Vagh, Anutai. ‘How to run a Balwadi: Sample of a do-it-yourself guidebook’. United Nations Children’s Fund, 1979, https://unesdoc.unesco.org/ark:/48223/pf0000036914 (accessed 16 November 2021).
Health and Medical Research The most notable success of post-Independence India, after self-sufficiency in food, is the improvement in the health of its citizens. The average life expectancy of an Indian was just thirty-two years in 1947. Communicable diseases were rampant and the general mortality rate was extremely high at 27 per 1,000. The highest number of smallpox cases were reported from India, epidemics of cholera and plague were frequent and the country did not have the resources and capacity for universal immunization of children. India has come a long way since then, though challenges of maternal and child mortality as well as malnutrition persist in some states. The life expectancy at birth has risen to 68.8 years which is more than double the number in 1947. Several communicable diseases like smallpox, polio and yaws have been eliminated. The general improvement in the health of Indians is a combined result of several innovative ideas, policies, technologies as well as community initiatives in the past seventy five years. Two innovations – a new patent law to allow Indian companies to make generic versions of available drugs; and the development of research and industrial capacity to make affordable vaccines – have had a seminal impact not just in India but in poor countries across Asia and Africa. Ideas like oral rehydration therapy, universal iodization of salt and Pulse Polio have helped save millions of lives. Innovations in healthcare delivery and access have made modern treatment available to common Indians. Examples of this include the Aravind model of blindness prevention and affordable heart surgeries (‘high volume, low cost and high quality’ model) pioneered by private hospitals. Innovative ideas in the public and private sectors that saw the beginning of Mohalla Clinics or the Kerala model of palliative care continue to unfold and improve the lives of people. During 2020–21, the coronavirus pandemic overwhelmed the health system with millions of Indians affected. New technologies and innovative practices helped address this challenge to a great extent.
16. National Family Planning Programme India’s population in 2020 was estimated to be 1.38 billion, which was equivalent to over 17 per cent of the world’s total population. The number in the early years of India’s Independence was 360 million, according to the 1951 census. The population rise can be seen as ironic because India was the first country in the world to have launched a state-sponsored family planning programme and an organized family planning communication campaign. India pioneered the international family planning movement as well as innovations in the marketing of new birth control technologies like condoms. Population control was debated vigorously in the decades preceding Independence but the opinion was divided on how to proceed with it. In 1943, the Health Survey and Development Committee chaired by Sir Joseph William Bhore suggested a national family planning programme to improve the population’s health status. Based on these recommendations, the government in 1947 formulated the first National Programme of Family Planning. The plan was ready but its implementation was tardy because of the heavy influence of the Gandhian idea of natural birth control and opposition to artificial means of contraception. Top policymakers like Health Minister Rajkumari Amrit Kaur – who was a disciple of Gandhi – were against propagating artificial birth control techniques. Like Kaur, Delhi’s health minister, Dr Sushila Nayyar (who later succeeded Kaur), had been Gandhi’s physician and was a believer in his thoughts on family planning. So, the idea of natural methods was incorporated, along with artificial ones, in the first Five Year Plan (1951–56) and funds were allocated for research into both categories. Kaur requested the WHO to advise on promoting the rhythm method among Indian women. Accordingly, international experts helped design a necklace consisting of twenty-eight beads of three different colours intended to allow women to keep track of their menstrual cycles. The ‘device’ was duly promoted as part of the first family planning programme, but it had few takers. The plan’s fundamental approach to family planning was clinicbased. Family planning clinics were established to offer couples available contraception methods like condoms, diaphragms and vaginal foaming tablets. The idea was an extension of similar clinics being run in metro cities by private practitioners. Family planning clinics continued during the Second Plan (1956–61) as well and their number rose to 4,000 by the end of the plan. The results of the 1961 census, however, showed that the approach was not yielding results. The planners soon realized it was futile to open clinics and expect people to come and avail of birth control methods. Social scientists also felt that the mere availability of methods would not lead to their adoption. Reproduction, they argued, was not just a biological phenomenon but also a behavioural one. Social and communication scientists, based on results of pilot studies, proposed that the programme should target males as it was men who were the key decision-makers in tradition-bound Indian families. All this evidence and thinking resulted in a dramatic shift in strategy in the third Five Year Plan (1961–66), from family planning clinics to public health outreach and extension, and birth control methods like vasectomies and condoms. It was decided to deploy trained family planning workers to popularize family planning services through education and communication in the community.
The plan, for the first time, fixed targets for intrauterine device (IUD) insertion, sterilizations and condom distribution. Incentives in the form of household items for the adoption of specific birth control methods, particularly vasectomy (nasbandi) were introduced. An elaborate communication and social marketing plan was worked out based on social science research. All these were novel ideas implemented for the first time anywhere in the world. It was a bold experiment as there was no previous experience of this kind from anywhere else in the world. Despite setbacks and delays, it was estimated that some 20 million births were averted between 1956 and 1975. Nirodh Among the contraception methods available in private and government-run family planning clinics in the 1950s were foaming vaginal contraceptive tablets, diaphragms and condoms. At that time, India did not have a manufacturing facility for condoms, which had to be imported from America, Japan and Korea. In 1962, the first shipment of 400 million condoms arrived to be marketed under an Indian brand name – ‘Nirodh’ (meaning restraint or control). Peter King, a consultant with the Ford Foundation and a visiting professor at the Indian Institute of Management (IIM) at Calcutta, suggested that these imported condoms could be marketed all over the country through distribution and marketing networks of private companies. Six consumer companies were selected – Lipton Tea, Brooke Bond, Hindustan Lever, Indian Tobacco Company, Tata Oil and Union Carbide (which sold pesticides). The condoms were sold at a nominal price of 15 paise for a pack of three. This gave birth to the idea of social marketing of contraceptives, which later spread to many developing countries. In 1969, indigenous manufacturing of Nirodh began at a public sector unit, Hindustan Latex, established in the rubbergrowing state of Kerala. Along with marketing and distribution of condoms through unusual channels came an equally innovative mass communication campaign. To sell the idea of a birth control method like a condom, it was proposed that people had to be convinced about the idea of a small family and why it was so important. All messages, slogans and branding were built around this. Slogans of ‘Hum do, Hamare do’ (We are two, we will bear two) and ‘Chota Pariwar, Sukhi Pariwar’ (A small family is a happy family) were designed to convey the idea of a small family and its benefits. The messages were disseminated through mass media and traditional media such as puppet shows, folk songs and theatre. The inverted red triangle (Lal Tikon), along with four smiling faces of mother, father, son and daughter was adopted as the logo for the family planning programme. Subsequently, the inverted triangle became a symbol of family planning programmes in many countries. Key Players Among the people who played a critical role in the dramatic shift from family planning clinics to a population- based outreach approach for family planning were officials from the Ministry of Health and experts from the Ford and Rockefeller Foundations. Lieutenant Colonel B.L. Raina, a former medical officer in the Indian army, was the first director of the family planning programme in the Ministry of Health. He had a deep interest in the subject and had established a family planning centre named Matra Sewa Sangh in Ujjain in 1937. Raina had also written a book titled Family Planning: Why, When and How in 1939. As an official in the ministry and later as director of the Family Planning Institute, he got an opportunity to promote scientific methods of family planning. He actively collaborated with Dr Moye Freymann, a public health expert and social scientist working
at Ford Foundation in Delhi and together, they conducted pilot studies to test new ideas. They found the outreach was an effective approach and that men held the key to the success of family planning in India. Studies in Uttar Pradesh showed men’s attitude towards condoms, which formed the basis of the social marketing campaigns to disseminate the use of Nirodh as an effective way to plan a family. Dhanvanthi Rama Rau, a social activist and a leading member of All India Women’s Conference, organized the first All India Conference on Family Planning in 1951 which recommended inclusion of family planning in the first Five Year Plan. Another key player was Dharmendra Kumar Tyagi, assistant commissioner of family planning, who developed extensive communication and behaviour change programmes, along with Frank Wilder, another Ford Foundation consultant in Delhi. The two are widely credited with the innovation of Lal Tikon and the branding of their programme around it, the first instance of branding a government policy or programme. The task of communication was challenging given the very low literacy levels and complete lack of awareness about modern contraceptive methods. Tyagi died young, at forty-one, and in accordance with his wish, flyers of Lal Tikon were distributed to people attending his funeral procession. 17. ASHA In the early years of the new millennium, it became clear that India was facing a double burden in the sphere of health. On the one hand, basic indicators like child and maternal mortality rates had shown some improvements, but were still a cause of concern along with the burden of communicable diseases. On the other hand, the rise of non-communicable diseases like cancers, diabetes and cardiovascular ailments was posing a major challenge. The government in 2004, increased the health budget threefold and in 2005, launched a new initiative called the National Rural Health Mission (NRHM) to revive the primary healthcare system in rural areas. One of its prime objectives was to promote institutional deliveries as well as arrest the rate of maternal and infant mortality. NRHM brought in a change in approach – from a state-led to a community-oriented approach. Among several institutional innovations introduced as part of NRHM was the concept of a multipurpose community health worker dubbed as ASHA (accredited social health activist). ASHA, very soon, became the face of NRHM and the fulcrum to deliver a host of services in rural areas. In 2019, the total strength of this all-women rural healthcare force was one million. It is the largest such programme in the world. The concept of health workers was not new in the Indian health system. For decades, health programmes and delivery depended on cadres such as the Auxiliary Nurse Midwives (ANMs), Male Health Workers, Lady Health Visitors and Male Health Assistants, in addition to trained doctors and nurses. Yet health services could not fully reach people. What made ASHA unique was that she, being a member of the village community, was supposed to provide the crucial link between people and the primary healthcare services. The inspiration for this kind of a community worker came from experiences in the voluntary sector in different parts of the country, and elsewhere, that trained and supported community health workers can make a difference to health outcomes. The role of ASHA was defined as that of a health activist in the community who will ‘create awareness on health and its social determinants and mobilize the community towards local health planning and increased utilization and accountability of the existing health services’. She would also provide a minimum package of curative care as appropriate and feasible and make timely referrals. Women with a minimum education up to the eighth standard were selected and trained on basic health topics. In 2015, NRHM was subsumed in the National Health Mission and ASHAs were extended to marginalized urban areas. ASHAs are not salaried government employees but get incentives based on their performance.
Despite problems in implementation such as low incentives, delays in payments and inadequate training, ASHAs remain at the forefront of health services in rural areas. Following the introduction of ASHAs in the health system, several studies have shown that the number of institutional deliveries in many states has risen substantially and neonatal mortality rates have declined. Key People The rejuvenation of the primary health system was on the agenda of the National Advisory Council (NAC) which was formed in 2004 to oversee the implementation of the National Common Minimum Programme of the UPA government. The council had a sizeable representation of civil society. Public health experts and activists played a central role in shaping NRHM and the role of ASHA. They built upon the collective experience of community health experiments such as the Gadchiroli model of home-based neonatal care (developed by Drs Abhay and Rani Bang), the Parinche project (of the Foundation for Research in Community Health or FRCH) and the Jamkhed model of community health devised by Dr Rajnikant Arole and Dr Mabelle Arole. Another scheme that guided the formulation of the ASHA programme was Mitanin, launched in 2002 by the state government of Chhattisgarh, in partnership with civil society. During the formulation of NRHM, Dr Noshir Hormasji Antia, founder of the FRCH, galvanized health activists and presented his ideas to Prime Minister Dr Manmohan Singh as well as to the NAC. This resulted in giving a shape to the role of an ASHA. S. Gopalakrishnan, an official in the Prime Minister’s Office (PMO), who had earlier implemented a community worker scheme named Jan Swasthya Rakshak in Madhya Pradesh, was also involved in the process. 18. Generic Drugs In 2017, an intriguing news story appeared in the Indian and international media. It was about an Australian citizen, Greg Jefferys, who had formed an online group for people suffering from Hepatitis C so that they could buy medicines for the treatment of their liver infection. The reason: the medicines to treat Hepatitis C – Sofosbuvir and Daclatasvir – were available in India for a fraction of the price compared to the advanced countries. In America, the cost of a full course was 84,000 dollars and it was 53,000 dollars per patient in the UK. In comparison, it was just 483 dollars in India. Jefferys himself had got cured of Hepatitis C with Indian medicines, so he wanted to spread the word through his ‘buyers’ club’. This was not just about Hepatitis C medicines, but also the fact that India makes affordable drugs for a range of ailments, including HIV. The country is the largest supplier of antiretrovirals (ARVs) for the treatment of HIV to countries in Africa and elsewhere. Medicines for everything – from coughs and colds to cancers – are among the cheapest in India, which is why India is often called the ‘pharmacy of the world’. The Indian pharmaceutical industry is the third largest producer of medicines by volume in the world, accounting for one-tenth of the global production. The situation at the time of India’s Independence was exactly the opposite. India depended on imports for all important medicines, as a handful of Indian companies produced only tonics, vitamins, cough syrups and similar remedies. Until the 1960s, the Indian market was dominated by transnational drug companies that sold patented formulations in the country. As a result, drug prices in India were among the highest in the world. Aware of the situation, the government embarked on a path of self-reliance in this sector, as it did in many other fields. Public sector units were established to manufacture bulk drugs and antibiotics, such as Hindustan Antibiotics Limited (HAL), which came up in Pune in 1954, followed by Indian Drugs and Pharmaceutical Limited (IDPL) that was set up to manufacture bulk drugs at Hyderabad in 1961. Research laboratories like the Central Drug Research
Institute in Lucknow, the National Chemicals Laboratories in Pune and the Regional Research Laboratory in Hyderabad (later named the Indian Institute of Chemical Technology [IICT]) were also established in the 1950s. All these efforts helped develop technical know-how and also gave birth to a few entrepreneurial firms. Still, the market in 1970 was dominated by multinational drug companies which imported even essential drugs such as penicillin and insulin and did not have any substantial manufacturing facilities locally. This was because these companies enjoyed patent protection for their drug brands under the archaic Patents and Design Act of 1911. The law encouraged foreign inventors and foreign research and development (R&D). The process to revisit this patent law had been initiated in 1948 with the Patents Enquiry Committee, followed by another committee headed by Justice N. Rajagopala Ayyangar, which submitted its report in 1959. Based on the recommendations of this panel, it was decided to repeal the 1911 law. A new Patents Bill was first introduced in 1965, and was amended based on recommendations of a Joint Parliamentary Committee – it was finally passed in 1970. The new patent regime sought to balance the rights of a patentee and the welfare of the Indian people. It exempted ‘pharmaceutical, food and agricultural chemical products’ from product patent compliance and protected only process patents in these fields. The duration of the process patent was also restricted to five to seven years. This meant that a drug patented by a company elsewhere could be manufactured by another company using a different process. It became legal for Indian companies to manufacture brand-name drugs protected in other countries and market them in India as well as overseas. The pharmaceutical scene in India changed completely in the 1970s, with multinational companies exiting and Indian firms getting into manufacturing, which brought down the prices. This new patent law gave rise to what came to be known as ‘reverse engineering’ of drugs and the manufacture of generic drugs, transforming India from an importer of medicines to a leading exporter and a global hub of pharmaceutical manufacturing over the next three decades. The situation remained so until 2005 when India had to change its patent law again – this time to fulfil its obligations under the global international property rights (IPR) regime. But the capabilities developed during the three decades since the 1970s helped Indian companies to remain competitive. Though ‘reverse engineering’ sounds akin to copying an already existing product, it is not so. It is a complex process involving chemical synthesis and development to ensure that generic copies have the same chemical composition and show the same effects and side effects as the original one. The expertise for this process came from government research laboratories and public sector drug manufacturers. Academic institutions such as the University Department of Chemical Technology, Mumbai (now the Institute of Chemical Technology) played a key role in contributing to developing expert manpower necessary for reverse engineering. Indian companies, which started with reverse engineering in the 1970s, have gradually climbed up the value chain and are engaged in basic research and drug discovery as well. The CSIR laboratories developed processes for a range of drugs – among them, ciprofloxacin, diclofenac, salbutamol, omeprazole, azithromycin – and transferred the technology to private companies. Key Players If it was the Patents Act of 1970 that transformed the Indian pharmaceutical industry in the 1970s and ’80s, it was Dr Yusuf Hamied who used Indian generics to shake the healthcare industry globally. His dramatic
announcement at an international health conference in Brussels on 28 September 2000, that his company could supply a cocktail of AIDS drugs for 800 dollars a year caused tremors among pharma giants and brought cheer in Africa which was then facing an AIDS epidemic. This was a fraction of the 14,000 dollars Western companies were charging then. Subsequently, he brought the price further down to 1 dollar a day or 365 dollars for the yearly treatment for one person. This was a seminal moment and Hamied has been described as a ‘game- changer in the global fight against AIDS’. As chairman of Cipla (earlier known as the Chemical, Industrial and Pharmaceuticals Laboratories, which was founded by his father, Khwaja Abdul Hamied, in 1935), he has championed the cause of the Indian drug industry and generics for more than half a century. In the 1960s, he fought legal battles with multinationals, organized Indian manufacturers and lobbied vigorously for new patent law. Collaborating with industry pioneers like Hamied were scientists in government research labs, particularly after the new patent law came into force. One such was Dr Alla Venkata Rama Rao, then a young scientist at the National Chemical Laboratory (NCL) and later to be director of the IICT. The first drug which Rao reverse- engineered in the early 1970s was diazepam, an antianxiety drug manufactured by Roche. He could develop a simple and alternative route to make this drug and the technology was sold by NCL within months of its development. Dr M.F. Rahman at RRL Hyderabad also developed a process to make diazepam which was sold to Ranbaxy. Subsequently, Rao developed an anti-cancer drug from a plant source, which was earlier exploited by Eli Lily. Rao had a blockbuster generic in 1986 when he developed a cheaper process to synthesize Azidothymidine, the first drug that halted the progression of HIV. It was marketed by Cipla in 1993, eventually making it a global supplier of anti-HIV drugs. Professor M.M. Sharma (Institute of Chemical Technology, formerly UDCT), Dr K. Anji Reddy (Dr. Reddy’s Lab), Dr Deshbandhu Gupta (Lupin) are among several people who contributed to making India a leading drug manufacturer. Despite problems associated with a multiplicity of drug brands, irrational formulations, affordability and the post-2005 patent regime, the success story in pharmaceuticals continues. 19. Affordable Vaccines Vaccines are considered the most cost-effective means of preventing a range of diseases. Nearly 60 per cent of children born all over the world get immunized with one or more life-saving vaccines manufactured in India. Some of these vaccines cost less than what a cup of tea costs in India. The footprint of Indiamade vaccines spans over 160 countries, with global agencies like WHO and UNICEF procuring vaccines from India. During the coronavirus pandemic, Indian companies produced millions of doses of COVID-19 vaccines developed by them as well as those licensed by foreign companies. India’s health indicators at the time of the Independence were poor – the highest number of smallpox cases were reported from India, epidemics of cholera and plague were frequent and the country did not have the resources and capacity for universal immunization of children. Vaccine production units existed for diphtheria, tetanus and polio but they were not adequate to meet the demand. The infrastructure and trained manpower needed for immunization campaigns were yet to be developed. The first mass campaign for the BCG vaccination could be launched nationwide only in 1956. Till 1985, the measles vaccine was being imported. It was only in 1991 that India became self-sufficient in vaccine production and subsequently began emerging as a player in the export
markets. In 2020, India was not only self-sufficient in vaccines for domestic use but is a global supplier of affordable vaccines. The transformation is a combined result of investments in R&D, manufacturing facilities, manpower training and enabling government policies. On top of all this is the innovative streak of Indian vaccine manufacturers – the technique of reverse engineering similar to the one practised by drug manufacturers. Indian companies targeted traditional vaccines which were already proven but whose patents were expiring and began manufacturing them at lower costs. Indian companies could achieve economy of scale, given the large domestic market with vaccines for the Universal Immunization Programme (UIP) of the government. It caters to the needs of vaccination for over 26 million new-born children and 30 million pregnant women every year. Over the years, Indian firms have demonstrated how quality vaccines can be manufactured at low prices due to the availability of low-cost highly skilled manpower, multiple starting materials, small animals needed for quality testing, and efficient engineering production system for sterility. The development cost is lower as highly skilled people, such as microbiologists, chemists, chemical and biochemical engineers, are abundantly available. Much of this is a result of investments made by government agencies such as the Department of Biotechnology and the ICMR. The companies also operate at lower margins to serve the domestic market at affordable prices. In addition, Indian companies have acquired the technical capacity for services necessary for good manufacturing without any contamination. In addition to keeping the costs low, Indian vaccine makers have been trying out new ways to improvise the vaccines, such as tweaking the formulations so that the vaccines could withstand hostile climates without losing efficacy or working around an injectable vaccine to produce an oral version. As a result, nine Indian companies have been certified by WHO for the supply of quality vaccines that can be purchased by international agencies. India thus is on the top of the list with a maximum number of such vaccine suppliers. Together, Indian companies supply vaccines worth one billion dollars a year to the world. The list of vaccines includes traditional ones, such as the DPT vaccine for protection from diphtheria, pertussis (whooping cough) and tetanus or TT for tetanus, measles, mumps, rubella (MMR), Hib (to protect against Haemophilus influenzae type B disease), typhoid and rabies vaccines; as well as several modern vaccines like Hep-B, rotavirus, cholera and varicella vaccines. Ironically, while Indian companies produce affordable vaccines for the world, India has one of the highest rates of childhood mortality due to diseases that are preventable with vaccines. Though the situation has been improving, it is a matter of concern. Vaccine hesitancy and anti-vaccine sentiments have also been reported from some parts of the country. Key Players Vaccines are lifesaving but many of us may not know that animals play a big role in the manufacture of some of these vaccines. For instance, horses are used as antitoxin factories as they produce antibodies for various toxins which then go into the making of vaccines. It was this fact that lies behind the founding of the Serum Institute of India Private Limited – a Pune-based company that is the world’s largest vaccine manufacturer. The family of Dr Cyrus Poonawalla was into horse breeding and racing. During a casual chat with a veterinarian at his stud farm in Pune in the 1960s, Poonawalla came to know that discarded horses from the farm were donated to the
Haffkine Institute in Mumbai, which used horse serum to make vaccines. He then thought he could do the same and manufacture vaccines. That’s how he founded the Serum Institute. The Mumbai institute, incidentally, is the oldest vaccine facility in India which was founded by Waldemar Mordecai Haffkine, a Russian scientist and a student of Louis Pasteur, who had developed cholera and plague vaccines. Poonawalla founded the Serum Institute in 1966 to manufacture immuno-biologicals which were being imported at high prices. He then diversified into tetanus anti-toxin and anti-snake venom serum, and DPT as well as MMR (Measles, Mumps and Rubella) groups of vaccines. In 2020, the Serum Institute was producing 1.5 billion doses of vaccines and has a stockpile of several million doses of lifesaving vaccines to deal with outbreaks. In the 1990s, biotech entrepreneurs entered the field to make modern vaccines based on recombinant DNA technology. K.I. Varaparasad Reddy, an electrical engineer, founded Shantha Biotech in 1993 to make an affordable Hepatitis B vaccine. He sold the vaccine at one-tenth of the international prices, challenging multinational companies. Another Hepatitis B manufacture that came up in Hyderabad around the same time was Bharat Biotech – founded by Dr Krishna M. Ella in 1996. It has also developed rotavirus, typhoid, H1N1 and other vaccines indigenously. It shows that Indian firms are good not just in reverse engineering but in developing new vaccines through innovation. 20. Pulse Polio One of the several medical phrases that entered the popular lexicon during the coronavirus pandemic was ‘herd immunity’. It refers to a situation in which most members of a community acquire immunity against a virus through immunization. It helps break the chain of virus transmission and also protects unvaccinated people who may be present in small numbers. The concept of herd immunity helped India eradicate polio – which is one of the most remarkable public health successes not only in India but globally. Herd immunity was achieved through ‘pulse polio’ – a technique of simultaneous and synchronized vaccination of all children in a given geographical region. Pulse Polio was innovated and tested in India before it became the strategy for polio eradication globally. Poliomyelitis, which causes infantile paralysis, was one of the biggest public health problems with outbreaks and epidemics occurring in many countries in the twentieth century. Despite the availability of polio vaccines in the middle of the century, cases continued to occur due to easy transmission of the virus through faeces and pharyngeal secretions. Improving vaccine efficiency by increasing the dose from three to five also did not help in the eradication of polio. Achieving herd immunity to break the transmission chain was the only way out. The proof of this came from Vellore in Tamil Nadu which is known for a pioneering medical school, Christian Medical College (CMC) established in 1900. In the late 1970s, researchers from CMC, working with the local branch of Rotary Club, launched a measles immunization campaign in Tamil Nadu. Encouraged by the success of this campaign, they decided to work together for polio immunization between 1981 to 1983 in Vellore. The idea was to see if the chain of virus transmission could be broken by immunizing all the infants simultaneously. The town was divided into sixteen zones and three doses of oral polio vaccine were administered at monthly intervals. An awareness campaign was launched to inform and convince people about the special immunization campaign, through slides in cinema theatres, newspapers and handbills. The goal was to vaccinate all children below the age of four in one go. The
results of this campaign were dramatic – the number of clinically confirmed cases of acute paralytic poliomyelitis dropped from forty-three in 1981 and to zero in 1982. Clem Renouf, a former president of Rotary International, who was in Vellore when the campaign was underway, got impressed with the outcome. He requested Rotary International to take up targeting polio eradication. As vaccines were already available, pulse immunization provided an innovative way to deliver them to achieve the desired results. Convinced by the results from Vellore, the Rotary International formed the ‘Polio 2005 Committee’, setting 2005 – the centenary year of Rotary – as the target year for global eradication. Caught unawares by the Rotary move, WHO moved a resolution in 1988 in the World Health Assembly to eradicate polio globally by 2000. At that time, wild poliovirus was endemic in 125 countries, paralysing more than 1,000 children every day. In India alone, 200,000 polio cases were occurring annually. To achieve the eradication of polio, WHO formed a unique public–private partnership, the Global Polio Eradication Initiative (GPEI). It involved national governments, Rotary International, US Centers for Disease Control and Prevention (CDC) and UNICEF. The partnership adopted Pulse Polio as a key element of the global eradication strategy. By 2011, wild poliovirus was finally banished from India. The global incidence of polio has dropped by 99 per cent and wild poliovirus circulation is restricted to only two counties. Key People The eradication of polio in India is a great public health success, given the humungous nature of the challenge it posed. Pulse polio – simultaneous immunization of children below five on a designated day – meant vaccinating millions of children on a single day. At one point, mass polio vaccinations in India targeted 165 million children. In February 2003, over 1.3 million vaccination teams of volunteers and health workers equipped with nearly 200 million doses of vaccine went from house to house and specially erected polio booths in communities to reach every child under five. Novel communication strategies were devised to mobilize communities for vaccination and to counter vaccine refusal. Scores of film and sports celebrities were chosen for awareness campaigns – the most popular being ‘Do boond zindagi ki’ featuring Amitabh Bachchan. Efforts were made to reach out to the unreached through mopping operations and a robust disease surveillance system was put in place. All this involved many national and international agencies, millions of dedicated frontline health workers and community leaders. Early studies by Dr T. Jacob John, a virologist at CMC, Vellore, pointed to not only the efficacy of pulse immunization campaigns but also problems such as the low efficiency of the widely used oral polio vaccine (OPV) as opposed to the inactivated polio vaccine (IPV). He was among the first to notice polio caused by the vaccine virus and advocated that eradication should mean the end of both wild and vaccine viruses. As a founder member of the PolioPlus committee of Rotary International, he helped shape the global strategies for the elimination of polio. 21. Aravind Eyecare Model
The town of Madurai in Tamil Nadu is better known for the grand Meenakshi temple that has always attracted devotees and tourists from all over the country. Not far from the famed temple stands the Aravind Eye Hospital, home to the world’s most affordable eyecare and blindness prevention hospital chain. The cataract is the most common cause of preventable blindness that can be rectified by simple surgery, but many of those who need it can’t afford the surgery. To help people who face this kind of problem, Aravind has developed a low-cost model of high-quality eyecare and cataract surgery that has benefited millions of people in India and across the world in the past four decades. Aravind started as a free eye clinic for the poor in 1976. Now it is the largest provider of eye surgeries in the world with a chain of thirteen eye hospitals. The Aravind eyecare system benefits some 2.5 million patients and performs 478,000 eye surgeries and procedures a year. For people who can’t afford it, surgery and treatment are free – both paying and free patients get the same quality of care. The revenue earned from paying patients is used to subsidize patients who can’t pay, and this is sufficient because of the high numbers of paying patients. All this makes the Aravind hospitals financially self-sustainable. Aravind does not accept any donations or government grants. This makes it a unique model of ‘high volume, high quality and affordable cost’. For people with no means to travel to Madurai or centres located in other cities, Aravind holds camps for screening patients in villages. People who need treatment or surgery are identified in such camps and transported by bus to the nearest Aravind facility for surgery. After a free stay and post-operative care, people are escorted back to their respective villages. During 2017–18, over 2,500 screening eye camps were organized in which the eyes of half a million people were screened. Strangely, it was the fast-food chain, McDonald, that inspired Aravind’s founder, Dr Govindappa Venkataswamy. He believed that just like the burger company uses the power of ‘standardization, product recognition, accessibility and scale’ to provide affordable fast food to consumers, Aravind could provide affordable cataract surgeries. Dr Venkataswamy deployed assembly-line techniques and hospital systems that facilitated Aravind surgeons to be five times more productive than others. Patients are readied for surgery in batches by qualified ophthalmic assistants who do all the preparatory work, including administration of anaesthesia. After surgery, supplies are quickly replenished as the next patient is brought in and the treated one is moved out. Each operating theatre has multiple operating tables to optimize the number of supporting staff. Each table has multiple sets of instruments and support staff to ensure that the waiting time between surgeries is zero. A surgeon at Aravind performs 2,000 cataract surgeries a year compared to an all-India average of 400, some surgeons at Aravind performing up to 100 operations in a day. In the US, the figure is 200 to 300 surgeries a year. Another innovation is that young women from surrounding villages are recruited and trained in paramedical services and care, forming the backbone of the system. Over the years, Aravind has identified factors that boost surgical productivity – it has standardized the necessary procedures and taken bold steps to keep the costs low. For instance, when the import of intraocular lens implants became too expensive, it decided to take up local manufacturing in 1992. Its internationally certified plant started making the lens implant, bringing down global prices from 150 dollars to 10 dollars. The facility exports 200 million lenses a year to about 120 countries. It also manufactures eye drugs, equipment and other products needed for eye care and surgeries. This benefited patients not just in India but in many developing countries. Aravind freely shares the know-how of its low-cost model with others through structured training programmes and consultancy services. Hundreds of hospitals in India and other continents have adapted elements of the Aravind model to drastically boost their productivity.
Key People The man behind the Aravind model is Dr Govindappa Venkataswamy (1918–2006), who along with members of his extended family started the eyecare clinic in 1976 as a postretirement occupation. After his medical education at the Stanley Medical College in Chennai, he joined the Indian Medical Army Corps but was discharged after contracting a rare form of rheumatoid arthritis that left his fingers permanently crippled. He returned to medical school and obtained a postgraduate degree in ophthalmology and subsequently joined government service. Despite gnarled fingers, he learned to hold surgical instruments and started performing cataract surgeries. At the peak of his career, he used to perform 100 surgeries in a day and is credited to have done about 100,000 during his entire career. He was greatly encouraged in his career by Sir John Wilson, founder of the Royal Commonwealth Society for the Blind. Together, they took up the cause of blindness prevention in India and were responsible for the government launching the National Programme for Control of Blindness – which was the first such initiative in the world. While in government service, Dr Venkataswamy, greatly inspired by the values of Mahatma Gandhi and Sri Aurobindo, introduced the concept of rural outreach for eyecare through camps and for rehabilitation of the blind in the 1960s. 22. Affordable Heart Surgery In the new millennium, India has become a favoured destination for a range of medical procedures, including heart surgeries. Patients from many countries, developed ones like America and Britain included, come to India for medical treatment. The situation was the opposite in the 1960s and 1970s, when India did not have facilities and expertise for conducting heart surgeries. Essential equipment like heart–lung machines was available in just a handful of Indian hospitals. In the beginning, surgical expertise was available only in a couple of hospitals in Bombay and Vellore where patients from the rest of the country were treated. Patients who could afford it would head to America for treatment. In the 1960s, Texas was a favourite destination for those Indians suffering from heart disease who could afford the costs. Dr Michael DeBakey and Dr Denton Cooley (founder of the Texas Heart Institute) performed heart surgeries on several hundred Indians. In the early years, Indian surgeons learned new skills through contact with leading surgeons and experts in the West, particularly the US, via direct training abroad, visits of foreign experts to India and other such collaborations. The situation changed in the early 1980s when Americantrained heart surgeons returned to India and started practising in the country. They established new facilities, taking advantage of a new government policy that allowed the setting up of for-profit hospitals. The 1983 National Health Policy for the first time proposed the expansion of healthcare provisions through the private sector. Till then healthcare was provided only through government hospitals, private nursing homes and hospitals owned by charities and trusts. At the time, running a healthcare facility was a non-profit affair. Government-run hospitals were mostly tertiary care centres which were also teaching hospitals for medical colleges. Given the continuous decline in public investment in health, the sixth Five Year Plan (1980–85) had also suggested the utilization of the private sector. In 1986, the hospital sector was recognized as an industry to facilitate the entry of companies – this industry status for hospitals was meant to allow them to raise the necessary capital required to set up large hospitals from public institutions as well as international funding agencies. Import duties on high technology medical equipment were also lowered. All this helped bring in new technology, expertise and made heart surgeries available in India at affordable costs. Now hardly any Indian travels to Texas for a heart procedure.
The corporate hospital model of ‘high volume, low cost and high quality’ is based on a series of innovative ideas and practices – all such hospitals are led by physician-executives to ensure a patient-centric approach; they have applied management techniques from other sectors such as hospitality and engineering. Other innovations are differential pricing for rooms, efficiency in supply and delivery chains, self-manufacturing of medical supplies as well as devices to bring down costs, use of information and digital technologies, internal R&D to improve processes, real-time monitoring of data, use of telemedicine and teleconferencing to connect with facilities at different locations, and quality assurance, Key People Several doctors who were either working in America or had returned in the 1970s seized the new opportunity that arose due to the change in government policy in 1983. Dr Prathap Chandra Reddy, a doctor born and raised in Chennai, was one such. He had practised medicine in the US, including at the Massachusetts General Hospital in Boston and had returned to India in 1970. He was running a cardiac care centre, equipped with a cardiology lab and clinic, in Chennai but was forced to send abroad patients with complex problems. Those who could not afford to go abroad – mostly to America – suffered due to lack of adequate treatment in the country. One such patient, who could not make it to Texas for an open-heart surgery, died. This was the incident that inspired Dr Reddy to set up a hospital of comparable quality in India. Thus, was born Apollo Hospitals in Chennai as India’s first for-profit or corporate hospital in 1983. Dr Naresh Kumar Trehan, who went to the US in 1969, was another heart specialist who was inspired to come back and practise in India when Indians travelling to America for treatment used to ask him if they could get the same quality of treatment back home in India. He returned and set up the Escorts Heart Institute and Research Centre in Delhi in 1988, with funding from the Escorts group. This was the first corporate hospital dedicated to heart care. In 2001, Dr Devi Prasad Shetty, who had returned from the UK and then worked with Mother Teresa in Calcutta, founded Narayana Hrudayalaya in 2001. This hospital offers low-cost heart surgery for children. He has driven down the costs through higher productivity of surgeons, bulk purchase of medical supplies, use of telemedicine to connect with rural coronary care units, a selfsupporting insurance scheme and constant clinical advancement of surgeons. 23. Universal Iodization of Salt Iodine is an essential micronutrient needed for the normal functioning of the thyroid gland in humans. It helps in the synthesis of thyroid hormones, which play a determining role in the early growth and development of organs, including the brain. Therefore, iodine deficiency at critical stages during foetal growth and early life affects the development of the brain. It can cause retardation and lower IQ. Conditions resulting from suboptimal iodine intake are collectively known as iodine deficiency disorders (IDD). Lack of iodine in diet causes enlargement of the thyroid gland, a condition known as goitre. India was the first country to recognize iodine deficiency as a public health problem and launch the National Programme for Goitre Control in 1962 to address it. Indian scientists demonstrated that providing minuscule amounts of iodine mixed in salt can help address the problem. Salt was chosen to deliver iodine because it is
universally available and is consumed by everyone. Other options like weekly or biweekly oral or injectable supplements of iodine were not practical and would have been costly. Salt iodization today may sound like a simple strategy but it took decades to be accepted and implemented despite scientific evidence about its efficacy. The goitre control programme was subsequently renamed as the National Iodine Deficiency Disorders Control Programme in 1992. It was only in 1993 that WHO recommended salt iodization as a primary intervention to control IDDs globally. It was considered an effective, affordable and sustainable way to achieve the goal of controlling IDDs in developing countries. At the time of Independence, the problem of goitre was widespread. Earlier studies had pointed to goitre being endemic in the Himalayan region as well as parts of Uttar Pradesh, Bihar and Punjab. The ICMR undertook a survey in 1954 in Kangra district (then in Punjab and now in Himachal Pradesh) and found the goitre prevalence to be 55 per cent. Following this, an experiment was undertaken in the district. The district was divided into three zones. In two zones, salt mixed with iodine in two concentrations (one part of potassium iodide per 50,000 parts of salt and 40,000 parts of salt) was provided to people, while in the third zone, the population was provided with salt without added iodine. Five years later, the prevalence of goitre was dropping rapidly in two zones that got iodized salt while there was no change in the third zone. From 1962 onwards, all three zones got iodized salt supplies and a survey done ten years later showed that goitre prevalence had dipped substantially in the whole district. The evidence from Kangra provided the basis for launching the national goitre control programme. Scaling up the universal iodization of salt to the whole country took several years and faced many hurdles. This happened for many reasons – cultural, economic and political. Salt is an essential ingredient of Indian cooking and diets. In rural areas, it is sold unpackaged and in many places, rock salt is consumed. Salt manufacturing is a small-scale industry in most parts of the country and in this sector, adding iodine to salt was a problem. Gandhian thinkers opposed iodization because it would make salt costly and the business would pass into the hands of large manufacturers. After all, Gandhi had made salt a symbol of freedom. When a ban was imposed on non-iodized salt in 1998, the matter landed in the courts. The central government succumbed to the anti- iodization lobbies and lifted the ban in 2000. However, the ban on the sale of non-iodized salt was reimposed in 2005. Despite the setbacks, the household-level coverage of iodized salt in India had reached 92 per cent in 2018. Of this, 78 per cent is adequately iodized salt. Key People The credit for introducing iodized salt on an experimental basis in 1956 goes to Professor V. Ramalingaswami (1921–2001), who was then working as a pathologist in ICMR’s Nutrition Research Laboratories at Coonoor (it was later shifted to Hyderabad and renamed National Institute of Nutrition). As a possible strategy for the control of endemic goitre, he pointed out in 1953 that ‘of the methods of ensuring intake of adequate quantities of iodine daily, the iodization of salt used for domestic consumption is the most convenient and effective’. Subsequently, he led the study in Kangra with scientists like Dr N. Kochupillai from the All India Institute of Medical Sciences (AIIMS). Professor Ramalingaswami became director of AIIMS and later, director-general of ICMR.
24. The Jaipur Foot Afghanistan, Vietnam, Sudan, Zimbabwe, Somalia, Rwanda, Malawi, Nigeria, Honduras, Lebanon, Senegal, Iraq, Syria, Sri Lanka, Zambia, Sudan, Kenya, Dominican Republic, Liberia, Pakistan, Bangladesh, Papua New Guinea. What’s common among all these countries? They have all been affected by war, civil strife, violence and unrest at some point in the past half a century. And this has left thousands of troops and civilians disabled and maimed. Another uniting factor is an Indian technology – the Jaipur Foot – which is enabling such people to walk again like healthy humans. Wars and internal violence kill soldiers as well as civilians. Many people lose their limbs due to the extensive use of landmines in war and conflict zones. Not all of them can afford prosthetics available in developed countries. But then, in the past six decades, an artificial low-cost limb developed in Jaipur is helping hundreds and thousands of such people to lead a normal life. Rehabilitation of people who lose limbs due to disease, accidents and landmines is a major health problem in many countries. In rural areas, people fall from heights, are involved in traumatic road accidents and are severely injured while using unsafe agricultural equipment. In many such cases, amputation is the only option. In the absence of proper rehabilitation facilities and equipment, the quality of life of such amputees is greatly affected, a problem that was very acute in the 1960s. Imported prosthetics were available, but they were too expensive for ordinary Indians. Moreover, their design was not suited for Indian conditions. An artificial lower limb, based on the most prevalent Solid Ankle Cushion Heel (SACH) design, could not be used in tropical and hot environments. For instance, those fitted with a foot based on this design could not sit on the floor or squat, walk barefoot or work in wet and muddy fields, which meant that those fitted with such artificial legs would discard them fast. Dr Pramod Karan Sethi, a general surgeon-turned-orthopaedic working in the 1950s at the Sawai Man Singh Medical College in Jaipur, wanted to find a solution to this problem. He tried to modify the SACH foot and examined other available foot designs, but ended up developing a completely new design in 1968. The original design of the Jaipur Foot consisted of three main parts – a hindfoot made of micro-cellular rubber; laminated wood for the ankle and forefoot shaped and wrapped by tyre cord rubber; and an outer layer of skin- coloured soft rubber. The foot was vulcanized in aluminium die casting to look human-like, and attached to an aluminium socket. The rubber block at the hindfoot acted as a universal joint and the foot could rotate on the leg, enabling the wearer to walk on uneven surfaces and sit cross-legged. In addition, it did not need a shoe and amputees could walk barefoot. All these features made the Jaipur Foot popular. Over the years, the design and materials used have undergone several changes, making it lighter, more comfortable and affordable. It weighs about half a kilogram and costs just about `2,000. Owing to its simplicity and cost-effectiveness, the technology has spread to dozens of countries in Asia, Africa, Latin America and elsewhere – local centres for its dissemination have been established in many countries. Afghanistan, which had a large number of amputees due to landmines spread in many areas during the Soviet occupation, was among the early adopters of the Jaipur Foot. The technology has spread mainly due to the efforts of a voluntary body, the Bhagwan Mahaveer Viklang Sahayata Samiti (BMVSS) established in 1975 by former bureaucrat, D.R. Mehta. The Samiti provides the Jaipur Foot to the poor at no cost. In the first seven years after its development, the Jaipur Foot was fitted in about fifty amputees, while in 2018, about 65,000 people benefited from it globally. The total number of limbs fitted since 1975 is as many as over half a million.
The story of how the Jaipur Foot can transform the life of an amputee was captured in the biopic of dancer and television star, Sudha Chandran. She played herself in the Telugu movie titled Mayuri in 1984. The film was dubbed in Tamil and Malayalam and remade as Nache Mayuri in Hindi in 1986. Having lost one of her legs in a road accident in 1981 as a teenager, Sudha came to know about the Jaipur Foot through a newspaper article and approached Dr Sethi. He fitted her with an artificial leg and she was able to continue performing Bharatnatyam and rose to become a star. Key People A team of young doctors at the Rehabilitation Research and Regional Limb Fitting Centre of the SMS Medical College in the 1960s is credited for working on the idea of an artificial leg that could be made from locally available materials and was suited for Indian conditions. The effort was led by Dr Pramod Karan Sethi, who worked on the idea and made it a reality in 1966. The early scientific papers on the Jaipur Foot were co- authored by Dr Sethi along with Dr M.P. Udawat, Dr S.C. Kasliwal and R. Chandra. The role of Ramchandra Sharma, a master craftsman, in the design and development journey was pivotal (decades later it became a subject of controversy with Sharma claiming full credit). Over the next few years, Dr Sethi became the face of the group and presented the product to the world. At one of the scientific conferences, it was suggested that he should name the new technology as ‘Sethi Foot’, but he rejected the idea and chose to name it after the city of his work, Jaipur. He also did not patent it but instead wanted the technology to spread freely. That’s how the BMVSS was founded in 1975 by Devendra Raj Mehta, an IAS officer who later became chairman of Securities and Exchange Board of India (SEBI) and deputy governor of the Reserve Bank of India (RBI). Mehta was inspired to establish the charity after he became a victim of a road accident and nearly lost his limb in 1969. He decided to work for the rehabilitation of the poor, and worked to spread the technology in India through twenty- three branches, and globally. He forged technology partnerships with the IITs, ISRO, MIT and Stanford University for constant upgrades in the Jaipur Foot as well as for the development of new prosthetics like the Jaipur Knee. 25. Oral Rehydration Therapy In March 2021, the golden jubilee celebrations of the formation of Bangladesh were launched with great fanfare. The occasion evoked much interest in India as well because of the pivotal role the country played in the liberation of Bangladesh in 1971. The political, military and diplomatic significance of the jubilee for South Asia is unmistakable, but few in the region know that the 1971 war also gave the world a new medical tool, which sometimes is described as the greatest medical discovery of the twentieth century. The reference here is to Oral Rehydration Therapy (ORT) which saves millions of infants globally from the clutches of death every year. Diarrhoea is the fourth leading cause of death in children below five globally. Deaths due to diarrhoea can be averted by treating dehydration through the use of ORT. It involves giving children oral rehydration solution or ORS and administration of zinc tablets, along with improvements in nutrition. This ‘magic bullet’ for the treatment and prevention of diarrhoea has saved millions of lives since it was discovered half a century ago. Today ORS may be ubiquitous but it has a long history of development, in which Indian scientists played a key role. Before ORT was developed, diarrhoeal dehydration was treated with intravenous fluid therapy in hospital settings. The earliest use of oral therapy was reported by Hemendra Nath Chatterjee who used an oral solution
of glucose and sodium chloride to treat patients during cholera epidemics in the 1950s. Chatterjee used this solution – whose composition was similar to modern-day ORS formulation – in addition to avomine (a drug available in the market to check vomiting) in various doses and also the juice of an Indian herb. He found this combination was successful in treating diarrhoea in patients with cholera and reported the results in the medical journal, The Lancet in 1953. The use of oral therapy to replace electrolytes was novel, though scientists in Western countries still believed in the intravenous approach. This changed when in 1968 American scientists – David R. Nalin and Richard A. Cash – reported in The Lancet, that an oral solution of glucose and electrolytes was effective for replacing water and electrolyte losses in cholera. The finding was based on the work done at the Pakistan-SEATO Cholera Research Laboratory (which later became the International Centre for Diarrhoeal Disease Research) in Dhaka. Additional work was done at Johns Hopkins Center for Medical Research and Training in Calcutta as well, with ORT being field-tested in hospitals in Dhaka and Calcutta. While research and field studies established the efficacy of ORT, it still needed to be administered by doctors in hospital settings. It was the 1971 war that demonstrated that ORT can be administered even by untrained people. This knowledge was vital for the wide adoption of this new therapy. An Indian doctor, Dilip Mahalanabis, used ORS extensively to prevent and treat dehydration and diarrhoea among thousands of refugees, with the help of untrained family members. This experience established the usefulness of ORS in settings outside hospitals, paving the way for its mass use in developing countries. It helped overcome scepticism among doctors as well as people about the capacity of an oral solution of glucose and electrolytes in water to treat a killer. Based on the data from Mahalanabis and others in Dhaka, WHO in 1978 launched the global diarrhoeal diseases control programme with ORS as the main strategy. Since then, billions of ORS packets have been distributed in developing countries across the globe, saving millions of children from death due to diarrhoea. Key People The work reported in 1953 by Dr Hemendra Nath Chatterjee was the first one to show that an oral therapy – as opposed to the then prevalent intravenous therapy – could be used successfully to treat diarrhoea in cholera patients. It was purely an observational study and did not provide evidence of how the solution of glucose and salt gets absorbed in the gut. Still, it was a pioneering observation as far as the administration of an oral solution is concerned. Though the research findings were published in The Lancet, the work did not evoke any follow-up in India or in the West. Dr Dilip Mahalanabis, who was working at the Johns Hopkins International Center for Medical Research and Training in Calcutta in the 1960s, was instrumental in proving that untrained people could successfully administer the ORS solution. This finding helped establish ORS as a public health tool that could be used globally. During the liberation war, when a large number of refugee camps were established, there was a disease outbreak due to unhygienic conditions. Dr Mahalanabis was drafted for medical relief at the Bangaon camp. Given the large number of people who needed treatment, he realized that it would be impossible to use the traditional method of intravenous fluid or saline. He decided to administer ORS on a mass scale with the help of local people and family members, although it was difficult for him to convince people about ORS because they only knew about the saline treatment for cholera. The experiment was successful and illness and death came down drastically. Following this, pamphlets about the new treatment – how to mix salt and glucose – were printed and distributed along the border. While Dr
Mahalanabis was rolling out ORS in refugee camps, Dr Dhiman Barua, who was head of the bacterial diseases unit at WHO, visited and saw the use of oral therapy. He then started lobbying for its use within WHO as a potential tool for cholera and childhood diarrhoea. He also roped in UNICEF for mass production of ORS packets. All these efforts led to further clinical trials and the launch of a global programme for the control of diarrhoeal diseases with ORS as the main tool in 1978. 26. Mohalla Clinics The government healthcare system in India is based on a threetiered structure – a primary health system consisting of Primary Health Centres and subcentres; a secondary level with District Hospitals; and the tertiary level of large hospitals and superspeciality centres in cities. In addition, the country has a large number of private care providers at every level – from quacks and unqualified providers to private corporate hospitals. In large cities and urban states like Delhi, however, the primary care system is often not functional. People needing primary care either depend on private providers, including quacks or crowded tertiary care hospitals. The problem is more acute in the state of Delhi, which is a large urban conglomerate with rural pockets and urban slums. The state has one dozen different agencies providing health services, yet the poor have to spend a lot from their pockets. Going to tertiary care hospitals for common illnesses or a routine checkup means travelling long distances and losing a day’s wages. To address this situation, the state government in 2015 launched a new initiative called the Mohalla Clinic as a neighbourhood health facility. These clinics provide primary care, including consultation, medicine and diagnostic tests, free to people and under one roof. In a typical government hospital, one has to visit multiple places for these services. The clinics have brought healthcare to almost the doorsteps of people, made it affordable and may have contributed to reducing crowds at secondary and tertiary care hospitals. The concept of Mohalla Clinics has several innovations. Located in unserved and underserved areas, these clinics are within walking distance of the communities they are supposed to serve. Though fully funded by the government, these clinics are manned by doctors, nurses and pharmacists from the private sector who are paid on a per-patient basis. This helps overcome the shortage of manpower usually seen in government facilities. Unlike government-run centres, these clinics are open both in the morning and evening and medicines are dispensed in the clinic itself. As the entire process is digitized, this helps in bringing about proper management and organization of drug inventories. All this makes Mohalla Clinics accessible, affordable and equitable. They have made healthcare by qualified doctors accessible to the poor. One limitation, however, is that these clinics are equipped to provide only curative services. By the end of 2019, the state had close to 500 such clinics and had recorded several million patient visits; however, the plan is to scale it up to 1,000 clinics and for faster rollout in places close to communities, it was decided to open the clinics in rented premises or portable cabins. Several states – Telangana, Karnataka, Rajasthan, Madhya Pradesh, Jharkhand, Jammu and Kashmir and Maharashtra – have either started similar clinics or are planning to do so. Mohalla Clinics are seen as a possible means to achieve the goal of Universal Health Care (UHC). The success of these clinics led to health becoming an election issue, for the first time, during the Delhi assembly polls held in February 2020, with political commentators attributing the Mohalla Clinic initiative as one of the reasons for the success of the Aam Aadmi Party in the elections.
27. Home-based Palliative Care As the coronavirus pandemic raged in 2020 and 2021, millions of Indians went through multitudes of emotions – pain, grief, loneliness, fear and bereavement. These are the same feelings that people suffering from chronic diseases experience for many years. The number of such people is constantly on the rise in India, with the growth in non-communicable chronic diseases. For instance, every year in India one million new cases of cancer are reported, with nearly three million people living with cancer at any given point. The number of people living with HIV is close to one million. A huge number of people are also terminally ill, bedridden and in need of end-of-life or palliative care. Unlike Western countries, which have hospices or homes for the terminally ill, palliative care is a relatively new concept in India. The first hospice in India, Shanti Avedana Ashram, came up in Bombay in 1986, modelled after the St Christopher’s Hospice in the UK. Subsequently, a few more hospices were established by charitable institutions in different cities. All these centres have a combined strength of a few hundred beds and are all located in cities, while millions of people need such facilities and most of them in rural areas. Hospices may not be a solution in India also because of social norms and family traditions in which people want to spend their last years and days in their homes and with family members. Kerala has shown an alternative to hospices and institutional care for the terminally ill – home-based palliative care by trained community workers. The concept was pioneered in 1993 by the Pain and Palliative Care Society, a voluntary body founded by doctors in the Medical College at Kozhikode. It was the first such attempt in the world to deliver end-of-life care at home to people living with an incurable and terminal illness. In 1999, it was christened as the Neighbourhood Network in Palliative Care (NNPC) and adopted by three more organizations – the Malappuram Initiative in Palliative Care, the Alpha Charitable Trust and the Justice Sivaraman Foundation. Within a few years, it became the largest palliative care network of its kind, not only in India but globally. Initially, doctors at the medical college began with a palliative care clinic in the college itself and spread the word through personal networks. Within a short time, about 400 people began visiting the clinic every month, indicating that there was a huge unmet need. In 1995, a satellite clinic was opened in the clinic of a general physician in a nearby town. As the demand grew, more such clinics were opened with the help of community organizations and volunteers. Even this proved to be inadequate since it was difficult for people from remote areas to visit clinics regularly along with family members or relatives. This experience led to the idea of providing care closer to homes of the terminally ill by empowering caregivers in families. Under this programme, community volunteers visit patients at home, supplemented by home visits of trained nurses and doctors. Volunteers are trained in performing nursing chores, educating families to undertake care and in spreading awareness. They also act as a link between the patient and medical institutions. Local people are encouraged to address the social needs of patients and families, with the involvement of local governance bodies like the panchayats. The innovation has shown the efficacy of a community-centric approach to palliative care as opposed to a doctor-centric approach. Palliative care and pain-relief services have been integrated with the primary care system in Kerala and palliative care units have been formed in several medical colleges and hospitals in the
country. The biggest impact has been in ensuring access to morphine, one of the safest and most effective opioids for pain relief. Morphine was caught in regulations as it was covered under the Narcotics Drugs and Psychotropic Substances (NDPS) Act, 1985, which was originally meant for preventing abuse. The Kerala group advocated easing access to morphine with the government and in courts and after a long battle, these efforts led to an amendment to the central law and the formulation of rules for the medical use of morphine across the country. Key People The community approach for palliative care has been pioneered by Dr M.R. Rajagopal, who along with his then student Dr Suresh Kumar, launched the Pain and Palliative Care Society in the Government Medical College at Kozhikode in 1993. Dr Rajagopal was head of the department of anesthesiology then. The society was the first such pain relief clinic in the state. With the help of local communities, doctors and volunteers, Dr Rajagopal slowly spread the idea across the state. He advocated for a palliative care policy in the state and a national palliative care programme in the country. In his efforts, he collaborated with international medical institutions and bodies, including WHO. It was a result of his advocacy that rules relating to morphine were changed to make it accessible for pain relief. Earlier doctors did not stock it or dispense it for fear of arrest under the NDPS Act. During the pandemic, Pallium India, an umbrella organization helmed by Dr Rajagopal, launched India’s first grief and bereavement helpline for those affected due to sudden or multiple deaths in their families. Called Sukh-Dukh, it offered counselling by trained volunteers and experts in several Indian languages. 28. Open-source Drug Discovery A familiar term in the context of IT, open-source software refers to software whose source code is available in the public domain to facilitate the development of new tools and derived products using it. Anyone can use open-source software and deploy it in any field of application, its use promoting verification by multiple users, collaboration among users, cost reduction and development of new products and knowledge for common use. In contrast, proprietary software is protected and is commercially sold. In the field of drug discovery, a proprietary knowledge system lets multinational corporations with deep pockets develop new drugs, patent them and sell them globally to earn profits. They choose drugs that will give them maximum profits and not necessarily the ones needed to address health challenges in poor countries. The high cost of new drug development deters companies from entering this arena. The question of whether new drugs can be developed through open-source collaboration among researchers and then freely made available for manufacturing at low costs, gave birth to a novel initiative called Open Source Drug Discovery (OSDD) in 2006. The idea was to create a platform for the collaboration of a large number of scientists, clinicians, researchers and science students from national research laboratories and universities to develop new drugs for neglected
diseases like tuberculosis and malaria and make them available for manufacturing. All this was to be done using publicly available genomic data and open-source bioinformatics tools. The web-enabled interactive platform was anchored in the CSIR while the supercomputing backbone was provided by the Centre for Development of Advanced Computing (C-DAC), Pune. OSDD does not mean that all the work is done virtually. Drug development requires physical laboratories, clinical testing and manufacturing facilities as well, but a bulk of the work development work can be done in a collaborative and distributive way in silico or through analysis and simulation on computers. Generic drug companies were allowed to participate on the condition that they would not use knowledge generated from the platform for proprietary benefits. The first disease to be targeted by OSDD was tuberculosis. Despite TB being treatable, 1,000 Indians die due to the disease every day. This is because people don’t adhere to treatment which has to be undergone regularly for six months and also because medication may cause side effects. The TB bacterium has become resistant to some frontline drugs. Using OSDD, scientists started hunting for new drug targets using the genome sequence information of Mycobacterium tuberculosis. Several important leads have emerged from the project, including the discovery that a bacterial portion, NDH-I, can be targeted with the commonly used diabetes drug, Metformin, along with existing antibiotics. In another project, scientists are searching for naturally occurring plants that show anti-cancer properties. The data can help develop new drug candidates. In 2018, OSDD had 9,000 participants from 130 countries, with a bulk of them from India, the USA and Britain. The idea of open-source collaboration for R&D has become a part of the National Intellectual Property Policy of 2016. Key People The idea of open-source drug discovery was conceived by Dr Samir K. Brahmachari, a molecular biophysicist and an expert in genome analysis, while he was working as director of the Institute of Genomics and Integrative Biology in New Delhi in the early 2000s. He noticed that though the genome sequence of the tuberculosis bacterium was available, no new drugs were being developed. At the time, Indian research labs were doing very well in generic drug synthesis and companies were good at manufacturing generic drugs. Brahmachari saw open-source as a means to combine these strengths to develop new drugs. He got an opportunity to implement the idea when he became director-general of CSIR in 2007. 29. Swasthya Sahayak India has a vast healthcare infrastructure, but a bulk of it is in the private sector and concentrated in metro cities and towns. In rural areas, both preventive and curative health facilities are inadequate. The result of such a system is high out-of-pocket expenses people have to incur on health, coupled with problems such as late diagnosis of diseases. In recent decades, the burden of non-communicable diseases like diabetes, hypertension and heart disease has grown substantially, while communicable diseases remain a challenge in many regions.
Early diagnosis and regular monitoring of blood pressure and sugar can help prevent more serious impacts of diabetes and high blood pressure. Screening populations for diseases can help in early detection and treatment. For all this to happen, diagnostic laboratories are needed in rural areas and people need to travel to avail of their facilities. As a way out, mobile diagnostic vans are used in some states and medical camps are organized. Still, their reach is limited. The advent of digital technologies is changing this landscape, making it possible to provide diagnostic facilities at the doorsteps of people. Rural health workers can be trained in providing such services. One such innovative technological device is Swasthya Sahayak (health assistant), which provides a point-of-care diagnostic facility to people in rural and remote areas. Swasthya Sahayak is a handheld health monitoring device that enables a range of diagnostic tests and monitoring of health parameters. It is a battery-operated and Bluetooth-enabled Android device for easy storage and transmission of test results. The device can either be used in a primary care centre or carried door to door by ASHA workers or Auxiliary Nurse Midwives (ANMs). They can record a person’s medical history, monitor blood sugar and blood pressure, conduct diagnostic tests and transmit data to doctors at health centres for further consultation and clinical management if needed. The device is ideal as a ‘last mile’ diagnostic tool for remote areas. The tests available on the basic version of Swasthya Sahayak include blood pressure, body temperature, pulse oximetry, urine protein, urine sugar, blood glucose, haemoglobin, malaria, pregnancy, hepatitis B, typhoid, dengue, syphilis and HIV. An advanced version of the tablet can help conduct on-the-spot ECGs, blood sugar attached to haemoglobin (HbA1c), lipid profiles, kidney function tests, urine creatinine, microalbumin, besides the tests available in the basic version. The tablet can be programmed for specialized applications and more tests. The tablet, developed by the Public Health Foundation of India (PHFI), has been deployed in rural areas, mainly in hilly and remote districts. After initial testing and training of health workers, the device has been used in 6,500 villages in India and has evoked interest in several developing countries. Key People The tablet, originally called Swasthya Slate, was developed by Kanav Kahol who returned to India after working in the US as a biomedical engineer for a decade after his doctorate in computer science. He started working at the health technologies division at PHFI which was engaged in devising new ways to make healthcare affordable for poor Indians. While studying the health system in India, Kahol noted that frontline health workers were overburdened and spent more than half their time manually filling forms and then inputting data in computers kept at health centres. This is when the idea of a device that empowers a health worker – and improves her efficiency – occurred to Kahol. The result was Swasthya Slate. Subsequently, public health experts Dr Dorairaj Prabhakaran and Dr Sunil Saxena Raj took over the project and the product went through several iterations before being rolled out as Swasthya Sahayak. 30. Green Corridor for Organ Transplants Organ transplantation is one of the greatest miracles of modern medical science, helping scores of people live longer despite debilitating ailments. Transplantation of the kidney, liver and heart is being done in many hospitals across the country, subject to the availability of such organs from living or dead donors (cadavers).
Organs harvested for transplantation can survive outside the human body only for a very brief period and get wasted if the transplantation does not take place within the available window of opportunity. Sometimes, organs become available at short notice and must reach the place of transplantation swiftly, either in the same city or outside. All this makes organ transplantation a challenging task, both medically and logistically. This factor makes organ transport a critical element in the jigsaw puzzle of transplantation. In developed countries, large hospitals and organ transplant clinics have helicopters or air ambulances for transporting organs from one place to another. In India, hospitals depend on road and commercial air transport since air ambulances are prohibitively expensive. Given the unruly traffic situation in Indian cities, emergency vehicles like ambulances often don’t get right of way and get caught in traffic jams. To overcome this challenge, a new idea emerged from private hospitals in Chennai sometime in 2007. Doctors argued that if roads can be cleared and traffic signals manually operated for the smooth movement of vehicles carrying VIPs, why can’t the same be done for an ambulance carrying a freshly harvested human organ? Since all traffic lights in the route need to be green on such a route, the concept was given the name ‘green corridor’. A green corridor was created for the first time to transport a heart from Apollo Hospitals in south Chennai to Frontier Lifeline Hospital in the western part of the city. It took eleven minutes instead of the usual forty-five minutes. Wide publicity to the event through a live telecast on local television channels generated awareness about the concept and it was soon replicated in Hyderabad, Bangalore and even far off Indore. On 4 September 2014, a heart was transported from Bangalore to Chennai using what was the first intercity green corridor. The 55-kilometre distance from the BGS Global Hospital in south Bangalore to Kempegowda International Airport in north Bangalore was covered in forty-five minutes. When the heart arrived at the Chennai airport, an ambulance and a police escort were ready on the tarmac. The heart reached the Fortis Malar Hospital, covering a 12-kilometre distance in seven minutes. The recipient of the donated heart was already on the operation table, ready for the transplant. The Post Graduate Institute of Medical Research and Education, Chandigarh, which used a green corridor to transport a liver to Research and Referral Hospital in New Delhi on 14 April 2015, has shared twenty-seven organs with hospitals in the National Capital Region by creating a green corridor twenty-five times since then. The Indore Society for Organ Donation has facilitated several organ transports via the green corridor in Madhya Pradesh. Several agencies and people work in tandem to create a green corridor – hospitals, traffic police, district administration, voluntary bodies engaged in organ donation and airport authorities. Once an organ becomes available and a recipient is identified through organ registers maintained by the National Organ and Tissue Transplantation Organization and its zonal centres, the hospitals concerned alert traffic police and other agencies for initiating a green corridor. A police van is deputed to the hospital to accompany the ambulance carrying the organ, and traffic police posted at all signals up to the airport or another hospital in the city, as the case may be. Chennai-based voluntary body MOHAN (Multi-Organ Harvesting Aid Network) Foundation has played a major role in popularizing the concept of the green corridor and providing necessary training and technical help to hospitals to manage this. Dr Sunil Shroff, a transplant surgeon and urologist, is the managing trustee of the foundation. Green corridors have not only facilitated efficient use of harvested organs but have helped raise awareness about organ donation, in general, among people. During the coronavirus pandemic, green corridors were created in many cities for the smooth movement of oxygen tankers so that they could reach hospitals running out of oxygen supplies as quickly as possible.
31. FELUDA and Low-cost Ventilators When the coronavirus pandemic hit India in March 2020, it was anticipated that the country could face a shortage of medical supplies like face masks, hand sanitizers, PPE kits, diagnostic kits, ventilators, lifesaving drugs and so on. Keeping this in mind, the Indian government announced a competition, the COVID-19 Solution Challenge, for start-ups to come up with innovative solutions, products and technologies to face the crisis. The Challenge, open from 16 March to 30 April 2020, attracted hundreds of entries from all over India. In addition, national laboratories, IITs and other research institutions developed a host of products like low-cost sanitizers, novel masks, diagnostic tests and other medical equipment. Scientists also helped identify existing drugs that could be repurposed to fight COVID-19. Several of these new technologies were developed rapidly, tested and transferred to industry for mass production. For instance, the Delhi-based Institute of Genomics and Integrative Biology developed a rapid and point-of-care test for the detection of COVID-19 using gene-editing technology, CRISPR-Cas. Dr Debojyoti Chakraborty and Dr Souvik Maiti developed this test and named it FELUDA (FnCas9 Editor Linked Uniform Detection Assay) for its ability to specifically identify vital genes just like the detective character, Feluda, did in Satyajit Ray’s movies. Subsequently, FELUDA was adapted for the detection of different variants of SARS- CoV2 and was named RAY (Rapid Detection of Variants AssaY). The technology was transferred to Tata Medicals and Diagnostics for commercial production. Another pandemic-related innovation that attracted wide attention was a low-cost ventilator developed by a Pune-based start-up by two graduates of the IIT, Kanpur. Nikhil Kurele and Harshit Rathore of Noccarc Robotics developed a fully functional low-cost ICU ventilator from scratch within three months. As soon as IIT Kanpur circulated the COVID-19 Solution Challenge call among the start-ups incubated at the institute, the Pune duo started working on the ventilator project even though neither of them had ever seen a ventilator or had any background in medical electronics. Abhishek Kulkarni and Tushar Agarwal, also IIT-K alumni, who were stuck in Pune due to the national lockdown, pitched in. They quickly consulted all available literature and YouTube videos on ventilators and started looking for components needed to assemble one. They developed electronic circuits for the ventilator, using parts used in the solar panel cleaning robot that Noccarc was working on. In parallel, other members of the team started work on mechanical parts. Ventilators need a pressure pump that could not be procured immediately due to the lockdown, so in the prototype, they used a pressure pump used in fish tanks. Sensors were obtained from a hobby store in Pune and a mobile app for the ventilator was developed overnight. A prototype was ready on 26 March 2020. IIT-K formed a consortium that included clinical mentors, experts and entrepreneurs to take the project further. Experts from the Bridge Ventilator Consortium set up by the University of California Irvine were also consulted. The government facilitated the import of components from Singapore. The prototype of a pressure-controlled ventilator was ready in the first week of April, following which the company signed manufacturing agreements with AVI Healthcare and Bharat Dynamics Limited. After a couple of more prototype versions, the ventilator was tested in the ICU of Ruby Hall Clinic in Pune and then deployed in two more hospitals in Gurgaon. By the end of June 2020, the ventilator was ready for mass production after going through safety testing, pre-clinical and clinical validation. By April 2021, over 1,000 units of Noccarc ventilators had been installed in hospitals across the country. At `400,000 a unit, the ventilator is about 25 to 30 per cent cheaper than others with similar features. This example of coming together of academic institutions, start-ups, angel investors and government
agencies to rapidly develop and deliver high-tech medical equipment offers a template worth emulating across sectors. 32. Oxygen Langar The second wave of the coronavirus pandemic that hit India in April 2021 overwhelmed the already overburdened health system. With the daily caseload rising to nearly 400,000 in the third week of April 2021, everything – from diagnostic tests to hospital beds – was in short supply. The most tragic was the shortage of oxygen in hospitals in Delhi and several other cities and towns. The situation was so acute that dozens of patients admitted to the ICUs died as the supply of medical oxygen supply dipped. Relatives of patients needing oxygen were seen scurrying to factories with empty cylinders for a refill. Other lifesavers like oxygen concentrators were being sold in the black market at exorbitant prices as the demand rose. Thousands of SOS messages for oxygen were posted on social media platforms like Twitter and Instagram. Responding to such appeals, self-help groups, voluntary agencies and individuals started coordinating to get hold of available oxygen cylinders to help the needy. Reaching out to every COVID-19 patient waiting for oxygen with a cylinder was impractical and challenging. The answer to this crisis was the oxygen langar – a common facility where people could come and receive oxygen therapy for free, drawing its inspiration from food langars that all gurdwaras hold for devotees and visitors throughout the year. In this way, multiple people could be served from available oxygen cylinders, just like a drivein service for oxygen. During the lockdown, just one gurdwara – Bangla Sahib in Delhi – was preparing and supplying 100,000 meals to migrant workers and the jobless in Delhi every day. The first facility for oxygen delivery was organized at Shri Guru Singh Sabha Gurdwara at Indirapuram in Ghaziabad, near Delhi on 22 April 2021. A video of COVID-19 patients receiving oxygen while sitting in their cars parked on the street went viral and popularized the concept. Within days, similar langars were organized not only in the National Capital Region which faced the worst oxygen shortage but in gurdwaras in many cities across the country. Oxygen cylinders were procured from faroff locations by volunteers to keep replenishing the langars. To serve multiple people from one cylinder simultaneously, gas was supplied through makeshift pipelines using plumbing pipes. Many gurdwaras opened makeshift COVID care centres and hospitals as well, with generous donations from people in India and elsewhere. Oxygen langars saved the lives of thousands of critically ill patients. Khalsa Help International, which pioneered the concept, estimated that the langars helped revive 15,000 patients in twenty-two days. The concept is a unique example of volunteerism, service, crowdsourcing and humanitarian aid during emergencies. It inspired several innovations related to oxygen supply such as the ‘Oxygen pheriwala’ initiated by Dr Vijaya Nath Mishra of Banaras Hindu University (BHU). It involved reaching out to villagers at their doorstep with screening facility and mobile oxygen van just like a street hawker (pheriwala) does. References Abraham, Thomas. Polio: The Odyssey of Eradication. New Delhi: Oxford University Press, 2018.
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Transport and Mobility A well-organized transport infrastructure to move people and goods is key to economic development in any country. This includes roads, railways, airports and intracity mass public transportation systems. In 1947, the road infrastructure in the country was poor, while a reasonably efficient railway system developed during the colonial period existed. Major cities had air connectivity but air travel was affordable only for the elite and the wealthy. In major cities, public bus systems and tram services were available. Private means of transportation, such as cars, were considered luxuries and heavily taxed. Over the decades, innovations in the public sector and private industry have helped India develop a robust transport system. Some of these innovations relate to the policy domain, such as entrusting a special agency to develop national highways instead of the archaic and inefficient public works departments. Another such administrative innovation was to create a new mechanism to develop and run a metro rail in Delhi, learning from the experience of such projects in Kolkata. The design and development of a small car ushered in a new revolution in the personal transport segment beginning in the 1980s. Air travel became affordable to the common man with no-frills services in the new millennium. Over the decades, innovative transport solutions like three-wheeled scooter rickshaws and e-rickshaws have boosted mobility.
33. Three-wheeled Scooter Rickshaws In 2016, the newly appointed ambassador of Mexico, Melba Pria, caused ripples in the staid diplomatic circles of New Delhi when she chose a three-wheeled autorickshaw as her official vehicle over a luxury sedan or a bullet-proof SUV. Her tastefully decorated autorickshaw bearing a diplomatic numberplate became a centre of attraction wherever she went. At times, it raised a lot of eyebrows and controversies. For instance, Pria was not allowed to enter the Parliament complex in the autorickshaw. Her idea behind using this vehicle was not to make a statement in simplicity or to grab attention. She was driven by practical reasons – the carbon footprint of an autorickshaw is just a fraction of a car, and it has better manoeuvrability in a highly congested city like Delhi. Above all, the diplomat felt an autorickshaw was uniquely Indian. Three-wheelers are the cheapest mode of transportation with a very low carbon footprint in urban areas in India and many developing countries. Three-wheeled scooter rickshaws or TSRs cater to the mobility needs of millions of people who do not own private means of transport like cars and two-wheelers and reside in areas poorly connected by public transport. These vehicles can carry almost the same number of passengers as a small car, at a much cheaper price as they are more fuel-efficient. Since TSRs have a much smaller engine (175 cc) compared to a small car (800 cc), they are much less polluting. In most Indian cities, TSRs run on compressed natural gas. Yet, they can travel up to speeds of 50 kilometres per hour, matching the speed limits of city roads. As the name indicates, the autorickshaw was designed to serve as a motorized version of a pedal rickshaw, just as early scooters were meant to be motorized versions of a bicycle. In the past seventy years, the autorickshaw has become an essential part of the mobility ecosystem in India, ever since the technology of making the autorickshaw came to India from Europe and was widely adopted here, paving the way for its dissemination to several countries across the globe. A German firm, Vidal & Sohn Tempo-Werke GmbH, based in Hamburg, is widely credited as the inventor of the tricycle motorized vehicle. These vehicles were originally meant to be used as goods delivery vans marketed under the brand name ‘Tempo’, while a transport and camping version was called ‘Matador’. These vehicles were brought to India in the 1940s by Bachhraj Trading Corporation jointly owned by Ramakrishna Bajaj and N.K. Firodia. As the demand grew, the company started assembling both the Tempo and Matador locally. Subsequently, a separate manufacturing company called Bajaj Tempo Motors was formed in 1958 to make three-wheeled delivery vans as well as autorickshaws. Another Bajaj company, Bajaj Auto Limited, which already had a technical partnership with Piaggio, the Italian company for manufacturing scooters, also got into autorickshaw manufacturing under the Piaggio Ape brand in 1961. When this partnership with Piaggio ended in the 1970s, the product was rebranded as Bajaj Auto. Rahul Bajaj, who was inducted into Bajaj Auto in 1965 and helmed the company for four decades, introduced several changes in the autorickshaw design, such as the rear-engine, and marketed the product aggressively. Bajaj Auto is now the world’s fourth largest three- and two-wheeler manufacturer and its autos are sold in thirty-six countries in Latin America, Africa, the Middle East, South and Southeast Asia. During 2018–19, Indian companies sold more than 7 lakh three-wheelers in the country and exported over 5.5 lakh of them. The ride-sharing app, Ola, has included autorickshaws in its offering in India and other markets where it operates.
34. Maruti 800 It has been an aspiration, a dream purchase and a lived experience for millions of middle-class Indians for three decades. From the day the first unit of Maruti 800 rolled out on 14 December 1983, until the last one manufactured in February 2014, it was India’s bestselling car. It came like a breath of fresh air in the country’s automobile market dominated by outmoded and highly priced cars and became an instant success. At a time when the total number of cars sold in India was a measly 30,000 units a year, booking orders for Maruti 800 stood at 125,000 as against the production capacity of 100,000 units in the first year. It was not only modern- looking and technologically superior (coming from a Japanese company, Suzuki), but was affordable and had innovative features that made it highly suitable for Indian roads and driving conditions. It satisfied the latent demand for car ownership and opened up a new segment in the Indian automobile market as the Indian economy opened up in the 1990s. In the 2020s, India is positioned as the fourth largest car manufacturing country in the world, producing four million passenger cars in a year, with almost all leading car brands being present in the Indian market. At the time of Independence, there were no indigenous manufacturers. Instead, foreign companies like Ford and General Motors used to assemble cars, using completely knocked down (CKD) kits, and those who could afford it, would import cars after paying hefty duties. The government considered car a luxury product and taxed it heavily. Three companies – Hindustan Motors (the Ambassador), Premier Automobiles (makers of the Premier Padmini or Fiat) and Standard Motors (the Standard Herald) – were licensed but the government controlled the number and type of cars they could manufacture. Since the demand far outstripped supply, the waiting period for getting a car after booking extended up to five years and even used cars commanded a premium. Technologically, the Indian car industry was at least two decades behind the global industry. The entry of Maruti Udyog Limited in 1980 changed the situation dramatically. In 1970, the Planning Commission suggested that a small car should be manufactured in the public sector, and talks were initiated with Renault, Ford and Nissan for possible collaboration. The idea was, however, given up because of high capital investments and foreign exchange requirements. Instead, it was decided to invite the private sector, but without the need for foreign collaboration and import of capital goods. Three companies were licensed, including Maruti Motor Limited floated in 1971 by Sanjay Gandhi, the younger son of Prime Minister Indira Gandhi. However, after producing a few units, the company got caught in political controversies and faced charges of financial bungling. After the sudden death of Sanjay Gandhi in an air crash in June 1980, the government decided to nationalize the company and renamed it Maruti Udyog Limited while roping in Suzuki as a partner. The company is now a fully owned subsidiary of Suzuki – Maruti Suzuki Limited. Maruti 800, an Indian version of Suzuki’s Fronte 800 model, combined design and engineering improvisations and marketing innovations for the Indian market. For instance, its air intake pipe was placed at a higher level under the bonnet to let the engine keep running in waterlogged streets. The feature was designed keeping in view user experience with other cars like the Ambassador that would too often come to a halt on waterlogged roads. The electrical circuits and parts of Maruti 800 were also made somewhat waterproof. The body design features, such as the front strut and rear beam suspension and unitary shell body, made the car cope with pothole-filled Indian roads. The braking system and headlamps were also superior to other brands. The marketing and distribution of Maruti 800 were highly innovative. Booking forms were sold through banks and the draw of lots was computerized. Financing was attractive since a Maruti 800 could be bought for equated monthly instalments (EMIs) as low as `2,500 which compared favourably with an average family’s monthly transport bill. The cost
of ownership was comparatively low, as it needed a service only after running 5,000 to 7,500 kilometres, besides better mileage. Key People Sanjay Gandhi, who founded Maruti Motor Limited, toyed with the idea of developing a People’s Car from scratch. He is said to have developed this passion during his apprenticeship with the British carmaker, Rolls- Royce Limited, during 1964–67. Upon his return to India, he teamed up with his instructor at the Delhi Flying Club, Captain Tillu and set up a small workshop in Gulabi Bagh in north Delhi. They started fabricating a car with the help of local technicians and mechanics, using parts and components from scrap markets. The workshop was later shifted to bigger factory premises in Moti Nagar in west Delhi. The company developed a prototype that was displayed at the India International Trade Fair in 1972, but it soon ran into trouble. After the government takeover of the company in 1980, Prime Minister Indira Gandhi entrusted the task of reviving and forging collaboration with Suzuki to a technocrat in the Planning Commission, V. Krishnamurthy. Though the core technology came from Suzuki, he ensured its proper absorption, skill training, component manufacturing as well as vendor and dealer development. Krishnamurthy handpicked R.C. Bhargava, an IAS officer, to be director (sales and marketing) in Maruti. Bhargava was instrumental in convincing Suzuki to become a partner and worked closely with the component industry to improve the quality so that they could deliver parts that met Suzuki standards. Under Bhargava’s leadership, the company introduced the Japanese- style work culture among workers as well as suppliers. In the initial couple of years, all major components and systems were imported but the company progressively increased the local content, thereby boosting local production of auto components. In effect, Maruti 800 proved to be an exercise in modernizing the Indian automobile industry. Another innovatively designed compact car, Tata Nano, made its debut in 2008 hoping to capture the market of Maruti 800. It, however, failed due to technical issues and consumer perceptions. 35. REVA Electric Car The launch of the Maruti 800 in 1983 heralded a new segment – of compact cars – in the Indian automobile market. More foreign brands entered the scene as the economy was opened up in 1991. Eyeing this expanding car segment, a Bangalore-based entrepreneurial firm announced its plans to make India’s first electric car. The Reva Electric Car Company (RECC) unveiled a prototype of a small electric car named REVA (short for Revolutionary Electric Vehicle Alternative) in 1994. It was a joint venture of the Maini Group of Bangalore and AEV of California. It took another six years for the company to commercially launch REVA in May 2001. Around this time, electric vehicles were beginning to gain popularity and consumer acceptance, given the need to reduce tailpipe emissions and the shift towards green energy. Besides being non-polluting, electric vehicles offer ease of handling and generally have low running and maintenance costs. They are relatively easy to drive in congested city conditions because of the absence of gears and clutches.
Developing an electric, low-energy car for Indian road conditions was a novel idea. Till then, only a couple of public sector units had experimented with battery-operated minibuses and three-wheelers, all limited to a few hundred units produced and deployed in select cities. Commercial production of these vehicles could not take off because of the high cost of components, lack of charging facilities in cities and the unfavourable duty structure. REVA was a well-planned commercial venture. The two-door electric car attracted global attention because of its innovative features and economic reasons – it had a running cost of less than a cent per kilometre, an on-board Energy Management System, thermoformed body panels, rotationally moulded bumpers, sandwich doors and climate-controlled seats. Compared to 6,000 components in an IC engine car, REVA had only 1,000 components and most of them were manufactured in India. The car could be run for 80 kilometres on a single charge and could be charged using any 220-volt, 15-amp power source. At the time of its launch, REVA’s price was comparable with Maruti 800 and highly competitive with contemporary electric cars of carmakers such as Ford. Tesla Motors was yet to be incorporated. REVA was an operational success, but its market was limited because of a lack of charging infrastructure and policy framework specifically to encourage electric vehicles. Within four years of its launch in India, REVA was test-marketed in the UK, the US, Hong Kong, Switzerland, Norway, Nepal, China, Japan, Ireland and Malta. It was launched in the UK markets as G-Wiz and won critical acclaim in several international automobile fairs. In 2010, the company was taken over by Mahindra and Mahindra and REVA was renamed as Mahindra Reva. The company launched new-generation electric cars subsequently. Other Indian and foreign car companies also have electric cars in the market, which got opened up due to REVA and favourable government policies on electric vehicles. Key People RECC was floated by the Maini group of companies headed by Sudarshan K. Maini. Founded in 1973, the group had business interests in the manufacturing of high-precision components and subassemblies for automobiles. Maini had nurtured the idea of a small electric car suitable for Indian road and infrastructure conditions for a long time, but it took a shape only in the 1990s. Maini’s younger son, Chetan, who studied solar electric and hybrid electric vehicles at the universities of Michigan and Stanford, returned from America to lead the REVA development team as chief of technology and the managing director of RECC. While in the US, he was working on government-sponsored projects on electric vehicles at an automobile technology firm, Amerigon, and for RECC, he signed a technical collaboration deal with it. Chetan adopted the design and technology to suit Indian conditions, evolved a cost-effective manufacturing plan and leveraged the existing manufacturing infrastructure of the Maini group. For instance, a new bumper was designed using the material used to manufacture overhead tanks. An intelligent battery management system was developed, learning from the mistakes of the past electric car ventures. 36. Delhi Metro Rail Cities are engines of economic growth that attract people for employment and business opportunities. Much of their success, however, depends on the quality of their physical infrastructure, such as transport systems that can move a large number of people within a city. In the absence of convenient public transport or poor connectivity, people are forced to use personal means of transport that results in congestion on roads and air pollution. Therefore, it is critical for city administrators and local governments to plan efficient mass rapid transport
systems (MRTS) – be it the tramway, suburban train service, or Metro Rail – as an essential part of the city infrastructure. In the early part of the twentieth century, many Indian cities opted for electric tramways, replacing horse-drawn trams, and city bus services. Rail-based MRTS or the suburban railway system emerged on the Indian urban landscape in Bombay at the beginning of the last century. In the post-independent era, suburban train services were introduced in many cities. In Kolkata, the country’s first underground rail project was initiated in 1973 as the MRTS. The Delhi Metro Rail, though not the first MRTS in India, stands out for institutional innovations that resulted in its rapid rollout, making it a model MRTS for other Indian cities to emulate. Both the Mumbai suburban railway system and the underground metro system in Kolkata were executed as projects of the Indian Railways. One of the reasons for massive time and cost overruns in the Kolkata project was the fact that the West Bengal government had no stake in it. In contrast, the Delhi Metro was executed by a separate corporation outside the Indian Railways system. The Delhi Metro Rail Corporation (DMRC) was incorporated as a joint venture of the central government and the government of the national capital territory. This facilitated pooling of funds by the two governments and also in tapping capital from other sources. In addition, the novel institutional framework effectively insulated the project from political and bureaucratic interference. A special law was passed in the Parliament to create the DMRC. Otherwise, the Delhi Metro would have been treated like another railway project under the Ministry of Railways and may have met the fate of the Kolkata underground. The Ministry for Urban Development went ahead with the DMRC Act despite protests from the Ministry of Railways. The DMRC model is now being followed in most metro rail projects underway in Indian cities, including Mumbai, where the Mumbai Railway Vikas Corporation Limited has been entrusted with the task of developing a modern metro rail system. Besides following the management and institutional model of the Delhi Metro, other projects are learning techniques to help them avoid time and cost overruns. Its first corridor between Shahdara and Tis Hazari was opened in December 2002 and was finished in two years and nine months, much ahead of schedule. In contrast, the first phase of the Kolkata underground took over a decade to finish. In 2020, the Delhi Metro network stretched to about 389 kilometres with 285 stations, making it among the five largest metro networks in the world. All this makes the Delhi Metro Rail a model for mass rapid transportation in urban areas in India. Key People The idea of establishing a separate corporation for the Delhi Metro project flowed from the success of the Konkan Railway Corporation Limited established in 1990 to build the coastal corridor from Mumbai to Mangalore. Bimal Jalan, then economic adviser in the Ministry of Finance, had suggested the formation of a corporation with the centre and beneficiary states taking up the project and raising money. Though the Delhi Metro project has a chequered history, the final go-ahead came from Prime Minister H.D. Deve Gowda during the meeting of the National Capital Region Planning Board in August 1996. In the public mind, the Delhi Metro is synonymous with E. Sreedharan, founding managing director of the DMRC, who is fondly called the Metro Man of India. He is largely credited with executing the project ahead of time and within given budgets, and without any instances of corruption. It is rare for a public project of this size to reach all milestones as planned. Having spent all his working life in the Indian Railways, Sreedharan knew both the strengths and weaknesses of working in the government. He was involved in the implementation of the Kolkata underground project too. He wanted to build it like the Tokyo Metro, but the Indian Railways in the
1970s was not equipped to take up such a challenging project. Sreedharan learned from the experience of the Kolkata project though he was not fully in-charge of it. He got a chance to implement some of his ideas when he was put in charge of the Konkan railway project soon after he retired from the Railways in 1990. He established the Konkan Railway Corporation Limited from scratch and recruited young professionals at various levels. The 760-kilometre project was sliced into portions of 100 kilometres each and one chief engineer was made in-charge of each section, ensuring that the long-delayed project could be executed within five years. He followed the same methodology at the DMRC and for a brief period, was heading both the corporations. 37. E-rickshaws In metropolitan areas like Delhi and Mumbai where the MRTS is available, vehicles like pedal rickshaws and three-wheeled autorickshaws provide commuters the ‘last mile’ connectivity. In Kolkata, human-pulled rickshaws are also in use in some urban pockets. It is this segment of the transport system that received very little policy and technological attention and intervention for several decades. It was only in the 2010s that this segment saw a new player – the electric rickshaw or e-rickshaw. It is a battery-operated vehicle that is ideal to ferry people for short distances. It has zero-emission, unlike other options such as diesel-run tempos, and is not driven manually like a pedal rickshaw. In the span of a few years, this innovation has spread to many cities in India and in 2018, the number of e-rickshaws on Indian roads was estimated to be 1.5 million. The electric three-wheeler or e-rickshaw evolved in a step-by-step fashion from the traditional pedal rickshaw over several years. In the first stage, attempts were made to improve the engineering design of the pedal rickshaw to reduce human drudgery. New design elements included three-speed gears, reduction in the length of long-chain drives, the introduction of back-wheel shaft braking, better suspension and less aerodynamic drag. The use of mild speed angles made it slightly lighter than the original design. Given the unorganized nature of rickshaw manufacturing and skewed economics of ownership, only a few of these changes got translated into the end product. The next innovation in design came in the form of adding a battery-operated motor to the cycle rickshaw. It was a hybrid design, in which the rickshaw puller could switch on the motor under increased loading conditions and while going up steep gradients. The first set of motor-assisted pedal rickshaws was developed at the Nimbkar Agriculture Research Institute (NARI) based in Phaltan in Maharashtra and these rickshaws were operated in the Pune University campus in 2002. The next logical move was to develop a completely electric autorickshaw, removing the need for pedals altogether. The result was ELECSHA, the first electric rickshaw and perhaps the first electric vehicle of its kind anywhere in the world. The development was supported by the Ministry of Non-Conventional Energy Sources (which later became the Ministry of New and Renewable Energy), and NARI got a trademark registered for ELECSHA, incorporating a special two-speed gearbox developed indigenously. In 2008, the Central Mechanical Engineering Research Institute (CMERI) in Durgapur – a laboratory working under the CSIR – announced the development of an e-rickshaw called Soleckshaw, in which the rickshaw battery could be charged with solar energy. The first set of this rickshaw was introduced in Chandni Chowk in Old Delhi where a solar charging station was also made available. Both ELECSHA and Soleckshaw could not reach a commercial scale for several reasons, but they inspired several ‘me too’ variants in the market and the technology got disseminated organically. This has given Indian cities and towns their first ‘green’ mode of transport. Key People
The thought of ending the drudgery of rickshaw pullers was the motivation for the development of the electric rickshaw. Dr Anil K. Rajvanshi, an engineering graduate from IIT Kanpur, returned from America in 1981 after obtaining a doctorate and a teaching stint at the University of Florida. Having been brought up in Uttar Pradesh, he was fully aware of the plight of rickshaw pullers and requested H.N. Bahuguna, a Member of Parliament who also headed a union of rickshaw pullers in Allahabad, to raise the issue in Parliament. Rajvanshi then began working on improving the design of the rickshaw at NARI which he had joined to work on rural technologies. He brought in several engineering and design changes in the pedal rickshaw and even tried to organize cooperatives for rickshaw pullers to disseminate the technology. During a visit to the US in 1993, he had a chance to meet Henry Oman, an electric engineer who had retired from Boeing Corporation and was working on electric bicycles. This inspired Rajvanshi to work on an electric rickshaw back home, ultimately resulting in the development of ELECSHA. 38. Air Deccan: Affordable Air Travel A Tamil movie released on an OTT platform during the 2020 pandemic could hardly be an option to learn some lessons in entrepreneurship, that too, in a high-risk sector like aviation. But that’s what Soorarai Pottru, featuring Suriya and Aparna Balamurali, did. It portrayed the struggles, tribulations and out-of-box ideas of an army officer-turned-aviation entrepreneur, G.R. Gopinath, whose Air Deccan caused the biggest ever disruption in the Indian aviation industry. For close to half a century after Independence, air travel remained a luxury in India. The fare for a Bombay–Delhi air ticket in 1947 was `140 which was more than what 10 grams of gold cost then. All along, the Indian civil aviation market had just one monopoly player – the Government of India that operated Air India for international travel and Indian Airlines for domestic travel at fixed fares. One had to book in advance through travel agents or booking offices of the two airlines located in big cities. Ticket prices were too steep and virtually out of bounds for middle-class flyers. As the winds of economic liberalization started blowing in the 1990s, the government permitted the entry of private players in the aviation sector in 1994. The new aviation policy ended the monopoly of the two state- owned airlines and a few private players started operating in some select sectors. This injected competition in the market but did not drive prices down much as most of the private airlines were also full-service carriers like Indian Airlines and Air India. Private players faced several other impediments. The situation changed dramatically in 2003 when a little-known company – Air Deccan founded by Gopinath – made its debut with an aggressive business strategy of low fares and no frills. The airline was an instant success, flying a record one million passengers in its very first year of operation and three million passengers in 2005. By 2007, Air Deccan became the largest low-cost carrier and the third largest domestic carrier. Its market share was 22 per cent, a little short of 22.6 per cent of Jet Airways. In terms of the network, it had become the largest in the country, ahead of even Indian Airlines. Air Deccan truly captured the imagination of the nation with its offer of a fare of ‘One Rupee’ on some routes. The low fares offered by Air Deccan were a result of a well-thought-out business model that combined several innovative features. It followed a unique dynamic pricing model that helped in optimizing yield management and the load factor. The airline intensively used IT in all its operations, including customer interface. Its overall staffing pattern was lean, resulting in a low aircraft-to-employee ratio. All these initiatives helped Air Deccan bring down its costs. For instance, Air Deccan introduced online booking of tickets for its customers. It was a boon for passengers in small towns, and for the airline it was cost-saving since it did not have to spend on
booking offices, booking clerks and printing tickets. The pricing was dynamic and at times one could buy a flight ticket at a pretty low price comparable to the AC train fare on trunk routes. In addition, the airline discovered additional revenue generation streams, such as the onboard sale of food and beverages, sale of advertising space on unconventional spots (seats, storage bins, headrests, tray tables, baggage tags, boarding passes, the aircraft body, among others). Cost reduction was also achieved through new operational and logistics strategies. For instance, the point-to-point route strategy helped the airline to achieve a faster turnaround as there was no need to time its flights to connect with its other flights or that of other airlines. Air Deccan was taken over by Kingfisher Airlines in 2007, but in the short period of its existence, it triggered a revolution in the Indian aviation sector. Several low-cost carriers entered the market and followed the Air Deccan model. Even full-fare carriers adapted innovative strategies of Air Deccan. Above all, the airline created a new segment of first-time flyers and helped expand the overall size of the market. Key People Gopinath first founded Deccan Aviation, a charter helicopter service with a fleet of just one helicopter, taking advantage of the new policy and regulatory environment of the 1990s. His goal, however, was commercial air travel which was capital-intensive and already had many private players. Still, he launched Air Deccan with a single ATR aircraft (the used aircraft was taken on lease) and started a service between Bangalore and Hubli in Karnataka. Using this strategy of leasing – instead of outright purchase – Deccan managed to expand its operations rapidly (the company acquired forty-five aircraft in that many months). Gopinath came from a rural background and after a stint in the Indian army, decided that he wanted to make air travel affordable for common people. He could open up the market for first-time flyers with airfares comparable with upper-class train fares. Roughly, half of the sixty-nine cities the airline connected were first- time destinations. To position Air Deccan as an airline that middle-class people could afford, Gopinath chose the ‘common man’ – a character created by political cartoonist R.K. Laxman – as the mascot of his airlines. 39. The Golden Quadrilateral Roads are considered the lifeline of a country and essential conduits for mobility, trade, industry and commerce. Grand highways have also been symbols of prestige, power and supremacy from ancient times. The sixteenth- century reign of Sher Shah Suri is still known for the Sarak-e-Azam, which was rechristened as the Grand Trunk Road in the colonial period. Another vital road was the ancient Silk Route of China, which has been reinvented in twenty-first century China as a new tool of global diplomacy that connects China with the West. In India, one of the largest infrastructure projects of the Atal Bihari Vajpayee government was the Golden Quadrilateral – a grid of national highways connecting India’s four metropolitan cities (Delhi, Mumbai, Kolkata and Chennai). The project changed the face of national highways as India entered the new millennium.
At the time of India’s Independence, the road infrastructure in India was inadequate and poor. Nearly 80 per cent of freight was carried by trains. Now, India has the second largest road network in the world, consisting of 3.3 million kilometres of expressways, national and state highways, district roads and rural roads. Roads are key to the economy, transporting 65 per cent of freight (by weight) and 80 per cent of passenger traffic. National highways bear most of the burden – though they constitute just 2 per cent of the total road network, they carry 40 per cent of the total road traffic. While the road infrastructure expanded over the decades, the quality of roads was poor for a long time. At the end of the 1990s, only 4 per cent of roads in the country had four lanes, while major cities and centres of economic activity were not connected by expressways. The surface condition was poor in 25 per cent of the national highway network, which meant that the time taken for travel between major cities was several times the duration to cover a similar distance in a developed country. In the absence of proper toll collection systems, highways reported congestions near checkpoints and entry points to cities. The Golden Quadrilateral was constructed not only to connect the four metros in a grid but to vastly improve the quality of the highways. The institutional frameworks needed for modern highway development were lacking for a long time though improving the road infrastructure was identified as a priority area for national development soon after Independence. In the 1960s, when India was caught in a series of wars with neighbours, the focus shifted to developing strategic roads in border areas through a new agency named the Border Roads Organization (BRO). It was only in 1988 that the government thought of an agency that would exclusively look after the construction, maintenance and management of national highways. It was then that the National Highways Authority of India (NHAI) was created through a law passed in the Parliament. Until then, highway building was handled by the public works departments in the central and state governments. In 1995, the National Highways Authority Act was amended to permit the participation of the private sector in highway development, in keeping with the economic liberalization unveiled in 1991. To improve the quality of roads and ease congestion, the government of Atal Bihari Vajpayee launched the National Highway Development Programme in 2001 and entrusted its implementation to NHAI. The first project was to connect the four metros with six-lane national highways by upgrading and modernizing existing highways as well as developing new links. The 6,000-kilometre Golden Quadrilateral project was the largest highway project in the country and the fifth-longest in the world. It connected the four metropolitan cities in the shape of a quadrilateral. Several other cities were also connected to the grid, including Ahmedabad, Bangalore, Bhubaneswar, Jaipur, Kanpur, Pune, Vijayawada, Ajmer and Visakhapatnam. The project was executed by using several innovative features. For the first time, a network development approach was adopted. For financing it, the government created a backbone financing framework based on a non-lapsable cess on petrol and diesel. A new law, the Central Road Fund Act, was enacted for this purpose in 2000. The biggest reform was allowing the participation of the private sector under the public–private partnership (PPP) model through mechanisms, such as toll-operate-and-transfer (TOT) and build-operate- transfer (BOT). The highways saw several new features such as grade separators, guardrails for safety, overbridges, bypasses, tunnels and underpasses for the smooth flow of traffic. The success of the project spurred other important highway development projects such as the North–South and East–West Corridors and the port connectivity network. The innovative features introduced in the Golden Quadrilateral have been improved upon and are now widely used in all highway projects.
Key People The Golden Quadrilateral was the largest road infrastructure project of its kind and faced many hurdles. Yashwant Sinha, finance minister in the Vajpayee cabinet, mooted the idea of a highways project inspired by the highways he had seen in Germany many years earlier. Vajpayee was unhappy with the condition of highways and rural roads in India, so he readily agreed to the bigticket project. Given political backing from the prime minister, a team of officials from various ministries, NHAI and the Planning Commission worked together to implement the project. They worked out necessary institutional arrangements and put in place the legal framework and financial arrangements to ensure the flow of resources for the project. It was the first time that private companies were involved in road development under the ‘PPP’ mode. An IAS officer, L.K. Joshi, who was a member of NHAI and later appointed secretary in the Ministry of Road Transport and Highways, played a key role. Gajendra Haldea, an adviser in the Planning Commission, pushed for the PPP model. B.C. Khanduri, formerly with the Indian army, supervised the implementation of the project as the minister for road transport and ensured its timely and corruption-free completion. Along with the highways project, Vajpayee also initiated the Pradhan Mantri Gram Sadak Yojana to construct all-weather rural roads. 40. Yulu Shared E-bike The urban transport system in Indian cities is undergoing a rapid transformation with the modernization of road transport fleets, introduction and expansion of metro rail system, construction of flyovers and signal-free expressways and so on. Yet traffic jams and congestion are a harsh reality, mainly due to the increase in the number of cars and two-wheelers. As most of the privately owned vehicles use petrol and diesel, the result is a high level of air pollution. Multiple options are being attempted to ease the situation, such as dedicated bus corridors, the use of electric vehicles, shared taxis, carpools, separate lanes for bicycles and electric bikes for ‘last mile connectivity’. New technologies, such as GPS tracking, artificial intelligence and the Internet of Things are facilitating this change. The Yulu shared electric bike is an innovative mobility option that combines many of these new technologies. It is a unique model that allows one to use an e-bike for short distances in a city on a ‘pay as you use’ basis. Using a mobile app, one can locate a bike zone, unlock a bike using a QR code, ride it and leave it at a designated place after the ride for the next user. The bike used is an electric vehicle that is faster than a pedalled bicycle and is much lighter than a scooter. The bicycle rental system has been in vogue in Indian cities for a long time. In the 1960s and 1970s, one could hire a cycle for half a day or a full day for about `10. The system, however, worked on faith in consumers. Rental shop owners, therefore, trusted people whom they knew personally. Public bike systems in the West were not a great success due to large-scale thefts of cycles. To tackle this, the next change came with the introduction of coin-deposit locks for bike-sharing. Newer technologies like GPS tracking, better locking systems, electronic booking and automated payment led to a new wave of bike-sharing. However, these improvements never made it to India, mainly because of the neglect of nonmotorized transport in the overall mobility policies. The good old cycle renting system also died. In recent years, local agencies and metro companies reintroduced bike-hiring systems but with little success. Learning from the experience and taking advantage of new technologies like mobile technology and the Internet of Things, coupled with the availability of electric bikes, Yulu introduced the app-based bike-sharing system in Indian cities in 2017. In 2020, it had a fleet of 10,000 cycles and 5,000 e-bikes and about 1.5 million registered users. It logs about 12,000 e-bike rides a day. The model has proved highly useful for ‘last mile’ connectivity for regular users of public transport
and also for thousands of e-commerce supply chain workers who cannot afford to own a bike or pay for petrol charges. Key People The company was founded by four serial entrepreneurs with technology and management backgrounds – three have graduated from IIT Kanpur. The team – Amit Gupta, R.K. Misra, Naveen Dachuri and Hemant Gupta – tied up with Bajaj Auto for the assembly of e-bikes from kits imported from China. Bajaj Auto is also an investor in the company. Amit Gupta got the idea of founding an e-bike sharing company after he saw the popularity of these bikes in China. Living in Bangalore, he was also frustrated at the long commuting time due to congestion. This triggered the thought that a solution could be found and he got together with others to launch Yulu. Initially, the company started with bicycles but found that people in Bangalore were reluctant to ride cycles even for short distances. It was then that the electric bike was introduced and it became a success. The e-bike has a 48-volt motor controller, can go up to 25 kilometres per hour – other advantages are that it needs no licence or helmet for the rider. References Ashokan, M.S. Karmayogi: A Biography of E. Sreedharan. London: Penguin UK, 2015. Becker-Ritterspach, Florian. ‘Maruti-Suzuki’s trajectory: From a national champion to a Japanese-owned subsidiary’. In M. Freyssenet (ed.), The Second Automobile Revolution. London: Palgrave Macmillan, 2009, 404–18. Bhargava, R.C. The Maruti Story: How a Public Sector Company Put India on Wheels. Noida: HarperCollins India, 2010. Chandran, Nisha, and Samir Kumar Brahmachari. ‘Technology, knowledge and markets: Connecting the dots – electric rickshaw in India as a case study’. Journal of Frugal Innovation, 1 (1), 2015: 3. Datar, Srikant M., ‘Interview with Rahul Bajaj’. Creating Emerging Markets Project, Baker Library Historical Collections, Harvard Business School (8 July 2014), http://www.hbs.edu/creating-emerging-markets/(accessed 16 November 2021). Gopinath, G.R. Simply Fly: A Deccan Odyssey. Noida: HarperCollins India, 2012. Gopinath, G.R. You Cannot Miss This Flight: Essays on Emerging India. Noida: HarperCollins India, 2017.
Kamath, M.V. Gandhi’s Coolie: Life & Times of Ramkrishna Bajaj. New Delhi: Allied Publishers, 1995. Krishnamurthy, V. At The Helm: Memoirs of a Change Agent. Noida: Collins Business, 2014. Krishnan, Rishikesha T. ‘Product development: Learning from “Reva” experience’. Economic and Political Weekly, 37 (19), 2002: 1787–89. Maini, Chetan Kumaar. ‘Development of a globally competitive electric vehicle in India’. Journal of the Indian Institute of Science, 85 (2), 2005: 83. Maini, Chetan Kumaar. ‘REVA electric car: A case study of innovation at RECC’. International Journal of Technology Management, 32 (1–2), 2005: 199–212. Mampatta, Sachin P. ‘How time flies: In 1947, a ticket from Delhi to Mumbai cost more than a gold coin’. Live Mint, 16 August 2017. Mann, Anupama, and Tridib Banerjee. ‘Institutions and megaprojects: The case of Delhi metro rail’. Environment and Urbanization Asia, 2 (1), 2011: 77–91. Mohile, Shally Seth. ‘Yulu Bikes looks to hitch a ride on the fast-expanding e-commerce segment’. Business Standard, 28 July 2021. Pandit, Deepak, Maheshkumar P. Joshi, Arun Sahay, and Rajen K. Gupta. ‘Disruptive innovation and dynamic capabilities in emerging economies: Evidence from the Indian automotive sector’. Technological Forecasting and Social Change, 129, 2017: 323–29. Piramal, Gita. Kamalnayan Bajaj: Architect of the Bajaj Group. New Delhi: Kamalnayan Bajaj Charitable Trust, 2015. Rajvanshi, Anil K. ‘Electric and improved cycle rickshaw as a sustainable transport system for India’. Current Science, 83 (6), 2002: 703–07. Ramachandran, M. Metro Rail Projects in India: A Study in Project Planning. New Delhi: Oxford University Press, 2011.
Singh, Y.P. ‘Performance of the Kolkata (Calcutta) Metro Railway: A Case Study’. In Proceedings of the 10th International CODATU Conference, 2002, 337–42. Sinha, Yashwant. Confessions of a Swadeshi Reformer: My Years as Finance Minister. Delhi: Penguin India, 2007. Startuptalky.com. ‘YULU: Environmentally viable mode of transportation for the last mile’, 25 November 2020.
Information and Communication Technologies The information and communication revolutions started in India in the 1980s and 1990s, fuelled by technological innovations, novel policy frameworks and unique application of technological advances. These developments laid the path to the software revolution and the mobile revolution as the country was at the cusp of the new millennium. A landmark innovation in this sector was the use of satellite communication for distance education via direct broadcasting, which was to later take the shape of Direct-to-Home or DTH broadcasting. The innovation of STD PCO in the 1980s and its later avatar of the internet kiosk propelled widespread dissemination of new information and communication technologies without the need for people to own a device (a PC or a phone). While the software business and outsourcing of software services had begun in the 1980s, what led to the exponential growth in software exports in the 1990s was a government scheme called the Software Technology Parks. The mobile revolution in the new millennium spawned novel applications like ‘missed call marketing’ and ‘Chota recharge’ to cater specifically to price-conscious consumers. New technologies also found applications to suit existing social customs and behaviours like matchmaking.
41. Satellite Instructional Television Experiment (SITE) Arthur C. Clarke, the legendary science fiction writer and futurist, called it the ‘greatest communications experiment in history’. For India’s space visionary, Vikram Sarabhai, it was a dream project that could effectively harness space technology for human development and welfare. It gave birth to India’s first popular television programme, Krishi Darshan, and also showed the way for the television revolution in the 1990s and beyond. The reference here is to the Satellite Instructional Television Experiment (SITE) – the first large-scale demonstration of satellite broadcasting as well as educational television in the world. SITE was a forerunner of what we know today as Direct-to-Home or DTH broadcasting. In the new millennium, India is among the world’s largest markets for satellite television with hundreds of channels covering every genre of broadcasting from news and entertainment to travel and shopping, and in multiple languages. It all began with this innovation called SITE conceived by Indian and American space scientists in the 1960s and executed from August 1975 to July 1976. The plan to use satellite communication for educational television was prepared even before ISRO formally came into existence. Satellite communication was just becoming a reality in the 1960s, and Vikram Sarabhai, the founder of ISRO, was exploring how it could be put to use for development purposes rather than military applications. At the request of the Indian National Committee for Space Research (which was to become ISRO) headed by Sarabhai, US space agency NASA (the National Aeronautics and Space Administration) agreed to lend one of its future versions of the Applications Technology Satellite series for an experiment in educational television. For the project, Sarabhai put together a team of scientists, engineers, social scientists, communication experts, filmmakers and television producers in Ahmedabad. The team developed necessary ground hardware and programming software for the unique ‘education via satellite’ project, besides conducting field research. When the ATS-6 satellite became available in 1975, educational programmes were beamed from the earth stations in Ahmedabad and Delhi to the satellite which then retransmitted them directly to 2,400 villages in six states (Andhra Pradesh, Bihar, Karnataka, Madhya Pradesh, Orissa and Rajasthan). Satellite signals were received by a specially designed chicken mesh antenna installed in selected villages, and programmes could be viewed on community television sets already provided there. The programmes covered topics like health, nutrition, sanitation, occupational skills, agriculture practices and family planning, besides a special package for the training of teachers. The content was designed not just for raising awareness but to bring about attitudinal change. About 28 lakh people had access to the community television sets and over 24,000 teachers were trained. The morning broadcast of 1.5 hours was meant for school children, while the evening transmission was for 2.5 hours, which also included entertainment programmes. Direct broadcasting under SITE happened at a time when the rest of India did not even have terrestrial television. This was the first time most people saw a television set in their life. One of the biggest technological takeaways of the project was the feasibility of beaming satellite signals, using affordable and modest ground receivers. Until this point, large and expensive ground infrastructure was needed for satellite communication. As satellites became more powerful, the size of the receiving antenna progressively kept shrinking. In effect, SITE established the viability of direct satellite transmission which came to be known as DTH.
For the government and policymakers in India, the experiment provided evidence that space technology could be utilized to address some major challenges, such as illiteracy, backwardness and lack of development. The successful execution of SITE encouraged the government to fund an ambitious programme of developing a communication satellite system, INSAT or the Indian national satellite system. However, the traditional approach of terrestrial transmission won the day when the question of expanding the Doordarshan network came up in the early 1980s. Instead of direct broadcasting, INSAT satellites were deployed for relaying programmes to ground-based transmitters for amplification and redistribution. Direct satellite broadcasting and DTH became a commercial reality a decade later, only after the monopoly of Doordarshan ended in the post-liberalization years. Key People Under Vikram Sarabhai, India’s space programme took roots in the 1960s with the establishment of the Thumba Equatorial Rocket Launching Station (TERLS) and planning had also begun for developing bigger launch vehicles indigenously. Sarabhai’s objective was to deploy space technology as a tool of national development, and SITE fitted very well in this framework. He believed in technological leapfrogging and not a step-by-step approach. It was audacious for Sarabhai to propose the use of space technology for television broadcasting and education in villages in a country that had no satellites or rockets, no television manufacturing and no electricity in villages. When SITE was being planned in 1969, only 7,000 Indian homes had a television set as television broadcasting was limited to Delhi. Given his clout within the government and personal rapport with Prime Minister Indira Gandhi, Sarabhai could get the go-ahead for the project, overcoming opposition from other government departments. The work on the project was initiated following an agreement with NASA, but Sarabhai did not live to see it become a reality, as he passed away in 1971. While Americans agreed to make the satellite available, the ground segment had to be developed by Indians. The Experimental Satellite Earth Station, established with help from the United Nations Development Programme (UNDP) in Ahmedabad, was upgraded to transmit signals to ATS-6. The task of developing receiving antenna and peripherals was entrusted to the newly formed Space Applications Centre (SAC) in Ahmedabad. Professor Yashpal, a physicist from TIFR was made the first director of SAC. He led the effort to develop a chicken-mesh antenna (it was a large parabolic dish of three-metre diameter), front-end converter and modified television set for receiving signals directly from the satellite. He was pivotal in introducing science education as part of the content developed for SITE. Since villages either had no schools or if they had one, there was no science laboratory, Yashpal told producers to make programmes explaining science in a way that children could relate with whatever they saw in everyday life – science in kitchens, farms, village ponds, kite flying, cycling and so on. E.V. Chitnis, who was associated with the space programme right from its inception in 1962, was the programme manager of SITE and was responsible for achieving cohesion in the work of software and hardware teams. 42. Software Technology Parks India is recognized globally as a major player in software development, IT services and business process outsourcing. The total revenue from this sector was estimated to be 191 billion dollars during 2019–20 – and of this, exports accounted for 174 billion dollars. The industry contributes substantially to the country’s gross
domestic product (GDP) and provides direct and indirect employment to millions of people. The IT industry has given India an edge in the emerging knowledge economy. Till the 1980s, India mainly exported gems and jewellery, leather goods and spices. It lacked the basic infrastructure necessary for physical exports – roads, ports, airports, manufacturing skills and conducive policies as well as duty structure. For such a country to become a knowledge exporter is nothing short of a miracle. One of the key factors that catalysed the transformation was an innovative government scheme called Software Technology Parks (STPs) launched in 1990. In the 1980s, several software development firms were floated by entrepreneurs in Bangalore, Hyderabad, Pune, Mumbai, Delhi and other cities. However, software development and exports were herculean tasks for them. Import duties on computers needed for developing software were very high, the internet was non-existent and data communication was a government monopoly. When data transfer via satellite links became technically feasible it was prohibitively expensive and needed a plethora of licences and permissions. In the early years, companies exported software in floppy discs, a practice that was very risky as data would often vanish or get corrupted when floppies were passed through scanners at airports. American customers were not willing to let Indian software firms have their hardware prototypes for developing programmes as they feared technical details could get leaked. The other option was to go and work at the client’s premises. To overcome these hurdles, the government permitted setting up private technology parks, allowed software experts via satellite links, and gave tax concessions for software exporters in 1986. All this still was of little help to small and medium enterprises as they could not afford earth stations and satellite links. This led to a revolutionary idea – state-run technology parks to provide all infrastructure facilities including satellite communication for private companies. The first set of three STPs came up in Pune, Bangalore and Bhubaneswar, which were later merged in June 1991 into a single autonomous society called Software Technology Parks of India (STPI). Many of the companies exporting software worth billions of dollars now were incubated in these STPs. The idea of the STP transformed the role of the state from being a regulator to that of a facilitator for the benefit of the private sector. To insulate the scheme from the government rules, unlike other export-promotion schemes, the STPs were made into autonomous societies and were governed jointly by officials and entrepreneurs. An STP was not meant to function as a government department. Small software firms got all the facilities they needed under one roof – single-window approvals, data communication links, core computing facilities, built- up areas, video conferencing and so on. All this was a big deal in the pre-internet era – at a time when there was a waiting period even to get a landline telephone. STPs could make offshore software development possible. As a result, software exports from STPs recorded exponential growth in the 1990s and gave birth to dozens of billion-dollar software companies. The number of STPs has grown to over fifty across the country, and it has helped in the growth of technology clusters like Bengaluru, Hyderabad, Chennai, Noida and Pune. In 2020, almost half of software exports took places through units located in STPs. The idea has been replicated in many developing countries. Key People The idea of technology parks to promote knowledge-based industries and R&D first figured during a discussion Prime Minister Indira Gandhi had with Indian entrepreneurs and experts during her visit to the US in 1982. At this meeting, Sharad Marathe, a young entrepreneur, suggested that India could leverage its technical and engineering strength for export promotion by setting up a special enclave on the lines of the Research Triangle
Park functioning in North Carolina. This, he felt, should be a privately owned and duty-free zone as opposed to government-run export processing zones already functional in Mumbai and Noida. Indira Gandhi accepted the idea and three companies, including Marathe’s, were permitted to develop technology parks. N. Seshagiri, a forward-looking technocrat in the Department of Electronics (DoE) – mooted a similar idea to boost software exports. He had carried out experiments to see the feasibility of highspeed data links for software exports. He suggested that the government could set up such links for software companies since the telecom department and the Ministry of Home Affairs were unwilling to provide such links for private companies. This culminated in the idea of a government-run STP where satellite earth stations were established and run by the government for the benefit of software firms. Another key person who shaped and nurtured STPs in their formative years was N. Vittal – first as secretary of DoE and later as secretary of the DoT. Fledgling software firms like Infosys Technologies, Wipro Infotech, Satyam and BFL Software were among early beneficiaries of the scheme. G.S. Vardan, a technocrat who had worked with the Electronics Commission, was the first director of STP, Bengaluru. In later years, B.V. Naidu steered the software parks at Bengaluru and Hyderabad and was instrumental in facilitating data communication for STPI units. 43. STD/PCO For many decades after Independence, the telephone remained a luxury in India. One had to wait for several years to get the connection of a landline phone for one’s office or home. Telephone subscribers had to book trunk calls through operators in the telephone exchange and it could take a few hours for a long-distance call to materialize. In the 1970s and 1980s, telegraph offices introduced phone booths to let people make intercity calls, using the newly introduced STD (Subscriber Trunk Dialling) facility. Coin-operated public phones were installed at a few strategic places in urban areas, but they would often be vandalized or functioned poorly. They were unsuitable for making STD calls as one needed a large number of coins. In any case, rural areas had no such public phones at all. The overall penetration of phones was abysmal as the supply could not keep pace with demand, the provision of telephone services being a government monopoly. Only a couple of public sector companies manufactured telephone instruments, so they were always in short supply. All telecom switches or telephone exchanges had to be imported. A single policy decision in 1985 changed all this. It allowed the setting up of STD/ISD (International Subscriber Dialling) phone booths on a franchise basis. Instead of the DoT setting up public phone booths, it was decided to allow private individuals to do so. This led to a proliferation of STD/ISD public call offices (PCOs) in the country. People could make calls and pay in cash to the person running the PCO and for each call made, the PCO owner got a 20 per cent commission. These booths worked round the clock, unlike those in the telegraph office. They were located in residential areas, business districts, highways, bus and railway stations, and very close to those needing the service. To make sure transparency in metering and billing, a call meter with an LED display was developed. The booths had a distinct identity – they were all painted in yellow just like red was used for public phone booths in Britain. These booths became a source of livelihood for millions of people. While selecting franchisees, preference was given to women, persons with disability, army veterans and others, who usually developed a small business around their booth. In rural areas, people also used STD booths to receive calls. For millions of Indians, these booths were the first introduction to telephony. The STD PCO was a frugal innovation suited for Indian conditions, compared to costly and sophisticated options such as card-operated payphones. It was also a clever way to bypass the government monopoly in
telephony. Given political and other factors like opposition from trade unions, the entry of private players in the provision of telecom services would have been impossible in the 1980s. The STD booths operated by private franchises only privatized the interface between users and the telephone service. It allowed the Telecom Department to expand its services rapidly in both cities and villages without giving up its monopoly. The booths in rural areas benefited from superior services made possible by the rural telephone exchange developed by the Centre for Development of Telematics (C-DOT). Within a decade, the country had two million PCOs across the country, boosting access to telephone services as well as creating jobs. Key People Sam Pitroda – the founder of C-DOT– was behind the idea of the STD PCO. In a country like India with a very poor telecom infrastructure, he argued, the focus should be on increasing access and not so much on increasing telephone density. He pointed out that though the government had a scheme of providing a village telephone in every panchayat, the phone would often remain locked in the house of the sarpanch and was not accessible to people. Pitroda proposed that public access could not be achieved with Western-style coin-operated public booths but with manned public phone booths. Coin-operated phones were expensive to make, install and operate, while STD PCOs used regular phones connected with a meter. The innovation dramatically enhanced telephone access and also created two million new jobs. As the concept demonstrated the clear utility of phones for the common people, it became easier to privatize telecom services in the 1990s. ‘We were not thinking of industrial progress at that time. We were thinking about connecting India from the bottom-up,’ Pitroda wrote in his 2015 biography. The legacy of STD booths continued even after mobile telephony spread in rural areas subsequently. These booths got transformed into internet kiosks, cyber cafés and community information centres offering a plethora of services to people. These innovations also spread to several countries in Asia and Africa. 44. Internet Kiosks When commercial internet services were first introduced in India in 1995 by the country’s only designated internet service provider – Videsh Sanchar Nigam Limited (VSNL), very few people could make use of it. To access the internet, one needed a device (a desktop computer or personal computer [PC]); a requisite software interface and a communication link (which then meant a wireline phone as wireless access was not yet commercial) and additional hardware like a modem. The PC penetration in the country was very low and getting a landline phone in any case was still a tall order. All this limited the access and affordability of the internet in both urban areas and villages. In response to this emerged a solution – shared public access to the internet known as the cybercafé in cities and the internet kiosk in semi-urban and rural areas. This allowed people to access the internet and online services cheaply and without owning a PC, modem or paying for a dedicated connection. The concept was similar to that of a privately run phone book or the STD/ISD PCO, which people were familiar with for making long-distance and local phone calls without owning a phone.
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