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.

In chapter four, we examine the North Korean regime’s attempts to overcome its secular economic decline through the opening of trade relations with the West in the 1970s. As elsewhere in the socialist bloc, declining growth rates and superpower detente led to growing engagement with the West. However, the collapse of raw material prices in the 1970s and North Korea’s failure to export its manufactures made it increasingly difficult for the country to service its debts and, as a result, Pyongyang defaulted in the mid-1970s. Locked out of world capital markets, North Korea made some attempts to attract FDI investment in the 1980s, though these attempts were limited and largely unsuccessful. As a result of a poor investment climate and continued geopolitical instability, North Korea became increasingly reliant on aid from the Soviet Union and China. However, the collapse of the Soviet Union along with the pragmatic shift in China’s foreign economic policy in the early 1990s immediately exposed North Korea’s excessive reliance on cheap energy imports. The earlier “privileges of backwardness” possessed by North Korea thus quickly became a curse, leading to economic collapse and to mass famine. North Korea’s strong developmental nationalism along with the almost complete elimination of civil society meant instead that the country’s socio-political system was relatively impervious to the transformations elsewhere in the socialist world between 1989 and 1991.

We argue that the North Korean developmental regime can be understood as an outcome of multiple combined historical lineages, including Korea’s history of colonial modernisation under Japanese rule and the imposition of the Soviet model of catch-up industrialisation in the immediate post-liberation era. The factionalised politics of the exiled anti-Japanese resistance movement and the ultimate ascendancy of Kim Il Sung’s Manchurian guerrillas led to a virulent form of postcolonial nationalism that emphasised autonomous national development rather than enmeshment with the socialist international division of labour. Following liberation, the new state underwent a series of "bourgeois democratic reforms” including a rapid land reform that addressed longstanding peasant grievances and ensured a degree of initial popular support for the new regime. The success of the land reform owed much to the fact of national division and that many landlords were able to flee southwards. The democratic reforms also served to integrate the population into the emerging corporatist mass organisations. Understood as a process of what Antonio Gramsci referred to as “passive revolution,” this has significant implications as to the state’s ability to mobilise society around developmental goals and contain any potential opposition to the state and its project of national development.

The Indian pharmaceutical industry has played an important role in the development of generic medicines (Farmer 2001). However, whether those who are heavily dependent on the public sector benefit from this advancement made by the industry is a critical question for several reasons. First, as is well known, the bulk of these generic drugs are exported to international markets and are inaccessible in India (Swain et al. 2014). Second, the market is dominated by branded generics, which are usually priced higher than their corresponding generics (Mathew 2015). The quality of essential generic medicines that are available in the public sector has been also under question (Bate et al. 2009). The prospect of drug development in India assumes paramount significance for public health in this context. This chapter discusses in detail whether drug and vaccine development in India is responsive to the disease burden of the population, epidemiological changes and accessibility of services. To begin with, we present the data on disease burden in the country from 2000 to 2015 and juxtapose the therapeutic focus of the drugs approved for marketing, the new chemical entities (NCEs) in the pipeline and vaccines. The data on disease-specific mortality are collected from the mortality database of health statistics and information systems of the World Health Organization (WHO) for the years 2000, 2005, 2010 and 2015. These data are further disaggregated across four age groups. Data on morbidity are extracted from the National Sample Survey Organisation (NSSO) 71st round on health in India (2014). Data on drugs approved for marketing are compiled from the Central Drugs Standard Control Organisation (CDSCO), Government of India.

Causes of deaths in India: a detailed analysis

We have extracted the data of causes of deaths for the years 2000, 2005, 2010 and 2015. As Table 3.1 shows, non-communicable diseases (NCDs) constituted the highest cause of deaths in all these years as compared to communicable diseases (CDs). Furthermore, there is a steady increase in deaths due to NCDs along with a decline in mortality due to CDs in general in the line of the trend of epidemiological transition. For instance, the share of NCDs in total deaths increased to nearly 61 per cent in 2015 from 46 per cent in 2000. Similarly, share of NCDs was reduced to nearly 21 per cent in 2015 from 30 per cent in 2000. The share of injuries and accidents in the causes of death also marginally increased during this period. Table 3.1 presents the causes of death for males and females. As the table shows, the trend of dominance of NCDs was true for both males and females. However, the burden of CDs was found to be more on females than males.

The previous chapter illustrated that innovation is a process of co-production in which several institutions and interest groups involve actively. This process of knowledge production essentially is not value neutral. What is, hence, important to understand is the nature of the institutions which are involved in the co-production of innovation and their priorities. This is important in medical innovations given the mutually conflicting priorities of public health and industrial interests. As is well known, research and development (R&D), especially in the pharmaceutical sector, in its initial period was supported by government institutions, public laboratories and government grants. However, with the new patent regime the private players have started participating increasingly in drug, vaccine and medical technology development. Studies have shown that the pharmaceutical industry is one of the sectors that have high R&D spending levels (Dhar and Gopakumar 2006, Abrol et al. 2011). Studies also showed that availability of medicines and medical technology products in the market has increased significantly in India with the expansion of domestic and multinational private companies, which benefited from a facilitating industrial policy environment (Joseph 2016). However, most of the R&D activities in India remain merely a small part of the large global value chain emphasising on contract manufacturing and contract research. The focus of research in the industry, therefore, has been predominantly guided by the consideration of the Western markets (the United States and the European Union), leaving less focus on neglected tropical diseases and population (see Viergever 2013). Studies showed that only 10 per cent of domestic firms’ investment on R&D is spent on the needs of developing countries (Rowden 2013). It is, hence, not clear whether the change in the policy design, though it has increased research activity, has taken care of the public health needs of the country.

This chapter attempts to understand the disease focus of health R&D in India. It specifically examines the drugs, vaccines, medical devices and diagnostic technology R&D of private and public sector firms/institutions in India. We have extracted the data on drugs approved for marketing in India from 2001 to 2017 from the Central Drugs Standard Control Organisation (CDSCO), Government of India, to understand the therapeutic focus of drugs R&D.

This introduction sets forth the puzzle of North Korean development trajectory, namely its initial successes, its collapse in the 1990s, and its subsequent recovery since then. It engages with existing theories of development and with the critique of methodological nationalism in the field of Development Studies and International Political Economy. It argues that liberal economic and dependency theory fail to account for the specificity of the country’s experience, or indeed projects of national development in general. We put forward an alternative framework of the ‘development-geopolitics nexus’ through a reinterpretation of the global history of national development, examining three geopolitical moments that have shaped that history, namely colonialism, the Cold War, and the rise of China. The discussion of the legacies of colonialism sheds light on the emergence of developmental nationalisms in the (post)colonial world and how the material legacies of colonialism aided or hindered post-colonial development; the analysis of the Cold War sheds light on how the US and the USSR sought to facilitate late development within their respective spheres of influence; the analysis of the rise of China examines the extent to which China’s influence can be said to reflect a process of neo-colonialism or win-win mutual benefit.

This chapter summarises the aims and objectives of the book. It contextualises debates about energy transitions: why they are important and what is at stake. It accounts for the multiple drivers of energy transitions and explains what makes energy so ripe for an analysis grounded in global political economy. It sets out the structure of the book and summarises the main arguments that are made in the book.