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Good evening, friends. It's a pleasure to welcome you to Summerville College this evening.

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I was very briefly at the conference yesterday. And one thing I didn't say at the time, which I think I should have said at the time,

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is that the whole ethos of Somerville College is including the excluded.

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And I think that people who have suffered from mental health problems have for far too long been excluded.

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So you are absolutely right. Place this evening to have a lecture about mental health.

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But I'm not going to introduce our principal speaker this evening.

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I'm going to ask, Go, I'm going to ask New Foundation Fellow and we are so delighted that Gopal Surinamese,

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who, as you all know, is the former solicitor general for in India.

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I'm going to ask him to to introduce this to cash out as a juror because I think it's so important this lecture and go for is just to say welcome.

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Some of this is the first time you have welcomed somebody to your college to come.

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What a pleasure. Thank you. Thank you, John.

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It's absolutely marvellous to be present here. Mr Kissel this restroom is a very distinguished civil servant.

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I had an opportunity to work with one of his predecessors, Sujata Rao.

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And in my capacity as solicitor general, I realised how important was policy and particularly in the context of public health.

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And more significantly, in the context of mental health.

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I had some role to play. In the. Downsizing of the 1987 Mental Health Act, when as a commissioner, I submitted the report,

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which led to the reconstruction of a mental health hospital in northeast called Taste Poor.

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Having said that, the importance I think of mental health is so fundamental to our existence,

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and it is not a surprise that England's chief medical officer in the 2013 annual report

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identified various groups of young people at risk of developing mental health problems.

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Children living at a socioeconomic disadvantage.

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Children with parents who themselves had mental health or substance misuse problems.

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Children who experienced personal abuse or witnessed domestic violence, or those who were excluded from school.

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Teen parents. Young offenders. And young lesbian.

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Gay, bisexual or transgender people. And, of course, ethnic minorities.

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What is important is that poverty produces an environment which is extremely harmful to individuals, families,

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communities and mental health, and the impacts of poverty are present throughout the life course before bed and into a ditch.

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And I do believe that there is something called cumulative impact on mental health, which needs to be addressed.

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I admire Mr Kirsch of disruption, although I have met him only this evening.

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The reason why I admire him is he is one of the very few civil servants who

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has been able to address what I call as cognitive dissonance in policymaking.

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He has been aware of it, and particularly how important it is that public health is not merely a project or a magic incantation,

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but is a real deliverable which adds to the quality of people's lives.

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Mental health problems are indeed the largest single source of disability in the United Kingdom.

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They account at the moment for over 23 percent of the total burden of disease.

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I want all of you to appreciate that there are no signposts all of us can

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suffer at some point of time in our own lives or in the lives of our dear ones.

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Mental health problems. They are indeed very significant, and they must be addressed.

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They must be addressed. I think not only in terms of education awareness, but most importantly, destigmatize issue.

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And I also believe that apart from these stigmatisation,

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there is so much of scope for new therapeutic curriculum, which should be introduced in schools.

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A lot of the work in India, particularly in the public health sector and in the public space,

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which Mr This Raj has written about is indeed available in the public domain.

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But what he has crafted out are actually ground level experiments and the ground level experiments,

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which are translated into real deliverables, make his work extremely significant.

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I said on behalf of Somerville College and the principal, extend you a very special welcome.

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And having had the privilege of worked with very distinguished civil servants in the government who have

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contributed so much to society and to thought and who are not merely the last levels of Whitehall's,

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I'm sure we are all looking forward to an evening of stunning disclosures.

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Thank you. Barrenness, royal friends.

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I'm delighted and honoured to be asked to give this lecture.

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Several people have made this possible. And I'm grateful to Dr. Pamela Webster.

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Dr. Facilitated and Ajani Dr. Annika Koestler, Dr. David Geller.

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For their kind invitation to meet. I'm particularly grateful to Mr. Gore possible venue for this very, very kind words of introduction.

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It is a very great honour. In calling the stock issues in public health in India, my intention is quite simply,

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just to identify those issues which have a bearing on the health and welfare of a very large population.

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There are many complications in this and regional variations.

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I will say something about this weather and disease burden. Health infrastructure.

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Health. Human resources. And there are also many, many implications in India, given India's federal structure,

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where the primary constitutional responsibility for health care is that of the states.

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Even if a not insignificant share of public spending on health care is by the central government or.

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By state governments using funds of the central government. And clearly, these issues will need to be addressed in a sensible and coherent way.

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Inefficient health systems ought to be built. Now, this talk comes at the end of a very interesting two day conference.

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On mental illness and mental health. But while there are very many critical issues.

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At the heart of a mental health policy or programme.

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It is essential that these issues are understood within the context of the health of the people, the public health context.

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There can be no mental health without public health. This would apply to other areas of discussion.

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It's very easy to go into silos and talk about malaria as the only thing that happened,

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what drove what you were closest, as though that was the only thing to address. But but that cannot be so.

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And so, as I said, there can be no mental health without public.

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Now, a good place to start is to look at what has gone wrong in a recent piece entitled Archives of Failures in Global Health.

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Professor Medical Pie of the McGill University looks not at the dramatic successes with which we're all familiar,

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but at failures areas where the global health community and individual governments have been either unable or unwilling to make a difference.

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And several of these failures identified by him relate specifically to India.

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These include India's failure to invest in Health India's premature declaration in 2005,

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leprosy elimination and India's failure to address child malnutrition and stunting.

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There are also situations where India is not alone, but where there is recognised shortcomings,

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such as the failure to deliver on the promises of the Alma-Ata Declaration of 1978,

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the failure of the Global Malaria Eradication Programme, the failure to achieve the Millennium development goal on maternal deaths.

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The failure to address the non-communicable diseases epidemic.

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The weakening of the campaign to end AIDS by by 2030 and the failure to address global mental health.

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So there are areas which are specific to India and areas where India is part of the community of nations.

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But the overall team being a failure at this very sorry list gives a good outline of the range of India's public health issues.

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One very striking feature is the continued prevalence of communicable disease,

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along with the rapid increase in the spread of non-communicable diseases in a country where maternal and infant mortality are still unacceptably high.

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I mean, there are people here from many disciplines. All of you will recognise if you work on India,

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that India is forever in a stage of transition and this is more true of public health as it is with other areas.

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Several developed countries have reduced maternal and infant mortality and also brought communicable disease under control.

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This allows them the resources, the space to address the threat of non-communicable disease.

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India does not have this luxury if we have successfully eliminated smallpox and polio.

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We are still fighting malaria, tuberculosis, leprosy, aids and a string of water rather sadly called neglected tropical diseases.

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This is actually is a recognised W.H. Attempt. None of this is actually new alma mater,

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the Conference on Primary Health Care 1978 urged that governments have a responsibility for the health of their people,

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which can be fulfilled only by the provision of adequate health and social measures.

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This was 40 years ago.

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I don't know how to recognise the importance of promoting preventive curative and rehabilitative services of nutrition and safe drinking water,

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public health, education, access to drugs, immunisation, family planning, maternal and child health.

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Most importantly, it recognised the need for health, human resources and went into some detail.

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Health workers, including physicians, nurses, midwives,

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auxiliaries and community workers as applicable, as well as traditional practitioners as needed,

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suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.

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So we've people we've known this for a while, and I think it's important to remember that this has always we know that.

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Now, I've been talking about communicable disease, the bird disease burden.

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I would like to say here the public health policy and practise in India has traditionally been driven by communal communicable disease.

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The very early developments in the public health policy related to drainage hygiene sanitation.

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Basically, the attempt being to control the spread of communicable disease.

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And there have been very significant achievements in the past and most recently in the case of polio,

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where it's now been over seven years that we have not had an incidence of the wild polio virus now.

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India's polio campaign was a combination of financial resources, superior technology, dedicated manpower.

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But we have not had comparable results in routine immunisation where you India figure average is still only 62 percent of approximately 20,

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somewhere between 27 and 28 million babies are born every year in India.

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On 62 percent of them, get the full round of nine shots in the first nine months or double digits, so this is right.

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It's it's better than what it was like so much else in India, but it's still not good enough.

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So. Malaria and other vector borne diseases as dinghy still a major public health challenge.

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We have seen a reduction in the number of cases, but 94 percent of Indians one point to five Britons are still at a risk of malaria.

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And our government has set a target of elimination of malaria by 2030.

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It's a similar situation in tuberculosis, where India still contributes 25 percent of the global burden,

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with an estimated 2.8 million new cases, new cases, two point eight million new cases in 2018.

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Off this about.

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2.8 billion with the new cases in 2018, the total number of persons living with tuberculosis was 28 million incidents and almost 28 million,

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about 1.4 1.5 million almost are afflicted with drug resistant tuberculosis.

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The situation,

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which has arisen almost entirely because of unregulated treatment by private providers and if India is to achieve elimination of tuberculosis by 2025.

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Which is a much publicised objective. Very much more needs to be done.

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We must also recognise the major threat of non-communicable diseases, diabetes, cardiovascular disease, cancers.

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For many years, India, with the rest of the world,

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believed the non-communicable diseases such as hypertension and diabetes would result in inappropriate diets in high income countries,

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and we now all know that this is not so.

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We now know more realistically the diabetes and hypertension, as also cancers and mental illness have comparatively little to do with incomes.

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Much more to do with the known risk factors of tobacco.

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The uncontrolled use of alcohol, the lack of exercise and poor diets.

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India, which moved the global mental health resolution of the World Health Assembly in 2012,

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has consistently called for a recognition of the fact that mental illness must be regarded as one of the major non-communicable diseases.

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W.H.O. has now agreed to this, but this is a very recent admission.

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Approximately five percent of India's population is believed to have common mental disorder with a further 1.5 percent with severe mental disorder.

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This translates into about 80 million persons, which is a staggering number by by any account.

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In particular, while all continue, all noncommunicable ailments need continuous and regular treatment over the life course.

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The stigma surrounding mental illness makes it all the more difficult for appropriate measures to be taken.

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India's Mental Health Policy of 2014 and the Mental Health Care Act of 2017 laid down very salutary principles which placed the interests

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of persons with the illness of before and not necessarily the interests of families or guardians or of treating psychiatrists.

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It is a legislation that recognises the rights of persons with the illness to appropriate treatment,

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which I believe was a very major move in a country where the rights to health care itself is not properly understood.

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Other diseases, whether communicable and non-communicable may affect smaller number of persons,

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but in a country of India's size is still add to the burden of disease.

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These include rheumatic heart disease, leprosy, thalassaemia, sickle cell anaemia,

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congenital disorders and accidental deaths, especially road traffic deaths.

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So the numbers add up very substantially.

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Now, having spoken about communicable and non-communicable diseases, we need to look also at maternal and infant mortality,

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and while numbers do not tell us everything, we must still know what they are and.

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Despite its magnificent efforts, largely driven by government, maternal mortality nationwide is still at 142 deaths per 100000 births.

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We were not successful in reaching the Millennium Development Goal target, 209 deaths by 2015.

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Now the sustainable development goal of this disease now requires us by 2030 to

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reduce global maternal mortality ratio to less than 70 per 100000 live births.

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As I said, we had 142. We need to get to 70 now.

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Interestingly, many states and India have already achieved this care of 61 modest 68 promenades of 79.

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But there is also Rajasthan, a 244 interpretation 285.

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And assignment three. So whether at the national level, we will achieve the sustainable development goal.

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It's great it's out there at this point of time. Now let me also say infant mortality.

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Infant mortality requires us by 2030. Sustainable Development Goals require us to reduce by 2013 infant mortality to 12 deaths, 1000 live births.

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We are currently at thirty nine and we have 10 11 years to get from thirty nine to 12.

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As I said, we. The last published figures with 41 in 2015 is believed to be around 39 now.

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Here again, Canada is already at Rhode Island after 23 and Delhi is at 26.

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But with what is 66 by reputation, 69 and asylum at 73.

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It's it's a very, very wide variation. The chances that we will meet our targets.

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Again, it's very hard to say, you know. Now, these numbers indicate the size of the challenge, but what they conceal are the details.

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It is true more women and infants are surviving the trauma of childbirth.

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But not much else is changing in their lives. Women continue to be underweight, anaemic,

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married too early or becoming mothers too early and now giving and are giving birth to underweight babies at the risk of wasting and stunting.

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The Lancet has recently called attention to the fact the malnutrition was the predominant

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risk factor for death in children under five in every state of India in 2017,

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accounting for 69 68 percent of under-five total under-five deaths.

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There are. The additional details are grim. The prevalence of low birth weight in India,

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twenty one point twenty one point four percent of all births and I said so somewhere between 27 and 28 million births every year.

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Twenty one percent of these low birth weight 39 percent stunting 15 percent, wasting 59 percent anaemia in children.

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Now.

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And many of you would know very recently, the 2019 Global Hunger Index places India to rank of 102 out of 117 countries, 102 the worst in South Asia,

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the worst in our neighbourhood Bangladesh, Pakistan, Nepal, Sri Lanka, Myanmar are all ahead of India on this list of global hunger.

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So these are these are very, very. These are very significant and important figures.

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And I can't leave the subject of disease burden without saying something about population size,

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the relationship between health policy and population policy has always been very contentious.

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And for too long. Population policy has been seen as a question of population control and is only

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relatively recently that more voices have been heard primarily from civil society,

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calling for a population policy that addresses the questions of women's health, nutritional status,

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the ability of women within families and communities to take decisions relating to themselves.

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Women's literacy in education awareness amongst both men and women.

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Of the options for family planning available to them.

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And the recognition that higher standards of primary care can impact significantly on the health of women and children.

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This also raises necessary to recognise that whatever efforts are made by India today, howsoever Heatherwick and howsoever well-funded.

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The impact will not really be felt for the next 15 or 20 years.

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India's population today stands at approximately 1.3 billion.

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And in population growth, as in communicable diseases, significant variation across the states.

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Many states have achieved replacement fertility. Fertility rate of 2.1, but many other states, which are Pradesh, Bihar,

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Jharkhand just have not reached and that do not appear likely to reach this anytime soon.

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More positively, it's not. In the 70 odd years since independence,

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life expectancy has increased significantly from twenty six at independence to seventy point three for women and sixty six point nine for men today.

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So it is, it is. It is an achievement that we must we must recognise.

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There's another there's another caveat to be made here, which is that in a country of our size, there's a real danger.

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That not just about size, but with a population that has such unequal access to resources.

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There is a real danger that we concentrate only on the diseases of the urban population or the relatively better off

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sections of the population or persons who can have access to care or persons who are in a position to pay for care.

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It is possible that the diseases of those persons who were unable to access

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health care or falling outside the area of interest of health policy makers.

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Now, Professor Fine's list of failures significantly also highlights India's failure to invest in health care.

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Most discussions on the subject will tell will cite this fact that as against the ultimate objective of three percent of the GDP to health care,

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India has never gone beyond one point one percent.

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Now, there are several important writers. Expenditure as a percentage of GDP is both by the centre and by the states do traditionally,

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as I said earlier this evening, it is simply a government that has made substantial contributions.

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Now this expenditure includes the cost of maintaining hospitals, the salaries of doctors and nurses,

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and expenditures borne almost entirely by the states, who do not generally find it easier to generate significant resources of their own.

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The ability of state governments to generate resources through taxation is somewhat limited.

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It's also necessary to look again to look at the details, it's not enough to say so much percent of GDP.

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How are these public expenditures divided across infrastructure, human resources, hospital care, public health, medical education, medical research?

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Each of these would require a formidable level of investment,

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and the tendency has been both for the government of India and for the states to look for low hanging fruit,

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such as the construction of hospital buildings or the purchase of expensive equipment,

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rather than the more time consuming efforts involved in investing in the education of nurses or public health workers,

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or on clinical and health research. Now, most of the issues health care financing are quite well known,

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but I would like to say something about India's current policy as reflected in the scheme known as the Iceman part,

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predominantly General George or the Prime Minister's Healthy India programme.

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This there is there is a huge, widely publicised, social media driven campaign promoting this broken.

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But it is necessary not to be diverted by the by the glitz and to look at actual and projected achievements.

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Now, this scheme, the PMG White, has two components.

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The first is an insurance based hospital care scheme,

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persons enrolled under the PM G-A-Y are entitled to seek treatment with empanelled government and private hospitals.

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The payment for which up to a maximum of five hundred thousand rupees five lakh rupees

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per year for any one of 1350 packages for which rates have been negotiated with the BMJ.

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Why people? Now, this is the broad principle on which many health insurance schemes function, including the rest,

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she has lost the Bima Yojana, which India launched in 2008 and is now, for all practical purposes, abandoned.

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Now, but under BMG BMJ, which, as I said, five blacks per year.

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Thirteen hundred and fifty packages with rates of negotiated.

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The latest figures are that four point forty six million persons have received cashless treatment in over eighteen thousand hospitals.

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And while figures are frequently released on the numbers of claims settled with hospitals,

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information is not necessarily forthcoming on improved health outcomes even.

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Now, there are many, many difficulties in this insurance based model where it is the government's

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intention to negotiate the lowest possible rates for the prescribed treatments.

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It is the endeavour of private hospitals to increase these as much as they can.

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And while it's clear that even where negotiated rates have been announced,

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private hospitals will render only as much treatment as they believe they can afford to within the negotiated rates.

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They are not about to start losing money for the sake of my health.

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Another very serious problem with PM G-A-Y is that it only supports cases of hospital admission,

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ignoring the fact that a substantial number of cases could conveniently be dealt with in the outpatient wards.

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Indeed. In these cases, hospitalisation probably brings on a range of unrelated additional costs.

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Loss of wage for the for the family member who is accompanying the patient and stuff like this.

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And these are costs that insurance will not cover.

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The costs of food being eaten by the attendance of the patient, all or none of these are people covered by insurance.

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And there is also the issue of useless hospitalisation and useless surgeries being performed only in return for the insurance,

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which is available on such procedures.

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Now, all this leads to the suspicion that the scheme has been designed primarily to make use of unused capacity in private hospitals.

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Interestingly, a recent article authored by the two senior most civil servants in the health establishment relates with some pride that more than half

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the hospitals empanelled under the scheme are private and that private hospitals have witnessed a 20 percent increase in footfall.

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And these persons thought that this was something that needed to be publicised, and, as I said, with great pride.

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Now I said there were two parts to the NGO. I said this insurance based hospital treatment is one part.

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The other part is the establishment of health and wellness centres.

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This really appears to be a programme for upgrading and strengthening existing sub centres and primary health centres.

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12 services have been identified, which these wellness centres are expected to provide over.

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I mean, I'm like somewhat limited range of services currently provided. Now, in an ideal situation,

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this this part of the programme would have an address based on your understanding of the bulk

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of people's health concerns would have been taken care of within the umbrella of primary care,

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with only more complicated cases being referred to a second judicial level where, if necessary, costs could be covered by insurance.

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However, it's being done in the reverse.

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So the whole focus is on insurance base hospital treatment and less of the focus is on creating of these new health and wellness centres.

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And there's also very little information about how these wellness centres are doing.

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We know that there are over 24000 primary health centres that are lacking 56000 sub centres.

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But the only information I was able to find is that more than 20000 wellness centres have been established now.

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It is also not clear whether.

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How these wellness centres, even the ones that are supposed to been established, have addressed the problems of inadequate human resources,

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the limited availability of drugs, disposables, generally poor maintenance,

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the ecosystem in which the wellness centres are to function remains the same.

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And it is not clear that renaming them has effectively solved anything.

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There is also the more fundamental question of who should pay for health care.

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Having an insurance system still requires substantial amounts of government funds to be paid out as insurance premium for on population cover.

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There is no sign in any of the annual budgets since the scheme was launched of the increased funding that would be necessary to make the scheme work.

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Even the chief executive of The BMJ, why one of the two people who was talking about increased footfall in a much publicised interview admitted

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that he hoped India's investment in health care would reach two point five percent of GDP by 2025,

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of which only a small amount would come to PM's. You know, if government has not budgeted for the insurance claims,

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which would be received if it is not budgeted for the operation of the wellness centres.

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It is not at all clear how this is expected to function.

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It is also not clear why if the government has the resources or plans to have the resources to pay the insurance companies,

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why these funds could not be used to strengthen existing systems or to better equip

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them to function or to ensure the reliable presence at all times of trained health,

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human resources and public facilities. So these are all big and up to now unanswered questions.

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Human resources and the availability of well-trained and suitably motivated human resources remains.

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One of the most challenging issues in public health in India, the requirement is huge weather of doctors with the first degree.

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So for specialists, doctors with both parties. Qualifications.

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Nurses, allied health professionals, public health workers and each of these categories is a crisis situation in itself.

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As for the most recent information, the Medical Council of India, of which more or none has approved the award of MBBS,

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the first degree eight thousand three hundred twelve seats every year,

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of which slightly over 50 percent are in government colleges, the remainder being in private colleges.

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Everything to do with the establishment of medical colleges or the conduct of the Medical Council of India needs to be looked at very carefully,

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and the council itself has very recently been abolished with something called the National Medical Commission having taken its place.

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Now, a very large number of medical graduates are clearly being produced every year,

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but it's unclear how many of these are actually available for public service.

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It's also true that there's a very wide variation in the quality of these gadgets.

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Those leaving government medical colleges are generally regarded as being better

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trained and while there are outstanding institutions of medical education,

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the private sector such as the Christian Medical College in Vellore. Most of them do not have the same reputation.

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They survive on the strength of high fee structures,

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a feature which does not appear to be a deterrent given the very high status accorded to doctors in India.

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The fact, however, is that a student graduated from a private college howsoever well or badly trained is not going to be

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available for public service if she is to repay the debts she has incurred in acquiring a medical education.

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Issues of medical curriculum and syllabus were not given adequate attention by the erstwhile Medical Council of India before its unlamented demise.

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And the same is true of nursing education.

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As per most recent information, the Nursing Council of India, which for some peculiar reason has not been abolished and continues to function.

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There are 1630 colleges for the training of midwives,

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almost three thousand colleges with the training of staff members and seventeen hundred colleges with the training of graduate nurses.

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The overwhelming majority of these are privately owned and a very, very indeterminate quality.

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Not enough positions have been created by state governments for nurses, many of whom look for employment opportunities abroad.

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The nursing council also has regulatory control over the training of midwives and then shamefully neglected area.

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Now, it's not all grim on the positive side.

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There is legislation currently pending the Allied Health Care Professions Bill, the Allied and Health Care Professions voted gene,

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which aims to define and regulate the conduct and training allied health professionals,

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defined as an associate technician or technologist, trained to support the diagnosis and treatment of any illness, disease, etc.

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The bill also lists 15 categories of professionals with 53 specific professions.

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Now, this was a long overdue exercise, but it is still pending in parliament, and we have no idea where the parliament will at any stage approve this.

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There's also I was also mentioned the National Medical Commission bill, which is just been passed by.

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The Medical Commission exists as enliven the debates on health human resources considerably by introducing

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absolutely at the last minute a provision for the creation of a category of worker called community health worker.

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Now there is considerable. Anguish, really of this, because there's nothing which tells us where this person will come from,

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what kind of training this person should have, what duties this government health worker will perform or any of these things.

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But it just gives the government under a kind of.

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Omnibus section. Actually, it could really enable government to appoint anyone they want as a as a community health worker.

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So this is something to look out for now in identifying these three big areas of disease burden, financial resources and human resources.

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I've still followed what might be called a hospital driven approach to health care.

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How differently do we need to think? If we are talking of public health policy for India now, one of India's better known public health specialists,

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You're Not Ready has recently called attention to six key elements of health system identified by W.H.O. Healthcare Infrastructure Health Workforce.

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The availability of. A. I'm sorry, the availability of drugs and technologies, the level and use of health financing,

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health information systems and the overall governance of health services,

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and that already makes the important point that these six elements identified by W.H.O. do

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not include the role of the community in driving adequate demand for adequate health care.

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Now. It is still common in India for public health to be understood as basically concerned

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with hygiene and sanitation and controlling the spread of communicable disease,

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but. One can think of a more useful definition,

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and we could more usefully understand public health or public health policy is the

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establishment of a viable and functioning primary health care system serving the community,

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which takes into its fold all matters relating to the health and welfare of the public, including preventive measures, appropriate nutrition,

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well-functioning drinking water and sanitation systems for all members of the public, and particularly for women and children over their life course.

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I made this up, this isn't from someone very grand, it is or this is not W.H.O. or anything, but this seemed to me.

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A definition would take some which takes in all the essential elements of what public health ought to be covers all the relevant issues,

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the prevention of communicable diseases, the treatment of non-communicable diseases over the life course, the need for government investment,

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the need for qualified persons at all levels, the role of the community.

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Now all this, by the way, you said in India's National Health Policy of 2017, the policy actually says more.

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He talks about traditional systems of medicine,

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but as in the case of much of India's policy and legislative statements and much more statements of aspiration than of commitment.

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And it's also important it's not also just a question of resources.

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Nothing can be done without resources, but resources without the necessary motivation.

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Political will and executive ability will also not deliver satisfactory health outcomes.

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I. I must, however, call attention.

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To several remarkable civil society interventions.

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Which in their motivation, work on the ground reflect the best elements of what I have defined as a public health policy.

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I think here about your guest gene and his colleagues at the Johns Fosters.

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A yoga instructor is good in the heart of India.

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The Jazz says runs a hospital which provides a very high quality of care to a large and vulnerable population.

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I am grateful to Dr. Jain for always calling my attention to what he describes as the diseases of the very poor.

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I think also Dr. Vandana will pick them up and her colleagues at the Banyan in Chennai,

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an organisation that has worked for 25 years now with homeless women with mental illness in India to be female,

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poor and sick is to be very vulnerable indeed.

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And it isn't the work of the Banyan that one sees a combination of professional excellence and compassionate imagination.

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I must also mention to institutions for children with disability.

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But I think our Roy Foundation and the room done by the remarkable George, Oprah and Vidyasagar in Chennai set up by Poonam Natarajan.

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I was also mentioning the Cancer Institute area in Chennai run by the remarkable Doctor Santa.

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Then there is my friend, Dr. Amar Rajagopal of Pallium India in Trivandrum, an organisation devoted to establishing palliative care services.

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Now these institutions and many, many more that I have not mentioned are marked and are distinctive in many ways.

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But most importantly, by the human and ethical quality of the individuals behind them.

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And while this gives these institutions that distinction,

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it also makes it ask the question of what one we expect from institutions which are not guided by a hugely charismatic figure.

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Government does not believe in charisma. But yet it is government's responsibility to fund and manage health care institutions.

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The best examples we have in India are in the non-profit sector and where and how are we going to bring about a meeting between these?

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India's experience in tackling the AIDS epidemic stands as one possible way in which this coming

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together of both the public and the private sector and their respective strengths came to the fore and.

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The National AIDS Control Programme, and if you want to pay for all of them,

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demonstrated how significantly community involvement can impact on the efficacy of health investments.

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My distinguished friend and my one time boss, Sujata wrote in her book Do We Care?

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Makes the point that India showed the capacity to respond to a situation which required not only clinical intervention,

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but also changes in societal attitudes.

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For possibly the first time, issues of sexuality and sexual orientation were brought into the public discourse,

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with the recognition of the fact that behavioural change needed to drive India's response to controlling the epidemic,

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India's national AIDS control programmes will always be remembered for their pioneering efforts.

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Since 2014, however, ostensibly because the prevalence of AIDS in India has reduced and also because the government of

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the day believes that abstinence is a more appropriate response to sexually transmitted diseases.

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Public investment in AIDS in AIDS control has declined. And this is a very worrying situation.

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But I'd like to. Sort of bring this to an end.

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And. What I would like to see in conclusion, is that public health is about social justice.

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The Sustainable Development Goals recognise, and in their different areas, they target inequality.

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But it is also true that even with substantial progress has been made towards achieving the Sustainable Development Goals,

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gaps between countries and between communities within countries continue to rise enormously.

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The distinguished psychiatrist and public health practitioner, Bikram Patel, his edge and I quote from something that Kim wrote.

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Inequality corrodes the fabric of a society that is crucial for all people to feel that they belong to it and have a stake in a shared future.

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Social scientists refer to this connectedness as social capital.

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It acts as an invisible glue that binds us all together. Both rich and poor through good times and bad.

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It is this communion of hearts and minds which promotes individual and ultimately societal will be ensured.

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Inequality destroys the soul of nations, of societies, of communities and ultimately of every individual's well-being.

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And when Uncle Nolan, when government's aim at making quality health care accessible and affordable, when they strive in the words of Alma Typekit,

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the provision of adequate health and social measures, they work towards removing inequalities that is at the core of good governance and the D.

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And these noble thoughts have been read say to very recently,

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even in the United Nations General Assembly high level resolution of last month, 23rd September 2019,

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using almost the same words as our motto,

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everything lies with national governments and the context of today's address India's government and its ability to show leadership.

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And ownership in establishing effective health governs its ability to promote access to safe,

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effective, quality and affordable essential medicines and vaccines.

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Do you invest in adequate, sustainable resources to invest in education, recruitment and retention of a fit for purpose,

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public health workforce and to address the social, environmental and economic determinants of health and health and equity?

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These are monumental challenges. But they are of great importance to all who care for the future of India.

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Thank you.