjan, vice president of Zomato’s delivery business. 

But what percentage of Zomato’s customers actually opt-out? “Very early two digits,” is all Ranjan offers.

Zomato, too, offers packaging solutions to restaurants, but it’s more customised than SPA. It categorises restaurants as platinum, gold, silver, base, and ‘risk’ based on customer ratings. Packaging is an important criterion for ratings. Consequently, spill-proof, tamperproof, reusable, or aesthetic packaging fetches restaurants better ratings. More often than not, this means plastic.

Zomato encourages platinum- or gold-tier restaurants to choose eco-friendly alternatives by offering a 20% off on cornstarch clamshell boxes and bamboo materials. This treatment doesn’t extend to lower-tier restaurants. While the top two tiers only account for 30% of partner restaurants, they handle 80-90% of Zomato’s orders, explains Ranjan. It’s a fortunate overlap and one Zomato uses to its advantage to promote its sustainability store.

“I’d rather work with a Cafe Coffee Day than your local neighbourhood eatery. Because Coffee Day already pays attention to its packaging. Asking them to switch to sustainable materials is easier,” he says. So far, Zomato had been importing plastic substitutes from China at a hefty cost. A long feedback loop with the manufacturers, and almost a 35-40% cost difference has Zomato looking for alternatives in India.

An in-house team of designers, vendor managers and engineers, says Ranjan, is working with Indian manufacturers to re-design packaging solutions for hot, gravy-based food. Though cheaper, this custom approach has its limitations. Ranjan admits to still featuring plastic containers, straws and trays—albeit ones more than 50 microns thick and more recyclable. Virgin plastic—which contains only one type of plastic—is on the shelf as well, in addition to cornstarch and bamboo-based materials.

Despite their non-plastic food packaging solutions, Zomato and Swiggy’s rating ecosystems prioritise packaging condition rather than eco-friendliness. And yet, they can’t be held by the collar, because this is also what customers care about. Materials design, still relatively nascent in India, hasn’t given us affordable, hardy, plastic-free delivery alternatives.

All of this is compounded because the many plastic bans by various Indian states don’t do nearly enough.

Bogus bans

Starting in 2009 with Himachal Pradesh, India’s tryst with plastic bans is almost a decade old. In the intervening years, versions of the same ban—on single-use plastic, plastic cutlery, cups, containers—have popped up in 25 states.

A recent 2018 ban in Maharashtra on plastic bags, which also extended to food packaging, came down like a hammer on e-commerce companies. Zomato and Swiggy were in the trenches with Amazon, Flipkart and a host of restaurants now stuck with no packaging options. The reaction to the ban made two things clear. One, it was a knee-jerk reaction to a deep-seated, complex problem. And two, the likes of Zomato and Swiggy realise they have skin in the game since these bans make their everyday business harder. 

Jurisdictionally, however, food aggregators don’t feature on the food chain of responsibility, says Ravi Agarwal, founder of Toxics Link, a Delhi-based, nonprofit think-tank. Even restaurants are a stretch since Extended Producer Responsibility (EPR) guidelines mostly apply to FMCG brands. EPR guidelines are a global policy measure that makes brands financially responsible for collecting and treating their plastic products after use by customers. 

Agarwal has been pushing for the use of more sustainable and less toxic materials in consumer items like paint, electronics and most recently plastic. In 2016, he was part of the drafting committee on Plastic Waste Management Rules. Facing pushback from brands on EPR guidelines, little more than diaphanous plastic bags came under scrutiny. So whether establishments are procuring and using “food grade” plastic is difficult to answer. “Also, EPR extends to branded packaging. With unbranded stuff, who knows what toxicity levels they have?” says Agarwal.

Still, the bans keep coming. Despite being highly unenforceable, especially in the food and beverage industry, 80% of which, says Ravi Wazir, is unorganised. Wazir is a restaurant and food business consultant. He adds that culturally, India’s food preferences range from street-food and local eateries to fancy, high-end restaurants. This makes scrutiny of food grade packaging material almost impossible to do. Wazir, a member of several national restaurant associations, agrees that without proper enforcement, packaging compliance by food joints is uncommon.

It doesn’t help that authorities have limited manpower and expertise to catch anyone in the act. “In Maharashtra, you had police inspectors trying to book restaurants for flouting norms. But what these norms are, no one’s quite sure,” says Agarwal. 

To be fair, these norms—created by the Food Safety and Standards Authority of India (FSSAI)—aren’t easy to monitor. FSSAI, inspired by a 2017 draft of World Trade Organisation (WTO) packaging regulations on Food Safety and Standards, passed its own version in 2018. The document defines food grade as materials safe for packing food and which won’t change the composition of the food they carry. The regulations list standards for almost every possible material for food packaging, mentioning 20 different standards for plastic alone.

Additionally, there’s a chemical-wise breakdown of specific ‘migration limits’ for plastic that comes in contact with food. This means that there is a cap (measured in milligrams/kilogram of food) on materials released from the container into the food it’s carrying. The limit on barium, for instance, is 1 mg/kg, whereas iron’s limit is 48mg/kg.

These regulations are as detailed as they are obtuse. To the untrained eye, any transgressions of these packaging rules would be impossible to catch. “Everyone is excited about banning plastic. But can any of the deployed officers tell what is food grade-quality plastic?” asks Wazir. Making matters worse, FSSAI’s involvement stops at creating regulations. The onus of implementation is left to individual states. According to one report, Delhi’s food safety department had only three active inspectors for over 50,000 establishments in 2015.

No entry

The Indian government has aimed to cease all imports of plastic waste into the country by August 2019. Imports of PE and PET waste had increased by 50% between 2016 and 2017. India’s ban comes after China stopped the import of plastic waste to its shores

With authorities unable to keep pace, platforms like Zomato are also not in a position to check things like composition or migration rates of plastic containers. “If we find restaurants packing food in really low-grade plastic, then they’re an automatic reject,” clarifies Ranjan.

Wazir doesn’t want food aggregator platforms policing restaurants. For him, it’s more about self-regulation for restaurants owners and creating awareness for smaller, local vendors. He’s quick to emphasise the harsh business realities at play. A premium milkshake outlet, for example, can charge extra for glass bottles, but not every food operator will be able to absorb the cost, he says. Rather, it’s the customer who will bear the cost of knee-jerk, blanket bans.

The definition, or rather identification, of food grade plastic remains stuck in no man’s land. Ultimately, without any clear chain of responsibility, or easier explanation of standards, plastics will abound in the food packaging sector.

This shifts the onus from production and enforcement squarely back onto recycling.

Plastic’s true colours

Back in Delhi, GPWM’s Rajesh Mittal claims to incur monthly losses of about Rs 3 lakh ($4,320) recycling the colony’s plastic waste. Mittal says his 500-square metre facility could host enough equipment to process a tonne of plastic waste daily. The capacity of the existing unit is 200kg, but it’s being fed only 50kg. His request to process garbage from outside the colony was declined.

“We weren’t even being paid for our services until two years ago when we threatened to shut shop,” he shakes his head. Just then, two handcarts filled with cardboard boxes, containers, bags, and other garbage, arrive at the facility. Mittal points out that while residents have separate bins for waste segregation, segregation is rare. His employees, as a result, spend a large part of their day sifting through plastic.

The disposability of plastic and the collective indifference towards segregation has ensured plastic waste doesn’t fetch money. Why would waste collectors collect plastic that only fetches around Rs 3 ($0.04) a kilo? This is important, as no discussion of plastic generation by the food delivery juggernauts is complete without talking about the kinds of plastic and the monetisation of waste.

BBMP’s special commissioner of solid waste management, D Randeep, wants food containers banned because they’re “single-use disposables”. However, Indians tend to reuse these, and they also command higher prices than disposable trays and cutlery, which have no value for waste collectors.

And yet, there’s a kicker. If Mittal is to be believed, black food containers, the kind food delivery has made ubiquitous, have a resale value of Rs 5 per kilo at most. If this is the good stuff, think about how truly worthless styrofoam is.

“Black containers rarely sell at higher rates because the material is thinner. This is why restaurants bulk-buy them to cut costs. Black plastic is also a great way to hide defects that’d otherwise be spotted in clear and white containers,” says Hiten Bheda, former president of All India Plastics Manufacturers’ Association (AIPMA).

Think back to when you ordered food before the advent of delivery apps. The containers you got, in all likelihood, were either white or clear. Black food containers have flooded the delivery market, but there’s no India-specific data to determine how much.

“Black plastic [food containers] contains carbon black and other dyes. We can’t rule out the danger posed by black food containers in India, but we also can’t prove how toxic they are, yet,”

Suneel Pandey, TERI

A 2018 study by University of Plymouth scientists found that recycled black plastic, mostly used for food storage, is choc-full of heavy metal and flame retardants. Black container microplastics are suspected to leach into food. But, says Suneel Pandey, director of the Environment & Waste Management Division at TERI (The Energy and Resources Institute), there isn’t enough research to determine how likely hot gravies or meals are to trigger leaching. “Such plastic also contains carbon black and other dyes. We can’t rule out the danger posed by black food containers in India, but we also can’t prove how toxic they are, yet,” he stresses.

This quandary magnifies the task ahead of the FSSAI, whose 2018 packaging regulations specify plastic migration limits for just seven contaminants. There are stipulations for carbon black under IS:9833 standards for colourants, too, but no way of knowing how many manufacturers adhere to this. Not all food containers even have the IS marking at their base. Pray tell, what is food grade, and what isn’t?

Lalit Agrawal is the director of Glen Industries Pvt Ltd, a Kolkata-based plastics manufacturer. In a telephonic interview, he rubbishes claims that black plastic is an inexpensive way to hide material defects. All storage containers made in his facility, he adds, pass food contact thresholds. “Black containers first became popular abroad because they simply look better than milky and clear plastics,” he counters.

Glen Industries is export-driven, selling 30% in the domestic market. Of this, only 3% is accounted for by eateries. That’s still an average of 30 lakh units monthly. “Everyone just wants black. Judging by how things are going, I foresee double demand,” mulls Agrawal.

Manufacturer, restaurant, aggregator, regulatory body, municipal corporation. Just where does the ‘food grade plastic’ conundrum begin… and end?

Sweet spot

Definitely not with food delivery services.

“There is no clear definition of food grade packaging material passed down by the FSSAI,” says Zomato’s Ranjan. Does a roll wrapped in paper, and covered in plastic (not touching the food) make the cut? Ranjan says he understands the minimum 50-micron rule and asks partner restaurants to follow that regulation. There isn’t much platforms can do beyond that.

Zomato’s instead chosen positive incentives to trigger voluntary action by partner restaurants. “Do we penalise them for sending cutlery even though the customer opted-out? No. It would create issues on both sides,” says Ranjan. Similarly, Zomato isn’t inclined to push its partners towards more sustainable packaging, leaving it to economies of scale and technology to produce more cost-effective and sturdier packaging. 

While Agarwal, of Toxics Link, believes that these well-funded platforms have enough leverage and heft to influence a greener, more sustainable packaging channel, food aggregators are loath to push for disincentives that might hurt order volumes. 

Wazir, on the other hand, doesn’t even consider Zomato, Swiggy or any other platform as serious stakeholders in solving the plastic issue. “At best, these food delivery platforms can devise some kind of auditing process, like they did with food hygiene standards,” says Wazir. According to him, their measures are reduced to mere CSR photo-ops, because they’re neither manufacturers, food producers, part of the recycling industry or the customer. Other than being intermittent, unofficial inspectors, says Wazir, food aggregators are going to have little impact on reducing plastic waste.

While measures like notifying partner restaurants on the ‘opt-out’ option through a dashboard are easier to implement, cost and convenience make plastic-alternatives much harder to digest. The economics, without scale or support from the government, can easily snap and continue the flood of black, low-grade plastic containers. “At 1.6 items per order, at our order size, it’s just not viable to be completely plastic-free, even if we wanted to,” says Ranjan.

Aggregators are stuck in an awkward spot between arbitrary regulations on plastic containers, and a partner network that, at best, is extremely heterogeneous in its attitude towards reducing plastic waste at source. The lack of suitable alternatives makes the job even harder. By Zomato’s own account, plastic waste from online food delivery adds almost 22,000 metric tonnes to India’s garbage pile every month, most of which, they admit, is dumped sans recycling.

But the awkward position is also a sweet spot of sorts. Without any overarching regulation scrutinising them as food producers, aggregators are free to run experiments with plastic-alternatives and tiered incentive structures. And media buzz around their sustainability efforts to reduce plastic usage is just icing on the cake. These optics are great for Zomato and Swiggy, positioning them as woke leaders of an ever-expanding e-commerce universe. How much that’s preventing land-fills from overflowing or gutting marine life is another matter.

How India landed in the rabies vaccine doghouse

22-year-old Bale Hasda, who goes by the name Sumi, was bitten by a stray dog in Delhi’s upscale Lodhi Colony on 11 March. She wasn’t the only victim, or even the worst affected. A few others in the neighbourhood were bitten as well, with one senior citizen dying as a result of the dog attack. 

Fortunately for Sumi, her employer rushed her to Delhi’s Safdarjung Hospital, one of the few public health centres in the national capital that still have stocks of the vital anti-rabies vaccine (ARV). As ARV supplies at other public hospitals dry up, Safdarjung Hospital has seen its anti-rabies clinic overwhelmed with victims of dog bite cases.

Sumi received a tetanus injection and a shot of the life-saving rabies immunoglobulin—a serum administered for deep animal bites and scratches—and also a series of five ARV injections over the next few days. The last of these injections was on 8 April, nearly a month since her ordeal began. All told, the treatment cost her Rs 3,000 ($44), while the serum was given free of cost. At a private healthcare provider, this could have cost as much as Rs 15,000 ($218).

Without timely medical intervention and the availability of the ARV, Sumi’s story could have panned out very differently. Others have not been as lucky, turned away from their closest public hospitals due to the non-availability of the ARV in Delhi. Elsewhere in the country, the situation is equally dire. Karnataka, Jammu and Kashmir, and Punjab among various other states are all running out.

“Various reports in the past few months indicate that several states in the country have reported 60-80% shortage of ARV, due to a combination of factors including growing demand, imperfect demand signal, and supply disruptions”

Prasanna Deshpande, deputy managing director of Indian Immunologicals Limited

That this would be the case in India is a bit of an oddity because literally nowhere else is the need for ARV more obvious. India accounts for 36% of deaths due to rabies worldwide. Some 20,800 deaths every year, most of them children under the age of 15, according to a 2015 study published in the PLOS Neglected Tropical Diseases journal. 

India is also home to the largest anti-rabies vaccine manufacturer in the world—formerly GSK-owned Chiron Behring Vaccines, which has now been acquired by Bharat Biotech. 

On its own, Chiron Behring’s facility had a capacity of 15 million doses, almost a third of the national yearly requirement of 35-48 million doses. In fact, India’s four ARV manufacturers—Hyderabad-based Bharat Biotech and Indian Immunologicals Ltd, Ahmedabad-based Cadila Healthcare, and Pune’s Serum Institute of India (SII)—have a combined capacity of 40-50 million doses annually. (These figures are based on media reports and Bharat Biotech’s founder-chairman Krishna Ella’s estimates. There are no official figures as no official study/estimate has been done on the demand.)

But even with adequate demand, tremendous market potential, and adequate combined capacity, state governments are finding it hard to procure the vaccine. India is staring at an 80% shortage of ARV.

Government authorities have put the blame squarely on manufacturers, claiming their focus on exporting ARV is the reason for the shortfall. Government officials say this is because ARV fetches a higher price abroad—around $30 versus Rs 300 ($4.4). Consequently, manufacturers have ignored various tenders floated by state governments for the bulk purchase of the vaccine. With the state unable to procure the vaccine, public health centres have been told to deal directly with distributors who sell the vaccine at a considerable mark-up.

With a looming public health crisis in the offing, the Indian government has mulled capping exports of ARV altogether. Manufacturers, however, believe the government’s knee-jerk reaction will solve nothing in the long-term. They claim they simply do not have the capacity to meet states’ requirements and point to systemic issues with procurement as the root cause of the problem. The cap, they argue, will only hurt their international commitments. 

Meanwhile, the likes of Sumi must hope that their nearest public hospital is one of the rare ones still stocking ARV.

SOS from states

The World Health Organisation (WHO) estimates that rabies causes some 59,000 deaths worldwide each year. The overwhelming majority of these—95%—take place in Africa and Asia. This number, however, is believed to be lower than it should as widespread underreporting and uncertain estimates mean the true burden of the disease is unknown. The disease is also largely dog-mediated, with rural populations disproportionately affected.

India, with its lax animal sterilisation measures, sees 1.75 million dog bites a year according to the National Health Profile 2018. Unsurprisingly it is the worst-affected country when it comes to rabies. And things are getting worse. In 2017-18, the southern state of Karnataka reported 1,09,462 dog bites. With just over half of 2019 gone, the number of dog bites already stands at 83,837. According to government figures, Karnataka and West Bengal together account for half the country’s rabies cases.

Even so, Karnataka is woefully underprepared for the rabies situation in its backyard. Earlier this month, it asked neighbouring Kerala and Tamil Nadu for ARV supplies after public hospitals in the state began to run dry. While Kerala sent 10,000 vials of ARV and 2,000 vials of rabies immunoglobulin serum, Tamil Nadu sent 5,000 vials of ARV. These supplies, though, are like a bandaid on a bullet wound. The state announced that these supplies would only last for the next two to three months. 

The situation is similar in Delhi. Ashok Rana, the city’s director general of health services, told The Ken that ARV stocks will last for the next two months. Mere weeks ago, the state floated a tender to procure ARV; it received just one bid. Now, the state is counting on the single manufacturer who came forward to bail it out of its current predicament. Rana refused to divulge the name of the manufacturer as the tender is yet to be finalised.

Kerala and Tamil Nadu, on the other hand, were able to help Karnataka because they have three-year contracts with manufacturers for ARV supply. Karnataka’s contract was just a year-long. Since December, Karnataka has floated two tenders for ARV procurement; manufacturers stayed clear of both. The procurement is handled by the  Karnataka State Drugs Logistics and Warehousing Society (KDLWS).

Latha Pramila, chief supervisor of drugs for KDLWS, says they are unable to make centralised procurements because manufacturers are not bidding. “We have released money to healthcare facilities for local purchase, but at a higher price,” she says.

Bulk buys

With a shelf life of 12 months and at an average price of Rs 200 per vial, it costs Rs 8 crore to make a bulk purchase of 4 lakh vials for Karnataka

 Having to buy from dealers is not sustainable, as they come with a substantial mark-up. “The dealers’ margins are 30% to 35%,” Latha says. But while a tender system would allow governments to procure ARV at lower rates, manufacturers prefer doing business with dealers who require smaller quantities but are willing to pay more.

Broken tenders

Buying from dealers, however, is not a solution to the problem at hand. Karnataka’s annual requirement is 350,000-400,000 doses of ARV, a quantity no single dealer can match. At present local health centres in the state are directly dealing with different dealers in their districts to bridge the shortfall.

All of this could be avoided with a centralised system of procurement, and, to be fair, it exists. But it’s broken and antiquated.

According to manufacturers, the rate-contract system employed by states asks a lot from manufacturers while giving precious little in return. Right at the outset, the rates governments are hoping to procure at leave vaccine makers feeling shortchanged. According to Sunil K Bahl, former director of business development at SII, prices per dose under tenders are particularly low. “In the open market, the manufacturer can get Rs 250 ($4),” Bahl says. These prices are already low as ARV is listed as an essential drug, meaning its price is capped by the National Pharmaceutical Pricing Authority, he adds.

Karnataka is a great example of this price discrepancy. In 2017-18, the Karnataka government procured 250,000 vials of ARV from Indian Immunologicals at a price of Rs 172 ($3) per vial. Currently, since the Karnataka government has asked hospitals to purchase the vaccine from local dealers, they are getting it at Rs 270-290 ($4-$4.2) per vial. The market rate is higher still—Rs 340 ($5).

Waste not, want not

Used intradermally, one vial can be used to treat five patients. Intramuscularly, though, it can be used on only one patient. But once opened, it has to be used within eight hours. As a result, for facilities with low patient footfall, intramuscular injections are more preferred despite the scarcity of ARV

“If you don’t bid low, you won’t get the tender. State governments should introspect why manufacturers are not coming forward to bid,” Bahl said. As of now, only primary manufacturers are allowed to participate in tenders due to quality concerns.

But this is only the tip of the iceberg as far as tenders go. According to Prasanna Deshpande, deputy managing director at Indian Immunologicals, the rate-contracts employed by various states are riddled with shortcomings. While they fix the purchase price of vaccines, they do not specify the exact quantities of vaccines required. This is down to the fact that estimates of vaccine demand are often inaccurate—usually projections based on utilisation in the previous two years.
“This makes it difficult for manufacturers to plan their capacities properly, and this adds uncertainty and leads to demand-supply friction,” Deshpande says.

While long-term contracts gives states the assurance of supply, manufacturers are uncomfortable with this as they are liable to governments for longer periods. None of this is helped by the lack of central guidelines on vaccine procurement.

KDLWS’ Latha Pramila makes no bones about the exacting nature of these contracts. “Our contracts require the manufacturers to pay an advance amount like a security deposit (to assure quality and accountability), and contracts come with a penalty clause. They don’t have to adhere to our conditions if they sell in the open market,” she says.

The conditions of the government are getting tougher every day, Bahl points out. “Earlier, there was a one-year tender, now they want a contract for two years. Payments are delayed for 90-120 days,” he says. 

With the terms seemingly stacked against them, it’s little wonder that Karnataka’s most recent tenders for ARV have gone unanswered.

A shot in the arm

Is the current vaccine shortfall doomed to continue then? Not quite. Industry insiders say that the situation is particularly bad at present owing to recent circumstances, and believe it will improve in a few months.

The biggest change on the ARV front has been Bharat Biotech’s all-cash acquisition of Chiron-Behring from pharma major GlaxoSmithKline. Bahl told The Ken that the current shortage was because of the halting of production by Chiron-Behring. Chiron-Behring’s Ankleshwar facility previously produced 15 million doses of the vaccine, making it the single largest producer of ARV in the world. 

While it will still take another few months before the plant is up and running again, the ARV crunch should ease considerably after this happens. Bharat Biotech did not respond to The Ken’s emailed questionnaire regarding its plans.

Indian Immunologicals, which has manufactured ARV for more than 15 years now, is also looking to increase ARV production. It has a current capacity of 10-15 million doses, more than 50% of which is sold in the domestic market. “In the past, we used to supply to more than 10 state governments, but now it is down to a single digit,” he says. This was because of the difficulty of dealing with state governments—fulfilling their criteria and delayed payments. The company also exports to countries in Asia, the Middle East, and Africa.

On 24 June, Indian Immunologicals announced the setting up of a new manufacturing facility in Telangana. This will increase its capacity to supply its ARV, Abhayrab™. The new facility is expected to be ready later next year. The company currently has one operational facility in Tamil Nadu. This will also help the situation going forward, however, it will be two years before the vaccines from the new facility hit the market.

Despite the current supply crunch, Indian Immunologicals’ Deshpande insists that the situation doesn’t require drastic measures. “The problem is being solved with the government tracking supplies and manufacturers ramping up capacity. The situation will ease in the coming months,” assures Deshpande.


The government, however, feels otherwise. As lines outside anti-rabies clinics grow longer, the government is mulling a 30% cap on ARV exports if not an outright ban. “The government should have a dialogue with the manufacturers before mulling a cap or ban on exports,” Bahl says. In April this year, it did just that. Still, states continue to receive no response to their tenders.

But while an export cap may force manufacturers to come to the table, an outright ban would seriously wound them. “We have contracts with international partners. If we are not able to supply, there will be financial repercussions. It will also not be good for India’s reputation as an exporter of pharmaceuticals and vaccines, as we are a bright spot in the industry. A ban will be undesirable,” Deshpande said.

Rajeev Dheere, executive director of SII, concurs. Only SII and Cadila are WHO pre-qualified, meaning they are approved by the WHO to provide their vaccines to international agencies and markets. This, understandably, makes export a very important market for both. Even so, Dheere says, exports won’t exceed 4-5 million doses for both Cadila and SII combined. 

“The government must tell us in advance what they want. One cannot estimate the number of dog bites but they have to take risk, buy stock, and replace it in two years if unutilised”

Rajeev Dheere, executive director of SII

“When the health ministry called for a meeting, we explained that if they inform us of their requirement, their tender volume, and if it is for a particular period or month, we will tackle it easily,” Dheere said. Like Indian Immunologicals, SII also maintains that at least 50% of its vaccines are sold in the domestic market.

Manufacturers suggest that adding ARV to the Centre’s universal immunisation programme could solve this problem altogether. It would ensure the Centre procures the rabies vaccine like it does in the case of other diseases. For example, the Measles-Rubella vaccine was centrally procured for the whole of India. “No state bought it. Pentavalent, Hepatitis B, Tetanus, Measles-Mumps-Rubella, Measles-Rubella, all vaccines are bought by the Centre. Rabies is the only vaccine which states procure,” Dheere points out. 

This is how it’s done the world over, Dheere adds. The central government should take inputs from states on their requirement, procure it and then distribute it, he suggests. When all other vaccines are centrally procured, there is no reason why the rabies vaccine is any different. While caps and bans may make for good optics and show a sense of urgency, they will ultimately leave the root cause of the problem untreated.

Higher quality, lower costs: India’s cancer grid promise

No matter the time of day, the visitors in queue at Mumbai’s Tata Memorial Hospital (TMH) always have a discomfiting poise. Most have travelled long distances; but the group seems curated by one illness, cancer. An illness that can be manageable, like a chronic disease, but often isn’t. 

In 2012, the leadership at TMH, the largest cancer centre in the country, took a decisive step to address parts of the colossal task at hand. Having brought existing centres in Guwahati, Chandigarh and Visakhapatnam into its fold that year, it set about framing common standards, setting up an IT platform, and sharing best practices—the entire structure for a functional network. 

Then, in a benevolent gesture, they decided to open this up to scores of regional cancer centres across India. Thus, the National Cancer Grid (NCG) was born. An unprecedented initiative to tame a disease that the World Health Organisation (WHO) estimates will affect one in three household in India by next year. The numbers look ominous—1.73 million new cases by 2020, with only 12.3% of patients receiving early treatment.

Already under Ayushman Bharat—the government’s universal healthcare insurance scheme which covers 40% of the population—30% of reimbursements are for cancer treatment. Is that money optimally spent? It’s certainly worth examining since there are rumours the scheme may be expanded to cover more people. 

Seven years on, the NCG sees 700,000 new cancer patients pass through its network of 177 centres each year. Some of the world’s leading cancer centres are even helping the NCG build out its capabilities since it’s also serving 40-plus countries in one way or another. These include the National Cancer Institute and American Society for Clinical Oncology in the US, King’s College London, and Cancer Research UK.

Fast emerging as a global health centre, could NCG also impact the sprawling, yet largely unregulated, private healthcare providers in India which serve the remaining 60% of cancer patients? CS Pramesh thinks it could. A director at TMH, Pramesh, a practising thoracic surgeon and the lead architect of NCG, talks about this democratic, ground-up machinery that has caught the world’s attention.

The Ken: Why have a cancer grid? 

The single most important mandate of NCG is to have uniform standards of care. Look at the patients that come here or at any top centre; only a small percent comes from the state where the centre is. At TMH, only 15% of our patients come from Mumbai; 25% from other parts of Maharashtra. We geotagged 75,000 patients (map below).  A large percentage comes from pockets like North, East, or North-East; not so much from the West or the South. 

Overall, the biggest challenge for patients is to stay here with their family. Think of the cost of staying in Mumbai, the loss of income for the family… So our main aim was to provide the same level of care close to their homes.

The Ken: In seven years, how far have you come? 

The network has grown phenomenally. From the 14 centres which participated in our first meeting in August 2012, when 29 regional centres were invited, when there was a lot of scepticism, it has grown to 177 centres. These centres see 700,000 new cancer patients every year, almost 60% of India’s total cancer cases. 

The Ken: That’s volume. But what about quality and impact on clinical practice? 

NCG has grown in size and scope. From the single mandate of quality care, it grew to improving the quality of human resources. We have stringent rules in this country which determine which centres can train medical people and which cannot. This means several centres which can train are not training because of these rules. We wanted to break these silos and get any centre capable of training to train. If not in a formal way, then at least in an informal way—by task sharing and task shifting, where the time of the oncologist, a rare expertise in India, is better used. 

We run so many quality [testing/assurance] programmes for pathologists and physicians. For instance, somebody from the North-East (NE) said they were finding it difficult to attend medical conferences in big cities—traveling from Naharlagun (in Arunachal Pradesh) to Chennai is a two-day affair. We created continuing medical education (CME) programmes and ran them across 11 cities in 26 days, covering the entire NE. This kind of a model doesn’t exist anywhere. 

Quality control in cancer pathology is critical. TMH follows the College of American Pathology (CAP) guidelines, but at NCG we have created a leaner version of CAP and put it online. It’s offered free of cost to any centre voluntarily wanting to upgrade. Today, 100 centres avail this quality certification. They think getting an NCG stamp is important. Now the National Accreditation Board for Testing and Calibration Laboratories (NABL) has started suggesting to centres that they go through NCG’s quality control of pathology.

Then there’s research, which is uncommon in India. TMH is the largest cancer centre in the country, and hence it can do all kinds of research by itself that other places can’t. It’s a very inefficient way of doing research. If you are doing a 1,000-patient study, it takes 7-8 years to do it. By the end of it, and when the outcome is analysed, we realise that the original question may or may not be relevant. We need to be quicker, more efficient; we need to know if this research, which works in TMH, will work in Silchar or Guwahati or Kanyakumari. 

The Ken: Can NCG drive the cost down? Magical cell therapies like CAR-T are available, which cost anywhere from $500,000 to $850,000. Will India have to wait a decade or more for such treatments?

CAR-T is not sustainable, even in the US. In fact, it’s at the tipping point. They are at 18.5% of GDP expenditure on healthcare. If they reach 20%, the bubble will burst. 

We are looking at it in two to three different ways. First, educate people and physicians about the value of care. This doesn’t come intuitively to either patients or physicians. If you ask an individual ‘what is the cost of your life?’, the person will say, the earth. The reality of life is money is finite. Public health budget is earmarked for it. While I agree that India’s health expenditure must go up, what we can do now is make sure that the 1.5% of GDP that is spent on public health is spent well. Unfortunately, that’s not happening now. It’s mostly because of the market hype. When you have blockbuster drugs, advocates of that disease want that drug to be paid for in all cases, regardless of patients’ ability to pay. 

I am all for universal health coverage. But do we know that money is spent well, based on value? Let’s assume there are drugs which improve survival by two months, but cost Rs 10 lakh ($14,286). What is happening today is that with this Rs 10 lakh expense, somebody with a perfectly curable condition is not getting those funds. We need to make value judgments. It’s not easy. You could effectively be saying you can’t fund two months of someone’s life. 

I’ve been on panels where government officials have said they did not know most of the cheques they have signed are for treatment of patients in their final months.

Which is why our revised guidelines are stratified. 1) Optional care: You can have state-of-the-art care. If the richest man wants to spend $1 million for two days, so be it. It’s his life. He can get that. 2) Optimal care: Where we bring value into the equation—what is the quality of value adjusted as years of life saved versus the cost one pays. If Rs 10 lakh improves survival by two months, say no; if it saves 10 years, say yes. This may seem like rationing, but this is the rational way of rationing. Better than what we have today where the first 50 people get the treatment and the remaining 950 are deprived because the money has run out. 

The Ken: Is there a life before and after NCG, for patients and for doctors? 

There are some areas where we can see the impact. We are nowhere close to conquering the cancer problem in the country, but I can say that serious inroads have been made. We are very conscious of the fact that we need early surrogates of success. We started with a flat way of how the system would operate. We didn’t say these are 1-6 things that need to be done and let’s start with #1. In the past, most collaborations in India have been top-down and prescriptive. One of the reasons NCG has worked is because every centre feels it is contributing.

Mind you, TMH is not driving it. To say that would be undermining the effort of many, many people. NCG is extremely democratic. Most ideas have come from member centres. For instance, guidelines for treatment is not a new idea; we have set these in the past. Typically, they are formed by getting a group of experts from elite cancer institutes, who look at the guidelines from abroad and select a bunch based on evidence. We [at NCG] are not trashing that effort, it’s systematically done. But they are extremely cumbersome for physicians to follow. Some guidelines for a single cancer, like colorectal, run into 70 pages. The moment you have 70 pages, no chance a busy physician would even turn the pages. So we made it very concise—two pages, and in an algorithmic format.

The Ken: You mean input-based?

Yes, all that the clinician needs to do is to fill the specific figures/report outcomes in the matrix and the algorithm comes up with a treatment recommendation. For instance, if your patient has early breast cancer, then what’s the size of the tumour, has it spread to lymph nodes or any other part of the body, what is the biopsy report, etc. You fill in the data and the guidelines will tell if surgery has to be followed by radiation or chemo and so on. The same information is available in 72 pages otherwise.

An important part of this method is that the moment you get new evidence, you revise your guidelines. Our first set of guidelines came in 2017; a revision is underway as we speak.  

The Ken: Talk about one instance of data-based treatment driving this revision. 

Take the breast cancer drug, Herceptin. [Sold in India by Roche (the innovator), Mylan and Biocon; costs upwards of Rs 10 lakh ($14,286) for a full cycle.] It’s a breakthrough drug. We did a survey in 2008 at TMH where we looked at what proportion of women eligible to get the drug actually get it. It was 8%. Half of those got the drug because they were part of the clinical trial. Effectively, only 4% could afford to take the drug. This is true in most cancers based on western guidelines. 

We looked at data afresh. A study shows that instead of a year, if you give Herceptin for nine weeks, it is almost as effective as giving it for a year and at a fraction of the cost. We put this in the guidelines and now we repeated the survey, 10 years after the first survey. Now, 50% of women who need this drug are getting it, up from 4%. Of course, we were supported by philanthropic money, but still. We cannot allow ‘perfect’ to become the enemy of ‘good’. This practice is now being adopted in several other low-income countries, including several in Africa. 

The Ken: Have you been able to reduce migration? 

A lot of patients travel for the second opinion. Even coming from a capital city like Bhubaneswar in Orissa to Mumbai—to see the doctor, do the tests, come back to the oncologist and go back home—is an ordeal. We created an online second opinion platform in partnership with Navya Networks. Any patient, either from India or anywhere in the world, can take a photo of their reports and upload. We have given them, at the backend, a set of minimum requirements, what reports to collate in a structured manner for each cancer. For example, if it’s lung cancer, then we need a chest X-ray, a biopsy, a CT scan; and if there are other symptoms, then an MRI or a PET scan.

Entire scans can be uploaded. This is then structured and sent to experts at NCG. I get formal and informal reports seeking second opinion. But to look at 75 pages of a report over email isn’t possible. But if it comes in a structured format, it takes just 3-4 minutes to give my opinion. This platform has machine learning technology at the backend which continually improves it. It already comes up with 2-3 suggestions, which takes into account evidence elsewhere in the literature. In many cases, this is all that the patient requires. If the second opinion is different from the local doctor’s prescription, she can share it with the local doctor. 

We were doubtful about how confident the patient will be in showing this virtual opinion to their local doctor. So we ran a survey on 1,000 patients and 78% had shared it with their local oncologist; more than 75% went for the second opinion treatment. 

This system was meant for patients in India, but the internet has spread it. Now, 80% patients are from India, 20% from overseas. People in close to 48 countries have availed this virtual second opinion service. It costs about $100. Poorest patients get it free. Doctors here get zero fee, they do it pro bono. 

We haven’t marketed ourselves well. We curate the experts carefully. We could handle much more but we don’t want to make it a commercial product. It’s spreading by word of mouth.

The Ken: Is the rising tide lifting other boats?

It is. And in many subtle ways, too. Earlier, smaller centres faced the problem of not getting a multi-disciplinary approach. It’s non-trivial in cancer. Even in developed countries, if you go with a problem to a surgeon, he’ll suggest surgery; if you go to a radiation oncologist, he’ll suggest radiation; if you go to a medical oncologist, he’ll suggest chemo. There’s a really nice study in prostate cancer in the US which proves this. Getting all specialists in the same room is important to arrive at a rational decision. Very few cancer centres in India have this kind of expertise or system. This is increasing but not as high as it should be. 

At NCG, we have created a virtual consultation service. In the last 30 months, for over five hours, three times a week, multiple centres log in and discuss cases disease-wise. Some 25-30 centres and 100-120 oncologists log in every time and complex cases are discussed. When we started the virtual tumour board, we wondered why simple cases are coming up. Now the cases discussed are so complex it’s safe to assume the local centres are addressing simple ones themselves. 

The Ken: You recently signed an MoU with Ayushman Bharat (AB). What for? 

Ayushman Bharat can truly be a game changer in cancer care. We want to give roadmaps to governments for optimal care. Under AB, we are partnering with the government to rationalise the packages because the tariffs in many cases are irrational and it would make no sense for any hospital to participate. We are also introducing evidence-based packages. AB was launched in a hurry [last year] and several things were missing. 

We are linking pre-authorisations [of hospitals] or reimbursements to the NCG guidelines. Earlier, there was no regulatory mechanism to find if any guidelines were followed. If any hospital wants pre-authorisation, our software gives recommendations. If the hospital treatment follows the guidelines, it’ll automatically pre-authorise. No human intervention is required. This will cover 70-80% of the situations. In the remaining 20-30%, if doctors disagree with the NCG recommendations and provide a rationale, then that goes to an anonymised expert in the NCG. If approved, then that case also gets pre-authorised. Considering that AB covers 40% of India’s population, and 30% of AB’s reimbursements so far have been cancer-related, NCG can extensively aid cancer care in this country. 

This should be a model for anyone else to follow. How can a cardiologist take a decision for stenting without getting an opinion from a surgeon. Or vice versa. Unless this kind of dialogue happens, patients will continue to get suboptimal care.  

The Ken: So the NCG takes care of 60% of patients who come via its centres. Can the remaining 40% who go to private hospitals or doctors benefit from NCG in any way? Moreover, the private sector is pretty unregulated, to each their own. 

It’s a difficult question. We need to look at it in two ways. There’s growing mistrust between providers and people. On private providers’ part, there’s reluctance to be regulated. And to be transparent about themselves. Take electronic medical records (EMRs). Most centres have adopted EMR, but it is merely a way for them to keep a record. The patient doesn’t benefit in any way. When we introduced EMRs at TMH 10 years ago, we ensured the system permits patients to access their complete records from anywhere in the world through a user ID and password. They get unrestricted access to all their records. Even in the US, patients get only partial access.

We encourage our doctors to share outcomes, long-term survival, short-term survival, and compare. It may not be useful for the uneducated patients, but this is available. This kind of transparency is lacking in the private sector. At some point, some kind of regulation is required. No healthcare system can work well without regulation. 

I believe at least 40% of the population getting the right treatment is a form of regulation. If I were the insurance provider, I’d be sold on the idea that patients get treatment under this. Why wouldn’t they? It saves money, both for the patient and the insurance provider. 

Ten years ago when TMH had paper records, 30% of them were lost. In fire, floods or stolen in train. EMR saves you. It must be accessible

Dr CS Pramesh, Director, TMH

The Ken: There are rumours that AB’s scope could be expanded beyond the 40% population it is now meant for.  

Even I hear that rumour. That’s how taxes in Canada and Australia work, and everyone gets the best college, healthcare and what not. 

You don’t want AB to be seen as a poor man’s policy. You want it to be a policy that is the best. It’s great that it starts with the poorest, but it should not stop there. Then it begins to be associated with low-quality, low-value care. Instead, it should be high-quality, high-value service at low cost. 

The Ken: With the volumes at NCG, are you able to leverage it for a national cancer drug pricing negotiation?

It’s already happening. About six months ago, we began collating demand for drugs from cancer centres. As we speak, the request for proposal and tender processes are being discussed. But you have to be very transparent in your processes because these are big sums of money we are talking about. We follow government norms—right from the choice of government-approved e-tendering vendors and other best practices.

We’ve collated demand, but not all centres are participating because the current government rules do not allow centres to negotiate as a group. (A hospital like AIIMS in Delhi cannot procure at rates that TMH has got for itself. Instead, it must float independent tenders.) This news reached the deputy CEO of AB. The government is drafting an advisory that will go to all central and state health agencies stating that if they are unable to procure at lower rates, they are free to procure at NCG rates.

Some change has already begun. The Punjab government asked us to share our procurement tender—our costs are low because of our volume. Punjab is procuring at our price, without floating a tender. But this is an exception, rather than the rule. 

The Ken: What kind of price reductions are we talking here? 

We studied six different states’ procurement to see what the variation was. It was anywhere from 5% to 60%. That’s substantial. We are also conscious of the fact that some states are procuring at rates lower than TMH, which is surprising because owing to sheer volume, we get the lowest rates. [Maybe quality is suspect.] We’d have be assured of best practices. TMH doesn’t buy off the shelf. We have a set of 17 criteria, which are surrogate markers of quality. 

The Ken: Many pharma multinationals in India are downsizing. Do we run a risk, as a country, of missing out on new drugs? All said and done, many of them work wonderfully. 

Why are costs high in India? Look at the price at the company’s point of sale and then you add the multiple levels of margins by distributors and retailers or hospitals. The markup is huge, often many times more than the actual price. The moment you eliminate that and factor in the volumes, India becomes a huge market. Even if cancer incidence is low, we see around 1.5 million patients every year. Just work those numbers out. In Herceptin, moving from 4% to 50%, they made profits. It’s the Walmart model. MNCs would be foolish to move out of India. 

The Ken: How about the really high-value, high-cost drugs? 

For high-value ones, we should work out ways. CAR-T is a good example. But at half a million dollars, which will fund a full cancer centre in India for a year, you are saving one patient. We should be asking how can we reduce the cost. You can develop your own CAR-T cells.

The Ken: But that’s proprietary technology. Plus, no Indian pharma company is interested in next-gen biologics. Who will produce it in India?

There are many ways to skin the cat [and not use Novartis’ proprietary tech]. Several academic centres in the US are doing it, and there’s no reason why we can’t. We are coming up with a CAR-T therapy centre at TMH, which is outside of pharma. We are building a GMP [good manufacturing practices] facility. It shouldn’t cost that much. Less than a tenth of the cost of CAR-T. 

The Ken: What is your baseline? Can you say this is how the average survival rate in XYZ cancer has improved? 

That’s something that has tormented us for a very long time. Even when we started we wanted some baseline to evaluate ourselves. The hardest endpoint is mortality or survival, but unfortunately, getting that kind of data is the toughest nut to crack. We wanted to start with getting the IT linkage. But two-thirds of these centres have no EMRs, at the remaining third, EMRs don’t talk to each other. Now, we are partnering with iSpirt (a think tank for the Indian software products industry) to sort this problem. Using speech-to-text and a few other technologies, we are running a pilot between four centres to see how we can capture and use the best patient data. 

So, we are forced to look at other surrogates, like how many people have we been able to train, how do people continue with research after our six-day boot camp, etc. But if you are asking for the big picture, how have we impacted the mortality of cancer patients, we are at least a decade away. That kind of data doesn’t exist. 

The Ken: Could NCG, at some point, become the audit bureau for private hospitals’ cancer centres? 

It most certainly could. It should. But from the NCG’s point of view, we’d like to make it voluntary. Restrictions and rules keep centres away for real and unreal reasons. 

If you have an NCG-approved process, that entitles you to 15% extra of AB tariff, that is an incentive. That’s how NABH (National Accreditation Board for Hospitals & Healthcare Providers) has done it—if you are accredited, your reimbursement from the government will be 15% higher. 

Resisting upto 99.9% antibiotics: India’s superbug war begins

When it comes to antibiotics, an over 10% resistance is almost too high.

Indians show resistance as high as 99.9% towards some antibiotics. This, as per a paper published in the Indian Journal of Medical Research (IJMR) on 3 June—the first paper that indisputably establishes that Indians are alarmingly antibiotic resistant. Not only are Indians resistant to older antibiotics like penicillin by over 90%, the resistance to newer antibiotics like ciprofloxacin is also over 40%. The World Health Organisation (WHO) classifies antibiotics into three categories—access, watch and reserve, with each category stronger than the last.

In India, the drugs in the watch category have long crossed the 10% resistance mark. Even worse, Indians are becoming more and more resistant to some of the precious few drugs in the reserve category as they enter the human body through meat. The reserve category drug, colistin, for instance, is used to fatten the chickens in poultry farms.

India is now starting to look deep into this problem. Starting with a government conference in Kerala’s capital Thiruvananthapuram on 11 June. One that the deputy director of the national health mission in Madhya Pradesh (MP), Dr Pankaj Shukla, attended.

Shukla returned to MP, and at a never-before-for-an-Indian-bureaucrat pace, he framed and executed an antimicrobial resistance (AMR) action plan. In six weeks. As you read this, he’s giving final touches to it. Other states have also swung into action. Assam hosted its first meeting last week. Delhi has started the process to frame its action plan. The bureaucrats plan to finalise it next month. Shukla is ahead of the pack and plans to launch MP’s action plan on July 25. 

The conference convinced Shukla that AMR, which is killing more and more Indians every day, can be controlled. By not feeding antibiotics to chicken in poultry farms. Shukla was astonished to learn that resistance to antibiotics could be so easily avoided. Moreover, the weight of the chicken and size of the egg remained the same, he says.

Finger lickin’ antibiotics

According to a bureau of investigative journalism report, animal pharmaceutical companies in India were openly advertising products containing colistin as growth promoters – including Venky’s, which supplies meat to fast food chains such as KFC, McDonald’s, Pizza Hut and Dominos.

This chicken-and-egg solution is a precedent to a larger drive—an ‘antibiotic stewardship’ programme. And as per Dr Sanjeev K Singh, who instituted the programme in Kerala five years ago, it has led to a significant reduction in the use of antibiotics.

Singh, medical superintendent at Amrita Institute of Medical Sciences in Kochi, narrates the story of a 3-year-old boy who was brought to Amrita with congenital heart disease. He caught an infection that resisted all antibiotics; he died after three weeks. Singh encounters at least one or two such pan-drug resistant cases every month. The only ray of hope for Indians are the preliminary results of the stewardship programme; Singh claims it’s brought down mortality by one-fourth.

Shukla, meanwhile, has commissioned the training of 100 doctors in antibiotics stewardship, who will then train other doctors.

What does the programme do that can save lives? It teaches doctors a combination of practices to rationalise antibiotic use through the “right dose, right drug, right duration, right frequency, right patient and right indication,” says Singh. The current practice in India is exactly the reverse. A combination of prescribing antibiotics to those who don’t need it and denying those who do has led to superbugs that are stronger than every antibiotic available. The country is now waking up to this reality.

Over the last few weeks, representatives of patients unable to fight tuberculosis due to drug resistance met in Delhi to discuss the lack of medicines stocked by government centres. Meanwhile, Dr Kamini Walia, head of the Indian Council of Medical Research on AMR, who co-authored the IJMR paper, wades deep into telling data. It has taken her over five years to build evidence from India for something the scientific community already saw coming since antibiotics were discovered. 

Chronicle of data foretold

Sir Alexander Fleming, who was one of the three scientists to be awarded the Nobel Prize in 1945 for the discovery of penicillin, the world’s first broad-spectrum antibiotic, had warned that this day would come, says Walia.

“The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself, and by exposing his microbes to non-lethal quantities of the drug, make them resistant,” Fleming had said in his Nobel Prize acceptance speech. AMR is not new, but the data from India is. As alarming as it looks with Indians showing such high resistance percentages, Walia says that this data is an indication, not a reflection of the community.

The data  has been collected via a network of 20 hospitals that form the AMR surveillance network that ICMR set up. The problem with this data, she says, is that it came from only tertiary care centres, where people come after being prescribed multiple rounds of antibiotics at the primary and secondary levels. The samples are collected from the sick. Still, she says, over 70% resistance is madness. And it is growing.

Going forward, ICMR intends to start collecting data from secondary care hospitals and nursing homes to get a better understanding of resistance to antibiotics among Indians. A clear answer would still be elusive as India does not have microbiology labs at the primary care level. Even if the surveillance network does build evidence from the ground to support nationwide policy intervention on AMR, the future seems exactly as Fleming had warned.

You see, India has almost no alternative to pumping people with antibiotics. 

Sneezed? Here’s an antibiotic

The flow of antibiotics, after being produced by drug manufacturers and before they reach the patients, can be checked at two points—at the pharmacist’s and the doctor’s. Except neither has reason to avoid sales or prescriptions, respectively. 

In 2015, Dr Singh started collecting evidence from the ground. His team interviewed 3,000 doctors, over 200 labs and over 100 pharmacists across Kerala. The data (that would eventually lead to Kerala’s AMR action plan) established that the doctors prescribed newer antibiotics without any knowledge of AMR, as medical representatives (hired by pharma companies to market antibiotics) never warned them about the risks associated with them. It also indicated that about 50% of the time, patients asked doctors to prescribe antibiotics in the hope that they would recover sooner. Finally, doctors did not have a choice but to prescribe antibiotics as they either didn’t have access to detailed diagnostic lab reports or they didn’t trust the labs.

Doctors don’t want to lose the patient and want to go all out to save them, says Singh. For instance, every patient in need of surgery requires just one dose of antibiotics pre-surgery, but doctors, as a precautionary measure, end up prescribing three doses a day for 5-7 days. This, says Singh, is an irrational but common practice. Another example of bad prescription practice, he notes, is dual prescription. For instance, in the case of typhoid, clinical protocols require starting with old-generation antibiotics like chloramphenicol (over six decades old), then moving on to the newer ciprofloxacin family (five decades old) and then trying the decade-old ceftriaxone, moxifloxacin and gatifloxacin. But doctors, explains Singh, usually prescribe two drugs that do the same thing together as a safety net. This doesn’t make any clinical difference in outcomes, but it increases the chances of resistance to the newest drugs available. 

Not only do Indian doctors prefer to prescribe newer antibiotics, they prefer broad-spectrum antibiotics over narrow-spectrum ones, says Walia. The former can be used to treat a variety of illnesses without diagnosing the underlying illness, while the latter requires proper diagnostics.

A doctor can prescribe a combination of antibiotics for immediate relief and order a test at the same time. This sort of thing happens the most with upper respiratory tract infection and diarrhoea. Both, Walia adds, are self-limiting and not always caused by bacteria. However, when the diagnosis of the disease is more expensive than the drug, drugs are prescribed. A blood culture costs between Rs 500 ($7.3) and Rs 1000 ($14.6) but drugs cost Rs 200 ($2.9) to 300 ($4.4). Taking a drug that is widely available is often easier than getting a test done that is not available everywhere, says Walia.

ICMR has recognised hospital-acquired infections as one of the primary reasons for mortality among patients who are resistant to antibiotics. Also, doctors don’t de-escalate dosage with hospitalised patients for they’re vulnerable to bacteria present in the environment. After seeing the results of diagnostics, they are supposed to de-escalate the therapy, but doctors often don’t to avoid the risk of patients deteriorating, says Walia.

Walia says that hospitals often see infection control as a resource-intensive exercise, involving cleaning AC shafts to prevent bacteria or fungal survival. Pills are cheaper, she says. “Overall, people see eating and prescribing medicines as easy but washing hands as difficult. This is precipitating AMR,” she adds.

Apart from hospital-acquired bacterial infections, Neonatal Sepsis and Tuberculosis are the leading causes of mortality from antibiotics resistance, she says. ICMR has framed guidelines on hospital-acquired infections, but these are not mandatory as government hospitals are overburdened and cash-strapped, while private hospitals are outside regulatory purview. 

And the government does not want to regulate pharmacists.

An antibiotic a day

Every time there has been a discussion to regulate the 800,000 pharmacies in India from selling antibiotics over the counter and making them prescription-only, the central government stops in its tracks. Because doctors who can prescribe drugs are not available in remote parts of the country but pharmacists are.

“The government worries that antibiotics can save lives where a doctor is not there to write prescription,” said a senior bureaucrat with a body associated with the ministry of health. He requested anonymity as he did not want to criticise the government policy on what he sees as a sensitive issue. “Pharma companies have reached every village, but the government has not been able to ensure that the doctor reaches every village,” he said. 

In 2013, under the Drugs and Cosmetics Act, the health ministry had put certain 3rd and 4th generation antibiotics in a Schedule H1—they can be sold under certain conditions. While drugs under the Schedule H and Schedule X can only be retailed to a buyer with a prescription from a registered medical practitioner, the drugs under the Schedule H1, when sold, need to be recorded in a separate register (with the name and address of the prescriber, the name of the patient, the name of the drug and the quantity supplied, and such records shall be maintained for three years and be open to inspection). But this is not effectively implemented. 

The bureaucrat acknowledged the central government’s failure in regulating pharmacies and building healthcare infrastructure at the primary and secondary level. When Singh had surveyed Kerala, he had found that 76% pharmacists admitted to selling antibiotics over the counter even when they were prescription drugs. 

Shukla, in MP, intends to enforce the law at the state level. “We are making software to ensure every H1 antibiotic will be uploaded in the software. We can see who were the prescribing doctors, patient and the pharmacist,” says Shukla. Last year, he had found that most of the antibiotics were prescribed in excess for diarrhoea and pneumonia, both of which may not need antibiotics at all. 

The problem, however, doesn’t end at the lack of regulation in sale. The governments (both centre and states) are also unable to ensure the sale of newer antibiotics at government centres for those suffering from drug-resistant tuberculosis (DR-TB). A form of drug-resistant disease that leads to mortality.

Missing drugs

According to a government’s survey conducted between 2014 and 2016, 2.84% of about 2.79 million TB patients added annually have multi-drug resistant TB. The highest in the world.

And yet, it’s all too common for government-funded TB centres to run out of life-saving DR-TB drugs. This was the topic of discussion at the Delhi meet on 1 July, where representatives of patient groups, DR-TB survivors and public health activists came together to “assess the extent of the shortages and find out why they were happening,” says Blessina Kumar, CEO of the Global Coalition of TB Activists. 

An activist from Jharkhand, who did not want to be named, reported a stock-out of levofloxacin, cycloserine, ethionamide and pyrazinamide in his state for over three months now. A DR-TB survivor, who lost her hearing during the treatment, reported a stock-out of pyridoxine, a supplement used for DR-TB treatment, in Maharashtra government centers.

Bio and antibiotics

In 2016, researchers at IIT, Hyderabad reported high levels of antibiotics (fluoroquinolone) residues in water and sediment samples of the Musi river. Another study, published in Infection, shows that water samples from the direct environment of bulk drug manufacturing facilities were contaminated with antimicrobial pharmaceuticals and resistance genes.

“Community representatives have been reporting shortages and stock-outs of TB and DR-TB drugs for months,” says Leena Menghaney, an HIV and TB treatment activist. She also manages the access campaign at nobel laureate not-for-profit Médecins Sans Frontières (MSF). “It could be for a variety of reasons, like delay in finalising tenders, supply chain inefficiency, or just red tapism,” she explains. When one of the activists wrote to the government TB department in Delhi, they said that the drugs were available in the central government warehouses and blamed the states for not ensuring access in district centers. Menghaney says the solution lies in supply chain reforms recommended by the World Health Organisation. Reforms, she says, can bring transparency, show which warehouse holds which medicine and ensure access. However, without transparency, the central government can blame state governments, states can blame the district TB officers, and no one knows the reason for the shortage of a crucial antibiotic at the government centre. An opaque supply chain for drugs where stock-outs are common can lead to even more drug resistance, she adds.

With every dose missed in the treatment regimen of a patient suffering due to drug-resistance, the chances are that the bacteria has become more resistant. Similarly, every misuse of last-resort drugs by patients who never needed them ruins their chances of getting better should they ever need a newer drug.

The result is fear. Fear that patients, doctors and bureaucrats feel for the future of AMR in India. 

MSF has recommended that linezolid—a higher-end antibiotic categorised as reserve by the WHO but sold over the counter in India—be withdrawn from the private market to prevent AMR. Meanwhile. the Delhi based not-for-profit Center for Science and Environment  is lobbying to ban colistin in chicken feed. 

States can do their part, but the clock is ticking. If the national government does not wake up to the dangers of AMR, soon there won’t be any drugs left that Indians wouldn’t be resistant to.