OBJECTIVES: With high costs of  some oncology and biological therapies, manufacturers have introduced patient access schemes in Asian countries including Indonesia, Malaysia, Philippines and China where the out-of-pocket is the main funding and access mechanism. These schemes have been welcomed by stakeholders involved including patients, clinicians and governments. Our objective was to understand why such programmes have not succeeded in India despite a large middle class and almost complete out-of-pocket funding for pharmaceuticals, and to find possible ways to overcome the hurdles presented. METHODS: The approach involved desk research followed by primary research across stakeholders in India. Twelve in-depth telephone interviews were conducted with stakeholders in the public and private sectors, NGOs, leading physicians and manufacturers. The information collected was assessed and analysed. RESULTS: Majority of the respondents (n=10) quoted bureaucracy and the informal economy, and thus difficulties with means-testing as the two most important reasons for the schemes not taking up. General ignorance about the potential of such schemes and cynicism surrounding them are a deterrent. Unethical medical practice, a great patient – provider knowledge gap and a lack of streamlined infrastructure for scheme delivery are thought to be important factors. Respondents confirmed that majority of the large middle class lacks access to innovative medicines for many diseases. The Gleevec patient access scheme was quoted by a few respondents as a rare example of such a scheme being run. Partnering with the public sector and NGOs was thought to be an alternative way out. There was mention of many local NGOs/charities which fund targeted oncology therapies for those with limited resources. CONCLUSIONS: India needs tailored, innovative ways of accessing high cost drugs for its local context being different from those in other countries in the region. Public-private partnerships involving large stakeholders such as the Ministry of Railways could be an option.