India

Health is a major issue in India. The COVID19 pandemic made clear that India’s response capacity and capabilities to a growing more structural demand needs a shot in the arm. The enormous economic impact of the pandemic confronts India with the need to deliver basic public health infrastructure for the poor. A fast growing middle class looks for care provision in the private domain.  

Reforms and investments
India aims to improve the access and the quality of healthcare. The national government is implementing a health insurance scheme for 500 million people. Plans for logical and proportional care provision have been developed. In addition to a fast growing national government spending (fiscal year 21/22 budget increase of 137%), a World Bank loan of US$ 1 billion was granted for health related pandemic response and structural investments in the provision of care in India. In addition to/ as part of infrastructural investments, India tries to leapfrog bringing health to the last mile through low cost-high impact digital solutions. In some areas the pandemic worked as an accelerator for e-health applications (like e-pharmacy).  As health is a state/decentralised competence, abovementioned positive preconditions do not result per se in swift and smooth implementation at state level. Main challenges remain in having the right medical staff with the right qualifications at the right place. 

The pandemic has accelerated the adoption of digital technologies, including telemedicine, creating a scope for emerging digital health solutions. An increasing number of consumers are using online consultations and remote-solutions. Healthcare is slowly being shifted from hospital to home care. More health and wellness initiatives are organised in home-settings, resulting in a change of care pathways. 

Overall there’s a lot going on in India, in the public and the private domain, in care provision, in financing, in the demand for care. Increased governmental spending, roll out of massive insurance schemes, implementation of digital platforms. Also in the private domain the Indian health care provision is growing rapidly. When indicating market options, it is paramount to keep in mind healthcare market in India differs from a western market. Western companies tend to focus on value capture, companies in India rather focus on scale, size and market share.

Digital
India’s health sector is highly fragmented in terms of financing, governance, the provision of healthcare but also in terms of alternative systems of medicine and quality of care standards. However the Covid pandemic has resulted in a more centralised approach. The Indian government is striving towards more integration/convergence, connecting the dots and building on data driven continuity of care. To achieve this the Government of India launched Ayushman Bharat Digital Mission - ABDM (formerly known as National Digital Health Mission (NDHM)). The Ayushman Bharat Digital Mission is in essence a national digital health architecture, defining roles and outcomes. Translating this architecture into daily life care provision (and in public health data) will be the main challenge ahead, for all stakeholders in the health domain. Indian government understands it will need private sector to build a robust health infrastructure. An open API-approach (e.g. using a sandboxes) enables good ideas to be integrated and validated, whilst working within the framework as defined by national government. This means the coming years substantial investment will be needed (in budgets, in manpower but in particular in clever solutions) to migrate hardware and software and data towards this new digital reality.

ADBM is envisioned to be a complete digital health ecosystem with four key features — National Health ID, personal health records, Digi Doctor and health facility registry. At this moment a national registry for 800.000 doctors, 1 million pharmacies, 60.000 hospital is being build. A national Health ID is being rolled out, allowing (in time) every Indian to manage his health data. At a later stage, it will also include e-pharmacy and telemedicine services, regulatory guidelines for which are being framed.

Implementation is however a Herculean task and the market is not waiting for this gradual process to complete. For any market player, the ability to scale up, agility and an ambition to set the standard is therefore an important condition for long term survival in this turbulent market. Main challenges will be a lack of (semantic) interoperability, big volumes of patients lacking basic (digital)health skills/education, major staffing issues at healthcare providers and complex data migration.

Pharmaceuticals
India is the largest provider of generic medicines globally, occupying a 20% share in global supply by volume, and also supplies 62% of global demand for vaccines. India ranks 3rd worldwide for production by volume. In value share India is dwarfed however by many other countries. The Make in India motto of the Modi-government, the global awareness to act towards supply chain resilience and Indian pharma giants ambition to climb the value ladder, will lead to substantial shifts in the production and supply of pharmaceuticals worldwide. For the Netherlands (home for the European Medicines Agency) in particular the stakes in this shift are high. With India’s role as a global manufacturing hub for (bio) pharma and vaccines and its growing strength in innovation, opportunities for partnerships surface, where players from both countries work together and leverage each other’s strengths for new product development. Co-creation is essential for success. India’s national biopharma mission will help drive partnership opportunities by stimulating the translation of research into viable products, supporting clinical validation, boosting collaboration between academia, and give an impulse to the country’s entrepreneurial ecosystem. Substantial governmental investment schemes aim to re-locate API-production to India and boost efficiency of existing pharma parks. A drive towards clean and or sustainable production will prove inevitable but is at the moment in an embryonic stage.

NL has long and excellent reputation in vaccine development. Our ambition is to further build on this relation and support market access of Indian developed vaccines in the EU market. For Indian vaccines & pharma companies, the Netherlands is the gateway to Europe. To expand their business in Europe Sun Pharma has opened an office in Amsterdam. Bilthoven Biologicals was established by the Indian Cyrus Poonawalla Group. The company is the biggest vaccine producer in the world, is a major player in the production of COVID19-vaccines as well and intends to move upwards in the value chain. Janssen COVID19-vaccine was developed in NL and partnered with Biological E for mass production in India.

From the perspective of the Netherlands the following market trends are of interest:

E-health and data

• Affordable mobile healthcare solutions; Point of care diagnostics, remote monitoring, data systems for microbiology labs

• AI based solutions to support medical decision-making and treatments (in tertiary private cure settings)
• Health management systems/IT architecture: Interoperable digital platforms to exchange data (patient2doctor, lab2 doctor, doctor 2 doctor, lab2 public health), implementation support

Public health & health care provision

• Establishment of 150.000 primary health care and wellness centers (HWCs), including staffing, establishment of medical colleges all over India, particularly in Tier II &III cities
• Hospital build in the tier-II and III cities via the public-private-partnership (PPP)
• Skills development and training of medical staff

• Child and maternity health as a political priority area
• Digital infrastructure and applications

Vaccines and therapeutics

• National Bio Pharma Mission
• Clinical trials & Contract research, manufacturing & development partnerships 
• Process optimisation and quality control, supervisory mechanisms

India’s National Action plan on AMR (One Health)

• The Government of India has formulated a National Action Plan to tackle AMR (NAP-AMR), largely modelled on the World Health Organisation's Global Action Plan on AMR.
• With plans for bulk API-and KSM-parks in India, clean production methodologies and processes need to be the standard. Stakeholders such as Access to Medicine foundation, Centrient, are exploring international partnerships that addresses sustainable production of antibiotics

Regional priorities

Life Science and Health related R&D is concentrated in Delhi, Bangalore, Pune, Hyderabad and Chennai.

The Dutch interest in India is substantial. Each year multiple trade missions from the Netherlands to India are organised. In 2018-2019 RVO has dealt with 161 India related requests from Dutch organisations that are active in the LSH sector. From 2020 to October 2021 87 requests have been received. Prominent Dutch multinationals that are operating in India are Philips, Elsevier, Stradus BV, Swymed, DSM and Danone-Nutricia. When looking at Dutch knowledge institutes Maastricht UMC, Erasmus MC, Joep Lange Institute, Leiden MC, Wageningen University are active in India. The majority of Dutch companies can be found in the category of small and medium sized businesses. 

Most prominent NL value chains

1.     The Digital Transformation of Health and Care and Accessible Medical Technology for Sustainable Health and Care: Growing market opportunities in India, combined with the Netherlands’ strengths in areas such as Digital Health, Medical Devices and Diagnostics, create opportunities for partnerships that address shared societal challenges with smart solutions. India’s growing focus on technology and entrepreneurship combined with its recent improvement in investment climate make it an increasingly attractive partner.

• Demonstrated (or expected) impact and activities:
  • Philips Innovation Campus Bangalore (a.o. Digital health platforms & AI) and Pune Healthcare Innovation Center (a.o. made in India cathlab)
  • 2010 & 2016, NWO – DST (5 projects) & NWO -DBT (3 –projects) focused on affordable medical devices
  • 2018 NL-India GlobalStars call  - Eindhoven Robotics, Radboud UMC, CMC Vellore & IIT Madras partner on spine surgical systems
  • 2018 Imaging partnership MUMC+ and NCCS pune
  • NWO – MEITY Calls – Bionic (2014) & Train (2019) projects – Bigdata approaches to cancer (a.o. Maastricht UMC, Tata Memorial, CDAC, Philips & HCG)
  • Swymed & Piramal Swasthya – Digital Health Backpack and Platform partnership
  • MoU between Microsoft India, Apollo Hospitals, Maastricht University, which will help expand AI Network for research on cardiovascular diseases in NL & develop an India-specific heart risk score for better prediction of cardiac diseases for the general population
  • Health in Slums project with is a joint initiative between Maastricht University and Zuyd University of Applied Sciences and Indian stakeholders
  • The Reverse Diabetes project with Joep Lange Institute and Indian stakeholders
• Potential opportunities:
  • The affordability and accessibility of healthcare is a theme where our countries have excellent opportunities for partnerships that address unmet needs of patients and doctors, improve lives, and help open new markets together. Private hospital groups and innovative Indian companies have shown enthusiasm for partnering and governments are willing to stimulate new partnerships.
  • Enhancing the underlying data infrastructure/governance, to connect data, systems, information and persons in a convenient, safe and secure way, in private and the public domain. The Dutch Health-RI approach and Personal Health Train concept based on FAIR principles could be illustrative for strategic cooperation for setting up India’s health data infrastructure.
• Barriers: difficult to enter the market, not transparent, local competition, low prices/reimbursement, legal regulations, challenge to capitalise on the opportunities of the private market
• Preferred region(s): Delhi, Bangalore, Hyderabad, Mumbai

2.     One Health and Biopharma.

With special focus on AMR, vaccines and therapeutics.

• Demonstrated (or expected) impact and activities:
  • The HOOKVAC India Partnership (HIP) of AIGHD
  • OneHealth AMR project in Andhra Pradesh (Krishna district) under the MoU between India and Netherlands: The project is in line with the objectives from the Indian National Action Plan: improving awareness and understanding of AMR through training (of professionals); strengthening knowledge and evidence through surveillance; reducing the incidence of infection through effective infection prevention and control; strengthening India’s collaborations on antimicrobial resistance at international, national and sub-national levels.
  • 2018 NL-India GlobalStars call – Inpochlam (Biospark & Shuats ) & Exoliv (Mantis therapeutics & Institute of Liver and Biliary Sciences)
  • 2018 Serum-Institute &Intravacc partnership to develop bioneedles and various other business partners between Dutch vaccine stakeholders such as Litevax and viroclinics and Indian vaccine companies.
  • 2019 Partnership between C-CAMP & AMR-Global
  • 2020 Eu-India Next Generation Flu vaccinces call: Start of 3 projects, Indigo (AIGHD, LiteVax BV, Viroclinics Biosciences BV), Endflu (University Utrecht, Curve Clinical BV) , Incentive (Academisch Ziekenhuis Leiden, Stichting Human Vaccines Project Europe). Projects support the development of a next generation of influenza vaccines aiming at higher effectivity, lower costs and better accessibility.
  • 2020 Covid Vaccine Partnership Jansen & Biological-E
  • With India we have two cohort study being executed:
    • Indo-Dutch Collaborative Program on HIV/AIDS Research: “Understanding Disease Dynamics Towards Effective Management of Prevention and Treatment of HIV/AIDS”. – executed by various partners in both India and the Netherlands including Erasmus University Medical Centre (Erasmus MC), Rotterdam, International AIDS Vaccine Initiative (IAVI), India, together with the other research institutions, with support from the Department of Biotechnology (DBT).
    • A Population Based Prospective Cohort Study ‘to Unravel the Causes of Stroke and Cognitive Decline: A cross-cultural perspective”  -AIIMS and Erasmus. Study that enhances understanding of Stroke and Dementia in Indian population and pave the way towards Precision Medicine (customisation of healthcare with medical decisions, practices, and/or products tailored to the individual patient), aim is to move towards precision medicine in the field of Stroke and Dementia (‘DNA to Dementia’).
• Potential opportunities:
  • One health and AMR are shared policy priorities between the Netherlands and India.  The rise  of Anti-Microbial Resistance is a global challenge which threatens healthcare as we know it. The Netherlands and India take this global challenge seriously and are actively working together in an effort linked to India’s National Action plan on AMR. The Bilateral pilot in AP is a first start, additional opportunities are being identified in Poultry, Aquaculture, Sustainable Production of Antibiotics, Sensoring & Detection and management & treatment of Effluents. Stakeholders such as Access to Medicine foundation, Centrient, are exploring international partnerships that addresses sustainable production of antibiotics & Stakeholders such as Water Institute KWR, and various sensor companies are focused on detection in food products, waste streams and the environment. 
  • AMR Global and C- Camp (Centre for Cellular and Molecular Platforms) propose an WAH! accelerator program that promotes innovations that follow a One Health approach, e.g. a collaborative, multisectoral, and multidisciplinary approach-working at local, regional, national, and global levels -with the goal of achieving optimal health outcomes that recognise the interconnection between people, animals, plants, and their shared environment.
  • The Netherlands and India have strong historic ties in the area of vaccines. Netherlands has a strong footprint in vaccine research/development and a substantial biologicals manufacturing capability. India is a powerhouse of large scale manufacturers of vaccines and pharmaceuticals and a fast growing pharma research capacity, moving more and more from generics to new and complex therapeutics development. India and the Netherlands are the perfect partners for joint research and development with a high potential of bringing successful developments based upon previous experiences in the vaccine sphere, joint research and improving the supply-chain for vaccines in India
• Barriers: often long term projects, many depending on external funding
• Preferred region(s): Vaccines: Hyderabad & Delhi and Pune. Therapeutics: Bangalore

Overview milestones & flagships

• G2G (MoU, state visits)
• Trade (PIBs, Market study E-health (2020)
• Research and Innovation (ecosystem connections, joint R&D projects, specific bilateral calls)
• Invest (significant investments in the Dutch LSH sector)

Collective Activities to India

2017

• Visit of Prime Minister Modi to the Netherlands

2018

• February, Innovation Mission to India: Vaccines
• March, eHealth mission to the Netherlands, organised together with RVO, Nuffic Neso and SIA
• May, Trade Mission to India (Delhi, Bangalore) with Minister Bruins.
• July, India and Belgium (Flanders region), Netherlands, Spain and United Kingdom launched a common Global Stars India call in the field of ‘One Health’ in July 2018.
• September, Incoming delegates from India for the physical edition of the Health~Holland Visitors Programme & World of Health Care. 

2019

• June, Innovation mission to India on Digital health (Delhi, Mumbai, Bangalore)
• July, Incoming delegation on vaccines
• September, Incoming delegates from India for the physical edition of the Health~Holland Visitors Programme & World of Health Care
• October, State visit and Trade Mission to India (Delhi and Bangalore) with Minister Bruins

2020

• February 2020, launch of the second Global Stars India call for joint R&D projects, Key Enabling Technologies for Healthcare, Agriculture and Water
• September 2020, virtual visit to  CII Hospital Tech
• September, Incoming delegates from India for the virtual edition of the Health~Holland Visitors Programme & World of Health Care

 2021

• BDC Market study in collaboration with KPMG India and Task Force Health Care towards business opportunities in India’s public and private sector in the field of digital health, including a series of roundtables and webinars[1].
• Innovation Mission Digital Key Enabling Technologies for Water, Agriculture & Health
• Strategic round table discussions in preparation of joint WAH! (Water, Agriculture, Health) research & innovation agenda
• Roundtable discussion on the Indian Healthcare Delivery Sector and Shifting Point of Care with Nexdigm
• Pre-PPS on reduction of antibiotics in waste water from (a.o.) the pharmaceutical industry has been approved
• September, Incoming delegates from India for the virtual edition of the Health~Holland Visitors Programme & World of Health Care

2022

• September, Incoming delegates from India for the physical edition of the Health~Holland Visitors Programme & World of Health Care in Rotterdam.
• November, trade mission on eHealth with Dutch companies. Visiting New Delhi, Chennai and Bangalore.
• December, launch of the WAH! Accelerator. Partnerships in this field through the Dutch Diamond are explored, and the innovative Dutch private sector will be supported and positioned in India.
• Bilateral R&D call under the Knowledge & Innovation Covenant (KIC) Health & Care
   

The way forward

For the Dutch Life Sciences & Health sector India is a high priority country. It is our ambition to develop a Roadmap Multi annual Integral Program in the course of 2023, in close cooperation with the public and private sector, the Dutch economic network in Germany, and the Ministries of Foreign Affairs and Economic Affairs and Climate Policy.

This Roadmap builds on a number of ongoing initiatives in the India and provides for an integrated approach for the coming years. It aims to strengthen the Dutch Life Sciences & Health (LSH) sector through coordinated cooperation between industry, knowledge institutions, economic network India and Dutch government, with less fragmentation and more focus. This roadmap will be in line with the research and innovation WAH! Agenda, and integrates LSH programming and activities on trade, foreign investments into the Netherlands and collaboration in R&D and innovation. For foreign direct investments we investigate the potential of high-tech and digital health solutions that could support the goal of the Netherlands in finding solutions for better, affordable and sustainable healthcare.

• To keep
  • The regular trade missions and smaller innovation missions in a physical format
  • Sharing market insights through reports and network sessions (e.g. Health~Holland re-connect)
• To strengthen and deepen
  • Identify the business opportunities for Dutch companies to enter the public sector in the Ayushman Bharat programme and with India’s private sector
  • Explore the opportunities to kick-start the AMR global and C-Camp WAH! Accelerator Program
  • Explore opportunities for health data infrastructure collaboration
• (New) activities to be explored
  • Bilateral Heath tech platform to be explored between /India & NL with key partners such Philips, NLC, Startup India etc
  • Explore opportunities for health data infrastructure collaboration

 Preferred actions

·       Organisation of incoming and outgoing physical trade and innovation missions, where relevant in connection to high level bilateral visits. India has the presidency of the G20 in 2023, which might give the opportunity to link activities to incoming ministerial visits or the broader G20 agenda. Main topics: digital health and biopharma (vaccines).

·       Further support on how to capitalise on the opportunities offered at the private market

·       Further guidance on how to access and capitalise on the opportunities offered at the public market

·       Third EUREKA GlobalStars call for market oriented R&D cooperation projects is explored with RVO, EUREKA and DBT/DST.