Striking the right balance between healthcare priorities and pharmaceutical policies is a critical public health challenge for India given their mutually conflicting nature and interests. On the one hand, the country has an expanding pharmaceutical and biopharmaceutical sector with a strong presence of domestic and multinational private companies. The sector, with significant state facilitation, could effectively position itself as the future engine of economic growth by reorienting itself to the new intellectual property and trade regimes. The dominant discourse now is that ‘all publicly funded research should be translated into private entrepreneurial activities because technological innovations contribute to nation's economic growth’ (Lehoux et al. 2016b: 115). The most important outcome of this discourse is the domination of the financial logic in all matters pertaining to state facilitation, research and development (R&D), dissemination, trade and market expansion of the industry over population health. On the other hand, India has a huge burden of diseases stemming from a gamut of public health problems, including the uneven distribution of demographic and epidemiological transition, increasing privatisation of healthcare, insufficiently regulated pharmaceutical market, low affordability of life-saving medicines and, most importantly, the escalating out-of-pocket healthcare expenditure coupled with poor financial risk protection. Public health relevance of R&D in healthcare is to be assessed in the context of these conflicting concerns of health and industrial policies in India.

Challenges of responsive medical innovation

What should be the focus and priorities of medical innovations in countries like India? The simple answer should be the diverse epidemiological needs of the country across regions, income groups, age groups and gender. Unsurprisingly, what is strongly emerging from the data of growth, expansion and the disease focus of R&D across the globe in general and India in particular is the mismatch between the priorities of industry and public health. We identified five overriding patterns in the product innovations in the drug, vaccine and medical technology sectors that illustrate these mismatches in India. First is the near-complete dominance of ‘me too drugs’ (including branded generics and biosimilars) in the R&D in drug development in the pharmaceutical and biopharmaceutical sectors.