WHO Country Cooperation Strategy 2006-2011

India

© World Health Organization Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for South-East Asia, application should be made to the Regional Office for SouthEast Asia, World Health House, Indraprastha Estate, New Delhi 110002, India. The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. November 2006

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Contents
Preface .............................................................................................................. v Message from the Regional Director ................................................................. vi Acknowledgements ......................................................................................... vii Abbreviations ................................................................................................. viii Executive Summary ........................................................................................... x 1. Introduction ............................................................................................... 1 2. Health and Development Challenges .......................................................... 3
Burden of Diseases ................................................................................................ 4 Health Sector ......................................................................................................... 9 Health in the Future ............................................................................................. 14

3. Development Assistance and Partnership .................................................. 17
Overall Trends in Assistance ................................................................................. 17 Sector-Wide Approaches ...................................................................................... 18 Donor Coordination ............................................................................................. 19

4. WHO Global and Regional Policy Directions ............................................ 21
Global Challenges in Health ................................................................................. 21 Global Health Agenda .......................................................................................... 22 Regional Policy Framework .................................................................................. 23

5. WHO Current Policy Framework and Cooperation ................................... 24
Policy Framework and Strategic Directions ........................................................... 24 Current Country Programme and Organization .................................................... 25 Financing the Technical Assistance Activities ......................................................... 26 Decentralisation and State Level Responses .......................................................... 26

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6. Strategic Agenda: Priorities for Cooperation 2006–2011 ........................... 33
Reduce the Burden of Communicable Diseases ................................................... 33 Promote Maternal and Child Health ..................................................................... 35 Scale up Prevention and Control of NCDs ............................................................ 36 Strengthen Health Systems Development ............................................................. 38

7. Implementing the Strategic Agenda........................................................... 45
Responsibility of the Country Team ...................................................................... 45 Support from the Regional Office (SEARO) ........................................................... 47 Support from WHO Headquarters ....................................................................... 47 Risks facing the CCS ............................................................................................. 47

Annexes: Tables, Organizational Charts, CCS Matrix ....................................... 49

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Preface
The purpose of this country cooperation strategy document (CCS) is to reflect the mediumterm vision of the World Health Organization for its cooperation with India and to elucidate the strategic framework for such cooperation. The CCS represents a balance between evidence-based country priorities with Organization-wide strategic orientations and priorities in order to contribute optimally to national health development. It is the result of extensive cumulative consultations, both internal and external. While India is being propelled to a position of international eminence, it faces the challenge of dealing effectively with unfinished agendas as well as with new emerging challenges, including those related to globalization. While WHO India Country Office (WCO) will maintain its technical collaboration in various important areas of work in the health sector, it intends to scale up its efforts aiming at four strategic objectives, major components of which are central to the pursuit of the Millennium Development Goals. The four strategic objectives address the following: (a) communicable and emerging diseases; (b) maternal and child health; (c) non-communicable diseases and the formidable rising burden of preventable premature morbidity and mortality; and (e) health systems development within the national and global environment. Since India has a lot to offer in contributing to the management and shaping of the policy environment for health, both inward and outward-looking perspectives have been taken into consideration. The CCS elucidates the areas of technical support, including cross-cutting priorities, such as promoting equity. WCO will support ethical and evidence-based policy and advocacy positions; monitor health information and database for appropriate decisions; and support operational studies with special reference to gender, children and vulnerable populations. The private sector accounts for more than 70 percent of health expenditures. WCO will support the forging of public-private partnerships and will increase its outsourcing with centres of excellence, collaborating centres and professional associations. WCO aims to interact more closely with the states, in coordination with the Union Ministry, and in support of ongoing decentralization efforts of the Government of India. WCO will pursue its CCS guided by the mandate, functions and governance of WHO, and will fulfil its technical support role with passion to serve health development efforts in India. Dr S. J. Habayeb WHO Representative to India

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Message from the Regional Director
The collaborative activities of the World Health Organization in the South-East Asia Region are geared to improve the health status of the population in the Member States. Though WHO has been contributing as a key catalyst to India’s health policies and programmes, there is a need for a thorough analysis and discussion of how WHO can further improve its contribution to health development in India. The South-East Asia Region was the first Region to promote Country Cooperation Strategies (CCS) as a process to identify how best WHO can support health development in our Member States. Over the past six years, all 11 Member States in the Region have prepared their CCS. In the case of India, though there has never been a formally published CCS, work has progressed on the basis of a series of drafts. Therefore, the publication of this CCS for India is a key milestone in the work of WHO in the country. An analysis of the current health situation and the likely scenario over the next six years have formed the basis for the priorities outlined in this CCS. We appreciate the inputs and suggestions from the Ministry of Health, whose official have been the major collaborators in developing this document. In addition, consultations were held with various WHO Collaborating Centres in India, which provided valuable suggestions. Finally, the advice and recommendations of our health development partners in India were extremely valuable in guiding the development of the CCS. The consultative process here will help to ensure that WHO’s inputs provide the maximum support to health development efforts in the country. To help achieve the objectives of this CCS, we recognize the importance of a strong WHO Country Office to work closely with key counterparts, keeping in mind local conditions. Nonetheless, the entire Organization is committed to the work of the CCS. The staff of the WHO Regional Office will use this CCS in determining regional priorities and in supporting collaborative activities in India. Furthermore, we will also seek assistance, as necessary, from WHO headquarters to assist these efforts. I would like to thank all those who have contributed to developing this Country Cooperation Strategy, which has the full commitment of the Regional Office. We will provide our maximum support towards achieving its objectives over the next six years. Our joint efforts, I am confident, will help in achieving the maximum health benefits for the people of India.

01 September 2006
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Samlee Plianbangchang, M.D., Dr.P .H. Regional Director

Acknowledgements
We acknowledge with sincere thanks the significant inputs of WHO staff at the levels of the country, the region, and headquarters. We are deeply indebted to the officials of the Union Government and State Governments; UN, multilateral and bilateral agencies; collaborating centres; professional associations; civil society; and academic institutions for their views and valuable advice.

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Abbreviations
AIDS ANM ARI ART ASHA AYUSH CCS CHC CVD DFID DLHS DOTS FCH FCTC FETP GATS GAVI GDP GFATM GOI GPW GPPPs GNP HIV HRH ICC IDSP IEC IHR IPHS IMR IMCI IMNCI INC IT
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Auto Immuno Deficiency Syndrome Auxilliary Nurse Midwife Acute Respiratory Infection Anti Retroviral Treatment Accredited Social Health Activist Ayurveda, Yoga, Unani, Siddha and Homeopathy Country Cooperation Strategy Community Health Centre Cardio Vascular Disease Department For International Development District Level Household Survey Directly Observed Treatment Short-course Family and Community Health Framework Convention on Tobacco Control Field Epidemiology Training Programmes General Agreement on Trade and Services Global Alliance for Vaccine Initiative Gross Domestic Product Global Fund for AIDS, TB and Malaria Government of India General Programme of Work Global Public-Private Partnerships Gross National Product Human Immuno Deficiency Virus Human Resources for Health Inter-agency Coordination Committees Integrated Disease Surveillance Programme Information Education Communication International Health Regulations Indian Public Health Standards Infant Mortality Rate Integrated Management of Childhood Illnesses Integrated Management of Newborn and Childhood Illnesses Indian Nursing Council Information Technology

WHO Country Cooperation Strategy 2006-2011

LEP LF MCI MDG MOHFW MPS NACO NMH NPSP NCMH NCD NCRB NFHS NGO NRHM ODA PHC PLWHA RBM RCH RGI RNTCP SARS SDE SEAR SEARO STEPS SWAp TRIPS TFI UIP UN UNCT UNICEF UNFPA UNDAF WCO WHO WR WTO

Leprosy Elimination Lymphatic Filariasis Medical Council of India Millennium Development Goals Ministry of Health and Family Welfare Making Pregnancy Safer National AIDS Control Organization Noncommunicable Diseases and Mental Health National Polio Surveillance Programme National Commission on Macroeconomics and Health Noncommunicable Diseases National Crime Records Bureau National Family Health Survey Non Governmental Organization National Rural Health Mission Overseas Development Assistance Primary Health Centre People Living With HIV and AIDS Roll Back Malaria Reproductive and Child Health Registrar General of India Revised National Tuberculosis Control Programme Severe Acute Respiratory Syndrome Sustainable Development and Healthy Environment South-East Asia Region Regional Office for South-East Asia Stepwise surveillance of risk factors Sector Wide Approach Trade Related Intellectual Property Rights Tobacco Free Initiative Universal Immunization Programme United Nations United Nations Country Team United Nations Children Fund United Nations Population Fund UN Development Assistance Framework WHO Country Office World Health Organization WHO Representative World Trade Organization

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Executive Summary
This Country Cooperation Strategy (CCS) of WHO’s Country Office (WCO) in India for the period 2006-2011 forms the basis for undertaking technical assistance in collaboration with the Government of India, the states, development partners and civil society. The CCS is WHO’s tool for alignment with national health priorities and for harmonization with other development partners. While India is being propelled to a position of international eminence, it faces the challenge of dealing effectively with unfinished agendas, strengthening of public health systems, and critical issues of human resources, management, health information and health sector governance on one hand; and new emerging challenges such as globalization and a formidable rising burden of preventable premature morbidity and mortality due to noncommunicable diseases on the other. Since India has much to offer in contributing to the management and shaping of the global policy environment for health, both inward and outward-looking perspectives have been taken into consideration in framing the CCS. The spectrum of human resource issues in India is vast and complex and is not limited to health practitioners, but extends to managers, administrative and support staff and allied health personnel. There are issues of quantity, quality, relevance, motivation, utilization and distribution. Shortages of human resources in the health sector are widespread with disproportionate concentration in urban areas. WCO will work with GOI and its partners in dealing with major issues, notably developing systems for relevant quality education and training of health workers; supporting them; enhancing their effectiveness; and tackling health imbalances and inequities. WCO aligns its strategy with the priorities and evolving needs of the country. It intends to scale up its efforts in four strategic objectives discussed below and would adjust its country presence accordingly. Major components within these strategic objectives are central to the pursuit of the Millennium Development Goals. Concurrently, WCO will maintain its technical collaboration in numerous other important areas of work, such as those related to health action in crisis, environmental health, water and sanitation, but without the enhancement of related country presence capacities. WCO will support the regional public health initiative while promoting multi-disciplinary and multi-sectoral approaches. WCO will support healthy public policy. Besides, WCO would contribute to facilitating the work of the Commission on Social Determinants in India. WCO will take into consideration paramount cross-cutting priorities, notably poverty, equity, access, gender, quality assurance and capacity building. The primary
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partnership of WCO is with the Union Ministry of Health and Family Welfare, including day-to-day liaison with the International Health Division. Also, WCO works closely with the state governments, centres of excellence, collaborating centres, professional associations and civil society. Given the fact that 85% of WHO’s regular budget is allocated to activities at the state level, WCO aims to interact more closely with the states in support of ongoing decentralization efforts (see Figure 7, page 29). WCO will implement the CCS, which would be guided by the mandate, functions and governance of WHO, with a focus on and technical collaboration in critical areas such as capacity building, advocacy and policy development. Promoting equity and addressing disparities in the health sector are cross-cutting priorities. WCO will support ethical and evidence-based policy and advocacy positions; monitor health information and database for appropriate decisions; and support operational studies with special reference to gender, children and vulnerable populations. Also, WCO will support national public health programmes and the National Rural Health Mission (NRHM) where the government’s inbuilt focus is on rural, underserved areas. The four main strategic objectives of the CCS are the following: Reduce the burden of communicable and emerging diseases by enhancing surveillance and response capacities. The main thrust areas will be strengthening surveillance and information systems, and responding to emerging and re-emerging diseases. Towards this, WCO would continue to extend technical support to strengthen integrated disease surveillance for epidemic-prone diseases, laboratory diagnostic capabilities, and enhance national and local capabilities to cope and deal effectively with the threats of newly emerging diseases like pandemic influenza. WCO will assist in the strengthening of epidemic intelligence and preparedness and building core capacities for implementation of the revised International Health Regulations (2005). Through its network of field consultants, WCO would support better management of diseases of public health importance, such as tuberculosis and multi-drug resistant TB, polio, communicable childhood diseases, and leprosy, thus accelerating disease control/ elimination/ eradication efforts. It would also support improved control strategies for diseases like malaria, JE, dengue, leprosy, filariasis, kala-azar, HIV/AIDS, including HIV-TB. WCO will provide support for the whole cycle of disease prevention and control, including technical guidelines, standards and norms, policies, strategy development, programme planning, monitoring and evaluation. Support would also be provided for evaluation and introduction of newer vaccines by the government. Promote maternal and child health by improving the continuum of care and strengthening immunization. WCO will continue to focus attention on provision of skilled birth attendance, integrated management of newborn & childhood illnesses, adolescent health,

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population stabilization, universal immunization, and nutrition. Through its technical inputs, WCO will support the National Rural Health Mission and the Reproductive and Child Health Programme. These programmes provide convergence and an integrated framework for accelerating the decline in maternal, newborn and child mortality and morbidity as well as providing accessible and affordable health care to rural areas and weaker sections of the population, particularly through the promotion of community level workers and activists, convergence of programmes, and forging government partnership with other sectors. Scale up prevention and control of noncommunicable diseases (NCDs) through support for developing new policies and programmes. WHO estimates that an additional two percent annual reduction in chronic disease death rates in India over the next ten years would prevent six million deaths. This would result in an economic gain equivalent to US$15 billion for the country. Since the pace of the epidemiological and demographic transition varies between states, WCO will assist in developing policies and intervention strategies which are flexible so as to accommodate the differing needs and resources of various states. Technical support will be provided for NCD risk factor surveillance to make it sustainable, especially in data management and translation of data into appropriate policies. Multi-sectoral interventions have maximum effectiveness in primary prevention, hence WCO plans to advocate and facilitate their development. The WHO Global Strategy for Diet, Physical Activity & Health provides feasible options for addressing important risk factors. WCO will continue to provide technical support for the effective implementation of the provisions of the Framework Convention for the Tobacco Cotrol (FCTC) and the enforcement of the National Tobacco Control Legislation, including the strengthening of the National Tobacco Control Cell, establishment of a National Tobacco Control Programme, and setting up of a Multi-sectoral Coordination Committee for tobacco control and NCD prevention. Capacity in the area of tobacco control will be built at the state level through training of relevant state authorities, law enforcement and, health professionals, and civil society organizations. Technical assistance will also be provided for implementation of a sustained anti tobacco public awareness campaign and for expanding the tobacco cessation services to reach the masses through existing health systems. WCO will support the development, scaling up and implementation of the national programmes for diabetes, cardio-vascular disease, stroke and cancer. WCO will support health system strengthening, including capacity building for addressing NCDs. Health promotion across the life span will be adopted with emphasis on providing a supportive environment to promote healthy behaviour. WCO will encourage horizontal integration across all NCD prevention and control programmes.

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Strengthen health systems development within the national and global environment, with a focus on human resources. WCO will provide technical support to India in its pursuit for improving access, quality and accountability of the health systems in consonance with the World Health Assembly Resolution adopted in May 2005 on sustainable health financing, universal coverage, and social health insurance. Escalating health care costs constitute an important cause for indebtedness among the poor and middle-income groups, and lead to the impoverishment of 2.2 percent of the population annually. WCO will assist in increasing risk pooling, including health insurance and innovative financing initiatives. At present, the public sector health investment in India is only 0.9 percent of its GDP one , of the lowest in the world. WCO will promote the evidence base and updated information on health expenditures through the National Health Accounts System. Concurrently, WCO will assist in assessing options to facilitate efficiency and decisionmaking in channelling funds to priority areas. WCO will support the recommendations of the National Commission on Macroeconomics and Health. The private health sector accounts for more than 70 percent of health expenditures. WCO will support the forging of public-private partnerships, and would assist GOI and the states to develop mechanisms for regulation which would not discourage needed investment in the health sector, but which would be rigorous enough to protect the interests of both patients and providers. In this context, WCO would assist in developing objectively verifiable service standards, protocols, technology assessments and accreditation systems which would promote consumer choice and improve accountability of service providers. It is self-evident that a coherent policy framework for service provision is needed. WCO will support the broad spectrum of inputs required for the relentless demands made for strengthening public health systems with a focus on human resources, health workforce strategies, evolving needs of sectoral skills and relevant management issues. WCO will support the creation of health information and database for evidencebased decisions, including documentation, sharing of lessons and best practices at various levels: among states, nationally, and at the global level. In the context of the global policy environment for health, WCO will provide technical support to India in managing the impact of spill-ins and spill-overs particularly in international trade agreements and health-related undertakings. WCO will further strengthen the WTO cell within the Ministry of Health, assist in promoting networks, technical alliances, information sharing and mobilizing expertise to advise on options and policy instruments related to international agendas. Risks There are three main risks facing the CCS and its strategic objectives: (a) The effectiveness of WHO technical support and the anticipated impact may remain limited.

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Ensuring the highest possible standards of quality and credibility of the technical advice provided would alleviate this risk, which is closely related to the country’s own implementation capacities. The biennium workplans are intimately linked to the country’s institutions with the inevitability of mixed outcomes in a vast subcontinent with large disparities existing among the states. In order to further mitigate related risks, greater attention would be provided to upstream planning, quality at entry, thorough assessment of institution-specific implementation capacity, and closer monitoring. (b) Competing demands and priorities, both within WHO and the country, as well as unforeseen and unfunded demands, may dilute the focus on priority objectives and overstretch the capacity of WCO. This would be addressed through advocacy, persuasion, striving for widespread endorsement and seeking valuable technical support from SEARO and HQ. (c) Finally, potential resource constraints may hamper the strengthening of WHO’s country presence and its contributions. Increased outsourcing to centres of excellence, partnerships, sustained resource mobilization efforts by WCO, SEARO and HQ, and effective utilization of internal WHO capacities at all levels would alleviate this risk.

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Introduction

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Given the size of India’s population, its diversity and the burden of disease, the challenge of attaining good health for the people of India is a daunting one. Since independence, due to focused action by the Government and civil society, India has made substantial progress in controlling communicable diseases and reducing child mortality. The World Health Organization (WHO) has been a partner with the Government of India (GOI), academic institutions, other United Nations (UN) agencies, development partners and civil society organizations to realize these goals. This has been managed through the WHO Country Office, India (WCO); the Regional Office for South-East Asia (SEARO), New Delhi; and the Head-Quarters of WHO in Geneva. Most of WHO’s interaction with India is channelled through the WCO in the major clusters of Communicable Diseases and Disease Surveillance, Family and Community Health, Noncommunicable Diseases and Mental Health, Health Systems Development, and Immunization and Vaccine Development. Furthermore, WCO works extensively with the Government, bilateral agencies and stakeholders in special programmes, which are Routine Immunization, Disease Surveillance, National Polio Surveillance, Revised National Tuberculosis Control, Commission on Macroeconomics and Health, HIV/ AIDS Technical Assistance, Leprosy Elimination, Roll Back Malaria, Tobacco Free Initiative, Lymphatic Filariasis, Knowledge Management and Health Internetwork. The Country Cooperation Strategy (CCS) endeavours to merge WHO’s global and regional agendas with India’s national priorities. This second generation CCS was developed by the WCO team through cumulative consultations with major partners. The CCS is WHO’s tool for alignment with national health strategies and priorities as well as for harmonization with other UN agencies working in health and its development partners. It clarifies the roles and functions of WHO in supporting the National Health Plan and other national health and development frameworks such as the poverty reduction strategies, the Sector-wide Approach (SWAp), the National Rural Health Mission (NRHM) and others. The CCS is an organization-wide reference for country work, which guides planning, budgeting and resource allocation. It is based on the health situation in the country, government health policies and plans, work of key health partners, and on WHO’s own experience in the country as well as its comparative advantage. The document will become a framework for WHO. It would assist in mobilizing human and financial resources for strengthening WHO support to India in order to contribute optimally to national health development.

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The CCS would provide a framework for WCO to build upon its existing country presence and responsiveness through technical support, skilled staff and strengthened capacities, establishment of WHO Collaborating Centres and enhanced partnerships. Besides providing support and advocating the conventional priorities of communicable diseases and maternal and child health, WCO will step up its role in dealing with emerging issues of globalisation in reference to trade related agreements and their impact on health. It would support the reduction of non-communicable disease risk factors and advocate efficient resource allocations, decentralisation, and public-private partnerships. Furthermore, it would also promote knowledge management; improve information systems and infrastructure, and support capacity building. The CCS takes into consideration the human rights based approach to development and the gender sensitivity adopted by the UN system. The CCS will contribute to the broader efforts seeking the achievement of the Millennium Development Goals (MDGs). This document will form the framework for designing WCO’s collaboration with the Government of India, civil society and development partners for the period 2006 to 2011 and would contribute to the achievement of good health by the people of India.

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Health and Development Challenges

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With over one billion people, India is the second most populous country in the world, and accommodates 17 percent of the world’s population in 2.4 percent of the world’s area. The demographic profile of India’s population is changing and the proportion of the elderly is increasing significantly. The female-to-male sex ratio in the age group of 0-6 years has decreased from 945 in 1991 to alarming proportion of 927 as of 20011. One of the major challenges to the health sector is to respond to these demographic phenomena. Since India is home to diverse socio-cultural groups, the health needs of the people also vary from region to region. Census data of 2001 has estimated that 64.8 percent of Indians are literate. The female and male literacy rates were 53.7 and 75.9 percent, respectively (Annexure – Table 1). In India, 73.2 percent of rural and 90 percent of urban households have access to safe drinking water2. As of 2002, 37.7 percent of the population has access to improved sanitation facilities3. Since independence, India has pursued a policy of planned economic development led by the public sector. However, influenced by the transitions in the international arena, India adopted structural adjustment policies in the 1990s. This emphasized liberalization of controls on economic activities and greater integration with the global economy. Consequently, the Indian economy grew at a fast rate though concerns were raised regarding issues of equity. During the Ninth Five-Year Plan (1997-2002), the state aimed at improving the living conditions of the poor and increasing employment opportunities. India is currently implementing the Tenth Five-Year Plan (2002-2007) that stresses human development by promoting quality of life and access to basic social services. India is the 10th largest economy in the world4. The Gross National Product (GNP) at current prices per capita stood at around Rs. 25,781 (US$ 572) in 2004-5.5 The Gross Domestic Product (GDP) per capita annual growth rate has been 3.3 percent for 1975–20036 with the current annual growth rate being eight percent. The economy of
Census of India 1991 & 2001, Provisional Population Totals: India, Registrar General of India, Ministry of Home Affairs, GOI. 2 Economic Survey 2005-2006, Ministry of Economic Affairs. Government of India. 3 India – Water Supply & Sanitation, The World Bank, January 2006. 4 World Bank Website http://siteresources.worldbank.org/datastatistics/Resources/GDP . 5 Quick Estimates of National Income, Consumption Expenditure, Saving and Capital Formation 2003-2004, Central Statistical Organization, Ministry of Statistics & Programme Implementation, GOI. 6 World Development Indicators, 2005, World Bank 2005.
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India has grown steadily in the last few decades and the percentage of poor persons in the population came down from 47 percent in 1973-74 to 26 percent in the year 20007. Due to focus on improvement in public health and living conditions, a substantial enhancement in the health status of the people has been witnessed in the last 50 years (Annexure – Table 2). India’s public health sector, however, has not grown in proportion to its economic growth (Annexure – Table 3). To understand the challenges faced by the health sector there is a need to review issues in the country, such as health sector governance and organization, burden of disease, occurrence of natural disasters, condition of women and children; as well as anticipation of issues in the future.

Burden of Diseases
The disease burden for India for all age groups by major causes of death are presented in Figure 1.
Figure 1: Estimated percentage of deaths (all ages) in 2005 by cause

Source: http://www.who.int/chp/chronic_disease_report/en/

Women and Children: The past decade witnessed improvement in the health of women and children in India. With regard to reproductive health, the Government policies and programmes have shifted from a target-oriented family planning approach to a broader comprehensive strategy. Pregnancies and deliveries are safer in India today than they were in the years immediately following independence. Yet the number of avoidable deaths of mothers and infants in India is still high.

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Tenth Five-Year Plan Document, Planning Commission, GOI

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India’s annual population growth rate is 1.74 percent and contributes to about 20 percent of births worldwide. New technologies have been accepted into every day sexual and reproductive life, such as new methods of contraception and termination of pregnancy. The median age of marriage has been rising in India. Yet 61 percent of all women (69 percent rural and 41 percent of urban) are married before the age of 16. The median age at first pregnancy is 19.2 years. Each year in India, roughly 30 million women experience pregnancy and 27 million have live births8. About 65 percent of pregnant women receive antenatal care. Of the total pregnant women, only 34 percent had institutional deliveries and 42 percent received professional medical care. The maternal mortality ratio, an important indicator of maternal health in India, is estimated to be 301/100,000 live births9. With an estimated 136,000 deaths, India has the highest burden of maternal mortality in the world. Forty seven percent of maternal deaths in rural India are attributed to anaemia and haemorrhage, causes that are very much avoidable. Abortions are the third leading single cause of maternal mortality, being responsible for 12 percent of deaths. Regional disparities in maternal and neonatal mortality are wide. Delays in accessing specialised maternal care happen at all levels, starting from the decision to seek medical care to reaching a health facility and receiving timely and quality emergency obstetrics care. More than one-third of women in India (41 percent rural and 23 percent urban) are undernourished. Among children, 47 percent are undernourished and 74 percent are anaemic. Among adolescents, 18 percent are malnourished. Due to lack of awareness and socio-cultural taboos, only 16 percent of the infants are breastfed soon after birth and 37 percent on the first day. Only 55 percent of children are exclusively breastfed up to four months.10 With over 2.4 million under-five annual deaths, India accounts for a quarter of the global child mortality. The major killers of children are acute respiratory infections, dehydration due to diarrhoea, measles with accompanying malnutrition, neonatal diseases and in some areas malaria. The high prevalence of malnutrition contributes to over 50 percent of child deaths. In recent years, the impressive rate of decline of the infant mortality rate seen in the decade of the 1980s has slowed down considerably. There are wide inter and intra state variations in infant and child mortality. A significant proportion of child deaths (over 40 percent of under-five mortality and 64 percent of infant mortality) take place in the neonatal period. Apart from infections, other causes like asphyxia, hypothermia and pre-maturity are responsible. About one-third of the newborns have a birth-weight less than 2,500 grams (low birth-weight). A significant proportion of mortality occurs in low birth-weight babies.
Health Information of India, DGHS, MOHFW, 2003. Maternal Mortality in India: 1997 – 2003, Trends, Causes and Risk Factors, Registrar General of India, Ministry of Home Affairs, 2006 10 National Family Health Survey (NFHS-II), 1998-99, IIPS, Mumbai and ORC Macro, 2000.
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Only 47.6 percent of children in the age group of 12–23 months receive all the vaccinations recommended under the Universal Immunisation Programme (UIP). The percentage varies from 14 percent in some states to 92 percent in Tamil Nadu. The three major illnesses that contribute to mortality among children are fever (30 percent), acute respiratory infection (ARI) (19 percent), and diarrhoea (19 percent).11 There are 225 million adolescents comprising nearly one-fifth (22 percent) of India’s total population12. Of the total adolescent population, 12 percent belong to the 10-14 years age group and nearly ten percent are in the 15-19 years age group. More than half of the illiterate currently married females have been married below the legal age of marriage. Nearly 27 percent of the 1.5 million girls married under the age of 15 years are already mothers13. More than 70 percent girls in the age group of 10-19 years suffer from severe or moderate anemia14. Nearly 27 percent of married female adolescents reported unmet needs for contraception15. Most sexually active adolescents are in their late adolescence. Over 35 percent of all reported HIV infections in India occur among young people in the age group of 15-24 years, indicating that young people are highly vulnerable. The ratio of girls to boys in the age group 0-6 years in India is becoming increasingly skewed in favour of boys. The child-sex ratio, calculated as the number of girls per 1000 boys in the 0-6 years age group, reported by the 1991 census was 945 girls per 1000 boys. The ratio declined to 927 girls per 1000 boys during the 2001 census. Cultural, social and economic factors predicate son preference. Neglect of female children has resulted in substantially higher death rates in girls, which impacts the child-sex ratio. Pre-natal sex determination is a prelude to abortion of female foetuses. Communicable Diseases: In India, the communicable disease burden remains significant. Every year, there are over 1.8 million new cases of tuberculosis and about 370,000 deaths resulting from the disease. Over one and a half million people contract malaria each year. It is estimated that over 550 million people live in areas endemic to filariasis are exposed to the risk. As many as 90,000 persons are undergoing treatment for leprosy. More than five million people were living with HIV in India in 2005 with a mixed distribution in the country and with higher prevalence in most southern states and the north-eastern region. The total all India prevalence remains under one percent. With regard to polio, major strides have been achieved in the country. The number of affected districts has been reduced from 159 in 2002 to 35 in 2005. The disease is localized now to two geographical areas in Uttar Pradesh and Bihar. Up to the end of 2005, 66 Acute Flaccid Paralysis (AFP) polio cases were reported in the country, where polio surveillance is managed by WHO (Annexure – Table 4). Dengue outbreaks have been reported from all over the country and 378 million persons are at risk from
National Family Health Survey (NFHS-II), 1998-99, IIPS, Mumbai and ORC Macro, 2000. Census of India 2001, Provisional Population Totals: India, Registrar General of India, MOH, GOI. 13 Census of India 2001, Provisional Population Totals: India, Registrar General of India, MOH, GOI. 14 District Level Reproductive Health Household Survey, IIPS, 2004. 15 National Family Health Survey (NFHS-II), 1998-99, IIPS, Mumbai and ORC Macro, 2000.
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Japanese encephalitis. The resurgence of kala-azar has emphasized the need for improved case detection, complete treatment, vector surveillance and control. The global pandemic of SARS and avian flu has also highlighted the threat of new emerging and re-emerging diseases and the need for regional and global collaboration. Noncommunicable Diseases: Noncommunicable Diseases (NCDs), especially Cardiovascular Diseases (CVD), diabetes mellitus, cancer, stroke and chronic lung diseases have emerged as major public health problems in India, due to an ageing population and environmentally driven changes in behaviour (Annexure – Table 5). Premature morbidity and mortality in the most productive phase of life is posing a serious challenge to Indian society and its economy. It is estimated that in 2005, NCDs accounted for 5,466,000 (53 percent) of all deaths (10,362,000) in India. The WCOICMR study on NCDs in India has estimated that the burden of Diabetes Mellitus, Ischeamic Heart Disease and Stroke are 37.8 million, 22.4 million and 0.93 million respectively. In the age group 30-59 years, NCDs account for a substantial proportion of mortality as presented in the pie diagram (Figure 2).
Figure 2: Estimated proportion by cause of death in 30-59 year age group in India-2005

Source: Preventing Chronic Diseases: A vital investment. WHO; Geneva, 2005

The National Cancer Registry Programme estimates that there will be more than 800,000 new cancer cases every year. Tobacco related cancers predominate with cervix and breast cancers being the leading cancers in women. It has been estimated that in 2005, India lost US$9 billion in national income from premature deaths due to heart diseases, stroke and diabetes alone. It is projected that over the next 10 years deaths from NCDs will increase by 18 percent and an estimated 60 million deaths will occur in this period. India stands to lose US$237 billion over the next decade due to premature NCD deaths16.
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Preventing Chronic Diseases: A vital investment. WHO; Geneva, 2005.

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Contrary to popular belief that NCDs are a problem of rich urban males, the poor have been found to be more vulnerable to chronic diseases because of material deprivation, psychosocial stress, higher levels of risk behaviour, unhealthy living conditions and limited access to good quality health care. Once a disease is established, poor people are more likely to suffer adverse consequences than wealthier people. This is especially true of women, as they are often more vulnerable to the effects of social inequality and poverty, and less able to access resources including health care. Chronic diseases inflict an enormous direct economic burden on the poor, and push many people and their families into poverty. The causes of NCDs are universally known and are the same in India as in wealthy countries. The common causal risk factors are tobacco and alcohol use, unhealthy diet and physical inactivity. Changes in the population prevalence levels of these factors can therefore predict future disease burden. The WHO STEPwise approach to surveillance of NCD risk factors (STEPS) which has been carried out in 5 sites in India by WCO and ICMR has revealed that only 50 percent of the population aged 15-64 years consumed vegetables daily and 60-80 percent led a sedentary lifestyle. At least 80 percent of premature heart disease, stroke, Type 2 Diabetes and 40 percent of cancer can be prevented through avoidance of tobacco products and the adoption of healthy diet and regular physical activity. Tobacco is the foremost cause of preventable death and disease in the world today. In India, 47 percent of men and 14 percent of women use tobacco in some form, resulting in nearly one million premature deaths annually. The total economic cost of the three major diseases caused by tobacco use in India was Rs. 308 billion (US$7.2 billion) in 2002-0317. India has played a leading role in the development of the Framework Convention on Tobacco Control (FCTC) and was one of the first countries to ratify the convention. This lays the foundation for implementing a range of comprehensive policies. Mental health and injuries: Apart from chronic NCDs, mental disorders are also a common form of disability. It is estimated that in the year 2001, 67 million people with major mental disorders, 20.5 million with common mental disorders and 10.2 million with alcohol dependence problems required services18. Road traffic injuries every year result in death of more than 100,000 persons, two million hospitalizations, 7.7 million minor injuries and an estimated economic loss of 55,000 crores of Indian Rupees or nearly 3% of GDP every year.19 Natural Disasters: India is prone to natural disasters such as cyclones, floods and earthquakes. While floods in the Indo-Gangetic and Brahmaputra plains are annual
Report on Tobacco Control in India. Ministry of Health and Family Welfare, Government of India; New Delhi, 2004. Burden of Disease in India, Background Papers, National Commission on Macroeconomics and Health, GOI, 2005. 19 Gururaj G. Road Traffice Injury Prevention in India, NIMHANS Publication No. 56, Bangalore, India 2006.
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features, around eight percent of land is vulnerable to cyclone. Around 54 percent of land is vulnerable to earthquakes, out of which 12 percent areas fall under severe earthquake zone. Natural disasters in India cause heavy losses - in terms of human life, mental stress as well as financial loss of property and personal belongings. The average annual impact from natural hazards in India has been estimated at: mortality – 3,600; crop area affected – 1.42 million hectares; and property (houses) – 2.36 million dwellings. The average damage to crops, houses and public utilities from floods during the period 1935–95 was estimated at Rs. 9,720 million (equivalent to US$216 million) every year, while the maximum damage was Rs. 46,300 million (equivalent to US$1,030 million) in 1998. In the Orissa super cyclone of 1999, over 10,000 people were killed. In the Gujarat earthquake of 2001, at least 16,000 people died. The damage has been estimated at US$4.6 billion. The number of people injured and treated due to the Gujarat earthquake had been reported to be around 170,000. In the recent tsunami of 2004, which struck the Andaman and Nicobar Islands and the states of Andhra Pradesh, Kerala, Tamil Nadu and Union Territory of Pondicherry, the estimated death toll was about 10,000 with around 5,000 persons reported as missing.

Health Sector
Organization: India is a Democratic Republic consisting of 28 States and 7 Union Territories (directly administered by the Central Government). According to the Constitution of India, state governments have jurisdiction over public health, sanitation and hospitals while the Central Government is responsible for medical education. State and Central Governments have concurrent jurisdiction over food and drug administration, and family welfare. Even though health is the responsibility of the states, under the Constitution, the Central Government has been financing the national disease control, family welfare and reproductive and child health programmes. India is home to many indigenous systems of medicine, including Ayurveda and Siddha. Homeopathy, Unani, Naturopathy and various other systems are also widely practiced. The Government of India and many state governments have taken steps to formalize and initiate standardization of these systems. These include evolving pharmacopoeia standards for drugs, upgrading educational standards in indigenous medicine and in homeopathy colleges in the country and encouraging research on applicability of these systems to specific diseases. In terms of its organization, the health sector primarily comprises of the public and private sectors. Public sector: Government health care services are organised at different levels, generally corresponding to the organisational structure of the administrative machinery. The Primary Health Centre (PHC) is the core of the rural health services infrastructure in India. It has both outpatient and outreach services. These outreach services are provided by sub-centres and staffed by multipurpose health workers. Inpatient and more specialised services are provided at the community health centres (CHC). Each

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sub-centre is expected to cater to a population of 5,000; each PHC to a population of 30,000; and a CHC serves a population of 100,000. District hospitals and medical college teaching hospitals along with specialized institutions provide referral care. Private sector: India has a large and unregulated private sector, both in formal and informal sectors. In the formal sector, the private sector accounts for 68 percent of the hospitals and 64 percent of the beds.20 There are large numbers of informal health care providers, most of them being less than fully qualified service providers. Adequate information is not available on the number of informal health care providers. Expenditure data reveals that more than three-fourths of outpatient curative care services are accessed through private health care providers.21 Private non-profit sector: The private non-profit sector includes health services provided by voluntary organizations, charitable institutions, missions, and charitable trusts among others. Till the mid-1960s, voluntary effort in heath care was confined to hospital-based care. Later, perhaps inspired by the Chinese experience of a motivated health cadre delivering care at the community level, models of community health programmes and decentralized curative services began to receive attention. The National Health Policy 1983 and 2002 called for expanding the coverage of services through the non-profit sector to improve access and availability. The efforts of the non profit organizations in the health sector cover a wide range of activities and can be classified broadly into: • • • • Organizations implementing government programmes; Organizations running specialized community health integrated programmes for basic health care delivery and community development; Organizations sponsoring health care for blindness control, polio eradication, management of blood banks, and support during disasters/epidemics; Organizations/individuals, health researchers and activists who undertake applied research in health service delivery, health economics, health education and play an advocacy role.

According to a rough estimate, more than 7000 voluntary organizations in the country work in these areas of health care22. Although a systematic documentation of NGO contribution is lacking, it is obvious that NGOs and non profit institutions could improve access, quality and equity of services either through direct provision or through advocacy and other action. The potential of non profit institutions in helping to reach public health goals have not been fully realized for several reasons, beginning with their limited size and spatial distribution. The challenge is to find strategies that will
Better Health Systems for India’s Poor : Findings, Analysis, and Options, David H. Peters, Abdo S. Yazbeck, et al, World Bank, 2002. 21 Morbidity and Treatment of Ailments, NSSO 52nd Round, (2001), Dept of Statistics, GOI, New Delhi. 22 India Health Report, Mishra R L, Chatterjee R, Rao S, OUP 2005. ,
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facilitate a far more substantial participation in the health sector, particularly in poor performing states and remote areas, and to ensure systems that will keep participation accountable and transparent. In India, new public health challenges have emerged from demographic and epidemiological transitions, environmental degradation, emerging infectious diseases and anti-microbial resistance. India’s public health infrastructure, however, is unable to respond to these new challenges as the delivery system is not functioning optimally and as it is not based on the current needs of the community. The Government in its National Health Policy 200223, advocated the need for ensuring adequate availability of personnel with specialization in public health. There is an urgent need to strengthen public health education in India. The main challenges for public health institutions in India is to reflect social responsiveness and accountability, develop quality assurance systems, keep pace with advancing technology and develop an interface with the community and health care delivery system. Financing: India spends 4.6 percent of its GDP on health, of this 0.9 percent is public expenditure and 3.5 percent is private expenditure (Annexure – Table 6 and Figure 4). The National Health Accounts are estimated within the boundaries shown in Figure 3. Of the private expenditure, the major financing sources that provide funds
Figure 3: Scope of National Health Accounts with overall National Health Financing

Source: National Health Accounts India, 2001-02, MOHFW, GOI, 2005
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National Health Policy – 2002, MOHFW, GOI, 2002.

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Figure 4: Total Health Expenditure in India 2001-02

Source: National Health Accounts India, 2001-02, MOHFW, GOI, 2005

are households, which account for 72 percent of the total health expenditure incurred in India. This includes out of pocket payments borne for treating illness of family members and insurance premium contributed by individuals for enrolling themselves in various social voluntary health insurance schemes. The remaining sources which contribute substantially for provision of health care services in the country are State Governments (13 percent), Central Government (six percent) and the public and private firms which provide medical benefits to employees and their dependents (five percent). External support from bilateral and multilateral agencies accounts for two percent of health expenditure in India (Annexure – Table 7 and Figure 5).
Figure 5: Health Expenditure by Financing Sources – 2001-02

Source: National Health Accounts India, 2001-02, MOHFW, GOI, 2005

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Data reveals that 70 percent of the financial resources are flowing to health care providers in the for-profit private sector. Another 23 percent of resources are being spent on public providers. The Ministry of Health and Family Welfare (MOHFW) spends a sizeable share of its resources on Public Health and RCH programmes, medical education and research and on specialty hospitals, while the State Departments of Health and Family Welfare spend substantial share of resources on hospitals (33 percent) and dispensaries/ PHC/ Sub Centres (17 percent). Workforce: Human Resources for Health (HRH) are one of the most important part of a country’s health system. The health system is dependent upon an efficient, motivated and vibrant health workforce. In the World Health Report 2006, the health workforce is defined as all people engaged in actions whose primary intent is to enhance health. There are two types of health workers – health service providers and health management and support workers. In India, the HRH can vary from traditional healers to modern health professionals. The modern sector comprises of trained and qualified doctors of allopathic system, a range of paramedical professionals and allied personnel such as policy makers, health planners and managers, researchers and health technologists. The other sector is replete with the richness of India’s traditional healing systems. Here one finds professionally trained and qualified practitioners of Ayurvedic, Unani, Siddha and Homeopathy (AYUSH). There are also less than fully qualified providers and traditional and household birth attendants amongst others. Till 2004, 633,108 doctors were registered with various State Medical Councils in India. This gives a doctor to population ratio of one doctor for every 1676 population (or 59.7 physicians for 100,000 population). A different picture emerges when one accounts for AYUSH practitioners. There were 492,550 qualified AYUSH practitioners registered with the respective councils by the end of 2003. As of March 2003, there were 839,862 nurses registered with the State Nursing Councils. The nurse to population ratio as of 2004 is 1:100-200. The nurse to doctor ratio is about 1.3:1 compared to a ratio of 3:1 in most developed countries. There were also 53,775 dentists registered with the dental council24. There is inadequate data on those working in the management or support capacity. Though medical education in India has been around for a long time, it has not fully kept pace with the changing disease patterns and advancement of science and technology. The goal of medical education should be to produce health personnel capable of managing common problems in realistic health care settings. WHO is supporting medical education by providing fellowships and also technical assistance to encourage linkages with public health programmes. The health manpower requirement needs to be forecasted and appropriate strategies need to be identified. The trend of increasing personnel for high
Financing and Delivery of Health Care Services in India, Background Papers, National Commission on Macroeconomics & Health, GOI, New Delhi, 2005.
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end care has to be reversed, keeping staff free for a broad range of services. Training for paramedical personnel would require additional emphasis. Notwithstanding the progress, some of the critical issues that need to be addressed include availability of HRH, the numerical and distributional imbalances, inadequate training and capacity building, inefficient skill mix of health personnel, personnel management issues, lack of support and poor working environment, lack of opportunities for personnel development and other factors leading to inefficient delivery of care. Information on HRH is fragmented and difficult to obtain. Hence, there is also a need to pay attention to HRH policy, planning and management issues in a consistent and planned manner.

Health in the Future
India is striving to ensure the health of its people by focusing on improving the health infrastructure, reducing inequity and regional imbalances (especially for the health of women and children), and alleviating the problems of malnutrition and by forging partnerships between the various stakeholders. India, under the Tenth Five-Year Plan, has focused on the following: • Reorganisation and restructuring of the existing health infrastructure at primary, secondary and tertiary levels so that they attain the capacity to render health care services to the population with appropriate referral linkages with each other; Appropriate delegation of power to Panchayat Raj institutions (local self government) to ensure local accountability of public health care providers; Integration of national disease control programmes including supplies monitoring, Information, Education and Communication (IEC), training and administrative arrangements; Development of an appropriate two-way referral system using information technology and exploration of alternative systems of health care financing; and Clear definition of the role of the various stakeholders – the government, private and voluntary sectors.

• •

• •

India’s National Health Policy 2002, takes into account new diseases and changes in medical science since the previous health policy of 1983. It aims to reduce inequities and regional imbalances in the health sector and to strengthen the primary health care network all over the country. The achievement of an acceptable, affordable and sustainable standard of good health and the presence of an appropriate health system to reduce the burden of diseases are the main thrust of the new health policy. India’s National Population Policy 2000, places the achievement of demographic goals in the larger social context. This Policy provides a framework for advancing goals

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and prioritising strategies during the next decade for meeting the reproductive and child health needs of the people of India, and for achieving net replacement levels of fertility by 2010. It is based on the need to simultaneously address issues of child survival, maternal health and contraception, while increasing outreach and coverage of a comprehensive package of reproductive and child heath services by the government, industry and the non-government sector, all working in partnership with each other. India’s National Nutrition Policy 1993, advocates for a comprehensive inter-sectoral strategy for alleviating the different problems of malnutrition and its related deficiencies and diseases so as to achieve an optimal state of nutrition for all sections of the society, but with a special priority for women, mothers and children who are vulnerable or “atrisk”. National Rural Health Mission: The National Rural Health Mission (NRHM) has been formed with a view to increasing the expenditure in the health sector from a current 0.9 percent of GDP to two percent over the next five years and to focus on Primary Health Care. The Mission has been made operational from April 2005 throughout the country with special focus on 18 states which include: eight Empowered Action Group States (Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttaranchal, Orissa and Rajasthan); eight North-Eastern States (Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura); Himachal Pradesh and Jammu & Kashmir. The main aim of NRHM is to provide accessible, affordable, accountable, effective and reliable primary health care, especially, to the poor and vulnerable sections of’ the population. It aims at bridging the gap in rural health care through the creation of a cadre of Accredited Social Health Activists (ASHAs), improved hospital care measured through Indian Public Health Standards (IPHS), decentralization of’ programmes to the district level to improve intra and inter-sectoral convergence, and effective utilization of resources. Furthermore, the NRHM aims to provide an overarching umbrella to the existing programmes of Health and Family Welfare, including RCH-II, malaria, blindness, iodine deficiency, filaria, kala-azar, TB, leprosy and Integrated Disease Surveillance. The NRHM also addresses issues which are basic determinants of good health such as safe drinking water, sanitation and hygiene, nutrition and other social determinants. It promotes greater convergence among related social sector departments namely, AYUSH, Women & Child Development, Sanitation, Elementary Education, Panchayati Raj and Rural Development. It seeks to build greater ownership of the programme among the community through involvement of NGOs and other stakeholders at National, State, District and Sub-District levels to achieve the goals of National Population Policy 2000 and National Health Policy 2002. Globalization issues: Globalization and trade liberalization can affect health directly and indirectly. Therefore, it is important to take into account the global environment when developing national and domestic strategies. Countries also need to take into
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account global, regional, and cross-border spill-ins and spill-overs when developing health policies. Governments have to manage both opportunities and risks that result due to globalization. In order to protect the population, MOHFW has to engage externally to mitigate some of those risks. It requires cooperation with other concerned ministries. There is a need to consider international policy developments and treaties when drafting national policy. For instance, the policy changes brought about by the World Trade Organization (WTO) regime have limited the choices available to nations to control trade practices that influence the health of their people. Safeguards are available in different policy instruments and trade agreements. But unless the implications of the different clauses and sub-clauses of the agreements are understood, public health officials will not be able to use these safeguard provisions. The new trade regime, especially the measures related to intellectual property rights and sanitary and phytosanitary measures, will have a significant impact on health systems, more since the product patent regime has become obligatory for India since 2005. The impact can be both negative and positive. India would be able to make effective use of the safeguards that have been inbuilt into the agreement if appropriate steps are taken. Trade Related Intellectual Property rights (TRIPS) attempts to balance two complementary public health goals – making drugs affordable and providing incentives for developing new drugs. As Indian pharmaceutical companies move up the value chain, both objectives become relevant for the country. India will also need to explore how the provisions of TRIPS can be used to enhance public health in developing countries and work out how India can contribute to it. As the product patent regime has become applicable, it is necessary to form strategic alliances to have access to the expanding knowledge base in pharmaceuticals. Indian pharmaceuticals also need support on availing the exemptions available for purposes of research and clinical trials. Increasing trade in health services challenges the capability of MOHFW to assess accurately and respond rapidly to the risks and opportunities for population health. The definition of trade in services in the Agreement hinges on four types of transactions or “modes of supply”. These are the cross border supply of services (e.g. telemedicine, eHealth), consumption of services abroad (patients who travel abroad for medical treatment), commercial presence (establishment of health facilities in the country concerned) and presence of natural persons (foreign doctors or nurses who seek to practice in the countries). Informed and evidence-based approaches are needed to manage any future effort to liberalize health-related services so as to ensure greater access to affordable, better quality and effective services, leading to increased choice for consumers and greater equity in health outcomes.

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Development Assistance and Partnership

3

Development assistance, including loans and grants, contribute a small percentage of India’s expenditure on the health sector, and has ranged between one and three percent of the total public health expenditure. The overall foreign assistance to India in 1999 was 0.4 percent of GDP and per capita Overseas Development Assistance (ODA) was US$1.6 in 1998 as against an average of US$9 for developing countries. Of this, the share of health in the total assistance was 6.7 percent.25 At present, assistance from only a few countries is accepted to be channeled through the Government. Other donors are requested to direct their contributions through UN agencies and nongovernmental organizations.

Overall Trends in Assistance
The pattern of development assistance to India in the health sector has undergone major changes. These include changes in the share contributed by different funding agencies, the method of financial inflow and the nature of programmes being funded. Until the late 1980s, the major source of external funding in the health sector was the US government (USAID) followed by UNICEF, the World Bank and WHO (Annexure Table 8). But after 1995, the World Bank has emerged as the major external funding agency for India in addition to the United Kingdom’s Department for International Development (DFID). The programmes funded by external assistance have also been changing, reflecting the evolving needs and shifts in the priority of both donors and the Government of India. In the initial phase, assistance has focused on malaria control, polio, and family planning. Currently, the emphasis has shifted to HIV/AIDS, tuberculosis and health systems development. Reproductive and child health also remains a priority area. Recent years have also seen the emergence of funding agencies that are not governments or part of the UN system. Important among these are the Global Alliance for Vaccine Initiative (GAVI), Global Fund for AIDS, TB and Malaria (GFATM) and the Bill and Melinda Gates Foundation, in addition to existing agencies such as the Aga Khan Foundation. These agencies could be expected to further influence the development assistance scenario in the medium term. Global Alliance for Vaccines and Immunization: GAVI was formed to harness the strengths and experiences of multiple partners in immunization. It is an alliance
25

Human Development Report, Globalization with a Human Face, 1999, UNDP

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between the private and public sector, committed to the mission of saving children’s lives and protecting people’s health through the widespread use of vaccines. GAVI has been supporting the Hepatitis B pilot project of the Government of India in 14 cities and 33 districts in Phase I of the project (2002-2006). The funds amounting to US$ 40 million are mainly for supporting procurement of Hepatitis B vaccines and Auto Disable syringes. WHO will continue to provide technical support to the expansion programme of Hepatitis B. Global Fund to Fight AIDS, Tuberculosis and Malaria: GFATM is an independent public-private partnership, working to increase funding to fight these three diseases in countries with the greatest need and contribute to poverty reduction as part of the Millennium Development Goals. The Fund complements existing programmes and activities. WHO serves as a member of the Country Coordination Mechanism (CCM) and provides ongoing technical support to proposal development and monitoring. WHO also supported the establishment of a secretariat to facilitate the functioning of the CCM. Bill and Melinda Gates Foundation: This Foundation is guided by the firm belief that all lives, no matter where they are lived, have equal value. Their global health mission is to help ensure that lifesaving advances in health are created and shared with those who need them most. To date, the foundation has committed more than US$6 billion in global health grants to organizations worldwide. The strategy focuses on two primary areas: (1) Accelerating access: funding to ensure that existing health interventions and technologies are made widely available in the developing world; and (2) Supporting research: funding for basic and clinical research to develop new vaccines, drugs, and other health tools to fight diseases that cause the greatest illness and death in developing countries. In India, around US$200 million were provided to establish Avahan, a national HIV prevention initiative. WHO will continue to provide technical support for HIV prevention to Avahan initiative. The Clinton Foundation HIV/AIDS Initiative India would also be provided with technical assistance in the area of paediatric HIV/AIDS.

Sector-Wide Approaches
Sector Wide Approaches (SWAps), which came into being in the mid 1990s, are an important element of the international effort to harmonize and align development assistance around national policies and strategies. From the beginning, WHO has made a globally significant contribution to the basic ideas underpinning SWAps at the conceptual level. For several years WHO provided the secretariat to the Inter-Agency Group on Sector-wide approaches and Development Cooperation.

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In India, the Reproductive and Child Health (RCH) Phase II was developed using a Sector-wide programme approach. The funding mechanism is flexible and supports sector policies. While part A of the programme will be funded entirely by the Government of India, part B will be through a pooled fund from various donor agencies. Part A will cover basic maintenance of the programme, including salaries of the core programme staff in the states. It will be released through consolidated state funds and grant-in aid to some central institutions and will cover the procurement of contraceptives for social marketing. Part B of the programme will enable the states to design and implement the RCH programme to suit their specific needs. It will also finance approved state plans through a flexible pool of funds. This will enhance the quality and scope of the RCH programme by supporting innovations such as Public Private Partnerships, demand side financing, and expansion of the programme to the urban poor and other vulnerable groups. Starting 2005-06, DFID and the World Bank have agreed to support RCH-II through pooled financing for five years. The commitment of the World Bank is US$350 million, DFID’s is British Pound Sterling 265 million and US$25 million by UNFPA for the common pool. Other development partners such as USAID will also support the programme through their ongoing projects. The non pooling partners, notably WHO, will be supporting the initiative under the overall framework of RCH-II programme.

Donor Coordination
Since the share of donor assistance is a small portion of the total health expenditure, donor and development partner coordination is vital for enhancing the productivity of development aid. Given the fragmented manner in which funds are channelled and lack of effective coordination of aid, it often results in duplications and overlap of activities, distortion of aid through conflicting approaches and schemes, and gaps among identified need that are not addressed by donors. Donor and development coordination helps to integrate technical collaboration and financial aid in line with national priorities. This may be carried out through mechanisms like Inter-Agency Coordination Committees (ICCs) as is being currently used in poliomyelitis eradication. ICCs have been recently expanded to include all immunizations. It can also be carried out through Consultative Group meetings, at present held on an annual basis for all major donors. The following collaborations currently exist in the health field: Expanded Theme Group on HIV/AIDS: The UN Theme Group on HIV/AIDS in India is an expanded Theme Group, which is co-chaired by the UN Resident Representative and Government of India. It includes the National AIDS Control Organization (NACO), bilateral donor agencies and the Indian Network for People living with HIV/AIDS. It works closely with the government, nongovernmental organizations, community networks, people living with HIV and AIDS (PLWHA), the private sector and other partners in generating a well-coordinated and enhanced response to HIV and AIDS.
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CHARCA: In addition, a joint UN project called ‘CHARCA’ (Coordinated HIV/ AIDS Response through Capacity-building and Awareness), is being implemented in six districts in partnership with NACO, State AIDS Control Societies, district administration and services, NGOs, community-based organizations and women’s groups. Being a member of this group, WCO is actively participating and providing technical assistance in the implementation of CHARCA. National Polio Inter-Agency Coordinating Committee: In India, many organizations take part in immunization activities, each contributing in different ways with vastly different resources. Much can be gained by coordinating the efforts of these organizations to avoid duplication and maximize the use of limited resources. Therefore, in 1995, a national ICC was created to coordinate immunization activities in general and polio eradication in particular. The ICC in India has been an effective mechanism in the Intensified Polio Eradication efforts. It is supported by the Government of India, development partners and UN agencies. The ICC is coordinated by WHO and has representation from UNICEF, World Bank, agencies such as USAID, DFID and NGOs such as ROTARY International. WHO orchestrates polio surveillance and supplemental immunization activities, convenes an international expert group which advises on strategies, coordinates funding requirements and mobilization of international support. UNICEF coordinates vaccine procurement and supply, and provides technical advice on cold chain renewal and maintenance. ROTARY mobilizes opinion leaders and communities through its extensive nationwide network. All the partners are committed to supporting the effort until polio is eradicated. United Nations Development Assistance Framework (UNDAF): In line with the UN Reforms, the UNDAF for 2008-2012 is currently under preparation. The UNDAF will be based on the 11th Five Year Plan priority areas highlighted by the Planning Commission of the Government of India. The UN Country Team (UNCT) as a group has agreed on the overarching goal of the next UNDAF, i.e. “promoting social, economic, and political inclusion” with the objective of “capacity development at local level to improve the quality of life for the most disadvantaged women and girls”. With the above objective in mind, the India UNDAF will be framed around the MDGs as these resonate well with the approach to the 11th Five Year Plan. The UNCT has agreed to set up eight Thematic Working Groups (TWG) to analyze the achievements and gaps around the MDGs. These are: 1) poverty and hunger, 2) education, 3) gender, 4) maternal and child health, 5) HIV (and malaria and TB), 6) environment, 7) disaster and 8) decentralization. The TWGs will perform a situational analysis, including the current scenario, achievements, gaps, major players and a mapping of who does what in each of these thematic areas. They will also identify the results at the output level based on the comparative advantage of the UN agencies working in that sector. WCO is participating actively in MCH and disaster groups and chairing the work on malaria and TB.

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WHO Global and Regional Policy Directions
Global Challenges in Health

4

The General Programme of Work (GPW) is one of the highest policy documents of WHO. The 11th GPW (2006-2015) sets out the direction for international public health for the period of 2006 through 2015. The document notes that there have been substantial improvements in health over the last 50 years. However, significant challenges remain, as described in the following four gaps: Gaps in social justice: Clearly, poverty is a key factor that impedes access to quality health services. In some countries the life expectancy of the poor is 20 years lower than other privileged members of society. Poor health and poverty form a vicious cycle. Other factors that reduce access to services are discrimination by ethnicity or gender, and women’s health which is often not adequately addressed. Gaps in responsibility: Health problems today are no longer merely the responsibility of those working on health, but require positive action by those outside the health sector. International conflicts and national crises often lead to the disruption of social services which include health care. Globalization and decisions made regarding international trade have a direct impact on health, especially in pharmaceuticals and the movement of health professionals. In many countries Ministries of Health often do not have the capacity to adequately influence important causes of ill-health outside the health sector. Gaps in implementation: Very often the technology to implement cost-effective interventions to improve health is available. But these are not implemented because of shortage of funds, lack of human resources or the absence of an effective health system. Available resources may often be allocated to high-cost curative services and favor urban areas, leaving inexpensive and effective interventions in rural and remote areas neglected. Gaps in knowledge: Global advances in science and technology have improved the effectiveness and efficiency of medical services and the prevention and treatment of diseases. However, information about these advances is often not available in many countries. Also, the lack of information about health conditions, and existing rigidities in many countries have in turn made it difficult to formulate and manage effective health policies and interventions. Even operational research for those most in need of health services is generally not done, thereby reducing the efficiency of key programmes.

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Global Health Agenda
In order to reduce these gaps over the coming ten years, the 11th GPW outlines a global health agenda consisting of seven priority areas: • • • • • • • Investing in health to reduce poverty Building individual and global health security Promoting universal coverage, gender equality, and health-related human rights Tackling the determinants of health Strengthening health systems and equitable access Harnessing knowledge, science and technology Strengthening governance, leadership and accountability

The global health agenda is meant for everyone working in the field of health development. WHO will contribute to this agenda by concentrating on its core functions, which have been built on the comparative advantages of the Organization. In accordance with the global health agenda and WHO’s core functions, the Organization has set the following priorities: (1) Providing support to countries in moving to universal coverage with effective public health interventions (2) Strengthening global health security (3) Generating and sustaining action across sectors to modify the behavioural, social, economic and environmental determinants of health (4) Increasing institutional capacities to deliver core public health functions under the strengthened governance of ministries of health (5) Strengthening WHO’s leadership at global and regional levels and supporting the work of governments at the country level.

WHO’s Core Functions
• • • • • • Providing leadership on matters critical to health and engaging in partnerships where joint action is needed. Shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge Setting norms and standards, and promoting and monitoring their implementation Providing technical support, catalysing change, and building sustainable institutional capacity Articulating ethical and evidence-based policy options Monitoring the health situation and assessing health trends

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WHO will pursue these priorities through its Medium-term Strategic Plan (20082013) and the biennium budget of the Organization. The Director General of WHO has clearly put a major focus on the work of the Organization at the country level. The Regional Offices and Headquarters have been directed to emphasize support for country work and implement these priorities in Member States, especially where the health needs are greatest.

Regional Policy Framework
The South-East Asia Region (SEAR) has the second highest population among the six WHO regions and has the greatest burden of disease. While there has been great economic development in this region in recent years, the problems of poverty and poor health remain significant. Many countries have faced health emergencies in the last decade and the threat of disease outbreaks is ever-present. At the same time, noncommunicable diseases have become an increasingly important cause of morbidity and mortality in SEAR countries. Therefore, the global policy framework of WHO is appropriate for the countries of the region, with special attention given on strengthening the capacity of Member States to support public health interventions. The South-East Asia Region has always placed a strong emphasis on its work in Member States. Of the total budget provided to the region, 75 percent is allocated for countries, the highest of any WHO region. The WHO Regional Director has recently increased the delegation of authority to country offices to enable them to plan and implement programmes with a higher degree of independence and to be more accountable for their work. At the same time, he has emphasized that the Regional Office staff should give the highest priority to support the work in these countries.

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5

WHO Current Policy Framework and Cooperation

Policy Framework and Strategic Directions
Article One of the WHO Constitution spells out the mission of WHO: “the attainment by all peoples of the highest possible level of health”.

Mission Statement of the WCO
Build a strong, proactive, technically excellent and dedicated WHO country team within a global network; provide leadership in health; and collaborate with governments, civil society and other partners. Provide technical expertise in public health through partnerships with the Ministry of Health and Family Welfare; state and local governments; development and other partners; and civil society; with focus on: • Promoting health as a fundamental human right, and working to place health as an integral part of sustainable socio-economic development for the people of India.· Proactive and committed leadership in public health, with emphasis on: – – – – – • setting norms and standards; reducing the burden of excessive morbidity, disability and mortality; reducing the risk factors associated with major causes of disease; developing health systems to ensure equity in health promoting an effective health dimension to development policies in social, economic and environmental areas.

Mobilizing, developing and optimally utilizing human and financial resources and promoting a conducive working environment

In India, WHO has built up a reputation for strong technical skills, neutrality and commitment to India’s health needs. These have been demonstrated time and again through successful collaboration between the GOI and WHO. Some of the recent examples of WHO’s technical support being acknowledged by GOI and other UN partners include:

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Assistance provided for a quick response to emergencies caused by epidemics (SARS, avian flu) and natural disasters (Gujarat earthquake, Orissa cyclone and Tsunami disaster); Recognition of WHO’s technical collaboration in programmes such as the Revised National Tuberculosis Control Programme (RNTCP), polio eradication, guinea worm eradication, National Cancer Control Programme (NCCP) and scaling up Anti-Retroviral Treatment (ART) for people living with HIV/AIDS; Increased credibility and trust on WHO displayed by the government and the civil society, such as when India faced the threat of SARS and avian flu; Recognition of WHO’s role in the Tobacco Free Initiative; and Mobilization of additional resources and better utilization of resources.

• • •

Some of the factors that made such increasing recognition possible were: • • • • • The ability of WCO in India to draw on global and regional experience; The technical expertise provided by a strong and proactive team at WCO; Increasing evidence-based decision-making; WHO’s image of neutrality giving WCO an ability to mediate between conflicting interests; and Acceptability of WHO by the government as a valuable partner and consequently having a close working relationship with it.

Current Country Programme and Organization
In India, WHO has focused on assisting in policy development and stewardship, supporting health services, advocating health promotion and building human resources. In accordance with its Corporate Policy and to channel global resources towards achieving measurable outcomes, WHO has chosen a set of specific areas of work based on their impact on the global burden of disease, vulnerability of poor people to these diseases, and the availability of cost effective technologies.

Core Programme Clusters
• • • • • • • Communicable Diseases and Surveillance (CDS) Family and Community Health (FCH) Noncommunicable Diseases and Mental Health (NMH) Health Systems Development (HSD) Sustainable Development and Healthy Environment (SDE) Immunization and Vaccine Development(IVD) Health Action in Crisis (HAC)

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The WHO’s Country Office in India (WCO-India), has the role of providing technical collaboration and coordinating with GOI, to move forward the national health development efforts within the corporate policy framework of WHO. The WCO is organized around Core Programme Clusters. Each of the core clusters has programmes on diseases (e.g. communicable and non-communicable diseases), or focuses on a specific area in the health sector (e.g. child and adolescent health, health system, etc.). The WCO also has special programmes that focus on specific initiatives, such as the National Polio Surveillance (NPSP), Routine Immunization, Disease Surveillance, Revised National Tuberculosis Control (RNTCP), Emergency and Humanitarian Action, National Commission on Macroeconomics and Health (NCMH), HIV/AIDS Technical Assistance, Leprosy Elimination (LEP), Roll Back Malaria (RBM), Tobacco Free Initiative (TFI), Lymphatic Filariasis (LF) and Knowledge Management. The WCO has technical personnel in the above areas; with some of them being stationed in the field, to provide leadership and to assist in collaboration with other stakeholders. The nodal ministry for WCO is the Ministry of Health and Family Welfare of the Government of India. However, all ministries of the GOI, UN agencies, various development partners and health-related NGOs access technical assistance from WCO. WCO also partners with designated WHO Collaborating Centres (Map 1) and national institutes of excellence in the country, mainly for research and capacity building. As appropriate, WCO may support activities of development partners and selected NGOs in identified priority areas of the health sector.

Financing the Technical Assistance Activities
The WHO–GOI collaboration works on the basis of a biennium plan jointly developed and agreed upon by both of them. In many areas, WHO collaboration is developed around the National Health Policy and the focus areas of the Five-Year Plans. The regular budget (RB) resources of WCO are used to support technical staff for collaboration and for programme activities. WCO mobilizes other sources (OS), previously called extra-budgetary (EB) for specific activities from donors. Some of the areas of work supported by OS are Polio Programme (NPSP), TB programme, LEP programme, disease surveillance, and HIV/AIDS. The schematic diagram in Figure 6 presents the proportion of RB and OS components of the WCO work and the broad areas in which they are used. The RB supports areas which do not have much OS support, like NMH and HSD.

Decentralisation and State Level Responses
States in India differ in epidemiological transition and in the quality of their response. If states with unequal needs are to be treated equitably they must receive technical

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Map 1: WHO Collaborating Centres

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Figure 6: India Workplan Budget Summary 2006-2007

Source: WHO Activity Management System Database, 2006

and material support sensitive to their specific needs. The Indian health system has sought to address this reality while assigning powers to different tiers of government. Many functions of public health importance have been assigned to units of local administration in rural and urban areas. New strategies in RCH II programme and the National Rural Health Mission have further strengthened decentralized programming at village and district levels. Since WCO works in areas of public health importance in India, there has always been a strong involvement at state and district levels. WCO has worked at generating information, building capacities, providing technical guidance to states, and at times directly carrying out operations at state level and below, even in the absence of formal structures at sub-national levels. The following schematic diagram in Figure 7 represents the collaborative programme and the relative proportion of resources utilized at the National and State levels. The work at the state levels are guided and facilitated by the Central Government. Most aspects of health systems, especially relating to public health and curative services, are managed by the states. The core programme clusters of WCO collaborate
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Figure 7: Collaborative Programme of WHO India and Government of India

with the states (see Map 2). WCO has collaborated with states to conduct studies on the efficacy of current methods of financing, creating awareness on alternate financing routes and build capacities on key issues related to health financing and health insurance. WCO has also collaborated with MOHFW and state governments to document and disseminate health sector reforms across the states of India. The following are the main activities performed at the state level. Improving guidelines and skills: WCO supports the state drug authorities by strengthening and improving diagnostic skills for better regulation, developing training capacities for good clinical and pharmacy practices, elimination of spurious drugs, developing protocols and guidelines for blood banks, strengthening drug testing laboratories and developing and disseminating material for consumer information. Non-communicable Diseases: WCO has helped states which are at an advanced stage of epidemiological transition to generate data necessary for planning through NCD risk factor surveillance in the general population and through an industrial surveillance network. A multicentric study has been carried out to generate the health profile of the elderly population in ten states. Health promotion has been initiated through schools and hospitals and IEC materials developed for a healthy lifestyle. The

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mental health survey in 11 states will provide reliable estimates of the burden of mental health problems. A sustainable community based psychosocial programme was developed for the tsunami affected populations. Cancer control programmes, cancer registration, and palliative care programmes have been initiated in 10 states, and the National Cancer Control Programme has been supported for strategy development, IEC and training. Cancer ATLAS of India has been developed. States have also been partnering with Government of India and WCO in scaling up programmes to control the use of tobacco. The partnership now includes 18 states. Strengthening environmental health: WCO works on environmental health issues and its impact on community and has maintained close links with state governments to manage the impact of environment on health. To improve the quality of drinking water, WCO is supporting 10 states with water quality surveillance programmes including strengthening of state water quality laboratories and rural sanitation programmes. WCO is collaborating with 11 states to manage pilot programmes on hospital waste management. The “Healthy Setting” programmes in selected areas of Mirzapur district (in Uttar Pradesh) and Bangalore city and Kottayam town (in Karnataka), are examples where the local community has been involved in planning and implementing activities. WCO has also provided assistance in conducting quality audit of all State Food Laboratories to improve food safety measures. Improving maternal and child health: Under the Making Pregnancy Safer (MPS) programme, guidelines for Antenatal care and skilled attendance at birth by ANM/ LHV/Staff Nurses and managing complications of pregnancy and child birth by Medical officers have been developed and disseminated to the states. A multi site demonstration project for expanding safe abortion services has been implemented in eight states. Maternal death reviews have been introduced in three states to develop a clearer understanding of preventable causes and to improve the quality of maternal health services. WCO has focused efforts in four states to combat the problem of female foeticide and foster ethical medical practices. Training in essential newborn care and services are being conducted in more than 100 districts. Integrated Management of Childhood Illness (IMCI) has been adapted as IMNCI, so as to include illnesses of the newborns. Trainers have been trained in different states and state-level planning workshops have been organised. Adolescent Friendly Health Service Centres have been established in 14 sites across the country. Following the development of Implementation Guide, the same has been disseminated and state planning has been initiated in six states. The nursing officers of the states and UTs have been provided with IT support and training for developing the Nursing Management Information System. Approximately 300 nurse professionals from different states have been trained in specialty nursing. State nursing councils registrars have been oriented/sensitized on different training programmes developed by the Indian Nursing Council (INC) and on nursing in disaster situations.

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Map 2: WHO’s Work in the States by Core Programme Clusters

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Health promotion: WCO has supported health promotion across the life span and has initiated health promoting schools in Varanasi and health promoting hospital in Lucknow. Tobacco cessation clinics have been set up in 18 states. Support has been provided to cancer detection and prevention programmes in states under the National Cancer Control Programme. Industrial settings in 10 states have been provided interventions for health promotion and prevention of NCDs. Disease control: WCO supports national communicable disease control programmes for outbreak investigations at the state level. WCO also supports state specific disease surveillance programmes in Maharashtra, Orissa and Tamil Nadu. More than 300 consultants support state and district health authorities in AFP surveillance. WHO also assists in building capacities to use epidemiological information to make decisions at the state and district levels through the three-month and two-year Field Epidemiology Training Programmes (FETPs). WCO consultants have been positioned at 120 divisional and state units to support the Revised National TB control programme. In the leprosy programme, WCO has placed 18 consultants in the states. In the area of HIV/AIDS, WCO has 10 consultants for ART. These consultants, whose capacities are constantly updated by WCO, have been a major source of support to state level managers of the disease control programmes. Disaster preparedness: Whenever a natural disaster has struck in any part of the country, WCO has responded with technical assistance directly to the state governments, in addition to collaborating with the Government of India to manage the impact on health. When the tsunami struck the southern coast of India, WCO maintained contact with state governments and field NGOs in affected states and liaised with WHO Regional Office and Headquarters. A WHO office was temporarily set up in Chennai in the premises of State Department of Health. On the ground WCO supported disease surveillance, immunization programmes and training of community level workers in providing psychosocial support. WCO provided technical assistance to district authorities for strengthening the monitoring of drinking-water quality, hygiene education and waste management. These activities were carried out in collaboration with WHO Collaborating Centers and other centers of excellence. Current country cooperation has encompassed all programme areas and has recognized the need for WCOs support to the states. This experience will be used to further strategize the cooperation in the coming years.

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Strategic Agenda: Priorities for Cooperation 2006-2011

6

While developing the CCS for India the global and regional priorities have been kept in view. The GOI has articulated a series of policy and plan documents for the health sector and the WCO is committed to supporting the efforts of the government in achieving its goals. Given India’s vast population, the size of the country and resource constraints, the WCO needs strategic deployment of its resources. The thrust of WHO support for the period 2006-2011 (outlined below) has been chosen carefully based on their share in the overall health problem in India; impact of proposed interventions, and comparative advantages of WHO.

High Priority Areas
(1) Reduce the burden of communicable and emerging diseases by enhancing surveillance and response capacities (2) Promote maternal and child health notably by improving continuum of care and strengthening immunization (3) Scale up prevention and control of noncommunicable diseases through support for development of new policies and programmes (4) Strengthen health systems development within the national and global environment, with a focus on human resources • • • Improve access, quality and accountability of the health system Improve effectiveness and efficiency Contribute to the global policy environment

WCO will take into consideration paramount cross-cutting priorities, notably poverty, equity, access, gender, quality assurance and capacity building. The WCO is committed, in association with its partners, to making a difference in these areas which are crucial to improving the health status of the people of India.

Reduce the Burden of Communicable Diseases
Although significant progress has been achieved in the control of communicable diseases in the country, the existing burden falls mainly on the poor. Therefore, the control of
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communicable diseases remains a major focus for state and central governments as well as WCO. Current disease control programmes do not give sufficient importance to the diversity of disease profiles in different parts of the country. Locally appropriate responses are needed in the national disease control programmes. This would involve generating reliable epidemiological data for states or regions within bigger states. The WCO will work with GOI and the states to generate the needed data and develop capacities to manage state specific responses. Substantial progress has been made in GOI’s Revised National Tuberculosis Control Programme (RNTCP), leading to a complete national coverage in 2006. Future challenges will be to sustain progress and address emerging issues, particularly in multi-drug resistance. The experience of polio eradication shows that mobilization level is high when there is a clearly defined goal. WCO will assist in identifying long-term integration options so that the benefit of the polio surveillance can reach the routine immunization system and integrated disease surveillance. WCO will continue providing technical assistance to the government for scaling up the HIV/AIDS response. WCO will assist the development of capacity in the country for laboratory, clinical and social support, as well as monitoring and evaluation for antiretroviral treatment. WCO will also support the government in evaluating and introducing newer vaccines for disease control programmes while ensuring high coverage with vaccines of high quality. Strengthen surveillance and information systems: The GOI is implementing the Integrated Disease Surveillance Programme (IDSP) at the district, state and national levels with WCO technical support and funding assistance from the World Bank. This programme is expected to detect, verify and respond rapidly and effectively to outbreaks and epidemics. Given the geographical size, population and diversity among health care providers, developing and sustaining such a system is an enormous challenge. Through its staff and collaborating centres, WCO will also provide support to monitor and evaluate the functioning of the system so that feedback can be provided to state and central governments. The WCO-supported Field Epidemiology Training Programmes (FETP) also come as a complement to IDSP so that epidemiological intelligence is built to use information for decision-making. Respond to emerging and re-emerging diseases: The WCO and GOI acted in unison to respond to emerging diseases such as Severe Acute Respiratory Syndrome (SARS) and avian flu. In the future, it is probable that new and more virulent forms of pathogens would emerge. Given the level of connectivity that exists between nations today, these diseases can be managed optimally only through regional and/or global co-ordinated efforts. To detect and monitor the presence of newly emerging diseases, India is strengthening the surveillance system to international standards, especially the International Health Regulations. This can be developed as an offshoot of the Disease Surveillance Programme. WCO will work with GOI to make the early warning systems

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and responses more effective and develop systems for dissemination of information on new pathogens. As more diseases are controlled, it is important to raise the level of surveillance to detect any re-emergence and draw up contingency plans to deal with them. The WCO will assist GOI in developing such generic preparedness and response plans, which will be adapted to specific diseases.

Promote Maternal and Child Health
Maternal health: To improve maternal and newborn health, it is essential to provide access to skilled care during pregnancy, birth and the post partum period. The continuum of care needs to extend from the household to skilled care at the primary level and further to a referral facility for women and newborns with complications. WCO will work with the centre and states and contribute in developing skilled workforce for safer pregnancy and birth; increased quality of services at all levels; build capacity for individuals, families and communities for self care and health decisions; and collaborate with other key public health programmes. To prevent maternal mortality and morbidity, unsafe abortion must be addressed as part of the MDG. WCO will foster evidence based ethical medical practices to address issues of sex selective abortions. It will also help build capacity of human resources by strengthening pre-service medical and nursing training, in service training of medical officers, and help develop standards and guidelines for making available evidence based Emergency Obstetric Care. Infant and child health: Evidence suggests that two-thirds of the infant mortality rate (IMR) is due to neonatal mortality. This makes essential newborn care vital to prevent deaths within the first day, first week and first month. WHO has supported the adaptation of Global Integrated Management of Childhood Illnesses (IMCI) into Integrated Management of Newborn and Childhood Illness (IMNCI). This covers childcare from birth until five years of age. WHO will further assist the Government in increasing capacity for management of neonatal conditions and expanding coverage employing the IMNCI strategy. Efforts for improving the effectiveness of interventions for control of communicable diseases like diarrhoea, ARI and measles will be continued. WCO will assist in the introduction of cost effective interventions like Zinc supplementation in the treatment of childhood diarrhoea. Assistance will be provided to prevent and treat malnutrition in children. Adolescent health: Considering that 22 percent of India’s population is in the adolescent age group, WCO supported initiatives on adolescent friendly health services have been started. WCO will continue to support the Adolescent Sexual and Reproductive Health Strategy that focuses on reorganizing the existing public health system in order to meet the service needs of adolescents. A core package of services, including preventive, promotive, curative, counseling services, and training modules have already been developed. WCO will continue to assist the government with tools, guidelines and training manuals for working with young people to address their

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nutritional, health and psychosocial needs and to make services available to them in a friendly manner. The National Rural Health Mission (NRHM) and RCH-II provide a broad framework for convergence and for accelerating the decline in maternal, newborn and child mortality and morbidity through building a skilled workforce, improving quality and provision of services at all levels, including referral systems, building capacities of individuals, families and communities and strengthening collaboration with other public health programmes. The WCO will extend technical assistance to GOI in making the programme operational. It will also help develop and analyze data on indicators to assess how close India is to achieving the objectives and sub-objectives of the National Population Policy, 2000, and MDGs. Population stabilization: The National Population Policy, 2000, advocated a holistic, multi-sector approach towards population stabilization. While many regions of the country have shown signs of stabilization in population growth, this has been hampered in other parts by the poor capacity and lack of appropriate systems to identify community needs and plan for their provision. The WCO will work with MOHFW in collaboration with the centre and state governments to develop and assess policies appropriate to identified states. New technologies are being introduced to expand the choices of contraception. WCO will partner with other UN agencies in assessing these technologies and make appropriate recommendations. In order to promote evidence based practices, WCO will be working with the government to update the technical standards and guidelines for family planning methods and contribute to quality assurance. Universal Immunization Programme (UIP): This is a government programme to provide immunization against vaccine preventable diseases. Under the UIP vaccines , are administered to infants and pregnant women for controlling six vaccine preventable diseases namely, childhood tuberculosis, diphtheria, pertussis, poliomyelitis, measles and neonatal tetanus. WCO will provide technical assistance for improving routine immunization coverage and safety; support capacity building of the National Regulatory Authority and provide advocacy for new vaccine introduction and vaccine development

Scale up Prevention and Control of NCDs
There is much evidence to show that NCDs are preventable through integrated and comprehensive interventions. Cost-effective interventions have been used in many countries. The most successful strategies have employed a range of population-wide approaches combined with clinical interventions directed at individuals. WHO estimates that an additional two percent annual reduction in chronic disease death rates in India over the next 10 years would prevent six million deaths and would

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result in an economic gain of US$15 billion for the country. As India is passing through an epidemiological and demographic transition, the pace of transition varies between states. WCO will assist in developing policies, intervention strategies and development of feasible models. The policies will be flexible and accommodate the differing needs and resources of the states in India. Surveillance: The WHO Step-wise surveillance for NCD risk factors has been introduced into the Integrated Disease Surveillance Project in India. The prevalence of NCD risk factors in the population will serve as indicators for planning and monitoring of intervention strategies. Technical support will be provided to the NCD risk factor surveillance to make it sustainable, especially in data management and translation of data into appropriate policies. Support will be provided for networking cancer centres and for cancer registries. WCO will support the implementation of the NCD Infobase in India to provide reliable data on NCDs in the country. Models for surveillance of Diabetes and Cardiovascular Diseases will be developed. Health promotion: The WHO Global Strategy for Diet, Physical Activity and Health provides options for addressing important risk factors for NCDs. WCO will facilitate the Global School Based Student Health Survey through the Central Board of Secondary Education, which will provide a basis for school health promotion programmes. Models for intervention will be developed for workplace settings and will be disseminated. Health promotion across the life span will be adopted with emphasis on providing a supportive environment to promote healthy behaviours. Disease control: WCO will support the development, scaling up and implementation of the National Programme for diabetes mellitus, cardiovascular diseases and stroke. Technical support will be provided to the existing and proposed National Programmes in these areas. The ongoing National Cancer Control Programme will be strengthened in areas of prevention, early detection and palliative care. Horizontal integration will be encouraged across all NCD prevention and control programmes. Emphasis will be maintained on health system strengthening, capacity building of health personnel, multisectoral involvement and community participation in NCD control. Tobacco Free Initiative: WHO will provide technical assistance and partner with GOI for effective implementation of the provisions of the FCTC and the enforcement of the national tobacco control legislation. This would include strengthening of the National Tobacco Control Cell, technical support for the establishment of a National Tobacco Control Programme with adequate funds, and setting up of a Multi-Sectoral Coordination Committee for tobacco control and NCD prevention. Capacity in the area of tobacco control will be built at the state level through training of relevant state authorities, law enforcers, civil society organizations and health professionals. Technical assistance will also be provided for implementation of a sustained anti tobacco public awareness campaign and for expanding the tobacco cessation services to reach the masses through existing health systems.
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Strengthen Health Systems Development
(1) Improve access, quality and accountability
India is one of the 192 Member States that adopted the resolution on “Sustainable health financing, universal coverage, and social health insurance” at the World Health Assembly in May 200526. Accordingly, WHO will support the Government of India to further improve the health financing system with the ultimate goal of attaining universal coverage, i.e. to ensure all people have access to needed interventions and services without the risk of financial catastrophe and impoverishment. This will involve a number of areas and activities: Advocacy for increasing resources: At present, public sector health investment in India is around 0.9 percent of its GDP one of the lowest in the world. Total health , expenditures are also relatively low at 4.63 percent of GDP Advocating to augment . resources available for the health sector, WCO would focus on: (i) advocacy with governments at various levels to increase allocation for health sector; (ii) assisting in coordination of external assistance in specific programmes; and (iii) development of evidence based tools needed to monitor and evaluate projects. WCO will continue working with GOI in maintaining and updating information on health expenditures through the National Health Account System. Channel funds to priority areas: When resources are limited, they ought to be spent on interventions that offer the greatest possible health improvements. In health this would translate into activities that would benefit the greatest number, programmes that benefit the poor, and interventions that are cost-effective. The WCO will advocate and generate instruments for evaluating interventions on the basis of cost effectiveness, and decision-making based on such assessments. It would also support the sharing of information and experiences from other settings. Increase risk pooling including health insurance: Data from the National Sample Survey Organisation indicate that escalating health care costs is one of the reasons for indebtedness not only among the poor but also in the middle-income group. Nearly 2.2 percent people of India are impoverished annually because of high health care costs. Health insurance is one of the various financing options being considered in India to decrease indebtedness. Health insurance is the pooling of resources to cover the costs of future unpredictable health-related events. At present, health insurance coverage in India is extremely limited, especially outside the formal sector. Health insurance can help mobilise revenue for the health sector, protect individuals and households from the risk of medical expenses, and promote efficiency, quality and equity of health-care services. The WCO would assist in identifying experts who can provide technical assistance, support capacity building, and facilitate exchange of
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World Health Assembly (58.33), Geneva, WHO

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country experiences and best practices. WCO will also provide technical support to the development and evaluation of selected innovative financing initiatives. Support public-private partnership: The private sector which accounts for 70 percent of the health expenditures has some advantages such as flexibility and better response to patient needs. But access to services is contingent upon ability to pay, thereby putting adequate private services beyond the reach of the poor. It is possible to develop a partnership between public and private sectors so as to leverage the advantages of the private sector and to partner in the national health development efforts. The WCO will attempt to forge public-private partnerships; analyse and disseminate strengths and weaknesses; stimulate discussion on the acceptability of strategies and provide assistance for trying them out in pilot sites. While engaging with the private sector, it is also necessary to have a regulatory framework for health care institutions in the public sector. Many states have found it difficult to develop such a framework due to the presence of conflicting pressure groups. The WCO will work with GOI and the state governments to develop mechanisms for regulation that would not discourage the needed investment in the health sector, but which would be rigorous enough to protect the interests of patients and providers. It is necessary to have accreditation of health care institutions so that the consumers know about the quality of care that they are paying for. The WCO will also attempt to develop systems to ensure the accountability of health care providers to the community. Regulate framework, standards and technology assessment: While the private health sector in India has grown, it has done so in an unregulated manner. With patients more aware of the scope and limitations of health care services, there is a growing demand for objectively verifiable standards for services. It is in the interest of both the patients and the service providers to have documented standards for diagnostic, treatment and referral services. Such standards can be developed either by government or by professional associations and endorsed by the government. The WCO will assist in analysing similar standards and protocols in other countries and in assisting GOI and professional associations to develop them for India. Health services have benefited from technological advances. However, the business segment aggressively introduces new technologies which lead to excessive use, wasteful investments and higher expenditure. There is a limited regulatory framework to govern the introduction of new technology. The WCO will assist in developing protocols for assessing technology and make it available to health care providers, government and civil society organisations. Document health information for evidence-based decisions: Knowledge is a vital input in health sector management. Changes in the financing and provisioning strategies are time consuming and expensive. The probability of a successful outcome is enhanced if one learns from past experiences. WCO will build capacity through the following:
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Documenting best practices and lessons learnt. India has had several significant successes in the health sector. It is important that these are documented so that lessons are learnt. WCO will commission a series of documentation projects to record the significant successes and how they were achieved. Generation of data to support evidence-based management. Any reform, with long term implications, should be based on careful research regarding costeffectiveness, welfare implications and sustainability. WCO will support the generation of such database to support and advocate for reforms, including documentation of those with access to needed services, and the extent of catastrophic payments and impoverishment due to out of pocket payment for health services. WCO will also support evaluation of many initiatives, donor funded and other wise, in health sector reform which are being attempted in some states in India. Support for operations research on issues relevant to India. The National Health Policy 2002 aims to increase expenditure on research to one percent of the total allocation for health by 2005 and to two percent by 2010. There is a need to identify knowledge gaps and undertake relevant research that is context specific and resource sensitive. WHO has considerable experience in supporting research in the health sector. It also has access to expertise available in some of the best research institutions in the world. WCO will work with GOI and academic institutions to identify areas of operational research relevant to India and to provide technical support for researchers.

(2) Improve Effectiveness and Efficiency
Human resources for health: Without an effective health workforce, healthcare cannot be adequately provided. Efforts to reach the Millennium Development Goals and to address emerging chronic diseases would be compromised. The spectrum of human resource issues is large and complex, including issues of quantity, quality, relevance, motivation, utilization and distribution. The issues are not limited to health practitioners, but extend to managers, administrative and support staff and allied health personnel. Also, shortages are widespread with disproportionate concentration in urban areas. WCO will work with GOI and its partners in dealing with relevant issues notably, developing systems for quality education and training of various health workers; supporting and protecting them; enhancing their effectiveness; and tackling health imbalances and inequities. In this context, WCO would align its own human resources in support of CCS priorities. Managerial issues: There is a growing need for health managers as more and more public health systems enter into partnerships with civil society, procure products and services, and deal with changing disease patterns. Even in hospital management, the emphasis has shifted from individual practice to team-based management. In order to respond to the challenges of the changing health environment, health personnel

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must be made more effective and health systems management more supportive. Public health programmes need efficient management to maximize their effectiveness. Personnel and financial management capacity has to be strengthened, as does management of such areas as procurement and distribution of supplies and equipment. WCO will advocate for and assist in building these skills among the health managers, especially in the public sector at all levels. A team approach to patient care will be encouraged. Positioning public health education and approaches: In today’s world of market economy and trade liberalization, even with the availability of funds and other resources, public health systems cannot function optimally due to human resources constraints. Rough estimates suggest that India needs around 10,000 public health professionals. The shortage is further exacerbated by the lack of skill mix required in today’s public health worker. Today’s health worker needs “leadership ability, strategic thinking and planning capacity, flexible management skills and enhanced communication ability” to cope with the demands of new public health. Training in many of the institutes is firmly embedded in the biomedical model of health care wherein public health is set within clinical practice. The curriculum is neither need-based nor objective oriented with a distinct gap between classroom teaching and practice in the field, unsatisfactory skill building during under-graduate as well as in post-graduates programmes and with limited career development opportunities. WCO will work with GOI and other partners in positioning public health high on the national agenda. It will work to strengthen the national and regional public health institutions and departments, develop skill-based trained professionals in public health, review and revise the curriculum and demonstrate the models of integrated teaching. It will also support professional development of public health professionals, develop standards for courses and institutions, facilitate the establishment of accreditation system and network of institutions, and foster regular interaction among them. WHO would increase its role as a convenor of centers of excellence to maximize the effective use of their work and expertise, thus benefiting both India and other countries. Nursing and midwifery education and practices: Qualified nurses can contribute to positive health outcomes such as reducing mortality, morbidity, disability and promoting healthy lifestyles. In India, nurses and midwives’ contribution to the quality and efficiency of health service is felt to be insufficient. While the absolute number of nurse to population or to patient is high compared to other countries, nursing and midwifery do not receive high recognition from the public. The number of nurses at the national and state levels for highlighting nursing practice, research, education, management, planning and policy development is inadequate. Roles and responsibility of nurses are not clearly defined, and nurses spend most of the time in non nursing care. Nurses and midwives have limited opportunities for continuing education.

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Considering the existing circumstances, it is evident that the skills of nurses and midwives are not optimally used. WCO will work with GOI, the Indian Nursing Council (INC) and other partners in developing strategic plans that can guide further action to prevent nursing shortage in specific areas and to increase efficiency in deployment, utilization and development. WCO will continue to strengthen nursing education by reviewing and revising the curriculum, and to further advance the standards of nursing education, research and practice, facilitate the development of quality assurance system, and enhance nursing autonomy in practice. It will support efforts to strengthen competencies of Auxiliary Nurse Midwives (ANMs); create advanced nurse practitioners; promote evidence based practice and nursing research; and contribute to establishing nursing development programmes. Additionally, WCO will work with INC in strengthening the nursing management information system. Moving closer to the States: The states in India differ in the extent and composition of their public health problems, disease burden, availability of resources and their management capacity. Recognizing this, the National Health Policy 2002 has recommended that the responsibility for public health be delegated to units of local administration, i.e. the Panchayats at rural levels and Municipal bodies in urban areas. Some states have already passed the facilitative legislation. This move calls for high quality capacity building at the central, state and local government levels. To develop state-specific strategies, it is necessary to generate statespecific data, and build capacity for planning, implementation and monitoring. In coordination with the centre, the WCO will facilitate state-specific planning by supporting capacity building at the state level. Systems have to be developed to ensure that the states and local administration units take action in accordance with national policies and strategies. In addition, the centre needs to develop a mechanism for monitoring and quality assurance. The WCO will support this process by providing technical assistance, documenting best practices from Indian states and other countries, and supporting pilot initiatives. The health strategy of each state has to deal with its complexity and diversity which has been recognised in the NHP In coordination with the centre, the WCO will . facilitate state-specific planning by supporting capacity building at the state level. The CCS envisages more strategic technical support to states in India. WCO will build capacities closer to the states through various approaches: • • assessment of needs for technical support of states with the involvement of MOHFW. Focus would be on the priority areas identified in the CCS; assessment of the available resources within WCO to respond to the states needs. If such resources are not available at WCO level, the assistance of the

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WHO Country Cooperation Strategy 2006-2011

WHO Regional Office and Headquarters would be sought. Therefore, there is a need to have adequate technical capacity at WCO to manage the state support system; • assessment of collaborating institutions, centres of excellence and other development partners available at state level, and drawing up arrangements to make them available for technical assistance. The thrust of the plan would be to transfer the needed knowledge and skills to institutions within the state.

(3) Contribute to the Global Policy Environment for Health
To address the risks and opportunities of globalization and the global policy environment for public health in India , WCO will focus on the following issues: Managing the impact of spill-ins and spill-overs: WCO will assist the dialogue at the national level among relevant ministries, including those of health, trade, commerce, finance and external affairs, in order to facilitate policy coherence and to ensure that the interests of trade and health are appropriately balanced and coordinated. In the international trade of health services under GATS, WCO will facilitate ‘evidence-based approaches’ so that the government can liberalize health services to ensure greater access to affordable, better quality and effective health services. This will lead to increased choices for consumers and greater equity in health outcomes. Other specific areas will include access to drugs and TRIPS, food safety, bilateral and regional agreements. Support will be provided to manage cross border opportunities or threats that could affect health, such as new technologies, climate changes, marketing practices, ‘trade in bads’ (such as: illicit drugs, organs, and people trafficking), communicable diseases, and unsafe food. Shaping the global agenda: India plays a leading role in shaping the global and regional agenda in many sectors, such as: trade, commerce, external affairs, as well as in selected issues in international health such as the FCTC. The potential of India as well as of other countries such Brazil, Canada, and China to become major actors in shaping the global health agenda is increasing. Potential areas are: • • Influencing global health governance: new rules in health and in other sectors influencing health (trade, GATS rules), new institutions and funding mechanisms; Export of best practices and knowledge in specific domains: education in health (cross border e-health to support training of health personnel, and telemedicine); traditional medicine (AYUSH); universal coverage of primary care in rural areas (NRHM).

In each of the above areas WCO will work with GOI to build capacity to identify and manage the impact of both existing and emerging policy regimes. In addition, WCO will also support relevant research and policy development. To carry out the above mentioned activities WCO will:

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• • • • • •

Work with Collaborating Centres, Centres of Excellence, and professional associations and organizations; Create networks among the existing centres; Facilitate the work of the WTO cell within the MOHFW and with other Ministries as appropriate; Participate and initiate global networks in selected areas of public health, linking centers of excellence within the Region and outside; Support South-South cooperation based on identified best practices, specific knowledge and strengths; and Develop strategic alliances with like-minded countries to better place their health priorities on the international agenda.

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WHO Country Cooperation Strategy 2006-2011

Implementing the Strategic Agenda

7

The CCS will be the strategic framework around which WCO will organise its country programme. The WCO is committing itself to the priority areas it has listed and will take all required steps to ensure that outcomes in these are achieved. This could be for generating support for the CCS goals, accessing technical expertise, as well as generating resources and adapting the organisation’s structure to suit the requirements of the CCS. The recent enhancement of delegation of authority to WCO with regard to human resources, programmes, financial and travel issues would facilitate the implementation of these strategies. A key characteristic of the CCS is that its focus areas have been chosen strategically. The high priority areas where WHO has comparative strengths such as Communicable Diseases, Maternal and Child Health and Non-Communicable Diseases, will have a substantial impact on India’s health. The strengthening of the health system and dealing with globalization issues will emerge as challenges in the future. To achieve results the WHO organization plans to divide tasks among the Country team, Regional Office and Headquarters.

Responsibility of the Country Team
Technical Assistance: WHO’s main strength, acknowledged by GOI and other partners, is its competence to provide technical support. Therefore, WCO needs to make available high quality technical assistance in sufficient capacity to assist the government and other partners in reaching targets in the priority areas (Annexure - Table 9). WCO will continue its existing technical assistance in the areas of Communicable Diseases, Maternal and Child Health and Non Communicable Diseases. Other priority areas in Health Systems Development include: policy analysis, systems development, management, quality assurance, health impact analysis, health financing strategies, and public health promotion. Some of the areas identified in the CCS such as expertise related to the globalization issues are new for India. Technical assistance will be provided through collaborating institutions. There will be increased collaboration and coordination with the Regional Office and Headquarters for technical support. Expertise will be made available to the government, partners and non-governmental agencies. Organisational Development and Human Resources: While implementing the CCS, the WCO will place a greater emphasis on organisational development. The
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WCO will develop overall indicative plans for 2006-2011 and detailed action plans on a biennial basis. Since human resources would be an important facet in the implementation of the CCS, the WCO would restructure and strengthen the technical capacity of the current staffing to meet future demands. Additional human resource needs would be met either by redeployment, retraining, hiring of new personnel or outsourcing functions to other institutions where needed. The WCO would place special emphasis on staff development to strengthen the capacities and capabilities of both the technical and general staff. Since the CCS lays emphasis on decentralised decision-making in health, the need to have a sub-national presence will be felt even more. India is a vast and diverse nation with highly varying health needs and capacities. The WCO will explore the options to strengthen its sub-national presence in the long run, in consultation with the Government of India. Collaboration and Partnerships: A major component of implementation will be to strengthen partnerships with other agencies. The WCO would explore ways and means for increased outsourcing to WHO Collaborating Centres and Centres of Excellence. It will help facilitate the activities implemented by UN agencies in the health sector. Synergy exists between activities of many agencies involved in such areas as safe drinking water, environment impact assessment and foreign trade policies, amongst others. WCO will leverage the comparative advantages of such centres and agencies and will seek their support to achieve the objectives of the CCS. Strengthening Management Capacities: India possesses immense capacity in most aspects of health care management. The role WCO and other agencies would be to strengthen capacity in specific areas. The WHO fellowship programme consists of specially tailored training programmes aligned to national health priorities and human resource needs. There has been a conscious shift to in-country fellowships as they are more cost-effective, help use the large pool of training talent available in the country, and help strengthen national training institutions to become regional and global training centres. WCO will continue the focus on national institutions and streamline and redesign the fellowship programme to align it to the technical support needs for implementing the CCS. Strengthening information systems and infrastructure: Information is a vital ingredient in all forms of reform. It is needed for advocacy, evidence-based planning and designing, monitoring and evaluation of systems. Information can be generated by documenting experiences in India, synthesizing international experience, and through operational research and pilot projects. WCO will support generation of information relevant to health. WCO will disseminate information to relevant stakeholders. Furthermore, WCO will make efforts to strengthen the office infrastructure in terms of automation, information technology, space, transport and other facilities for high-quality outputs.

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WHO Country Cooperation Strategy 2006-2011

Mobilizing financial resources: To implement the CCS, the regular budget (RB) and other sources (OS) will be used. The WCO, with the support of SEARO and HQ, will be proactive in mobilising OS funds for its technical support to the Government. Financial constraints would constitute an important risk facing the implementation of the CCS.

Support from the Regional Office (SEARO)
The Regional Office (RO) can bring in experiences from countries within the Region, in addition to providing technical support in the priority areas identified in the CCS. WCO will identify best practices within India where the RO can facilitate the dissemination of information. The regional office would assist in institutional capacity building of selected institutions to further develop them as regional centers. For mobilization of resources and support, the RO continues to update the donors’ profile and their areas of interest. It can help in the dialogue for India-specific mobilization of resources, especially in the identified priority areas.

Support from WHO Headquarters
Technical support: The HQ staff are expected to provide technical support in specific areas where they have comparative advantage. Some of these areas include costing of interventions, cost-effectiveness, innovative financing, non-communicable diseases and new initiatives in HIV/AIDS treatment. HQ conducts many pilot studies and generates technical reports, which provide valuable inputs to WCO. Standards, guidelines and tools: HQ has developed many standards, guidelines and tools on the basis of its global experience. Examples of areas that would be helpful to the WCO: tools for costing of different activities, method of estimating financial burden caused by catastrophic illnesses, multi-drug resistance of ARV medicines, Integrated Management of Adult Illness, etc. Resource Mobilization: It is expected that HQ would continue its efforts in mobilizing resources for India with its effective networking and advocacy capacities.

Risks facing the CCS
There are three main risks facing the CCS and its strategic objectives. The first is related to the effectiveness of WHO technical support and the possibility that the anticipated impact would remain limited. Ensuring the highest possible standards of quality and credibility of the technical advice provided would alleviate this risk. The risk is closely related to the country’s own implementation capacities and the fact that the biennium work plans are intimately linked to the country’s institutions. It is inevitable to witness mixed implementation outcomes in a vast subcontinent such as India with large

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disparities among the states. In order to further mitigate this risk, greater attention would be provided to upstream planning, quality at entry, realistic expectations, thorough assessment of institution-specific implementation capacity, identification of related gaps, effective hands-on-training and closer sustained monitoring. The second risk concerns competing demands and priorities, both within WHO and the country, thus diluting the focus on top priority areas and overstretching the capacity of WCO. This would be addressed through advocacy, persuasion, and seeking widespread endorsement. The third risk concerns potential resource constraints that may hamper the strengthening of WHO’s country presence and its contribution. Efficiency gains and sustained resource mobilization efforts would alleviate this risk through sustained resource mobilization efforts by WCO, SEARO and HQ. Also, rather than seeking to deal with too many areas on its own, WCO will partner more with other UN agencies, Centres of Excellence and WHO Collaborating Centres. WCO will draw up further arrangements for outsourcing and making such centres available for providing technical assistance. Concurrently, attention would be paid to develop the skills and capacities of such institutions within the states. Linking fellowships with institutions rather than individuals would be promoted to the extent possible. Also, WCO would enhance horizontal collaboration across countries in the region, and would seek to leverage the capacities and support of the regional office and headquarters.

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WHO Country Cooperation Strategy 2006-2011

Annexes
Table 1: Selected indicators for India

1 Census of India 2001, Provisional Population Totals: India, Registrar General of India, Ministry of Home Affairs, GOI. 2 Health Information of India, 2004 & 2005, Central Bureau of Health Intelligence, MOHFW, GOI. 3 Economic Survey 2005-2006, Ministry of Economic Affairs, GOI. 4 National Family Health Survey (NFHS-II), 1998-99, IIPS and ORC Macro, 2000. 5 SRS Bulletin, Registrar General of India, GOI. 6 Registrar General India, 2006. 7 National Health Accounts India, 2001-02, MOHFW, GoI 2005. 8 Annual Report – 2005-2006, Ministry of Health and Family Welfare, GOI. 9 Health Information of India 2005, Central Bureau of Health Intelligence, MOHFW, GOI.

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Table 2: Health indicators

Source: Sample Registration Systems Bulletin, 2004, Provisional Estimates and Census of India, Registrar General of India, Ministry of Home Affairs, GOI.

Table 3: Public health infrastructure

Source: Health Information of India, 2004 & 2005, Central Bureau of Health Intelligence, Ministry of Health and Family Welfare, Government of India.

Table 4: Trends in disease pattern

Source: National Health Policy, 2002, Dept. of Health, MOHFW, GOI, 2002; *National Polio Surveillance Project

Table 5: Estimated number of deaths in India from chronic diseases in 2005 and projections for 2015

Source: Preventing Chronic Diseases: A Vital Investment. WHO Geneva 2005. (http://www.who.int/chp/chronic_disease_report/en/)

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WHO Country Cooperation Strategy 2006-2011

Table 6: Health expenditure – India, 2001-02

# As per New Series (Base: 1999-2000) of National Accounts Statistics, CSO dated 28th February, 2006. US$1.00 = INR46.00 Source: National Health Accounts India, 2001-02, Ministry of Health and Family Welfare, GOI 2005

Table 7: Health expenditure by sources – India, 2001-02

Estimate based on data from NHA study on health financing by local bodies undertaken on behalf of MOHFW National Commission on Macroeconomics and Health, MOHFW, 2005 *Estimate based on NHA study on Health Financing by NGOS undertaken on behalf of MOHFW Source: National Health Accounts India, 2001-02, Ministry of Health and Family Welfare, GOI 2005 US$1.00 = INR46.00
# $

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Table 8: External funding to India for health (2000)

Source: Computed from Misra, R, Chatterjee, R, Rao, S (2003): “India Health Report”, Oxford, New Delhi. Pp.163, 168- 170,

Table 9: Health resources profile, WHO Country Office – India

* National Professional Officer ** Consultants include Short-Term Professionals (STP), Short-Term Employees (STE) and Special Services Agreements (SSA) working at WCO Note: Special programmes such as Polio, Routine Immunization, TB, Leprosy, HIV/AIDS, engage a variable number of SSAs in the field.

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WHO Country Cooperation Strategy 2006-2011

Organizational Chart – WCO India (Established Posts)
WR PHA

NPO (P&AO)
(Med. Epid.)
(Sanitary Engineer)

NPO NPO
(TB)

NPO Medical officer

Medical officer ‘3 by 5’

Medical officer
(Epid.)

Assistant III
(NMH) (CDS) (FCH) (HSD)

(Prog.)

NPO (HR) NPO NPO
(TB)

NPO NPO

MO Project Manager (NPSP)
Assistant Prog. Manager

Assistant III NPO
(TFI)

(Prog.)

Clerk I

Technical Officer (NPSP)

Assistant III Assistant II
(Statistics)

(Fin.)

Clerk I

(Fellowships)

Assistant II

Clerk I

Secretary II

Driver

Assistant I (S&E)

Driver/ Messenger
WCO India 19-07-2006

India

Assistant I (Fin)

Driver

53

Messenger

54

Proposed Organization Chart, WCO Inida, 2006-2011
WR PHA
NPO (UNDP) Knowledge Management

WHO Country Cooperation Strategy 2006-2011

MO Epid. MO Epid. – Polio
Med Enid

MO TB NPO

MO 3 by 5

Planning Officer

Admin Officer

NPO SDE

NPO EHA

NPO TB
NPO
Malaria

NPO CDS

NPO NMH
NPO NCD
Surveillance

NPO FCH

NPO HSD
NPO EDM NPO
Leprosy

Asst. Prog. Manager

Technical Officer Asst III (Prog) Asst III (Prog) Asst III (Prog) Clerk I Clerk I Clerk I Clerk I Asst III (Fin) Asst II (Fel) Asst I (S&E) Asst I (Fin)
Driver/Messenger

Technical Officer Asst (IT) Secretary II Driver Driver

Assistant AO

HR Officer

NPO
Mental Health

NPO
Health Technology

NPO
Laboratory

NPO
Tobacco Free Initiative

NPO
Surveillance

Messenger

NPO
Nutrtion

NPO
Support Staff engaged on STE and SSA basis
Adolescent Health

NPO
Child Health

Indicative chart subject to change based on evolving circumstances and operations

Country Cooperation Strategy Matrix

Communicable Diseases and Disease Surveillance
Opportunities • Significant successes in eradicating/eliminating some diseases in the entire country or some parts of the country • Political commitment towards welfare of the poor including promise of larger commitments to management of communicable diseases • Facilitate access to information and to international networks • Support evaluation and introduction of new vaccines • Capacity building at all level • Existing surveillance project financed by a loan from the World Bank, Integrated Disease Surveillance Project (IDSP) • International Heath Regulations available as a framework for monitoring and early warning systems • Technical guidelines, manuals and SOPs of various diseases made available to GOI and states • Evaluation report of new vaccines • Capacity building modules for strategy formulation MOHFW, Health Departments of state governments, and Development Partners • Adoption of WHO strategy, technical and operational advice WHO’s strategy Expected outcomes Partners

Area

Challenges

1. Reduction of Burden of Communicable Diseases, including strengthening of surveillance systems and responding to emerging threats

• High mortality and morbidity from communicable diseases, especially among the poor.

• Regional differentials in prevalence of various diseases

• Differential type and quality of health care providers across the country

• Provide technical assistance to the Ministry of Health and Family Welfare and State Health Departments in strategy formulation, technical and operational matters

• Inadequate and delayed information available for outbreak management

• Emergence of new pathogens in the region as well as globally

India

• Better connectivity across the country, facilitate the spread of diseases.

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Opportunities
• Political commitment to supporting poor women and children • Clear objectives in the National Population Policy, 2002 • Huge government program to address the mother and child health issues, such as: Reproductive and Child Health-2, Janani Suraksha Yojana and National Rural Health Mission

Maternal and Child Health
WHO’s strategy Expected outcomes Partners

Area

Challenges

2a. Reducing Maternal, Neonatal, Infant, and Child Mortality

• Slow decline of maternal, neonatal, infant and children under 5 year mortality rates. • Policy, technical and operational guidelines and training manuals for quality Reproductive, Maternal, Newborn and Child, nutrition and Adolescent Health services available and accessible

WHO Country Cooperation Strategy 2006-2011

• Socio-economic determinants of poor health of women, infant and children

• Non-availability of required health care personnel with skills and health facilities in parts of the country to address the problem.

• Provide technical assistance to the Ministry of Health and Family Welfare and State Health Departments in strategy formulation, technical and operational issues in the areas of maternal, neonatal, infant and child health, nutrition and adolescent health

Ministries and departments of union and state governments, of Health & Family Welfare and also Women and Child Development, Education, Development partners WHOCC

• Behaviour towards women and girl child

• Focus on strengthening systems for continuum of care, ensuring skilled attendance at every birth, and improving quality of Emergency Obstetric Care

• Guidelines and training modules for training of Skilled birth attendants, Emergency Obstetrics Care, Adolescent Friendly Sexual and Reproductive Health available and accessible • Coverage with Skilled attendance and IMNCI expanded • Updated curriculum and syllabi available

MCI and INC Professional Associations like FOGSI, IAP NNF, , IPHA, IAPSM Civil society organisations,

• Capacity building of various health professionals and workers at various level, in the area of maternal, neonatal, infant and child health, nutrition and adolescent health. Promoting nursing fraternity • Support the government in monitor progress on achieving the objectives of the National Population Policy, RCH-2 and NRHM

• Annual reports available on progress for achieving indicators of NPP RCH-2 and , NRHM

Media

Maternal and Child Health (continued...)

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Noncommunicable Diseases and Mental Health
WHO Country Cooperation Strategy 2006-2011

Health Systems Development
Opportunities
• Availability of updated NHA • Advocacy instruments available • Documentation and information dissemination on the pros and cons of PPP & pilot projects initiated • Evaluation of different modalities of social insurance made available • International experience appropriate to India made available to health managers • Various modules available for capacity building • Systems for sharing of information • Generic manuals prepared for regulation, accreditation • Reports on analysis of standards & protocols & its relevance to India. • Guidelines on assessing appropriateness of medical technology
Planning Commission & MOF & MOHFW development partners, NGOs, academic institutions Ministry of Rural Development, Law and Justice, Health in GOI and state governments, development partners, and academic institutions MOHFW, state governments, UN agencies, academic institutions Ministry of Science and Technology, Health, development partners, civil society organizations, and academic institutions

Area
• Commitment of the Government to increase public health investment to 2% of GDP • In few health programmes, good outcomes of publicprivate partnership (PPP) • Increased interest from high level government officials on public health and importance of other disciplines that relate to health, such as economics, demography, etc. • Growing demand from the community for objectively verifiable standards of service • Efforts to develop regulatory framework for health technology and medical devices • Advocacy for social health insurance, provide technical assistance for capacity building. • Document best practices from other countries and states in India and support pilot initiatives • Analyze and disseminate the strengths and weaknesses of publicprivate partnerships and provide assistance for pilot projects • Develop National Health Accounts (NHA) system to support advocacy and resource management. Advocacy to increase health allocations and channel funds to priority areas

Challenges

WHO’s strategy

Expected outcomes

Partners

4a.Improve access, • Limited current quality, accountability, government funding, effectiveness and only 0.9% of GDP . efficiency of the health • Unregulated health care system. private providers, account for 70% of the health expenditures. High out of pocket expenditures for health care lead to impoverishment of population

• Human resources for health issues: quantity, quality, relevance, skillmix (skill in health management and public health), motivation, utilization, distribution

• Ineffective systems to ensure accountability of health care providers to the community, and to assess diagnostic and technology advancement used in health care.

India

• Assist in coordination among development partners and GOI for information sharing and implementation of capacity building initiatives

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Health Systems Development (continued...)
WHO Country Cooperation Strategy 2006-2011

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