WHO country cooperation strategy: India 2012-2017

Ministry of Health & Family Welfare Government of India

WHO Country Cooperation Strategy

India 2012 – 2017

About the Cover

The Vedic chant “Sarve Santu Niramaya” meaning “may all be disease-free and enjoy good health” has been a part of Indian prayers for ages. A golden papyrus with this Vedic shloka in the background aims to convey the rich heritage of healthcare pioneered by Charaka and Sushruta in India.

This document is dedicated to the people of India… with the vision of ensuring better health for all Indians

WHO Library Cataloguing-in-Publication data. World Health Organization, Country Office for India. WHO Country Cooperation Strategy India: 2012-2017. 1. Demography 2. National Health Programs 3. Technical Cooperation 4. Health Care Costs 5. International Cooperation 6. Health Services 7. Strategic Planning 8. India ISBN: 978-92-9022-416-7 © World Health Organization 2012 All rights reserved Requests for publications, or for permission to reproduce or translate WHO India publications, whether for sale or for noncommercial distribution, can be obtained from World Health Organization, country office for India, 537, A-wing, Nirman Bhawan, New Delhi 110 011, India (fax: +91-11-23382252; e-mail: wrindia@searo.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part 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. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization. Design, Layout & Printing: Premier Fine Printers Private Limited, New Delhi Cover Design: Carat Fresh Integrated (NLM classification: WA 540)

Contents vi viii x xii

Foreword Message Preface Acknowledgments Acronyms and abbreviations Executive summary Introduction India’s health and development challenges and responses Development cooperation and partnerships Review of WHO’s cooperation over the past CCS cycle Strategic agenda for WHO cooperation Implementing the strategic agenda: implications for the WHO Secretariat References Annexure

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1 5 23 29 33 45 49 52

Foreword All around us we see signals of India undergoing an unprecedented process of economic, demographic and social transformation spanning more than a decade. In strategic sectors like information technology (IT) and pharmaceuticals we are seeing Indian companies becoming major players on the global scene; our cities, our roads and our countryside are being changed; our youth, and also the not so young, show a renewed appetite for knowledge and information; our homes, eating habits and lifestyles in general are changing. Better opportunities for improving health can be found everywhere, ranging from the more nutritionally balanced, varied and increasingly safe food to newer, safer roads; from higher child immunization rates to an unprecedentedly high Shri Ghulam Nabi Azad Minister of Health & Family Welfare Government of India

proportion of babies delivered under medical supervision; from more health-aware and better educated citizens to a decrease in traditionally life-threatening and crippling communicable diseases such as polio; from more effective pharmaceuticals to the blossoming of world-class medical institutions that have earned the trust and faith of health tourists from all over the world. Yet at the same time, the challenges for health that our country faces are also unprecedented. Millions of citizens are affected by a sedentary lifestyle, excessive consumption of fat and refined sugar as well as other risk factors leading to an unexpected explosion in the number of people affected by non communicable diseases; the cost of medical care is rising, and access to health services in some areas of the country is simply unsatisfactory; ever more road traffic and faster cars increase the risk of severe trauma and accidents; and what is worse, new risks are being confronted without necessarily having addressed the old ones.

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All the above means that to a large extent, the well being of our citizens depends on a number of strategic choices related to health and equity that must be made in the next few years. This means that not only our health but our children’s health too depends on us and is in our hands. It depends on what the citizens and professionals of this country will do – both, through public and private funding; it depends not just on the decisions made by the Union government and by the states and the municipalities, but also on the steps taken by the private sector, our industries and our service providers and the support provided by all our international partners. I am glad that the Ministry of Health & Family Welfare has carefully thought about this future in partnership with the United Nations specialized technical agency for health – the World Health Organization. For many months they have worked in close collaboration with each other, developing and refining this Country Cooperation Strategy. You will find within this strategic endeavour, an outline of the challenges, priorities and objectives that is intended to be implemented in the next 6 years. I am sure that implementing the strategy will make our country healthier and more equitable and I call upon everybody to join us in this effort and the noble cause of saving and protecting the most precious possessions we all have – Health and Life!

Shri Ghulam Nabi Azad Minister of Health & Family Welfare Government of India

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Message It is with immense satisfaction that I write this message for the Country Cooperation Strategy between the Government of India and the World Health Organization. India is crucial to global health not just due to its population numbers and geographic size, but also because of the extraordinary progress it has made in health amongst other areas, which has taken millions out of poverty and is a source of inspiration for many nations. In recent years, India has taken several bold initiatives towards solving challenges that lingered for decades. Its progress, for example, in the fight against polio, tuberculosis and in the field of mother and child health is immense, thereby paving the way to an era of promising new gains. True, formidable challenges remain, with new ones appearing on the Dr Margaret Chan WHO Director-General

horizon, such as the increased burden of non-communicable and chronic diseases. Nevertheless, it is very reassuring to see the Government confronting these challenges from a better platform than ever before. India is clearly moving in the right direction with resolute actions to provide Universal Health Coverage to all citizens. The entire world is witnessing these health improvements in India with great expectations. India’s contributions to global health, not least through its remarkable support to other countries in the context of South-South collaboration make it a first order player in the global health scene. The World Health Organization is proud to have contributed to some of these major achievements of the Government of India. More importantly, we are willing to improve in doing so – and hence we are in the process of reform. This Country Cooperation Strategy is a living proof of that commitment to enhance relevance and impact of our work – especially at country level. We want to promote health systems that ensure affordable and acceptable primary health care institutions

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and hospitals that provide quality services for all, besides encouraging more attention to education, housing, food, employment – “the circumstances in which people grow, live, work, and age”. We want to better collaborate with our partner organizations, both, inside and outside the United Nations in promoting win-win solutions. Let me conclude by emphasizing the importance of transparent evaluation in terms of assessing the quantity and quality of the health services provided, and their corresponding costs and sustainability. This calls for establishing baseline measurements at the time of launching this Strategy, against which future progress can be monitored. This Country Cooperation Strategy is our contribution towards health progress in this extraordinary country. We are convinced, India will continue improving the health of its people and this will have a major global impact.

Dr Margaret Chan Director-General World Health Organization

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Preface This Country Cooperation Strategy (CCS) has been jointly developed by the Ministry of Health and Family Welfare (MoH&FW) of the Government of India (GoI) and the WHO Country Office for India (WCO) in line with national priorities and health policy. We both see it as a guide for partnership, planning, budgeting and resource allocation. Through a process of systematic discussion of successive versions of the CCS document and a series of joint consultations with other key stakeholders we have come to propose a number of inter-sectoral actions on the broad determinants of health as well as necessary health system reforms for providing better services to individuals and communities. We hope Mr PK Pradhan Secretary, Health & Family Welfare Ministry of Health & Family Welfare

these proposals will facilitate joint action with the stakeholders concerned – national as well as international, public and private – for improving health and equity in India while fostering our contribution to global health. The CCS first identifies the challenges India confronts as key crossroads where action is needed and options exist in unleashing the role of India in the global health scene while resolving major remaining drawbacks as areas for future policy making. It then reviews the role of the most important stakeholders and partners for health. The CCS next pinpoints three Strategic Priorities for the period 2012–2017, and identifies eight “focus areas” where efforts should be concentrated. Finally it examines the implications for WHO of implementing the CCS objectives along with the MoH&FW and other stakeholders.

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Both partners pay special attention to strengthening performance assessment effort with emphasis on determining health services quantity, quality, costs and sustainability as well as the health system functions leading to the desired results in India. We believe that this CCS will contribute to setting a robust baseline measurement and fostering a much needed culture of evaluation. This CCS does not cover detailed implementation issues. It gives space instead for union government, states and districts to address their priorities and actions for implementing India’s 12 Five-Year Plan in agreement with the MoH&FW. Dr Nata Menabde World Health Organization Representative to India th

The CCS implementation plan will subsequently be developed in line with priorities and actions. We hereby also make an explicit call to global health partners, development agencies, international private sector development partners, nongovernmental organizations, citizens’ groups and other stakeholders to collaborate in the same direction. Everybody’s contributions are solicited.

Mr PK Pradhan Secretary, Health & Family Welfare Ministry of Health & Family Welfare

Dr Nata Menabde World Health Organization Representative to India

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Acknowledgements This document is the result of extensive consultation between WHO and the Government of India towards strategically focused and result oriented partnership that involved participatory, multi-stakeholder and multi-sectoral approach. It was produced under the overall direction of Dr Nata Menabde, WHO Representative to India, Mr PK Pradhan, Secretary (Health and Family Welfare) of the GoI and Mr Keshav Desiraju, Special Secretary (Health), with guidance of Dr Samlee Plianbangchang, the WHO Regional Director for South East Asia. The principal writer of the document was Antonio Duran. Support was provided by Reuben Samuel and Arunachalam Gunasekar, who also coordinated the CCS development process and contributions of WCO India. Core analytical and policy support was provided by Joseph Kutzin, Marie Andree Diouf, Poonam Khetrapal Singh, David Evans, Anuradha Gupta, Rajendra Shukla, Arvinder Sachdeva and Sanjay Prasad, who also coordinated the inputs of the MoH&FW. The writing of the document was informed by many individuals from various institutions, WHO staff at all levels and the Ministry of Health and Family Welfare, GoI, with valuable contributions and advice from government agencies, centres of excellence in India, civil society, bilateral and multilateral agencies, United Nations agencies and academic institutions. Susan Kaplan edited the report. Pradeep Diwan and Anuj Sharma provided administrative and design support.

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Acronyms and abbreviations AIDS AIIMS ANM ASHA AYUSH Acquired Immunodeficiency Syndrome All India Institute of Medical Sciences Auxiliary Nurse Midwife Accredited Social Health Activist Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy Burden of Disease Brazil, Russia, India, China and South Africa Country Cooperation Strategy Communicable Diseases Community Health Centre Children's Investment Fund Foundation Commission on Social Determinants of Health Directly Observed Treatment, Short course Global Alliance for Vaccines and Immunisation Gross Domestic Product Global Fund to Fight AIDS, Tuberculosis and Malaria Government of India Human Immunodeficiency Virus High Level Expert Group Health Management Information System IHR International Health Regulations IMR Infant Mortality Rate MDG Millennium Development Goals MoH&FW Ministry of Health and Family Welfare MMR Maternal Mortality Ratio NACP National AIDS Control Programme NCDs Noncommunicable Diseases NGO Nongovernmental Organization NPSP National Polio Surveillance Project NRHM National Rural Health Mission OECD Organisation for Economic Co-operation and Development OOP Out-of-Pocket PPP Purchasing Power Parity P-P-P Public-Private-Partnership RNTCP Revised National Tuberculosis Control Programme GoI HIV HLEG HMIS S-SC STI TB UHC UNDAF URP WCO WHO South-South Cooperation Sexually Transmitted Infections Tuberculosis Universal Health Coverage United Nations Development Assistance/Action Framework Uniform Recall Period WHO Country Office World Health Organization

BoD BRICS CCS CDs CHC CIFF CSDH DOTS GAVI GDP GFATM

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Executive summary This Country Cooperation Strategy (CCS) has been jointly developed by the Ministry of Health and Family Welfare (MoH&FW) of the Government of India (GoI) and the World Health Organization (WHO) Country Office for India (WCO) based on a review of evidence on the causes of health improvement. Its key aim is to contribute to improving health and equity in India by helping to develop inter-sectoral actions on the broad determinants of health while providing the right individual (“personal”) and population services. This aim is consistent with the assignments of government responsibility for health according to India’s Constitution between duties of the central government and the state governments. This strategic proposal emphasizes the links between first, second and third order causes and effects, identifies crossroads and signals options for key areas for action. It distinguishes between outward-looking challenges to unleashing India’s potential, and inward-looking challenges where the joint work of the GoI and WHO can help solve long-standing problems. Advancing the role of India in the global health scene requires: (a) using its economic development to pull millions of people out of poverty by the creation of employment, providing water and sanitation, etc; (b) supporting countries that see India as a reference through South–South cooperation; (c) facing the emergence of “consumerism” by opening a new era of service responsiveness. The most important challenges are: (a) the “unfinished agenda” of health system modernization including high out-of-pocket expenditures, insufficiency and uneven distribution of staff, service provision (overwhelmingly in private hands) and its quality, and a better alignment of regulation with present day needs; (b) the need for expediting progress toward achieving Millennium Development Goals (MDGs) 4 and 5 (child health, undernutrition and gender equity problems); xv

(c) the high burden of disease (BoD), even though important progress has been achieved with some diseases; and (d) the change in the epidemiological profile (emergence of cardiovascular and cerebrovascular diseases, metabolic diseases, cancer and mental illnesses as first order problems while tuberculosis [TB], acquired immunodeficiency syndrome [AIDS], water-borne diseases and sexually transmitted diseases [STDs] remain frequent). The GoI restrategised development cooperation and partnership in 2004–2005, accepting only direct development assistance from restricted donors and under specific conditions, and then only for socially important projects. International agencies and partners are now expected to provide only state-ofthe-art evidence, methodological inspiration and high-level support. Key bilateral support is provided by the United Kingdom Department for International Development (DFID), the United States Agency for International Development (USAID), the European Commission (EC) and the Japan International Cooperation Agency (JICA). The United Nations Country Team (UNCT) works within a Development Assistance/Action Framework (UNDAF). The World Bank and the United Nations Children’s Fund (UNICEF) have significant involvement in the health sector. Other stakeholders are Global Health Partnerships (e.g. Global Fund to Fight AIDS, Tuberculosis and Malaria [GFATM], Global Alliance for Vaccines and Immunisation [GAVI], Roll Back Malaria and Stop TB), international private sector development partners (e.g. the Bill & Melinda Gates Foundation, Bloomberg, Clinton, Sasakawa and Norway India Partnership Foundations among others) and international and national civil society organizations (e.g. Oxfam, Action Aid and the Red Cross). xvi

The WCO collaborated during 2006–2011 with the Ministry of Health and Family Welfare (MoH&FW) and other GoI bodies, United Nations agencies and other stakeholder organizations. It responded to requests to share its experiences from other countries, strengthened the collection and analysis of national data, facilitated mapping of service facilities and supported specific programmes and projects including polio surveillance, management of neonatal and childhood illnesses, TB, immunization, disease surveillance, emergency and humanitarian action, HIV/AIDS, leprosy, vector-borne disease, prevention and control of noncommunicable diseases (NCDs) and lymphatic filariasis. It has also worked in health systems. In the context of a global WHO reform, around five core areas, namely: Communicable Diseases; Noncommunicable Diseases; Health through the Life Course; Health Systems; Preparedness, Surveillance and Response, WCO seeks to reposition itself by fostering health policy dialogue and technical advice in strategic priority areas of collaboration. Experiences gained and lessons learnt during the CCS period 2006–2011 were reviewed, and evidence and perceptions were gathered and analysed in the global and national context to develop the strategic agenda for WHO cooperation (actions that the GoI agrees to implement during the next 6 years) for the CCS 2012–2017. The strategic prioritization process included a series of consultations with officials of the MoH&FW, other relevant ministries of the GoI and health ministries of states; and other key stakeholders, namely, United Nations agencies; international and national development partners; academic, technical and research institutions; professional statutory bodies; civil society organizations; the voluntary and private health-care sectors; and opinion leaders in the health policy

WHO Country Cooperation Strategy India 2012–2017 l Main Focus Areas

International Health Regulations

Pharmaceuticals

Stewardship

Financial Protection

Quality

Health of Mothers and Children

Combined Morbidity

Transitioning Services

arena. The results of analytical work on the challenges confronted and the lessons learnt were shared with the stakeholders at these consultations. In-depth discussions on the challenges and the comparative advantage of the WHO resulted in recommendations on the strategic priorities that were considered for inclusion in the CCS. The CCS thus incorporates the valuable recommendations of key stakeholders, balancing country priorities with WHO’s strategic orientations in order to contribute optimally in line with its comparative advantage to national health development. It includes “inter-sectoral” actions on infrastructures and regulations with an impact on health as well as reform of the provision of (personal and population) health services. The strategic priorities are as follows: n Strategic priority 1

n Strategic priority 2

Promoting access to and utilization of affordable, efficiently networked and sustainable quality services by the entire population: (a) providing universal health service coverage so that every individual would achieve health gain from a health intervention when needed; (b) properly accrediting service delivery institutions (primary health care facilities and hospitals) to deliver the agreed service package. Strategic priority 3 n Helping to confront the new epidemiological reality: (a) scaling up reproductive, maternal, newborn, child and adolescent health services; (b) addressing increased combinations of communicable and noncommunicable diseases; and (c) gradual, phased “transfer strategy” of WHO services to the national, state and local authorities with the sine qua non condition that no erosion of effectiveness occurs during the transition period. Such transition strategy will be developed though a consultative process. Achievement of the CCS objectives (in cooperation with the MoH&FW and partners) calls for major adaptations in the way the WCO plans, runs its budgets, works and organizes itself to show xvii

Supporting an improved role of the GoI in global health: (a) ensuring the implementation of International Health Regulations and similar commitments; (b) strengthening the pharmaceutical sector including Drug Regulatory capacity and Trade & Health; and (c) improving the Stewardship of the entire Indian health system.

WHO’s assets as a valued partner. These changes have both outward- and inward-looking implications. Outward-looking (“external”) implications of the CCS for the WHO secretariat are: (a) Shift from budgetary support to health policy dialogue and technical advice, and shift from replacing government services to strengthening the country’s own capacity; (b) Set up mechanisms for periodic joint progress review of CCS implementation; (c) Disengage from high-labour, low-impact activities and small-dose cash transfers. Shift to impact-ensuring practices in line with WHO’s role as a specialized health agency of the United Nations (e.g. assisting government in donor coordination). Government will consider options and mechanisms for mobilizing resources for WHO services in support of CCS implementation as is the practice in other BRICS countries; (d) Strengthen interlocution with and presence across the country, with emphasis on selected locations; (e) Foster WHO-led technical activities to promote the corporate label, championing health within the United Nations Country Team and during implementation of the UNDAF as well as with other stakeholders, (e.g. during United Nations Day); and (f) Take inter-sectoral action more seriously and engage with various stakeholders in fostering health actions.

Inward-looking (internal) implications of the CCS for the WHO secretariat are: (a) boost technical excellence in the office; bring in international experience and strengthen India’s health information and health intelligence; (b) upgrade internal and external communication (including website); (c) take extended advantage of WHO’s reform, particularly regarding the contributions and capacities of the three organizational levels; (d) align office structure with CCS implementation in the new context; promote horizontal collaboration between programmes and reduce fragmentation; (e) promote responsible management with the correspondingly increased demands in terms of discipline and accountability for results; and (f) pay increased attention to enabling functions. Prioritized action plans will be developed by the health ministry and other ministries and departments for implementing India’s th 12 Five-Year Plan. The biennial work-plans needed to implement the CCS will be developed in consonance with the objectives of the government in the health sector and have not been included in this document. The GoI and WCO for India jointly appeal to all stakeholders to get involved in a Indian health system performance assessment, with an emphasis on evaluating health services in terms of their quantity, quality, costs and sustainability to serve as baseline measurements against which progress can be reviewed. The specific modalities of such assessment will be defined and implemented under the leadership of MoH&FW.

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Introduction The world’s largest democracy, the second most populous country in the world after China (1.21 billion people according to the provisional 2011 census) and the 10th largest economy (with a gross domestic product of US$ 1377.3 billion) in 20091, India has undergone extraordinary socioeconomic and demographic changes, the detailed analysis of which has been well 2 documented and is outside the scope of this strategy. Suffice it to mention the evolution of the

Figure 1: Population distribution, by age and sex, India (Sample Registration System estimates, 2006) Female Age Group (in years) 85 + 80 - 84 75 - 79 70 - 74 65 - 69 60 - 64 55 - 59 50 - 54 45 - 49 40 - 44 35 - 39 30 - 34 25 - 29 20 - 24 15 -19 10 - 14 5-9 0-4 14 12 10 8 6 4 2 (Percentage) Source: Govt. of India (2007), Sample Registration System Statistical Report 2008, Report No 4 of 2007

Male

2

4

6

8

10

12

14

1

population pyramid with increases in both the very young and in the ageing population (Figure 1), as well as an urbanization process with megacities and expanded shanty towns.3 The urban population increased 4.6-fold between 1951 and 2001 4 compared to only a 2.8-fold increase in the total population. Between 1980 and 2010 India's Human Development Index which combines indicators of health (life expectancy), education (mean of years of schooling for adults aged 25 years and expected years of schooling for children of school entering age) and income (gross national income per capita) improved by 1.6% annually from 0.320 to 0.519 and yet the Index ranks the th country 119 out of 169 countries with comparable data. For example, although life expectancy at birth increased to 65 years in 2009, a gain of 8 years since 1990, it remains low in 5 comparative terms. These figures reflect the scale of effort

needed from all sectors to improve health and equity in health in India. This is so even when one accepts the three major sets of caveats of using GDP as a measure of wealth and societal wellbeing, namely that, n GDP disregards economic elements not linked to money (whether negative, e.g. pollution or fear of crime, or positive, e.g. happiness and cohesion); n GDP is just a sum of monetary transactions (it does not differentiate between expenditure on either of the above even when such expenditure occurs); and n it does not capture the benefits from people who provide support (e.g. caring for older and younger people) but who are not formally employed or paid.6 The key aim of WHO’s CCS with the GoI is to identify strategic priorities and approaches to support their achievement in its

Box 1: Values and principles of WHO's Country Cooperation Strategy (CCS)

WHO’s CCS represents the organization’s medium-term vision for its collaboration with a given country and reflects the overarching values of the United Nations which underpin WHO’s Constitution and its contributions to improving global population health. These include health-related human rights, equity and gender equality. The key principles guiding WHO cooperation in countries and upon which the CCS is based are: ownership of the development process by the country; n alignment with national priorities and strengthening n national systems in support of the National Health Policy, Strategy or Plan; harmonization with the work of sister United Nations n agencies and other partners in the country, towards better aid effectiveness; n collaboration as a two-way process that fosters Member

States' contributions to the global health agenda. According to these principles, the CCS is an organization-wide reference for country work, which guides partnership, planning, budgeting and resource allocation.

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Box 2: Impact of social determinants and health services on health

Understanding the factors and mechanisms for health improvement in the world has taken decades of intellectual effort.7-11 The role of the social determinants of health was recently confirmed by the Commission on Social Determinants of Health (CSDH)12 but the health impact of inadequate water and sanitation on illness, in terms of lost productivity and other consequences has been known for more than a century. Edwin Chadwick and the public health activists of the 1800s in the United Kingdom emphasized measures such as cleaning, drainage and ventilation, even if their intention was to make people less dependent on welfare.13 The seminal work of John Snow revealed the consequences of an unsafe water supply in mid-nineteenth century London.14 Similar phenomena were observed in the United States of America.15 In recent decades many countries have had a similar experience of improvements in health indicators and a reduction in premature deaths as a result of better water management, increased use of toilets, higher standards of hygiene and a mix of indirect social interventions (e.g. in education, nutrition and housing). Most of these interventions are public goods the

consumption of which by one person does not diminish consumption by another, and for which it is not possible or is prohibitively costly to exclude “free-riders”. This contrasts with private goods, whose consumption benefits only, or predominantly, the person receiving them. Others are quasipublic goods, in the sense that their consumption has benefits (positive externalities) that extend beyond the person consuming them.16 Also, there can be little dispute over the importance of delivering effective, well managed, high-quality services for improving health. International experience shows the effectiveness – in terms of saving lives – of maintaining social productivity and responding to people’s needs for population and personal/individual health services, such as those for the newborn and for the mother at birth, vaccines and treatment of wounds.17 According to recent research, health services in Organisation for Economic Cooperation and Development (OECD) countries might be responsible for between 44% and 57% of whatever increase has occurred in health in recent years.18 This is a much higher figure than the previous estimates.19

continued pursuit of health improvement. Although no detailed research has elucidated the precise causes for improving health indicators in India in the past decades, it is clear from international experience that the desired objectives will only be achieved if the right inter-sectoral actions on broad determinants of health are developed while providing adequate personal and population services to those in need. In other words, synergies have to be achieved between health promotion, disease prevention, diagnostics, treatment, rehabilitation and

supportive interventions to strengthen the Indian health system. The system may be defined as “the ensemble of all public and private organizations, institutions and resources mandated to improve, maintain or restore health within the political and 20 institutional framework of the country”. This strategy results from a joint development led by the WCO for India and the MoH&FW in the common understanding that working together and engaging with other partners will bring 3

better results. The government is leading a massive effort to improve the health situation in the country and is open to new approaches and solutions. WHO, in turn, as the United Nations specialized agency in health, is now revisiting its role and its management to better perform its Mission to serve the government in its efforts towards improving health.

WHO and the GoI, in partnership, intend to use this CCS, its framework and content as a guide for collaboration during the coming years. Detailed bilateral discussions have been held between the two partners and with key stakeholders in order to increase ownership. Specific emphasis is being placed on the demonstrable achievement of tangible improvements after the end of the CCS period.

This strategic document pays attention to the fact that according to India’s Constitution, government jurisdiction for health is divided into duties for the central government and the state governments (the union list, the state list, and the concurrent list of responsibilities shared between levels of government). States have the main responsibility, with support and coordination from the Union, of defining policies and providing a national strategic framework, financial resources, and medical education. States now spend twice as much public money on health as the Union. In 2009–2010, for example, the states’ budget for health was `43,848 crores (US$ 9,135 million) while that of the Union was `21,680 crores (US$ 4,517 million).21 The financial effort necessary has been considered in framing the outlay for the 12th Five-Year Plan period, which runs until 2017.

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2. India’s health and development challenges and responses India is in the middle of a process of change. Some of the critical challenges it confronts concern the socially mandated health system results. These consist of both final outcomes and intermediate objectives. The final outcomes are goals such as improving health levels and equity, protecting people against the catastrophic c o n s e q u e n c e s o f d i s e a s e, i m p r o v i n g responsiveness to peoples’ expectations and achieving all of the above efficiently. Examples of the intermediate objectives include: improving access, quality, continuity and sustainability. Other challenges affect the means by which India can obtain these desired results (inter-sectoral actions for health plus service delivery in primary health-care centres and hospitals, public health services and programmes, staff, buildings, technology, financing, laws, and information systems among others). For the past 30 years the geographically wide, densely populated and enormously varied Republic of India has made remarkable efforts in the field of health. The list of initiatives include the adoption of a National Health Policy in 1983; the 73rd and 74th Constitutional Amendments devolving power to local institutions in 1992; the National Nutrition Policy in 1993; the National Health Policy, the National Policy on Indian System of Medicine and Homeopathy and Drug Policy in 2002; introduction of (embryonic) health insurance schemes for the poor in 2003; and the inclusion of health in the Common Minimum Programme of Government in 2004. More recent achievements are the commitments to implement the National Rural Health Mission (NRHM) and proposals to achieve universal health coverage (UHC). The High Level Expert Group (HLEG) on UHC constituted by the Planning Commission of India in October 2010, with the mandate of developing the UHC th framework to be considered for the 12 Five-Year Plan of the GoI submitted its detailed report in 22 October 2011. While the effectiveness of the above initiatives has been variable, this section of the strategic document tries to identify today’s most pressing challenges and find logical links between “first-, second- and third-order” causes and effects, focusing on the distinction between: n outward-looking challenges to be overcome to unleash India’s potential in the global health scene; and 5

n inward-looking

challenges where joint work in partnership between the government (GoI) and WHO can mitigate or solve long-standing problems. Challenges to the role of India in the global health scene

2.1

India faces a number of challenges which few societies have ever addressed before. While the effects of these challenges are largely manifested in the domestic arena, they also have global implications, mainly due to India’s size and growing economic clout. India’s significant participation in the global economy and its increasingly influential role in global governance, in turn increase the urgency for the GoI to address domestic development challenges. 2.1.1

and inequalities have increased despite years of economic development (specifically annual GDP growth rates from 2004–2005 to 2010–11 which ranged from 6.8% to 9.6%; savings which were in the range of 32.21% to 36.85% of GDP and foreign direct investments which increased from US$ 2,188 million to US$ 27,330 million)23 and policies favouring those areas and population groups most in need (by means of “backward regions grant funds”). It is also relevant that although from 2004–2005 to 2006–2007, the average per capita comparable gross state domestic product of the bottom five Indian states grew from US$ 3,396 million to US$ 4,204 million, the absolute difference from the average of the top five Indian states increased from US$ 6,931 million to US$ 9,207 million and the per cent difference grew from 204% to 218%.24 The proportion of people living on less than US$ 1.25 a day purchasing power parity (PPP) decreased from 60% in 1981 to 42% in 2005, but the actual number of people living on less than US$ 1.25 a day PPP increased from 435.5 million in 1990 to 455.8 million in 2005 (see Table 1).25 In rural areas, the share of the poorest quintile in total consumption (that is, the consumption accounted for by the poorest 20% of the population) based on uniform recall period (URP) declined from 9.6% in 1993–1994 to 9.5% in 2004–2005 and the decline was even sharper in urban areas (from 8% to 7.3%). Inter-state differences in health status remain; for instance, there is an 18 year difference in life expectancy 26 between Madhya Pradesh at 56 years and Kerala at 74 years. In the context of the 12 Five-Year Plan, the Planning Commission has adopted a broad approach to health, which th

Economic development, inclusive growth and equity

The first challenge in the global context is to cope with India’s participation in highly competitive global markets as an “emerging” country and as part of the BRICS grouping (i.e. Brazil, Russia, India, China and South Africa). Millions of industry and service jobs are needed, as well as a highly qualified workforce, and their creation is dependent on an upgrade of a) the health and educational status of the population, b) the country’s infrastructure, c) the necessary “inclusive growth” that could pull millions straight out of the poverty, and d) the entire set of prevailing social relationships. The challenge of “inclusive growth” is magnified due to the massive territory and population of India and its enormous geographical and sociodemographic variation. India is divided into 28 states and 7 union territories, some large and others small. Poverty remains concentrated regionally in certain states 6

Table 1: Number of people living on less than $1.25/day (millions) Region or Country East Asia & the Pacific China Europe & Central Asia Latin America & the Caribbean Middle East & North Africa South Asia India Sub Saharan Africa Total 1990 873.3 683.2 9.1 49.6 9.7 579.2 435.5 297.5 1,818.5 2005 316.2 207.7 17.3 45.1 11.0 595.6 455.8 388.4 1,373.5 2015 137.6 84.3 9.8 30.6 8.8 403.9 313.2 356.4 947.2

India’s urban population do not make regular use of sanitary 28 toilets. When figures for 2008 were studied, only 366 million people had access to proper sanitation whereas more than half 29 of India’s 1.17 billion people were mobile-phone subscribers illustrating the differential penetration and adoption of technologies addressing health and development needs. 2.1.2

India and global development

Ravallion M and Chen S, 2008, Global Economic Prospects, The World Bank, Washington

includes key determinants of health, a range of resources like food supply chains and nutrition. In terms of policy this will translate into a stewardship role for the Health Ministry over other sectors in matters that have a direct bearing on health. It also proposes a roadmap which is intended to guide the health sector in this regard.27 Years of healthy economic growth are helping India to overcome problems such as integrated water management. The population fraction using drinking-water sources, however has only increased from 72% to 88% (rural 66% to 84%; urban 90% to 96%). Also, despite the government being keen to improve sanitation for the lowest socioeconomic quintile, from 1990 to 2008 the population using improved sanitation (the population sharing improved type of sanitation facility is deducted) only grew from 18% to 31% (rural from 7% to 21%; urban from 49% to 54%). According to a report by WHO and UNICEF, some 69% of rural dwellers and 18% of

The prowess of India in the area of biotechnology is clearly proving to have a global impact. The introduction of the Meningococcal A conjugate vaccine produced by the Serum Institute of India through the Meningitis Vaccine Project - a partnership between the Seattle-based nonprofit PATH (Program for Appropriate Technology in Health) and WHO in Burkina Faso, Mali, and Niger in 2010, has resulted in the lowest number of confirmed cases of meningitis A ever recorded during an epidemic season in 2011.30 The new vaccine is expected to be cost-saving when compared to current expenditures on these epidemics; an analysis shows that introducing it in seven highly endemic countries could save US$ 350 million or more over a decade. The vaccine's low cost – less than half a US$ per dose – makes it possible for the affected countries themselves to purchase vaccines for future birth 31 cohorts. Major success stories such as the above, point to a new set of relationships for India which offers a whole new world of opportunities. At the same time, some challenges emerge in the health-related policy implementation area.32 International experience indicates a need for skilled staff, administrative capability and infrastructure for implementing policies; 7

technological, financial and workforce limitations may make a 33 particular policy hard to implement. Issues related to international trade and health, pharmaceutical quality assurance, capacity for planning and policy formulation need to be mentioned. The second challenge in a global governance context is functioning as a reference for other countries. India could be a model for countries striving to find their own developmental pathways in a context of severe inequities and resource constraints. It is worth noting that while the burden of disease (BoD) distribution is estimated to be 93% and 7% between medium & low income countries compared to high income countries respectively, the medium & low income countries spend 10% of total expenses on health against 90% spent by the high income countries (as additional references, world income distribution is 18 – 82% and population distribution is 84 – 16%34, respectively between these country groups). In 2010, non-OECD countries released over 100 times more aid to developing countries – as requested by the Paris Declaration and the Accra Agenda For Action – than they had done in 1990.35 GoI is receiving in this context numerous requests for support and advice through South–South cooperation (S-SC), triangular cooperation in the Asia-Pacific region and beyond, and other modalities of collaboration between countries. These innovative mechanisms are based on solidarity, mutual benefit, capacity building and technological transfer, with a focus on equity in health within and between countries. The GoI has begun to commit between 0.08% and 0.11% of national income to meet these requests. Cooperation primarily takes place in 8

science and technology, trade, security, agriculture, industry and culture; initiatives are underway in the field of health, for example, on pharmaceuticals and biotechnology. These demands and engagements elevate India’s ranking in the world and are first-order incentives to find innovative solutions for supporting other countries. Under the Indian Technical and Economic Cooperation programme (ITEC) and the Special Commonwealth Assistance for Africa Programme (SCAAP) technical cooperation reaches out to 156 countries in Asia, Eastern Europe, Central Asia, Africa, and Latin America. Economic cooperation grants and loans, in contrast, are concentrated in smaller countries in South Asia (mainly Afghanistan, Bhutan, Nepal, Bangladesh, Maldives, Myanmar and Sri Lanka) and African countries.36 The number of conventions, treaties and agreements – many of 37 them supra-national – has sky-rocketed in recent years. Effective implementation of the multiplicity of norms and standards, in addition to International Health Regulations, is crucially dependent upon institutional arrangements, many known to be dependent in turn upon social structures, political culture and power dynamics and upon the quality of the 38 workforce. This is applicable also to India in its new role as an economic powerhouse. 2.1.3

People’s expectations responsiveness

and

health

system

The third challenge confronting India is the increased expectations of its population when using services. The sheer numbers of better trained and informed citizens lead to an ever-

increasing demand for improved, higher-quality services in all spheres. As societal creations, health systems “cannot be conceived outside the values and characteristics of the societies 39 concerned”. This means that the institutions that, for example, foster inter-sectoral actions, produce, finance and regulate services, and train staff, necessarily receive demands reflecting the aspirations of citizens (as well as the values, socioeconomic situation, technological development and political climate in which they are developed) and are also witnessing the emergence of “consumerism”. A new era is dawning in terms of expectations for quantities and varieties of affordable, efficiently networked and sustainable quality services. While public institutions strive to improve their standards, many Indian private hospitals have achieved impressive results in recent years and are quoted in international books and journals as successful case-studies in innovation. The Aravind Eye Care System, for example, with its mass production of cataract operations inspired by Ford and the fastfood industry’s business model, “performs 180,000 operations per year, 70% of them for free at a cost of US$ 10 per operation – whereas the cost in the United States of America is $1,650”.40 The same can be said of paediatric cardiac surgery at the Narayana Hrudayalaya Hospital; since 2001 it has been performing some 24 open-heart surgeries and 25 cardiac catheterization procedures a day – eight times the average at other Indian 13 hospitals – with services being offered free to the poor; it also provides telemedicine services for two rural hospitals in India and other hospitals in Malaysia, Mauritius and Pakistan – free to all.41

In that context, the Indian health system is under unprecedented public scrutiny. Initial arrangements such as the Right to Information Act, Rogi kalyan samitis (hospital users societies) and Village Health, Nutrition and Sanitation Committees favour increased responsiveness – the degree to which legitimate expectations of the public and the patients are met. This means ensuring respect for individuals (dignity, confidentiality and autonomy) and client orientation (prompt attention, basic amenities and choice). Such issues are also often highlighted by the media. 2.2 Health and health systems challenges yet to be resolved

Certainly the most complex challenge for India is what in 2005 the National Commission on Macroeconomics and Health called the “unfinished agenda” of health care.42 2.2.1

Health financing 43

At 4.2% of its GDP in 2009 , India's health expenditure relative to GDP is not too small a figure in comparative terms. The historically low tax-base and “revenue to GDP” ratio, however, have so far precluded sustainable action from the public purse. Governmental expenditure is only around 1.4% of GDP, with only 32.4% of the total spending as general Government contributions, some 15–20 percentage points below that of the United States or America, China and Brazil, and 40–45 percentage points below those of the European Union averages and Japan. In terms of the priority given by the government to health in recent years, centre and states combined allocate to health at the moment only around 4% of total public spending (among the 10 lowest countries in the world). The country’s per 9

Figure 2: India, Health Care Financing by Source, 2008

Private Public expenditure expenditure on Health on Health 67.6% 32.4%

Out-of-Pocket expenditure (74.4%) Pre-paid (2.3%) Others (23.3%)

Source: World Health Statistics, 2011

In short, the vulnerable sections of the Indian population hardly 44 enjoy proper financial protection when they fall sick. Low public expenditure and insufficient health insurance coverage (pre-paid health expenses) hamper effectiveness regarding health gain and equity because of the high risk of catastrophic/impoverishing payments by the population, as well as the financial barriers to access. As indicated above, “tracer conditions” send worrying signals, for example, that pregnant women do not receive the help they should, infectious disease outbreaks are not properly studied and children do not get immunized. From 1995–1996 to 2004, ailments that went untreated for financial reasons increased from 15% to 28% in rural areas and from 10% to 20% in urban areas according to

Median Expenditure in Rupees

capita health spending also remains among the five lowest in the world even if it has risen from US$ 21 in 2000 to US$ 45 in 2009 (with government expenditure within it increasing from US$ 6 to US$ 15). Public spending on health rose nearly 2.6-fold between 2004–2005 and 2009–2010 (the latter being budget estimates). Only a small fraction of total expenses is pre-paid and most are out-of-pocket payments (OOP). Even if these OOP payments have decreased as a percentage of private expenditure, from 92.2% in 2000 to 78% in 2004–2005, according to the National Health Accounts study in 2009, private services users clearly have considerable amounts of OOP expenses to pay including for excluded conditions and for ambulatory care. Those who access “free” government-sponsored services have, in turn, to buy medicines from pharmacies, pay for laboratory tests and often face the ubiquitous informal fees. As figure 3 shows, OOP expenses have major equity implications. 10

Figure 3: Medical Spending by Household Income (all members) 3000 2571

2500 2000 1500 1000 500 0 Lowest Second Middle Fourth Highest 182 200 179 188 196 1274 1343 1478 1610

(Household Income Quintiles) Short term illness (last month) Long term illness (last year)

Adapted from Source: Desai SB et al, 2010, Human Development in India: Challenges for a society in transition

the National Sample Survey Organization. With the right incentives, public funding offers space for spending reasonably more and better in health – although attention has to be paid to sudden big increases in expenditure that could lead to absorption problems (partly related to wider issues of public sector financial management such as rigid budget structures). The problems that some states have in absorbing the support provided by the Union45 through “Centrally Sponsored Schemes” – some of them at the 100% level, others in partnership – are probably the result of frequent gaps in planning combined with limited implementation capacity and uneven technological endowment. It is also partly linked to the paucity of and difficulties in handling health data (involving the use of substantial resources). To address this challenge, from 2010–2011 the GoI launched a health survey in 284 districts in nine states (Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttarakhand and Uttar Pradesh). The project is being carried out jointly by the MoH&FW, the Ministry of Home Affairs and the Registrar General and aims to assess the impact of schemes under the National Rural Health Mission (NRHM) in reducing fertility and infant mortality at the district level and maternal mortality at the regional level by estimating rates on an annual basis. State-specific problems have been recognized by the GoI. While expanding central government influence over state-level decisions, it has both increased public spending on health and introduced the NRHM at the national level in 2005 and the health insurance Rashtriya Swasthya Bima Yojana (RSBY) programme under the governance of the Ministry of Labour and Employment under the Union Budget 2007–2008.

Table 2: Summary of Health Systems Financing, India (2008) Total per capita expenditure on Health Percentage of national GDP spent on Health Out of pocket expense as a percentage of private expenditure on Health General Government contributions as a percentage of total medical spending Source: World Health Statistics, 2011

US$ 45 4.2 74.4 32.4

RSBY provides coverage to workers in the non-organized sector who fall in the category of “below the poverty line” with a total insured sum of Rs. 30,000 per family per annum (of the estimated premium of Rs. 750 per family, central government contributes 75% and the remaining 25% comes from each state). Reported total enrolment in RSBY as of September 2010 was more than 19 million households – or 46 close to 60 million individuals. Families have to enroll, and a small registration fee is collected at the time of enrolment. Provider payment is fee-for-service for marginal costs (same payment rates for public and private hospitals, although public hospitals also receive a budget subsidy for fixed costs). In addition, the High Level Expert Group on Universal Health Coverage has recommended that the Government (central government and states combined) should increase public expenditure on health from the current level of 1.2% of GDP to th at least 2.5% by the end of the 12 Five-Year Plan, and to at least 3% of GDP by 2022. 11

2.2.2

Human resources for health

Human resources are a particularly important challenge for India. Total numbers and distribution of staff were rightly identified recently as a “critical field for progress in introducing change”. Despite producing massive numbers of health professionals, the number of doctors with recognized medical qualifications under the Medical Council of India (MCI) Act and registered with state medical councils was only 0.9/1000 inhabitants in 2010 (some 816,629 doctors plus 104,603 registered dental surgeons); there are also 752,254 registered AYUSH (traditional medicine) doctors.47 The number of nurses is also 0.9/1000 inhabitants in India. Table 3 gives an international comparator with relevant countries. Moreover, every year India loses thousands of doctors, nurses and other health professionals to migration; in 2006, for example, almost 60,000 physicians (equal to 10% of India’s total physicians) practised in the United States of America, United Kingdom, Canada or Australia.48 Measures have been initiated to fill posts and contain absenteeism in rural and remote areas, such as recruitment on contractual appointment, compulsory rural posting for a certain period, earmarking percentages of postgraduate seats for those who have served in rural areas and a rural service allowance, but challenges remain both in PHC and in hospitals. Challenges also relate to the distribution of staff per 1,000 population. Urban areas are much better served than rural areas (1.3 versus 0.39 doctors; 4.2 versus 1.18 total health workers; 1.59 versus 0.41 nurses and midwives). 12

Table 3: Numbers of doctors, nurses and hospital beds per 1000 inhabitants Doctors Nurses (including midwives) 6.50 1.38 8.52 4.08 10.98 9.46 8.01 Hospital beds 2.4 4.1 9.7 2.8 8.2 3.3 3.1

Brazil China Russian Federation South Africa Germany United Kingdom United States

1.72 1.42 4.31 0.77 3.64 2.71 2.44

Sources: OECD Health Data 2011 and World Health Statistics 2011, WHO

The distribution of teaching institutions is also skewed: Andhra Pradesh, Karnataka, Kerala, Maharashtra and Tamil Nadu, which are home to 31% of the population, account for 58% of medical schools in the country, both public and private, and 63% of the General Nursing and Midwifery (GNM) colleges, 95% of them private. In contrast, the states with greatest human resources needs have the lowest capacity for meeting them; Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh together only have 9% of the nursing schools.49 While the intermediate professions currently included within PHC make heroic contributions to health, most job descriptions (male multipur pose worker, female multipur pose worker/registered auxiliary nurse midwife [ANM], accredited social health activist [ASHA], and even AYUSH professionals) would, in the long run, benefit from functional refinement, if not redefinition.

An overhaul of the health personnel production and utilization system will therefore be needed to achieve the required human resources numbers, skills and ethical standards of practice. The governments, both at the centre and states, are firmly committed. A consultation with all stakeholders in 2010 resulted in a proposal for setting up a National Commission for Human Resources for Health (NCHRH) with the dual purpose of reforming the current regulatory framework and improving the supply of skilled personnel in the health sector with the involvement of professional associations. The High Level Expert Group on Universal Health Coverage22 has recommended that adequate numbers of trained healthcare providers and technical health-care workers at different levels should be ensured, giving primacy to the provision of primary health care and increasing the density of human resources for health (HRH) to achieve WHO norms of at least 23 health workers (doctors, nurses, and midwives) per 10,000 population. It has also recommended increased investments to establish additional educational institutions to produce and train the requisite health workforce and also to enhance the quality of HRH education and training by introducing competency-based, health system-connected curricula. The production of these and other recommendations by the HLEG has been supported by the WHO. 2.2.3

inhabitants (see Table 3 for some international comparators), and shortages are worsened by the above-mentioned lack of clinical and maintenance/support staff, which makes nearly 50% of beds in the public sector and 30% in the private sector 50 non-functional. At the same time, modern inpatient and outpatient secondary care (hospital) is changing the health services landscape for the better but the challenge is the dominant presence of the private sector in all submarkets. Around 68% of an estimated 15,097 hospitals and 37% of 623,819 total beds in the country are in the private sector. Of these most are located in urban areas.51 This has occurred despite the fact that at the time of independence

Figure 4: Public versus private share of healthcare provision, India Immunizations Antenatal Care Institutional Deliveries Hospitalization Outpatient Care 0% 20% 40% 60% 80% 100% (Proportion of Share)

Provision of health services

Personal/individual and population health service provision, both routine and emergency, shows complex patterns in terms of availability, access and quality. For a start, India is endowed, on average, with rather few (only 0.6) hospital beds/1,000

Private

Public

Source: National Sample Survey Organization, 52nd Round, CSO, 1995

13

only 8% of qualified modern medical care was provided by the private sector and that limiting the need for private practitioners was one of the recommendations of the seminal 1946 Report on the Health Survey and Development Committee (Bhore Committee). The private sector now dominates the provision of personal medical care except in selected health programmes (80% of all outpatient care and 60% of all inpatient care), human resources and advanced medical technology and diagnostics (over 75%), pharmaceuticals and hospital construction and ancillary services. The share of private and public sectors is shown in Figure 4. The public-private-partnership (P-P-P) model is being extensively used to cover the gap between the demand and 52 supply of health care. In the public sector the situation is even more complex. Rural areas have a three-tier system (a sub-centre per 5,000 population staffed with a male and a female worker; a primary care (PHC) centre per 30,000 population with a medical doctor and paramedical staff, and a community health centre (CHC), per 100,000 population with 30 beds and basic specialists). Such public infrastructure is not evenly distributed across states, with

many institutions being hampered by lack of staff, essential equipment, drugs and consumables, as mentioned above. Furthermore, according to data updated in 2010, some 12.4% of primary health centres and 27.8% of sub-centres function without a regular water supply; 14.2% and 28.5%, respectively, without electricity; 7.5% and 8.1%, without an all-weather, motorable approach road; and 54.3% and 47% of primary 53 health centres have no telephone or computer respectively. Urban areas have a two-tier system (a basic health post for every few thousand population, wherever it exists) and/or an urban health centre/urban family welfare centre per 100,000 population attached to a general hospital). Based on the above, it is clear that access to good-quality health care is uneven. Recognizing the efforts that will be needed to address inequalities in the provision of and access to health services and thereby to enhance the “substantive freedoms” of large sections of the population in the coming years, major changes are being introduced in the context of the NRHM. This is in its own

Box 3: Public services and “substantive” freedoms

“When we assess inequalities … in being able to avoid preventable morbidity, or escapable hunger, or premature mortality, we are not merely examining differences in well-being… [T]he available data regarding the realization of disease, hunger, and early mortality tell us a great deal about the presence or absence of certain central basic freedoms”.54 – Professor Amartya K Sen Nobel Laureate from India

14

words, “a departure from earlier trends of financing specific lines of health care for identified diseases and health conditions that assumed a functional health system (which in most cases 55 was not so efficiently functioning)”. The NRHM is well-funded (85% by the Union and 15% by states), innovative in selected topic areas and has deployed more than 800,000 community workers who are paid based on performance. The NRHM is th likely to be continued under the 12 Five-Year Plan, to meet the health challenges and health transitions confronting the country. The planned allocation of resources by the MoH&FW and a number of donors and development partners increased from US$ 4.2 billion in 2009–2010 to US$ 4.8 billion in 2010–2011. Moreover, in order to meet the revised costs of construction, the GoI allocated in March 2010 an additional US$ 1.23 billion for six upcoming super-specialty tertiary care All India Institute of Medical Sciences (AIIMS)-like institutes and for upgrading 13 existing Government Medical Colleges.56 2.2.4

to create income and wealth and thus tax revenues, and not impose unreasonable financial burdens on the nation’s economy.59 It should also generate opportunities for philanthropy. The World Health Report 2000 recommended three types of capacity in the field of stewardship in a context of transparency and accountability: i) capacity to formulate strategic policy direction; ii) capacity to regulate, including building coalitions/partnerships; collaborating across sectors; and arbitrating, among others; and iii) capacity to generate relevant intelligence.60 It is understood that the lack of these three capacities is usually a major obstacle to effective performance. More than improving planning per se (which in many ways is already of sufficient quality), India faces the biggest gaps in relation to types 2 and 3 of the above capacities. Regulatory updating efforts are needed in many areas of the health system – to name a few: reshaping the structure of the market and the overall capacity of the system, setting standards for facilities, equipment, services, assuring quality of care, reviewing criteria for professional practice, redefining entitlements and rights, determining the major financial issues as well as rules of engagement for the public and private mix, capital and recurrent costs, prices, contracts, etc. The short supply of evaluation studies on the health system in India overall is an obstacle in this regard, partly related to health information issues and suboptimal operational research capacity. Recent research has shown that health research expenses are very unevenly distributed throughout the world: almost 95% of the total US$ 478 billion of research and development spending 15 61

Health system stewardship

Regulation in India is abundant. For a start, the right to health is recognized as a Fundamental Right by Article 21 of the Constitution and the Directive Principles of the State Policy of the Indian Constitution enjoin on all the responsibility to ensure that all stable action is directed towards the reduction of inequity.57 However, certain adjustments are required in order to help the health system confront the above-mentioned challenges.58 A robust modern regulatory framework is indispensable to protect society and the environment while allowing stakeholders to defend their legitimate interests. Ideally, theory has it that regulation should allow competitive businesses

in 2006 came from developed countries (topped by North America with 43.7%, Europe with 28.9% and Japan with 21.5%), whereas China and India spent 0.6%, the rest of Asia 62 4.8% and other countries 0.5%. In India, the Indian Council of Medical Research (ICMR), New Delhi, is the apex body for the formulation, coordination and promotion of biomedical

research; funding for health research has been substantially enhanced with the recent establishment of a separate Department of Health Research which administers ICMR institutions across the country. The scope for operations research focused on strengthening health systems has been significantly widened under the stewardship of this new department.

Figure 5: Infant Mortality Rates (IMR) by state in India, 2010

70 60 51 50 40 IMR 30 23 24 20 13 14 10 0 10 27 28 30 30 31 31 34 37 38 38 40 44 42 43 48 48 46 47 58 61 61 62

55 55

Tamil Nadu

Delhi

West Bengal

Nagaland

Uttarakhand

Himachal Pradesh

Jharkhand

Andhra Pradesh

Rajasthan

Uttar Pradesh

Arunachal Pradesh

Source: Registrar General of India(b), SRS Bulletin, Sample Registration System, Released December2011.

16

Jammu & Kashmir

Madhya Pradesh

Chhattisgarh

Sikkim

Mizoram

Punjab

Gujarat

Meghalaya

Haryana

Tripura

Assam

Goa

Kerala

India

Karnataka

Maharashtra

Manipur

Orissa

Bihar

Data collected at the moment are reasonably good for districtlevel planning and management but less so for performance assessment and policy analysis at the central level through either analyses of health system output growth,63 service quality, financial protection, health systems productivity and other final 64 and intermediate health system results or responsiveness and consumer interaction, usually via consumer satisfaction 65 66 surveys, or in patient-reported outcomes. Also, utilization of available data at the district level is often suboptimal. In order to improve programme management, practical mechanisms are needed to make feasible the uploading of data on to the district's web pages, as are suggestions as to which of the old forms could be abolished or streamlined. Improving the health information system (HIS) is therefore a crucial challenge, as an anchor for accountability. International evidence suggests that a unified or inter-operable information system is a technical prerequisite for efficient progress at all levels, including, for example, universal coverage. Building on the current health management information system (HMIS), the NRHM National Health Systems Resource Centre has created a district-by-district picture amenable to managerial follow-up, for example, in terms of trends. In terms of intelligence creation, experts suggest that more than having an identical system across the whole country, what matters is that the system should ensure interoperability, with share codes and compatible approaches so that data from different origins can be brought together and analysed. 2.2.5

share (21% versus 17%) and very inequitably distributed. No comprehensive wealth and income related mortality data are available but all estimates show a bias against poor households in this “spoilage of human capital”.67 Infant mortality rate (IMR) declined from 83 per 1000 live births in 1990 to 47 per 1000 live births in 200968 and maternal mortality ratio (MMR) was twice almost halved from 570 per 100,000 live births in 1990 to 390 in 2000 and further down to 212 in 2007–2009.69,70 However both remain high and show regional variations; e.g., a girl born in rural Madhya Pradesh has an almost 6 times higher risk of dying before the age of 71 1 year than a girl born in rural Kerala. Child health and under-nutrition and the issues relating to the Millennium Development Goals (MDGs) 4 and 5 constitute other major challenges. Meeting the goals has proved more difficult than expected; indicators are not improving fast enough and a more refined strategy is needed to identify key issues, propose more effective measures and develop a better follow-up protocol.

Box 4: Summary of current nutrition challenges, India Ranks 67 out of 84 countries in Global Hunger Index n 2010 22% of population is under nourished n 42% of the world’s stunted children reside in India n Obesity is emerging as part of the dual burden of n malnutrition

Maternal and child health; and gender issues

India urgently needs to catch up with certain health challenges also in order to unleash its development potential. India's share of the world's global BoD is several points above its population

17

Figure 6: Under-nutrition in under five children by wealth quintile 75 In percentage 60 57 49 41 25

54

49 41 34 25 20 13

50 25 0

22

19

17

Poorest

Second

Middle (Wealth Quintile)

Fourth

Highest

Stunting

Under weight

Wasting

Source: International Institute for Populations Sciences, 2009, National Family Health Survey (NFHS-3) India 2005-06, Nutrition in India, August 2009

Also the percentages of underweight children aged under 5 years are the highest in the world and are proving hard to reduce (48% of children in this age group are reported as “chronically malnourished” and 43% as “underweight for their age”). Seven out of every ten children aged 6–59 months are anaemic, with prevalence of anaemia ranging from 38% in Goa to 78% in Bihar. Of those classified as anaemic, 3% are severely anaemic (haemoglobin figures of less than 7.0 g/dl), 40% moderately anaemic (7.0–9.9 g/dl) and 26% mildly anaemic 72 (10.0–10.9 g/dl). Sickle cell anaemia is endemic in tribal areas and iron plus folic acid prophylaxis seems not to be working well in cases of severe anaemia. India’s current key nutrition challenges are listed in Box 4 (page 17) and the variation in the proportion of pre-school children who are under-nourished classified by wealth quintiles is shown in Figure 6. Gender inequality is also a concern (Box 5). The worrying proportions of selective gender abortion became visible again in

Infant mortality ranges in various states from 10 in Goa, 13 in Kerala and 14 in Manipur, to 61 in Uttar Pradesh and Orissa and 62 in Madhya Pradesh. The figure is significantly higher in rural areas and more than half of deaths are concentrated in the neonatal period.68 Figure 5 shows some of these striking interstate variations. The picture of the 640 districts (264 of them spread across 24 states considered “priority action districts” because they account for nearly 70% of infant and maternal deaths although they are home to only 35% of the population and have high fertility rates as well as low immunization coverage) is even more different. Maternal mortality ratio (MMR) at the national level is 212 per 100,000 live births, but rates range from 81 in Kerala, 97 in Tamil Nadu and 104 in Maharashtra to 318 in Rajasthan, 359 in Uttar Pradesh/Uttarakhand and 390 in Assam.70 18

Box 5: India: Summary of gender inequality issues Female to male sex ratios at birth: 0.914 (2011 census) n Literacy – Overall: 74.04% n n female:

65.5%

male n

: 82.1%

Every third woman in India is undernourished (35.6% have a n low body mass index) Girls marrying before the legal age of marriage: 2–46% n Currently married women who usually participate in n household decisions: 36.7% Source: http://planningcommission.gov.in/plans/planrel/12appdrft/ appraoch_12plan.pdf and http://www.nfhsindia.org/pdf/India.pdf

the 2011 census (see Figure 7: the female-to-male sex ratio in the 0–6-year age group declined steeply from 0.945 in 1991 to 0.927 in 2001 and alarmingly was down to 0.914 in the 2011 census). It is also revealing that while the overall literacy rate in India is 74.04%, female and male literacy rates are 65.5% and 82.1%, respectively. The Gender Equality Index (GEI), which captures loss in achievement due to gender disparities in reproductive

health, empowerment and labour force participation (values range from 0 = perfect equality to 1 = total inequality) in India is 0.748, well below, for example, China (0.405) or Sri Lanka (0.599). In 2008, India was 122nd in the ranking of 168 countries. Also, in 2008, between 2% (Himachal Pradesh) and 46% (Bihar) of girls were married before reaching the age of 18 years, the 73 legal age for marriage.

Figure 7: 2001–2011 census figures showing evolution of the sex ratio in India Sex Ratio (0–6 years) Census 2001 Census 2011

< 935

935 - 970

> 970

Source: Office of the Registrar General and Census Commissioner, 31 March 2011, Census 2011 Our Census, Our future, provisional population totals, Ministry of Home Affairs, India, Delhi

19

Box 6: Intra-country immunization coverage in India and its impact on regional benchmarks

The South-East Asia Regional Immunization Strategic Plan (2010–2013) envisages strengthening of routine immunization services focusing on district-level efforts as a priority to achieve the Global Immunization Vision & Strategy (GIVS) goals75 in 10 Member States by 2010, and in all Member States by 2013. Seven Member States (Bangladesh, Bhutan, DPR Korea, Maldives, Myanmar, Sri Lanka and Thailand) have already achieved >90% coverage for the third dose of diphtheria, tetanus toxoid and pertussis vaccine (DPT3) at national level. Indonesia and Nepal have >80% DPT3 coverage at national level. India and Timor-Leste are the only countries that have not achieved at least 80% DPT3 coverage nationally. The immunization coverage rates vary tremendously across Member States, as well as within countries between states,

provinces and districts or equivalent administrative areas. In India, according to the District Level Health Survey III (2007–2008), 90% of children who did not receive DPT3 resided in 11 states (Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Maharashtra, West Bengal, Assam, Jharkhand, Gujarat, Andhra Pradesh and Chhattisgarh in order of magnitude of unvaccinated children). Of these states Maharashtra, West Bengal, Gujarat and Andhra Pradesh are medium-performing states, with DPT3 coverage of at least 70% while the rest have less than 70% coverage. Source: WHO SEAR Regional Committee Sixty-fourth Session. Jaipur, Rajasthan, India 6–9 September 2011. Regional Committee Document SEA/RC64/8 Inf. Doc. (pages 3-4); 2 August 2011. Provisional Agenda item 5.3. http://www.searo.who.int/LinkFiles/RC64_Agenda-5.3-InfDoc.pdf accessed on 6 Dec 2011

The percentages of pregnant women who experienced delivery and post-delivery complications were 61% and 35%, respectively in 2008. Only about 18% of women received full antenatal care - a minimum of three antenatal care visits, at least one tetanus toxoid injection and 100 or more folic acid tablets or its syrup equivalent. In the past few years, however, hospital delivery services utilization accompanied by cash transfers has increased by 10 million. Free care for pregnant women and sick children, including free referral transport, aimed to bring OOP expenditure down to nil is now guaranteed in the public sector with some states offering free transportation for all sick children below the age of 5 years. Furthermore, public sector facilitybased deliveries and caesarean sections are being monitored monthly by State Project Management Units. The emphasis is 20

on outputs, outcomes and quality training towards capacity building, while ensuring that every health facility has medicines and means for diagnosis.74 From 2000 to 2009, immunization against vaccine-preventable diseases also improved (BCG immunization coverage among one-year olds rose from 74% to 87%, polio from 62% to 67%, measles from 50% to 71% and diphtheria, tetanus and pertussis from 60% to 66%). Further initiatives include the introduction of new vaccines in the national immunization programme, such as the second dose of measles, bivalent polio, hepatitis B and pentavalent vaccine. India has made significant progress in the journey towards Polio Eradication with the last case of polio recorded on 13 January 2011, thus completing more than one

year of being a Polio Free Nation. On achieving this historic public health milestone, the WHO has removed India from the list of countries with active endemic wild poliovirus transmission. This achievement has global public health significance. The impact of the slow improvement of national coverage on the achievement of South-East Asia Regional (SEAR) immunization coverage benchmarks and the magnitude of the intra-country variations in coverage that India needs to address are well illustrated (Box 6). Partnerships with the voluntary and private sector institutions for providing publicly-funded services in these fields have now been established in the Chiranjeevi scheme in Gujarat. 2.2.6

improvement in linkage of HIV-infected TB patients to freely available HIV care and treatment, most TB patients still do not know their HIV status. AIDS also continues to take its toll on the country: with about 2.5 million HIV infected persons, India has the world's third highest number of cases in absolute numbers – much less so in rates. A similar picture is seen with sexually transmitted infections (STIs). Nearly half of the leprosy cases detected in the world in 2008 occurred in India, where also one third of the people with lymphatic filariasis live. Annually more than 1.5 million malaria cases are reported (estimates suggest a 5–6 times higher burden) and 300 million episodes of acute diarrhoea occur in children under 5 years of age. Diseases like dengue and chikungunya have recently emerged in different new locations and more than 300 million people are at risk of acute encephalitis syndrome (AES)/Japanese encephalitis (JE). Infectious water-borne diseases are by definition linked with a shortage of drinkable water and toilets. They have also been reported recently to have a high cost in economic terms.77 The economic loss amounted to US$ 53.8 billion per year, equivalent to 6.4% of India’s GDP in 2006 and some US$ 48 per person per year. The health related economic impacts of inadequate sanitation were the most costly at US$ 38.5 billion, some 72% of the total economic burden, followed by productive time lost to access sanitation facilities or sites for defecation at US$ 10.7 billion, a further 20%, and drinking-water-related impacts at US$ 4.2 billion, another 7.8%.76 All such challenges require maintaining or even increasing previous commitments in the years to come. 21

Communicable diseases

A high proportion of the BoD in India is due to communicable diseases. For instance, in 2010, there were 8.8 million incident cases of TB globally of which 2.3 million were in India. The GoI's Revised National Tuberculosis Control Programme (RNTCP) has achieved some notable successes through the implementation of the WHO Stop TB Strategy. WHO has estimated that from 1990 to 2010, the prevalence of TB declined from 459 to 256 per 100,000 population and mortality from 38 76 to 26 per 100,000 population. Despite this progress, approximately 1.1 million incident TB cases remain either undiagnosed or are diagnosed and managed outside the TB programme with uncertain quality of treatment. Although in 2010 the RNTCP was able to diagnose and treat 2,178 cases of multidrug-resistant (MDR)-TB, this still represented only about 2% of the estimated MDR-TB burden that emerged in the country in the same period. Though there has been an

Figure 8: Distribution of deaths, by major cause, India: Million Death Study, 2001–03 Others 10% Injuries 10%

illnesses and other NCDs are already responsible for two thirds of the total BoD (an expected 66.7% in 2010) and about 53% of total deaths (up from 40.4% in 199079 and expected to increase to 59% by 2015). An estimate of distribution of deaths from the Million Death Study, 2001–2003 is given in Figure 8. Also, India is currently home to some 50.8 million people affected by diabetes (approximately 17% of the world’s total), commonly a major cause of blindness, kidney dysfunction, heart attacks and amputations (see also below, health system financing). India spends about 2.8 billion dollars on the care of its diabetic patients (1% of the total world expenditure in nominal terms, non adjusted by purchasing power – which indeed means that the proportion of patients taken care of in 80 India would be higher). The combination of fast growing NCDs with the abovedescribed rather high incidence and prevalence of CDs will increase the number of patients affected by more than one health problem (i.e. having combined morbidities), which calls for significant changes in the services required to confront them in terms of prevention, diagnosis, treatment, rehabilitation and th care. The government-appointed Working Group for the 12 Five-Year Plan has included the new epidemiological patterns among the priorities for the coming years which have been forwarded to the Planning Commission (together with PHC, tertiary health care and food and drugs). Also the MoH&FW is leading a large-scale effort aimed at ensuring early detection of diabetes; every person above 30 years of age and all pregnant women will be tested for diabetes in a phased manner (around 100 million people in 100 districts of 21 states, and slums in 33 cities in the first phase).

Non communicable diseases 42%

Communicable diseases, maternal & perinatal conditions, nutritional deficiencies 38%

(N=113,692)

Source: Jha P et al, 2005, RGI-CGHR Million Death Study

Although many of the diseases concerned are very visible in international terms, particularly if compared with the country's current economic status, it seems safe to say that in terms of trends they no longer represent strategic challenges for India of a comparable proportion to what they were in the recent past. In some cases the country is even moving from an “elimination” to an “eradication” stage in technical terms, very much as smallpox and Guinea worm disease (dracunculiasis) were eradicated in the 1970s and 1990s, respectively. 2.2.7

Noncommunicable diseases

Rapid changes in India’s core epidemiological profile have led to the double burden of CDs and NCDs. Cardiovascular and cerebrovascular diseases, metabolic diseases, cancer, mental 22

3. Development cooperation and partnerships Economic and social development has substantially changed India's landscape in terms of development cooperation and partnerships. Affirming its liberalizing economic policy, the GoI reviewed the policy of development cooperation81 in 2004–2005 and decided to: n refuse tied assistance and accept only direct bilateral development assistance from the G-8 countries and the European Commission; n allow European Union countries outside the G-8 to provide direct assistance only if they commit a minimum annual development assistance of US$ 25 million; n accept bilateral development assistance if routed through, or co-financed with, a multilateral agency and if the programme or project concerned is implemented by a multilateral agency under its own rules and procedures; n let external development partners provide assistance only to projects deemed socially important by the GoI; n welcome any country to provide bilateral development assistance directly to autonomous institutions, universities, and NGOs, but only to allow organizations registered under the Foreign Contribution (Regulation) Act, 1976 to receive bilateral assistance for projects cleared by the Department of Economic Affairs in the Ministry of Finance; and n let international development partners concentrate on providing state-of-the-art evidence, methodological inspiration and high-level support in decision-making; technical assistance programmes aimed at enhancing the knowledge and skills of Indian nationals are most welcome. Donors and other agencies are still contributing funds, but the quantity of this support is becoming rather small in relative terms (currently donor's contributions amount to less than 1% of total health expenses).82 External assistance funds received from multilateral and bilateral agencies are passed on to the states by the GoI through the Consolidated Fund on a “back to back basis”, i.e. on the same terms and conditions on which these funds were received by the GoI. The service cost and exchange fluctuations are borne by the states. 23

So-called “special category states” (Arunachal Pradesh, Assam, Himachal Pradesh, Jammu & Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura) receive external funds in the form of additional central assistance as 10% loan and 90% grant. The following picture of the entities providing support emerges: 3.1 Bilateral development partners

(funded with US$ 225 million sanctioned in 1992 plus US$ 100 million of technical assistance) and the “AIDS Prevention and Control” (APAC) programme is implemented in Tamil Nadu and Pondicherry (funded with US$ 47.25 million). The European Commission (EC) provides both development cooperation and economic cooperation. Its Country Strategy India (2007–2013) commits €470 million to the Health and Education MDGs. Of this €110 million (€99 million as sector support plus €11 million as services) is joined funding to the pool mechanism for the Sector Policy Support Programme of the NRHM/Reproductive Child Health Phase II. The EC has adopted a partnership approach in order to deploy the bulk of its development cooperation resources (health, education and environment) in Rajasthan and Chhattisgarh. The Japan International Cooperation Agency (JICA) administers an ODA loan assistance (¥3170 billion until March 2010) plus grant and technical cooperation. Grant assistance focuses on construction of facilities (e.g. hospitals, schools, roads and bridges) and procurement of products as well as services necessary for development projects (e.g. irrigation and public transportation vehicles). 3.2 United Nations System

In terms of bilateral support the United Kingdom is the largest provider of Grant Assistance to India, which is also the largest recipient of Overseas Development Assistance (ODA) from the United Kingdom. The aid is administered by the United Kingdom Department for International Development (DFID), which during 2008–2009 to 2010–2011 committed to disburse some £825 million for supporting national programmes (Sarva Shiksha Abhiyan, Reproductive & Child Health and AIDS Control Programme) in Andhra Pradesh, Bihar, Madhya Pradesh, Orissa and West Bengal. DFID also provides assistance to multilaterals (e.g. the Asian Development Bank [ADB], UNICEF, WHO and the World Bank) and civil society programmes (e.g. Poorest Areas Civil Society Programme [PACS] and International NGO Partnership Agreements Programme [IPAP]). The United States Agency for International Development (USAID) administers assistance entirely in the form of grants in partnership with the GoI. In health (one of the four priority areas, the others being energy, food security and education) it focuses on reproductive health services, child and maternal mortality, infectious diseases (TB and HIV/AIDS) and health system improvement. The “Innovations in Family Planning Services” (IFPS) is implemented in Uttar Pradesh, Jharkhand and Uttaranchal 24

The United Nations Country Team (UNCT) comprising 17 United Nations agencies is currently focusing on finishing the implementation of the India United Nation’s Development Assistance Framework (UNDAF) 2008–2012, in line with the 11th Five-Year Plan approved by the Planning Commission in February 2007. WHO’s contribution to the UNDAF is channelled through UNCT thematic clusters on poverty and

livelihoods, hunger and malnutrition, education, health, HIV/AIDS, gender based violence, governance, water, vulnerability reduction and convergence and United Nations Teams such as the United Nations Disaster Management Team (UNDMT) and the Pandemic Working Group (PWG). An intensively collaborative process in 2011 has resulted in the development of the new United Nations Development Action Framework (UNDAF 2013–2017) duly signed by the Planning Commission and the UNCT on 24 November 2011. The framework reflects the work of all United Nations entities working in India and has been developed in partnership with the Planning Commission as the nodal partner for the GoI and in collaboration with government agencies, civil society, donors and other key development partners. The design of the UNDAF document has evolved out of strategic discussions, both within the United Nations and with partners, to determine how the United Nation System in India can best support the development goals of the country as envisaged in the GoI’s 12th Five-Year Plan which is being finalized. The new UNDAF is harmonized with national goals of facilitating “inclusive growth” focusing on results of intervention in excluded groups, especially women and girls. Outcomes in six major areas, based on the collective comparative advantage of the United Nations in support of the national development priorities have been defined for the UNDAF: Inclusive Growth; Food and Nutrition Security; Gender Equality; Equitable Access to Quality Basic Services (Health; Education; Water, Sanitation and Hygiene; HIV/AIDS); Governance; and Sustainable Development. The UNCT thematic clusters have been realigned to enhance

collaboration on these outcomes and the United Nations Team which focused on pandemic management, called the Pandemic Working Group (PWG) has been reconstituted as the Public Health Working Group (PHWG) with an expanded mandate to focus on broader public health issues with WHO as its chair. The UNDAF and CCS processes have run in tandem with frequent exchange of ideas and active involvement of WHO in the UNDAF working groups related directly to health services issues as well as issues pertaining to key social determinants of health. The outputs that WHO would contribute to, jointly with other United Nations agencies, in achieving the UNDAF outcomes were well coordinated with the development of the new CCS and clearly focused on the inter-sectoral actions that would be promoted. These joint outputs focus on supporting multilevel advocacy; development of evidence-based policy options; enhanced capacity for decentralized planning, delivery, monitoring and evaluations of interventions; and promoting convergent inter-sectoral actions needed for achieving the outcomes. UNICEF can be singled out as a multilateral entity with significant involvement in the health sector. Its operation in India is its largest at country level, with presence at subnational levels and mandated collaboration with the Ministry of Women and Child Development and the Ministry of Rural Development. It partners with WHO (supported by the Norway India Partnership Initiative) in polio eradication, routine immunization strengthening and reproductive and child health. WHO, UNICEF and the World Bank support the District Review Meetings to help districts to adapt and reformulate their work-plans. They have agreed on explicitly emphasizing the 25

principle of “convergence” around 50 district goals (10 of them on health). Collaboration also takes place in the area of strengthening public health management following disasters. WHO's direct contribution is discussed further in Section 4. 3.3 Other development partnerships

The World Bank’s Country Strategy 2009–2012 (with a US$ 14 billion loan) focuses on fast-tracking the development of infrastructure, supporting the seven poorest states and responding to the financial crisis. Loan assistance tops Government outlays in several centrally sponsored national disease control programmes (e.g. TB, malaria and HIV/AIDS); sectoral programmes (e.g. reproductive and child health) and health systems components (e.g. integrated disease surveillance). It also provides assistance on health systems development to specific states (e.g. Tamil Nadu, Andhra Pradesh and Rajasthan). The World Bank collaborates closely with WHO in Joint Review Missions to evaluate project implementation. Several Global Health Partnerships such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), Global Alliance for Vaccines and Immunisation (GAVI), Roll Back Malaria and Stop TB also play a significant role in India’s health sector, mainly in the control of specific infectious diseases. They contribute a substantial portion of the external development assistance to the health sector. The various national disease control programmes strive to adhere to the global recommendations advocated through these partnerships and often provide evidence and experience for the formulation of the global strategies themselves. 26

The role of International Private Sector Development Partners in assisting the scaling up of health interventions at the national level and developing health system capacity has expanded in scope during this decade. The development assistance from the Bill & Melinda Gates Foundation has focused on HIV/AIDS control, while also supporting the control of neglected tropical diseases and strengthening maternal and child health services in some states. The Clinton Foundation and the Children's Investment Fund Foundation (CIFF) focus their assistance on the prevention and control of paediatric HIV/AIDS and mother-to-child transmission of HIV/AIDS. Through their advocacy and capacity building activities, which include addressing the concerns of people affected by leprosy, the Sasakawa and Nippon Foundations support the government's initiative to eliminate leprosy and the stigma attached to the disease. The Norway India Partnership Initiative has a focus on strengthening routine immunization services including the control of measles. The support from Bloomberg Philanthropies has been instrumental in advancing the sectoral and inter-sectoral actions of the Ministry in the area of tobacco control. Multisectoral interventions to promote road safety and prevent injuries have also been initiated in the country in partnership with this entity. International and national civil society organizations in the health sector in India focus mainly on health and care of vulnerable groups. Institutions like Oxfam, Action Aid, Water Aid, World Vision, the Red Cross and others support, in particular, the rural and urban poor, women, children, and minorities, and address issues including child health, gender equality, education, food rights, disaster preparedness and HIV/AIDS. The above-mentioned organizations provide, for

instance, access to water and sanitation; build food security; tackle child mortality rates; and promote community-based networks. Besides delivering support through programmes in these areas they aim to influence the way governments, and the other institutions involved, think. Institutions of Excellence involved in health policy, medical and public health education, training and research include, for example, the 44 WHO Collaborating Centres across India. These centres are working with WHO on areas such as nutrition, mental health, chronic diseases, nursing, communicable diseases and health technologies. The WHO collaborating centres such as the All India Institute of Medical Sciences (AIIMS), New Delhi; the Dr Mohan’s Diabetes Specialties Centre, Chennai; and the Postgraduate Institute of Medical Education and Research, Chandigarh are designated to carry out activities to support the improvement of health practices in India. Another aggregation of individuals and institutions that seeks to help policy-makers, patients, health providers and others to make well-informed decisions about health care is the Cochrane Network and Centre (http://www.cochranesacn.org/). The South Asian Cochrane Network (SACN), which has five network sites in India, is part of the Cochrane Collaboration and, by preparing, updating and promoting the accessibility of reviews, influences considerably the policy and community information for good health practice. Moreover, the Effective Health Care Research Consortium (EHCRC) helps to

ensure that research-based evidence relating to the health sector is adopted by health policy-makers and practitioners in India (as well as in several other countries) in order to make progress in the reduction of poverty. The EHCRC focuses on the production of up-to-date and scientifically defensible evidence to achieve progress in the control of malaria, TB, child and maternal health as well as in health systems. A large number of professional and patient associations, local social groups and the like contribute to the varied landscape of stakeholders of the health system in India. Some of these associations, such as the Indian Medical Association, the Trained Nurses’ Association of India and the Association of Surgeons of India represent health-care staff and are therefore influential in developing better health policies and programmes and in ensuring broad support for them. Other institutions such as the Public Health Foundation of India (PHFI), the Indian Institutes of Public Health, the Indian Council of Medical Research, the Indian Institute of Health Management Research and the Indian Association for Medical Informatics are instrumental in developing health and health system information to strengthen evidence-based policy. On their part, patients and user associations such as the Voluntary Health Association of India can help to develop people-centred policies for better health planning and management, reinforcing accountability and transparency within the health system as a means to improve the health situation of India’s population.

27

28

4. Review of WHO’s cooperation over the past CCS cycle 4.1 Organizational structure and areas of work

In keeping with its mandate, WHO has collaborated during the 2006–2011 CCS cycle with the MoH&FW, GoI. Support to India has been coordinated through its Country Office (WCO), mobilizing the necessary expertise from WHO Headquarters (HQ) in Geneva and from the WHO South East Asia Regional Office (SEARO) in New Delhi. The Ministry as the primary partner has ensured top-level participation in the World Health Assembly (WHA) and other WHOorganized events and initiatives. As part of a fruitful dialogue, the WCO has also responded promptly and efficiently to requests for good quality evidence on data and experiences from other countries relevant for India. Programme management in WHO has historically been based on organizational segmentation “by issues/technical topics”. Consequently the work of WCO India has been organized around different Core Programme Clusters, each working on some disease programmes or thematic areas, such as: (a) Communicable Diseases and Surveillance; (b) Noncommunicable Diseases and Social Determinants of Health;

(c) Family Health and Research; (d) Health Systems Development; (e) Sustainable Development and Healthy Environment; (f) Immunization and Vaccine Development; and (g) Health Action in Crisis. The WCO has strengthened the collection, analysis and interpretation of national data under various initiatives and disease control programmes such as the National Polio Sur veillance Project (NPSP), Routine Immunization, Integrated Management of Neonatal and Childhood Illnesses (IMNCI), Integrated Disease Surveillance Project, Revised National Tuberculosis Control Programme, Emergency and Humanitarian Action, HIV/AIDS, Leprosy Elimination, National Vector Borne Disease Control Programme, Integrated Prevention and Control of NCDs, Tobacco Free Initiative, National Programme for Prevention and Control of Cancer, Diabetes, CVDs and Stroke (NPCDCS), National Mental Health Programme and Elimination of Lymphatic filariasis. 29

The NPSP, a major collaborative project of WHO and the Government of India (GoI), has been instrumental in providing the MoH&FW and the donor consortium with technical guidance for conducting polio immunization campaigns. In this context, the GoI has been able to expand polio immunization coverage with a view to achieving eradication of polio while creating openings for improvements in the implementation of routine immunization. In the field of TB control, the WCO’s focus has changed from expansion of directly observed treatment, short course (DOTS) to quality assurance, scaling up of the newer components of the 2006 Stop TB Strategy (including MDR-TB and TB/HIV) and the MDG-related measurements of impact. The research activities supported by WHO involving key research institutions in the country have helped to answer important operational research questions, and have provided tools and evidence on the impact of TB control activities. WHO has also been a crucial partner in supporting the National AIDS Control Project (NACP) in areas of strategic information, care, support and treatment. Activities have included counselling and testing services and blood safety, and fighting continued stigma and discrimination, especially in health-care settings. Capacities of health-care providers regarding a variety of skills (programme management, financial management and skill-building for community organizations) have been strengthened, and the limited geographical access to treatment and testing services which still make costeffectiveness of service delivery an issue when facing the complex and diverse HIV epidemic, has been addressed with the support of the WCO. 30

Through advocacy and support, the WCO has facilitated the launching of a national programme for prevention and control of cancer, diabetes, cardiovascular disease and stroke. The focus is on integrated prevention and control of NCDs, including surveillance and health promotion to reduce risk factor prevalence; partnerships have been built for implementing the National Tobacco Control Programme, to increase the Tobacco Cessation Centres network and to improve capacity at subnational level. The WCO has also supported the MoH&FW and other partners in developing, implementing and evaluating numerous interventions in line with MDGs 4 and 5; e.g., making pregnancy safer, child health and development, adolescent health and development, nutrition for health and development, reproductive health and research, nursing and midwifery and gender and women’s health. Technical assistance has been provided for implementing the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) and introducing pre-service IMNCI training in the curriculum of the medical colleges (through state directorates of medical education), universities and ANM training centres (through the Indian Nursing Council). Other normative functions included provision of technical assistance for development of operational guidelines for facility-based newborn care, which proposes three levels of facilities for newborn care. In the area of health informatics, the WCO has facilitated the mapping of health-care facilities, provided support for studies on management of human resources and for improving and strengthening the efficient electronic flow of health information

from the periphery towards the Central Bureau of Health Intelligence. The National Health Profile has also been compiled and updated. In the area of Health Systems Development (HSD), since contributing to the work of the Commission on Macroeconomics and Health in 2005, WCO’s collaboration has focused on policy-making for human resources for health, essential drugs, Development and Trade agreements, health-care financing, social protection, and health research and ethics. The WCO also facilitated work to augment the country’s capacity to implement mitigation measures during the influenza A (H1N1) pandemic. Technical support and capacity building for the laboratory surveillance component of the Integrated Disease Surveillance Project was provided to the Central Surveillance Unit. Help was also provided for the MoH&FW to amend the Port and Airport Health Rules and sensitize various stakeholders through orientation workshops in compliance with International Health Regulations (IHR). National capacity in the field of epidemiology as well as the preparedness and response capacity for emerging and re-emerging communicable diseases, including dengue, chikungunya, Japanese encephalitis, Nipah/Hendra virus disease, meningococcal meningitis and zoonoses was also built up. The epidemic preparedness capacity of states and districts was strengthened and a National Health Sector Disaster Management Plan was developed. Capacity was strengthened for malaria control and elimination of leprosy, lymphatic filariasis, kala-azar (visceral leishmaniasis) and yaws.

Working in collaboration with the GoI, various civic bodies, research institutes and technical institutions, the WCO has also focused on water (quality monitoring and surveillance, development of guidelines and training manuals, research, capacity building and promotion of best practices including a Water Safety Plan in cities) and sanitation issues, health hazards of indoor air pollution and other related topics. WCO is also a member of the National Task Force on Climate Change set up by the MoH&FW in 2009 with the objectives of identifying agencies to conduct research, recommending strategies for awareness creation and suggesting health system capacity strengthening measures to address the health issues due to climate change. In addition to its work with the MoH&FW, the WCO has worked closely with departments in other ministries and state governments. United Nations agencies and development partners, NGOs and civil society organizations, WHO Collaborating Centres and academic and research institutions have also received specific attention (as explained in Section 3). 4.2 Financial resources

The funds mobilized by WCO during the six years of the CCS period (2006–2011) covering three biennia are given in Table 4 (on page 32). Voluntary contribution (VC) funds were mobilized to support, in particular, selected areas of work such as NPSP, disease surveillance and the TB, leprosy, HIV/AIDS and malaria programmes. The mostly earmarked sources of funding partially explain the structure of the WCO as well as the abovementioned, short-term, isolated interventions. 31

Table 4: Summary of funds mobilized during the current CCS period Biennium 2006–2007 2008–2009 2010–2011 Assessed contribution (AC) in US$ millions 12.61 13.80 13.60 Voluntary contribution (VC) in US$ millions 96.60 91.31 82.07 Total amount in US$ millions 109.21 105.11 95.67

4.3

Experience gained and lessons learned during the 2006–2011 CCS

In the following areas the WCO India's technical contributions were remarkably effective: First the WCO India’s support to the GoI’s efforts during the 6 years of the CCS (2006–2011) have most likely made a difference, contributing to better diagnosis of TB, higher immunization coverage, increased prevention of malaria, and in helping to build the competences of state officers. Second, technical support and partnerships have been strengthened in selected areas, with certain planning developments leading to some solid distribution of funds to the GoI by areas of work. Third, at an internal level, there has been a partial strengthening of human resources, a reasonably well conceptualized organizational structure and sufficient resources allocated to priority issues. On the other hand the development process of the past CCS probably did not involve sufficient consultation at the national and state levels during either drafting of the CCS or in the preparation and implementation of the work-plan. This led to 32

an insufficient alignment of the CCS with the country’s priorities, resulting in poor awareness and use of the CCS by staff and stakeholders. A related deficiency could be the insufficiency of programme evaluation or appraisal to ensure that work-plans and their implementation were based on the real health needs and capacities of the country. At the end of the six years, there is hardly any robust assessment of the contributions of WHO to the country’s health system results. The modalities of the delivery of WHO's collaboration have also privileged a multiplicity of small financial (cash) transactions in support of what were probably too many different programmes. The silo type of structure of the WCO and the sometimes poor coordination and synergy between the three WHO levels could have further eroded the effectiveness required to implement the CCS. In summary, the experience gained and the lessons learned during the finalization of the current CCS period are now leading to an emphasis on policy and health system work, the strategic formulation of fewer priorities and a careful design of the performance evaluation. The internal challenges are being addressed by means of audits and methodological as well as organizational changes in the context of the ongoing WHO reform. This is analysed in Sections 5 and 6 below, respectively.

5. Strategic agenda for WHO cooperation This section addresses the strategic agenda for cooperation between WHO, as an independent, neutral, inter-governmental technical specialized agency of the United Nations, and the GoI. It has been prepared through a series of both rather informal and very structured meetings with government high-level counterparts and partners in 2011, during which analytical work on the challenges confronted and the lessons learnt were shared. Much was learnt in particular from the processes of UNDAF detailed in Section 3 and from engagement with the working group meetings of the Planning Commission of India for example, the High Level Expert Group on Universal Health Coverage, as well as from discussions with selected high-level officials. Informal but structured interviews and consultative workshops with the private sector, the academic institutions, development partners and civil society organizations from around the country ensured that their views were also taken on board. Distilled evidence regarding the challenges confronted by India, the manner in which they have been addressed globally and the lessons learnt during the implementation of the current CCS were shared with the stakeholders by way of comprehensive presentations at those consultations. In-depth discussions on the challenges, options and lessons in the context of the health systems perspective and in light of the comparative advantages of WHO and its mandate resulted in stakeholders participating in the consultations to advance recommendations on the strategic agenda and approaches that should be considered for the CCS. This section addresses first the content of the CCS (the three Strategic Priorities of the Strategic Agenda) and then the process (the approach for the collaboration). It fully respects the GoI's policy of development cooperation while mainly feeding into its policymaking through knowledge and relevant experiences from BRICS countries and other newly industrialized countries, as well as countries in transition to higher developmental stages. 5.1 Content: Priorities The three Strategic

International experience shows that the role of ministries of health is gradually expanding 33

beyond the health sector and evolving to one of motivation, intelligence provision and leadership as well as better advocacy for health in all policies. From the challenges referred to above, two broad sets of measures emerge as being critical to enable the GoI to improve population health: launching “inter-sectoral” actions with an impact on health; and reforming the provision of (personal and population) health services. Sanitation provides a good example of improving health results by avoiding disease and death while also triggering economic activity (for example, avoiding lost tourism and the income related to it) through inter-sectoral action. Water and sanitation are paradigmatically public goods by their nature and thus investment in these critical social determinants of health should 83 predominantly come from the public purse. In the case of India, access to improved toilets and wastewater treatment can only be the combined result of increased investments by GoI in infrastructure creation, operations and maintenance plus investments by households and real estate promoters in efficient sanitation facilities. It is vital to accelerate such investment while India enjoys unprecedented economic growth. WHO will help support this multisectoral work with practical, feasible proposals, in line with the priorities set in other parts of this CCS. International experience shows that countries face two overarching objectives regarding personal health services. The first is adjusting service delivery structures to meet the health needs of the population in terms of quantities and modalities of affordable, efficiently networked and sustainable evidencebased services and modernizing outdated structures. The 34

second is improving the way in which health service delivery institutions in the public and private sectors are managed, introducing professional decision-making in the use of resources, serving the customer and maximizing quality and productivity. Ample evidence supports the idea that similar emphasis is applicable to population-based (“public health”, 84 “community”) services. As a result of the dialogue process with the stakeholders, and taking into account comparative advantages of WHO as well as resource availability, three Strategic Priorities have been agreed upon between WHO and the GoI. The main Focus Areas selected and agreed upon to address each of the Strategic Priorities are specific, measurable, achievable, realistic and time-bound. The Strategic Priorities and corresponding main Focus Areas are summarized below. Strategic Priority 1: Support an improved role of the GoI in global health Main Focus Areas: (a) Ensuring the implementation of IHR (b) Strengthening the pharmaceutical sector including drug regulatory capacity and trade and health (c) Improving the stewardship of the entire Indian health system Strategic Priority 2: Promote access to and utilization of affordable, efficiently networked and sustainable quality services by the entire population Main Focus Areas: (a) Promoting universal health service coverage so that every individual would achieve health gain from a health intervention when needed

(b) Properly accrediting service delivery institutions (primary health care facilities and hospitals) to deliver the agreed service package Strategic Priority 3: Help India to confront its new epidemiological reality Main Focus Areas: (a) Scaling up reproductive, maternal, newborn, child and adolescent health services (b) Addressing the increase in combined morbidities due to combinations of CDs and NCDs (c) De-verticalizing polio, AIDS and TB programmes and transitioning WHO service delivery in them to government 5.1.1 Strategic Priority 1

preparing for as well as responding to disease outbreaks (including emerging and re-emerging diseases) and other public health threats (caused by multiple hazards of natural, accidental or intentional origin such as chemical, radio-nuclear, biological and other risks) with direct implications for IHR is higher in the policy agenda of the country and is discharged through inter-sectoral actions. Health statistics should also be adapted to IHR requirements. In particular, mechanisms will be built to register and analyse the BoD (e.g. diarrhoeal diseases, TB and HIV) bearing in mind there are worries about completeness of information.85 The opportunity will be taken to improve death certification and related statistics; the Sample Registration System will need to be refined, since independent evaluation suggests that the system 86 only captures about 85% of deaths. Knowledge on international trade and health issues, including trade negotiation processes and mechanisms related to health should be promoted through multi-stakeholder collaboration and ownership while fostering South-South and Triangular Cooperation. Capacity needs to be built and networks strengthened to ensure full credibility in the international health scene while providing constructive inputs to international fora, making India’s expertise available to the rest of the world. Strengthening the pharmaceutical sector including drug regulatory capacity and trade and health for it to play a special role in India’s future is a key objective in the CCS (particularly in the context of enhanced access to generic drugs, vaccines and medical products). Increased access to 5.1.1.2

The first priority is to support an improved role of the GoI in global health. This could be achieved through three main Focus Areas: Ensuring the implementation of International Health Regulations (IHRs) and compliance with similar global commitments such as trade and health, both for ensuring safety in all exported products that can affect health, and for mitigating possible negative effects of trade on the health of the population. 5.1.1.1

International Health Regulations

All relevant norms should be aligned with the corresponding IHR and international commitments related to key determinants of health. This will ensure that providing food safety, improving water and sanitation, preventing and

Pharmaceuticals

35

drugs (including patent issues and Agreement on Trade-Related aspects of Intellectual Property Rights (TRIPS); continued advocacy for reducing prices as well as improvements in procurement and supply chain management) should be fostered, especially for quality essential products for managing NCDs, TB, HIV/AIDS, malaria and neglected tropical diseases (NTDs), among others. The number of “stock-outs” of medicines in public centres will also need to be reduced. Promising market niches (e.g. generics for NCDs) should be explored with a view to both identifying business opportunities and serving the needs of low income countries and emerging world markets. WHO will support the development of platforms and networks for horizontal collaboration, and transfer of technology between the international community, industry federations and relevant players, and generation of knowledge on international trade and health. This will help in building enhanced capacities for trade negotiations in cognizance of intellectual property rights issues and international covenants which have bearing on public health. Due consideration should be given to their implications for Indian industry and access to affordable quality pharmaceuticals locally and globally. Drug regulatory work by the relevant authorities including the Indian Pharmacopoeia Commission and other stakeholders should be strengthened in line with the emphasis on “trade and health” and access to medicines (described above). The number of trained Institutional Ethics Committees as per standard operating procedures or guidelines should be increased to improve standards of clinical trials and research. Research and development (for example, the creation of drug testing 36

laboratories) should be expanded and all trade legislation should strictly adhere to the Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property (GSPOA). Quality assurance and safety policies and, in general, good manufacturing practices (GMP) should be reaffirmed by consolidating the technical expertise developed in recent years while supporting the National Pharmacovigilance Programme and integrating reports of adverse drug reactions (ADRs) under national programmes on HIV/AIDS, tuberculosis, malaria and vaccines. Rational drug use initiatives and sector inspections (e.g. distribution, prescription, and delivery over the counter) should be scaled up in order to protect customers and contain antimicrobial resistance. Improving the stewardship of the entire Indian health system by supporting the GoI’s efforts is necessary for ensuring India’s leadership role in global health. Space for fertile collaboration between stakeholders needs to be found in a winwin relationship. 5.1.1.3

Stewardship

While planning capacity at the central level is robust, as already indicated, specific work is probably warranted to increase the policy-making and planning capacity of some states. Emphasis will be placed on implementation and the operational translation of ideas into action. Inter-state exchange of experience with the aim of setting up effective Health Strategy and Planning, Health System Innovation Units or the like will be fostered on a voluntary basis.

Another important step in better articulating the respective roles of the Union and of states, and of the public and private segments is the 2010 “Clinical Establishments Act” and subsequent legislation which empowers authorities to require mandatory enlisting and supervision of public and private sector institutions, supported by an effective health-care quality inspectorate. Creation, management and dissemination of an electronic inventory of enlisted clinical establishments; development of standard treatment guidelines and protocols; and normative instruments for the effective implementation of the Act would be facilitated. Improved health information/intelligence for decision-making supported by better epidemiological surveillance and policy analysis also plays a role here. WHO will support the use of internationally gained experience in measuring health systems performance, as part of a broader effort to strengthen evidenceto-policy links. Facilitating the inclusion of national centres of expertise into a global compendium of national expertise, conducting research on emerging infections and strengthening research capacity especially in clinical trials, health economics, health financing, infectious disease modelling and other critical challenge areas is also important, as is disseminating best practices (“What works at the scale of this country?”). Increasing the involvement of the private sector in information 87 systems will be an option, as already seen in other countries. In fact, private business activity in India often reaches worldclass levels and now the government has a crucial role in ensuring the contribution of corporations to protect the broader social good. Clearer indications are needed about where

investments in infrastructure are indispensable, where acute care and chronic disease programmes against both CDs and NCDs are most needed, where human capital in the health field should learn from successful business practices, and so on. Signals abound that the vibrant private sector is willing to contribute to improving population health, be it through donations, partnerships, targeted private funding from business leaders and philanthropists or similar arrangements as attested by Pulse polio and several P-P-P projects. 5.1.2 Strategic Priority 2

The second priority is to support the GoI in promoting access to and utilization of affordable, efficiently networked and sustainable quality services by the entire population. This could be achieved through two main Focus Areas: Providing universal health service coverage so that every individual would achieve health gain from a health intervention when needed by appropriate provisioning of health services. WHO devoted the World 88 Health Report 2010 to “Universal Financial Protection Coverage” to highlight the conviction that access to and utilization of services according to need is a critical challenge everywhere (and probably the biggest challenge India faces). WHO has contributed to the report by the High Level Expert Group (HLEG) on Universal Healthcare Coverage established by the Planning Commission. 5.1.2.1

WHO will play an important role in: (i) dissemination, technical and policy advice by creating and sustaining a sense of urgency and a strong drive from the Report to implementation; 37

(ii) advocacy for raising key technical aspects higher on the political health policy agenda, including development of common IT/HMIS standards in the public and private sector; and (iii) emphasizing quality standards, as well as embedding monitoring and evaluation in the reform implementation process. WHO will also support the Government in helping stakeholders assess the services to be covered, starting from a review of the existing vertical services arrangements and health programmes, a number of which have already been integrated under the NRHM. The GoI is committed to increasing the number of affordable, efficiently networked and sustainable quality services to provide cover for the entire population and up scaling the necessary workforce accordingly. To facilitate this, feasibility studies are needed to examine the coverage of different packages. A health technology assessment-inspired mapping exercise will thus be implemented addressing the personal and population health services that should be produced (profiles, not necessarily full details), their numbers and target populations, the delivery approaches and quality standards, service structures and organizations. If measured by the results 89 obtained in the OECD countries and many countries in transition to higher development stages, primary health care services should be a clear priority in India. The fact that they are not covered under the RSBY but only through the NRHM makes them especially relevant for UHC as stated in the report of the HLEG on UHC. One lesson learnt from the experience of other countries is that a unified IT system (or at least one with common standards so that different systems can “talk” to each other) is a critical prerequisite for fast, efficient progress towards 38

a universal health financing system. Most importantly, while some aspects of reform implementation can proceed step-bystep, the IT/HMIS must not; standards and architecture have to be identified to avoid an over-fragmented reality that will be very difficult to put right a few years from now. Properly accrediting service delivery institutions (primary health care facilities and hospitals) to deliver the agreed service package is the supplement to ensuring coverage. WHO will support the GoI in the process of accrediting service delivery institutions (primary health care facilities and hospitals) able to deliver the “covered” package with adequate staff and proper standards. 5.1.2.2

Quality

WHO will support a qualitative leap forward in the quality of licensing, accreditation and certification of public and private health services delivery institutions and existing schemes. This would ensure that chosen hospitals are really able to deliver the required package of services if and when accredited or quality certified to do so, in order to increase demand for the package of services offered, coupled with synergized patient charters with explicit mention of patients’ rights. Given the current ownership structure in service delivery, it is envisaged that the planned increase in public expenditure will involve a substantial supply-side intervention; it is intended in principle that there will be at least one public hospital able to deliver the required package of services in each defined area. Private hospitals (perhaps initially from the not-for-profit voluntary sector) may be contracted by the government to provide services using public funds wherever necessary.

To that end, improvements in the entire field of contracting arrangements (formulated in the NRHM as “increasing district accountability for the money received by making certain specifications”) also need support; districts and particularly hospitals need to have the necessary measurement, accounting and managerial instruments to make them accountable. Better Programme Implementation Plans and District Action Plans should also be developed, supported by refinements in the HMIS, contractual arrangements and other tools. Access to high-quality, affordable essential pharmaceuticals and other technologies will also be promoted in the context of accreditation; this is something that also connects with India’s duties in addressing health challenges globally through S-SC, BRICS commitments and beyond. Realistic health workforce plans including, for example, initiatives to encourage migrants willing to return to India at the end of their careers will become important in the efforts to meet the required standards of practice in India (numbers, skills and ethics). WHO would advise in work on the human capital that might entail different modalities, to be determined by the government and the concerned institutions, for example: (i) increasing the production of professionals; (ii) providing intensive, specific training to targeted groups; (iii) changing the skill mix of the workforce; and (iv) providing incentives, either positive (e.g. better job conditions or bonuses) or negative (e.g. tighter discipline and more sanctions). WHO will also support refinements in the HMIS needed for modern licensing and accreditation. As indicated above, under main Focus Area 1(c) on Stewardship, better registration and

reporting systems will have to be simple but effective. Professionals in the public sector are supposed to already have reporting obligations. For health authorities, better involving private doctors and institutions (clinics and hospitals) in the pursuit of national health objectives is an obligation that cannot be renounced – more so if private institutions aspire to contractual arrangements which would allow them to provide services using public funds. The human resource and technological implications of these improvements in HMIS should be taken into account. 5.1.3 Strategic Priority 3

The third priority is to help India confront its new epidemiological reality. This could be achieved through three main Focus Areas: Scaling up reproductive, maternal, newborn, child and adolescent health services beyond the traditional set of mother and child issues. Emphasis will be put on improving access for difficult-to-reach people to high-quality, certified and Health of Mothers and Children supervised services supported by training and controls. WHO intends to use a genderawareness approach for accelerating the achievement of MDGs 4 and 5, by synchronizing with the government in its effort to pay preferential attention in India to: (i) adolescent health, linked to nutrition¸ the cultural aspects of early marriage and intergenerational issues; (ii) home based care of the newborn and postnatal care (related to breastfeeding); and (iii) management of low birth weight related to the capacity of nurses and midwives. 5.1.3.1

Care of the pregnant woman, the mother and the newborn in primary health care facilities and hospitals will be subject to 39

well-designed protocols focusing on equity and quality. For example, the number of deliveries under the supervision of skilled birth attendants will be substantially increased. Child and adolescent nutrition and related health issues will be addressed by the government by means of both upstream measures (e.g. government subsidies and school activities) and downstream activities (i.e. regular medical and nursing supervision) and subject to specific follow-up throughout the country. WHO will support the mandates and activities of the government and other developmental partners (civil society and private sector players) paying attention to avoid duplication of effort and maximize returns. Better information systems, tracking resources and oversight will be promoted in accordance with the ten precise recommendations of the “Accountability Commission on Mother and Child”90 chaired by the Tanzanian President, the Canadian Prime Minister and WHO’s Director-General, and of which India’s Honourable Minister of Health and Family Welfare is a member. Significant steps will be taken in particular to support (i) integrated use of Information and Communication Technology (ICT) to improve the registration of births, deaths and causes of death combining data from facilities, administrative sources and surveys, and (ii) disaggregate the indicators on reproductive, maternal and child health, for gender and other equity considerations for the purpose of monitoring progress. WHO will also provide technical and policy support to the government aimed at reducing the gap between states in terms of health outcomes, with a specific aim of contributing to the reduction of selective gender abortion, increasing girls’ attendance at school, raising female literacy rates and improving the gender equality, a critical social determinant of health. 40

5.1.3.2 Addressing the increased combinations of CDs and NCDs (double BoD) in India linked to the unprecedented epidemiological transition, a gender related approach and the subsequent need for a three-pronged approach that WHO will support:

Combined Morbidity

First, there will be continued commitment to the fight against CDs under the new circumstances, as per the analysis in Section 2 above; for example, vector-borne diseases are acquiring an increasingly urban rather than rural-related profile due to specific rapid urbanization patterns and waterborne diseases require more robust inter-sectoral work in collaboration with municipal governments and urban developers, among others. Second, there will be a massive scaling up of upstream (that is, addressing broad determinants of health) and downstream approaches (addressing the symptoms of diseases and immediate needs of patients) to fight cardiovascular, cerebrovascular and metabolic diseases, cancer, mental illnesses and other NCDs in India. Inter-sectoral actions aimed at reducing the risks of contracting NCDs will be combined with effective health services to reduce death and disability once the diseases have started and the risk of acquiring the disease – for example, by diminishing exposure to tobacco and other addictive substances, decreasing consumption of salt, sugar and fat, increasing physical activity and increasing access to effective services, all socially influenced factors. Third, it is foreseeable that new service modalities of primary health care and hospital care will emerge. WHO will support

the government in designing approaches to minimize the catastrophic impact of repeated costly visits to health-care facilities and repeated tests, especially under OOP payment conditions, for those who suffer co-morbidities. At the moment, for example, almost half of Indian families with a member affected by cancer already experience catastrophic spending and a quarter of all families are pushed into poverty as a consequence of the disease.91 This will be a highly demanding change from the viewpoint of health service facilities and human resources. The National Commission on Macroeconomics and Health has already identified the delay in introducing changes as being responsible for an unduly high toll in terms of mortality, 92 morbidity and disability in India. If the majority of the population is to be served, enormous innovative efforts in terms of networking delivery arrangements, technologies, health workforce skills and training modalities, among others, will be needed in the coming years to overcome the challenges identified in Section 2 above. De-verticalizing polio, AIDS and TB programmes and transitioning WHO service delivery components in them to regular government structures run by district, state and central authorities, as the Transitioning public health system of India now has more Services than sufficient knowledge, organizational capacity, resources and service delivery mechanisms. 5.1.3.3

to medicines, strengthened surveillance, monitoring and evaluation and research, will face their acid test in the fight against the combination of CDs and NCDs in the next decade. No doubt, however, that management of AIDS and TB and the efforts for certified eradication of polio, will remain a major issue for India for a number of years to come. Sustaining results in these areas now requires a gradual, phased “transfer strategy” of WHO services to the national, state and local authorities with the sine qua non condition that no erosion of effectiveness occurs during the transition period. Such transition strategy will be developed through a consultative process. Both the GoI and WHO want to see more emphasis being placed on augmenting a healthy public policy combined with the much needed cross-sectional services for tackling diseases through the continuum of care. Population services (including improvement of dietary habits, promoting patient selfmanagement, implementation of no-tobacco rules, public health inspection services which are critical for fighting foodborne and water-borne diseases, and laboratory support for STI diagnosis) need to be scaled up and the same applies to preventative primary health care interventions, combined in turn with effective emergency and regular services as well as highly complex individual/personal services. Once more, a gender-related balance will be paramount here. In summary, WHO’s service delivery in polio, AIDS and TB has to continue for as long as necessary according to country needs, but it should take into account the lessons learnt and have exit in mind. A shift from focusing on polio to routine immunization, for example, in the context of maintaining polio-free status and achieving 90% reduction in measles mortality (baseline 2000) 41

In fact, all the improvements proposed under Strategic Priorities 1 and 2 in the field of financing, regulation, governance, access

by 2013 has to be accompanied by a timetable for transferring WHO work to the government authorities at all levels. The same applies to relevant objectives in the case of TB (e.g. integration with general health systems, with emphasis on access to drugresistant TB diagnosis and treatment, integrated TB/HIV services, and improving the engagement of all care providers). In the case of AIDS, technical and normative support needs to continue, including operational guidelines for integrating health service elements, such as quality assurance of clinical services, ensuring long-term retention of patients on antiretroviral therapy, preventing parent-to-child transmission within the NRHM, updating antiretroviral therapy to consolidate the progress achieved in the last 6 years and strengthening linkages with community services, monitoring of the development of HIV drug resistance, and reducing HIV transmission among members of the most-at-risk population. At the same time, the above priority services should be increasingly incorporated under regular service schemes linked to universal coverage and delivered by well trained staff and properly licensed facilities. In the coming six years WHO will maintain its technical support while increasingly focusing on policy advice and strategic work as indicated in Section 4.3. 5.2 Process: Strategic Approaches – Policy dialogue, evidence generation and new efficient types of collaboration

response to an intensified need to integrate services of vertical programmes into district and primary care subsystems, quality of implementation could be a concern. This means that the WCO needs to play a useful role in supporting the MoH&FW stewardship function by identifying where important policy gaps or fragmentation may exist and could lead to incoherence between different aspects of health policy. WHO will focus on proactive support to the MoH&FW leadership and offer policy advice with a perspective of health system performance assessment as well as suggesting international best practice in areas where the government might be looking for possible solutions. At the global level, WHO is currently undergoing a reform process emphasizing three objectives: (a) improved health outcomes, meeting Member States' and partners' expectations in addressing agreed global health priorities; (b) greater coherence in global health, with a leading role for WHO in enabling actors to play an effective role in contributing to the health of all people; and (c) being an excellence-pursuing organization (effective, efficient, responsive, objective, transparent and accountable). WHO reform is also focused on five core areas: (i) Communicable Diseases; (ii) Non-Communicable Diseases; (iii) Health through the Life Course; (iv) Health Systems; and (v) Preparedness, Surveillance and Response.93 In line with the above, the core feature of the next CCS will be WHO’s support to the MoH&FW/GoI by fostering health policy dialogue and technical advice to the authorities

The years 2012–2017 will be critical to ensure that the gains achieved recently by India are consolidated. While funding is being increased and decentralization is happening rapidly in 42

throughout the country, in strategic priority areas of collaboration. In other words, the WCO is striving to reposition itself to become more useful for the government, moving away from implementation and administration of resources to concentrating on the comparative WHO advantages upon 94 which its core functions are built as follows: n providing leadership on matters critical to health and engaging in partnerships where joint action is needed; n shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge; n setting norms and standards, and promoting and monitoring their implementation; n articulating ethical and evidence-based policy options; n providing technical support, catalysing change, and building sustainable institutional capacity; and n monitoring the health situation and assessing health trends. As indicated above, work is also needed on developing selective research capabilities in India. The WCO will need to facilitate generation of high-quality, relevant and timely evidence in terms of operational research-related issues such as assurance that specific courses of action are valid and consistent in light of other countries’ experiences. Comparative data on health system performance will be needed to help assess and strengthen routine data collection and analysis, including trends over time and projections into the future, providing support in reconciling different sets of data and different possible interpretations. In order to deliver this, the India WCO will get better connected to HQ initiatives such as the Health Metrics Network while also developing its own strategy for information and intelligence and deciding on which areas of measurement it will focus.

India has no shortage of research institutions and world-class researchers, but there do appear to be gaps in the “evidence-topolicy links”, another critical dimension of stewardship. It would be necessary to facilitate creation of a forum that would periodically convene researchers and key decision-makers to encourage and “steer” the translation of stated government policy objectives into a policy-relevant research agenda. This would require engaging the decision-makers to elicit their priorities and translate them into research topics, and then to support (and sometimes commission, though many others could do this as well) research on various aspects of reform implementation linked to these priorities. The WCO will specifically commit to producing a repository, in which to pool successful experiences reported across India, and to fostering the exchange of lessons among states as a way to facilitate practical learning from within the country. Handling evidence and information as well as knowledge management and openness to innovation and different ways of seeing things were the three attributes ranked top in a recent assessment of “organisational processes and cultures supporting health policy capacity” as per the experience of Australia and New Zealand.95 It is expected that such research activities in India will be geared towards generating evidence for policy making. All the main stakeholders will be involved in strengthening this area, with the South Asian Cochrane Network and Centre playing a role. Shortcomings in capacity in appreciating the relationships between health policy and health systems and particular functions (such as health financing) are frequently mentioned formally and informally with regard to state health administrations and health societies. Given this situation and in 43

light of past experience, WHO should explore the potential for implementing robust series of Flagship courses on health system development in collaboration with the World Bank Institute, targeted at mid-to senior-level managers and decisionmakers, as well as key private and NGO players. Such courses would be aimed at broadening and deepening knowledge and understanding of health policy and the economics of the sector. Partnership would also be sought with a network of Indian experts (e.g. PHFI, the Health Economics Association of India). There should also be close collaboration with the National Health Systems Resource Centre which is responsible

for training and is a “natural” partner for such an initiative (particularly if one aim is to reach the state health societies) and the NCHRH with its dual mandate for reforming the current regulatory framework and improving the supply of skilled personnel in the health sector. Collaboration with selected stakeholders such as the World Bank, the Global Fund and GAVI, for example, will also focus on providing realistic strategic direction and inspiring India to shape up its health policy in line with WHO’s principles and values, that is, advocate an integrated approach to development. All these issues are addressed in more detail in Section 6.

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6. Implementing the strategic agenda: implications for the WHO Secretariat The critical challenge for the WCO will be adjusting and scaling up its capacity to provide support for the required technical excellence that would be able to contribute meaningfully to and influence national health policy processes, that is, to influence the government’s health agenda. The WCO has been privileged for years to work hand in hand with major, technically excellent Indian institutions; it has the will, the technical capacity and the necessary resources to continue doing so. WHO will continue to support the initiatives of the MoH&FW and its relationships with all major ongoing health initiatives in India, from the High Level Expert Group on Universal Health Coverage and the Planning Commission to the National Rural Health Mission, the Polio Eradication Programme, and the Swajaldhara Clean Water Scheme, among others. However, working towards achieving the objectives listed in Section 5 in collaboration with the MoH&FW and partners calls for major adaptations in the way the WCO plans, runs its budgets, works and organizes itself by focusing on WHO's own asset as a valued partner. Outwardlooking ( “external” ) and inward looking (“internal”) implications of the CCS for the WHO Secretariat are addressed below: 6.1 6.1.1

External implications

Shift from budgetary support to health policy dialogue and technical advice, and shift from replacing government services to strengthening the country’s own capacity. As indicated, WCO India will continue to support the initiatives of the MoH&FW and other stakeholders but will do so by focusing on harmonization of policy recommendations, that is, first inspiring and then “decoding” the practical implications of decisions made by GoI inside and outside the Five-Year Plan framework. This means that the WCO will now develop an enabling approach, focusing on harmonization and integration of policy recommendations across groups, agencies and social actors. More attention will be paid to policy dialogue with the GoI and to working with partners such as the United Nations organizations and other stakeholders. Set up mechanisms for periodic joint progress review of CCS implementation. WCO will give 6.1.2 45

maximum priority to being focused, concentrating on priorities and ensuring that it delivers at all times. A key change that needs to be made is moving from isolated programme management and input-related funding to integrated country work and expected country results. In order to ensure transparency and accountability of the implementation of the CCS, an oversight/advisory committee for periodic progress review will be set up jointly headed by Secretary, Health and Family Welfare and WHO Representative. Terms of Reference and the scope of work for such committee will be jointly designed by WHO and the MoH&FW. Such progress review will be undertaken at least once a year with involvement of other stakeholders, as appropriate, using a limited list of robust indicators which focus on outcomes and deliverables of the identified CCS priorities. A critical culture of health system performance assessment will be promoted. 6.1.3 Disengage from high-labour, low-impact activities and small-dose

adding fields (e.g. standards setting, quality assurance, stewardship mechanisms and tools, and economic and functional evaluation). WHO is uniquely positioned, for example, to bring experience, know-how, expertise and credibility to complex development areas such as those dealt with by the “Commission on Universal Health Coverage”. It will also assist the MoH&FW in multisectoral initiatives, making the case for health becoming an investment opportunity. WHO will continue to strengthen national capacity through variety of existing and new mechanisms (including fellowships both, in India and abroad) and align such initiatives to the CCS priority areas. Strengthen interlocution with and presence across the country, with emphasis on selected locations. Every country has its own health system reflecting its history, values, resources, and the preferences of the essential players, among other things and there is a need to identify the gaps to be addressed in order to strengthen India’s health system at all levels. India WCO will review its human resource policies, budget allocations and structures in order to manage the above-mentioned policy and technical support work in order to improve relevance and impact. A network of regional hubs in support of states needing particular help in the areas agreed with the GoI will be carefully designed and implemented according to resource availability. 6.1.4

cash transfers. Shift to impact-ensuring practices in line with WHO's role as a specialized health agency of the United Nations (e.g. assisting government in donor coordination). Review the mechanism of human resource support (such as covering staff costs) to the national programmes and institutions through WHO collaboration, linked to the transitioning strategy. Government will consider options and mechanisms for mobilizing resources for WHO services in support of CCS implementation modelled on mechanisms already operational in India’s NPSP and in other BRICS countries. WHO will continue to provide top quality technical support as necessary, filling capacity gaps and concentrating on high value46

Foster WHO-led technical activities to promote the corporate label of WHO (e.g. during United Nations Day). This means championing health within the UNCT and during the implementation of the UNDAF as well as with other stakeholders. WHO is working in an increasingly populated environment in which its mandate as the specialized agency in 6.1.5

health of the United Nations may become blurred. Efforts are needed to distinguish WHO from organizations whose prime function is to manage and disburse loans and grants as their main lines of business, and from institutions that develop knowledge without necessarily being responsible for its application. This should be achieved by aligning WHO proposals with the needs and capacities of the country while taking into account the capacity of the United Nations and other partners. Take inter-sectoral action more seriously – engage with various stakeholders in fostering health actions and policy decisions in other sectors that address the social determinants of health. Achieving th more influence on India's 12 Five-Year Plan is a major objective for which better understanding of its deep mechanisms and of the stakeholders involved is a precondition. Country work-plans reflecting agreed strategic priorities within the core areas of work should be the preferred instrument. Specific room will also be made available for civil society institutions, with whom data and information will be widely shared. 6.1.6

Upgrade internal and external communication (including website). Properly communicating to partners and users the contribution WHO makes to specific improvements in health outcomes and impact is one of the accountability areas WHO has identified as most in need of improvement in recent years. Internally, communication between units has also proved indispensable for ensuring coordinated action (e.g. in defining objectives, identifying expected products, and improving processes). 6.2.2

WHO’s reform, particularly in areas regarding contributions and capacities of the whole Secretariat. Great importance is currently being attached to the contribution of Country Offices, Regional Offices and Headquarters, their respective strengths and the need for synergistic action around well-elaborated, comprehensive country work-plans (which ideally should also help gather not only WHO’s contributions but also those of different partners) around priority programmatic needs. Align office structure with CCS implementation in the new context. Promote horizontal collaboration between programmes and reduce fragmentation. The architecture and functionalities of the Country Office will be substantially streamlined to make it more fit for the purpose of CCS implementation. Organizational arrangements in the WCO will undergo an indepth review. 6.2.4

6.2.3 Take extended advantage of

6.2 6.2.1

Internal implications

Boost technical excellence in the Office, bring in international experience and strengthen health information and intelligence on India, including research capabilities. The foremost priority for the WCO is reviewing its toolbox. This will include mobilizing international expertise and excellence to complement already existing excellent national capacity and expertise by opening international positions in core CCS areas and developing capacity in critical areas (e.g. health economics, policy-making and programme evaluation).

Promote de-concentration of authority and responsible management with corresponding increased demands in terms of discipline and accountability for results. A cornerstone of this effort will be empowering managers in a context of responsible freedom to manage subject to transparent monitoring and 6.2.5 47

evaluation. Individual and unit performance assessment, will be emphasized starting with effective use of WHO’s Performance Management and Development System (PMDS). 6.2.6 Pay increased attention to enabling functions. Shifting the

focus from the prevailing budgetary support practices of various initiatives (e.g. fellowships) to provision of policy and technical support will not be viable without streamlining WCO operations and management by developing the WCO enabling functions (e.g. linking WHO fellowships with proper capacity building approaches in line with the CCS priorities).

In the coming months it is expected that union government departments, states and districts will address their priorities and actions for implementing India’s 12th Five-Year Plan in agreement with the MoH&FW. The relevant steps and implementation instructions (including task assignments and other implementation process issues such as duration, pace and sequence of interventions, deadlines, budgets, and monitoring arrangements) will only then be revealed. As a crucial adaptation test, the Action Plan(s) needed to implement the CCS will be addressed in the near future and they are therefore not included in this document.

48

References 1. 2. India at a glance, World Bank, 2010. (http://devdata.worldbank.org/AAG/ind_aag.pdf) Desai SB, Dubey A, Joshi BL et al. Human development in India: Challenges for a society in transition. Oxford, Oxford University Press; 2010. Government of India, Ministry of Home Affairs, Our census, our future, Provisional Population totals. New Delhi. Office of the Registrar General and Census Commissioner;2011. Government of India, Planning Commission. Report of the steering committee on urban development for Eleventh Five Year Plan (2007-2012). (http://planningcommission.nic.in/aboutus/committe e/strgrp11/str11_hud1.doc accessed 22 Dec 2011) World health statistics 2011. Geneva, World Health Organization, 2011. Stiglitz J, Sen A, Fitoussi J. Report by the Commission on the measurement of economic performance and social progress; 2009.(http://www.stiglitz-sen-fi toussi.fr/en/index.htm, accessed 5 June 2011). Dubos R, Mirage of health:Utopias, progress and biological change. New York, Harper & Row,1959. McKeown T, Lowe CR, The modern rise of the population. Oxford: Blackwell, 1966. Preston S, Causes and consequences of mortality declines in less developed countries in the twentieth century, in Easterlin RA, ed. Population and economic change in developing countries. Chicago, University of Chicago Press, 1980. Marmot MG, Shipley MJ. Do socioeconomic differences in mortality persist after retirement? 25 Year follow up of civil servants from the first Whitehall study. British Medical Journal. 1996:313:1177-1180. 17. 11. McKee M, Nolte E. Does health care save lives? Avoidable mortality revisited. London, Nuffield Trust. 2004. Final Report of the Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health, Geneva, World Health Organization, 2008, p. 94. Science Museum,(http://www.sciencemuseum.org.uk/ broughttolife/people/edwinchadwick.aspx) Snow J. On the mode of communication of cholera. London: John Churchill, 1855. (http://www.ph.ucla.edu/EPI/snow/snowbook.html) Last JM. Public health and human ecology. Upper Saddle River, NJ, Prentice Hall, 1987, p. 245. Durán A, Kutzin J, Financing of public health services and programs: Time to look into the black box, in Kutzin J, Cashin C, Jakab M, eds. Implementing health financing reform; lessons from countries in transition. World Health Organization on behalf of European Observatory on Health Systems and Policies. 2010. The World Health Report 2008: Primary health care, now more than ever, Geneva, World Health Organization, 2008, pp. 2–23. 28. 18. Arah OA et al. Conceptual framework for the OECD health care quality indicators project. International Journal of Quality Health Care, 2006, 18(Suppl.)1:5–13. 29. 19. 20. Lalonde M, A new perspective on the health of the Canadians. Ottawa, Government of Canada. 1974. Duran A, et al. Understanding health systems: scope, functions and objectives. In: Mckee M, Figueras J, eds. Health systems: Health, wealth, society and wellbeing. Maidenhead, Open University Press and McGraw-Hill, 2011, pp. 19–36. 30. 24. 21. Government of India. Annual Report to the people on health. New Delhi: Ministry of Health and Family Welfare; 2010 Sep. p. 34. Report of the High Level Expert Group Report on Universal Health Coverage for India, 2011, (http://planningcommission.nic.in/reports/genrep/re p_uhc2111.pdf) Government of India. Growth data for use by Deputy Chairman Planning Commission;2011. (http://www.planningcommission.gov.in) Government of India. Report of the 13th Finance Commission of India. New Delhi: Central Statistical Organization of India;2009. Ravallion M, Chen S. Global economic prospects. Washington, DC, World Bank. 2008. Balarajan Y, Selvaraj S, Subramanian S. Health care and equity in India. Lancet, 2011;377:505-515. Report of the Steering Committee on Health for the 12th Five-Year Plan. Health Division of the Planning Commission, Feb 2012; P 4 (http://planningcommission.nic.in/aboutus/committe e/strgrp12/str_health0203.pdf accessed 21 March 2012) Business Week, 2010. (http://www.businessweek.com/news/2010-0609/uncollected-feces-highlight-urban-indiansanitation-challenge.html) Mobile telephones more common than toilets in India, UN report. United Nations News Centre, 2010, (http://www.un.org/apps/news/story.asp?NewsID=34 369&Cr=mdg&Cr1) Meningitis Vaccine Project. (http://www.meningvax.org/files/PR_MenAfriVacimpa ct_9June2011_EN_000.pdf, accessed 6 December, 2011).

12.

22.

3.

23. 13. 14.

4.

15. 16.

25. 26. 27.

5. 6.

7. 8. 9.

10.

49

31.

LaForce FM, Okwo-Bele JM. Eliminating epidemic group A meningococcal meningitis in Africa through a new vaccine. Health Affairs, 2011;30:1049–1057. Chan M.Remarks delivered by WHO Director-General addressing first meeting of BRICS health ministers, Beijing, China; 2011. (http://www.who.int/dg/speeches/2011/BRICS_20110 711/en/index.html accessed 11 July 2011) Buse K, Mays N,Walt G, Making health policy. Maidenhead, Open University Press;2005.p. 67. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva, World Health Organization, 2009. Shifting wealth: Perspectives on global development. Organisation for Economic Co-operation and Development, 2010, High Level Forum on Aid Effectiveness in Accra, Ghana, September 2008. Nagesh K, Asia-Pacific Development Cooperation Forum: Regional Workshop on Trends and Progress in Triangular and South-South Cooperation, Key Note Address, Bangkok, 21–22 October 2008. Ross A. Global health diplomacy and governance: Tools for a changing world and landscape. Presentation at theCanadian Society for International Health, Ottawa, World Health Organization, 27 October 2009. International health regulations (2005), Geneva, World Health Organization, 2008. Leichter H, A comparative approach to policy analysis. Cambridge University Press, New York, 1979. Magretta J, What management is. The Free Press, New York, chapter 4.2003. Hospital pioneers new model, Harvard Business School, 2009. (http://hbswk.hbs.edu/item/4585.html, accessed 1 June 2011). Report of the National Commission on Macroeconomics and Health, A synopsis. National Commission on Macroeconomics and Health of India, New Delhi, 2005, pp. 2–10. High Level Expert Group on Universal Health Coverage, Health financing and financial protection, Chapter 2, in High Level Expert Group on Universal Health Coverage. New Delhi, 2011, p. 3.

44.

32.

Reddy KS et al. The Lancet Group for Universal Healthcare, Towards achievement of universal health care in India by 2020: a call to action. Lancet, 2011; 377:760–768. Sen B, 2011. Securing the right to health for all in India. The Lancet. Published online, January 12, 2011, DOI: 10.1016/SO140-6736(10)62182-4. (http://www.lancet.com/journals/lancet/article/PIIS01 40-6736(10)62182-4/fulltext?_eventId=login accessed 31 March 2012) Palacios R, Das J, Sun C. India’s health insurance scheme for the poor. Evidence from the early experience of the Rashtriya Swasthya Bima Yojana. New Delhi: Centre for Policy Research; 2011. Rao K, Bhatnagar A, Berman P. India’s health workforce: size, composition and distribution. In: La Forgia J, Rao K, eds. India Health Beat. New Delhi: World Bank, New Delhi and Public Health Foundation of India;2009. Mullan F, Doctors for the world: Indian physician emigration. Health Affairs, 2006; 25:380–393. Government of India. Annual Report to the people on health. New Delhi: Ministry of Health and Family Welfare; 2010.pp. 21,29 and 34. Report of the HLEG on UHC, Health Financing and Financial Protection. New Delhi: High Level Expert Group on Universal Health Coverage 2011. Government of India, Annual Report to the people on health. New Delhi: Ministry of Health and Family Welfare;2010. p. 21. KPMG and ASSOCHAM, Emerging trends in healthcare: A journey from bench to bedside, 17 February, quoting First call Research, Apollo Hospitals Enterprise Limited Company Research Report. Q2, 2011. Government of India. Rural health statistics 2010. New Delhi; Ministry of Health and Family Welfare; 2010. Sen AK, Inequality reexamined. Oxford, Clarendon, 1992, p. 6. NHSCR Health Financing Division, Public financing of health care in India in the first decade of the new millennium. New Delhi; 2011.

56.

International News and Views Corporation website, 8th Meeting of the International Advisory Panel (IAP) for reviewing the National Rural Health Mission, New Delhi, February 2011, Health Minister of India speech, accessed 22 June 2011. Constitution of India, 1949.(http://india.gov.in/govt/documents/english/co i_part_full.pdf accessed 31 March 2012) Ma S, Sood N, A comparison of the health systems in China and India. RAND Center for Asia Pacific; 2008. WHO Regional European Office, The Tallinn Charter, EUR/08/5085699/6, Copenhagen, 2008.(http://www.aedh.eu/plugins/fckeditor/userfiles /file/Conventions%20internationales/The_Tallinn_char ter.pdf, accessed 16 December 2011). The World Health Report 2000: Improving performance. Geneva, World Health Organization, 2000. Identify challenges, inform actions, correct inequities, Report from the Ministerial Summit on Health Research, 16–20 November, Mexico City: World Health Organization. 2004, Booz Allen Hamilton Database, in The Economist, Something new under the sun: A special Report on Innovation, 2007 Oct 11. Castelli A et al., Improving the measurement of health system output growth. Health Economics, 2007; 16:1091–1107. Smith P et al., Performance measurement for health system improvement: Experiences, challenges and prospects. Cambridge, Cambridge University Press.2009. Coulter A, Jenkinson C, European patients’ views on the responsiveness of health systems and healthcare providers. European Journal of Public Health, 2005; 15:355–360. Department of Health, Guidance on the routine collection of Patient Reported Outcome Measures (PROMs). London, Department of Health. 2008. District Level Household and Facility Survey 2007-08, New Delhi. SRS Bulletin, Sample registration system. Registrar General of India, Released December 2011.

45.

57.

33. 34.

58. 59.

46.

35.

47.

60.

36.

48. 49.

61.

37.

62.

50.

38. 39. 40. 41.

63.

51.

64.

52.

65.

53.

42.

66.

54. 55.

67. 68.

43.

50

69.

United Nations Statistics Division, 2010, UN Data, WHO, UNICEF, UNFPA and World Bank, 2010. Trends in maternal mortality: 1990 to 2008, Estimates. (http://data.un.org/Data.aspx?q=maternal+mortality& d=MDG&f=seriesRowID%3a553, accessed 22 February 2011). Jha P, Laxminarayan R, Choosing health: An entitlement for all Indians. Toronto, Centre for Global Health Research. 2009. SRS Bulletin, Sample registration system, Registrar General of India, Released June 2011. National Family Health Survey (NFHS-3) India 200506, Nutrition in India. Mumbai, International Institute for Populations Sciences, 2009, pp. 6 and 15. International Institute for Population Sciences (IIPS), District Level Household and Facility Survey (DLHS-3), 2007-08: India. Mumbai: 2010, P. xxii. World Health Organization, United Nations Children’s Fund. Joint statement, 2009, WHO child growth standards and the identification of severe acute malnutrition of infants and children and World Health Organization, United Nations Children’s Fund. Joint statement, 2009, Home visits for the newborn child: a strategy to improve survival. GIVS goals. Geneva, World Health Organization. (http://www.who.int/immunization/givs/goals/en/ind ex.html) WHO Report 2011. Global Tuberculosis Control, WHO Geneva 2011. Economic impacts of inadequate sanitation in India. New Delhi: World Bank, Water and Sanitation Program;2010. (http://www.wsp.org/wsp/sites/ wsp.org/files/publications/wsp-esi-india.pdf, accessed 30 December 2010).

78.

Bloomberg, 2010, India’s toilet shortage costs more than $50 billion, World Bank study. (http://www.bloomberg.com/news/2010-12-21/indias-toilet-shortage-costs-more-than-50-billion-worldbank-study says.html, accessed 20 December 2010). Preventing chronic diseases: A vital investment. Geneva, World Health Organization, 2005. Beaglehole R, et al., for The Lancet NCD Action Group and the NCD Alliance, Priority actions for the noncommunicable disease crisis. Lancet; 2011,377:1438–1447. Position paper on external assistance received by India. New Delhi: Government of India, Ministry of Finance Department of Economic Affairs Project Monitoring Unit, 2008. (http://finmin.nic.in/ the_ministry/dept_eco_affairs/pmu/PositionPaper_Ext Assist.pdf, accessed 22 October 2011). Economic survey of India 2011-12 (http://indiabudget.nic.in/ accessed 31 March 2012) Carande-Kulis VG, Getzen TE, Thacker SB, 2007, Public goods and externalities: a research agenda for public health economics. Journal of Public Health Management Practice, 13:227–232. Figueras J, Lessof S, McKee M, Duran A and Menabde N, 2011, Health systems, health, wealth and societal wellbeing: an introduction, in McKee M,andFigueras J, eds, Health Systems: Health, Wealth, Society and wellbeing, Open University Press, McGraw Hill, New York, pp 1-19 Global Burden of Disease. http://www.dcp2.org/pubs/GBD accessed 20 February 2011 Hill K et al. Interim measures for meeting needs for health sector data: births, deaths, and causes of death. Lancet, 2007, 370:1744–1746.

87.

Wilkinson J, Bailey K, Information needs for managing for health, in Hunter DJ, ed. Managing for health. Abingdon, Routledge, 2007, pp. 99–128. The World Health Report 2010: Health systems financing: the path to universal coverage. Geneva, World Health Organization, 2010. Mazinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Services Research, 2003;38:831–865. Report of the Commission on Information and Accountability for Women’s and Children’s Health. Keeping promises, Measuring results. Geneva, World Health Organization, 2011. (http://www.everywomaneverychild.org/images/conte nt/files/accountability_commission/final_report/Final_ EN_Web.pdf) Mahal A, Karan A, Engelgau M, The economic implications of non-communicable disease for India. Washington, DC, The World Bank; Jan 2010. Report of the National Commission on Macroeconomics and Health. New Delhi: Government of India, Ministry of Health and Family Welfare;2005 WHO. Sixty-fifth World Health Assembly; Provisional agenda item 12; WHO reform: Consolidated report by the Director-General. document A65/5, 25 April 2012. Engaging for Health, WHO 11th General Program of Work, 2006-2015. A Global Health Agenda. Gleeson DH, Legge DG, O’Neill D, Evaluating health policy capacity: learning from international and Australian experience. Australia and New Zealand Health Policy, 2009, 6:3.

88.

79. 80.

70.

89.

71. 72.

81.

90.

73.

82. 83.

74.

91.

92.

84.

75.

93.

76. 77.

85.

94. 95.

86.

51

Annexure List of people consulted for CCS development Dr AC Mishra Director, National Institute of Virology (NIV), Pune Dr AK Shivakumar Adviser, UNICEF and Member, PHFI Board, New Delhi Dr AS Rathore Additional Director General, National Program for Control of Blindness, MoH&FW Dr A Sathish Kumar Associate Director, Technical, Solidarity and Action Against The HIV Infection in India (SAATHII), Chennai Mr A Vaidheesh Managing Director, Johnson & Johnson (Medical), India Dr Ala Alwan WHO Regional Director for the Eastern Mediterranean Mr Alam Singh Assistant Managing Director, Milliman Actuarial Services, India Ms Albina Shankar Director, Mobility India, Bengaluru Ms Alka Narang Head, HIV & Development Unit, United Nations Development Programme (UNDP) Dr Alok Banerjee Technical Advisor, Parivar Seva Sansthan (PSS), New Delhi Mr Aloke Gupta Consultant, Health Financing, New Delhi Dr Amarjeet Singh Minhas Professor, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh Mr Amit Mohan Prasad Joint Secretary, MoH&FW Dr Anafri Asamoah Baah WHO Deputy Director-General Ms Anagha Khot Former Technical Officer, WHO Country Office for India Mr Anders Thomsen Deputy Representative, United Nations Population Fund (UNFPA) Dr Anil Kumar Secretary, Indian Association of Epidemiology, c/o National Centre for Disease Control, Delhi Dr Anil Kumar Paleri Honorary Secretary, Indian Association of Palliative Care, Kozhikode Dr Anil Ninan Cherian Director, Community Health, Emmanuel Hospital Association (EHA), New Delhi Ms Anita Jha Senior Vice President, Sulabh International Social Service Organisation, New Delhi Dr Anjana Saxena Deputy Commissioner (Maternal Health), MoH&FW Dr Antonio Duran Chief Executive Officer, Tecnicas de Salud, Spain Mr Anuj Kumar Shrivastava National Manager, External Engagement & Advocacy, Population Services International (PSI), New Delhi Dr Anuj Sharma Technical Officer, WHO Country Office for India Ms Anuradha Gupta Additional Secretary & Mission Director National Rural Health Mission, MoH&FW Prof Arbinder Singh Kohli Professor, Department of Social Work, Jamia Millia Islamia, New Delhi Mr Arun Panda Joint Secretary, MoH&FW Dr Arunachalam Gunasekar Technical Officer, WHO Country Office for India Dr Arvind Kasturi Professor & Head, Department of Community Medicine, St. John's Medical College, Bangalore Dr Arvind Pandey Director, National Institute of Medical Statistics (NIMS), ICMR, Dept. of Health Research, MoH&FW Mr Arvinder Sachdeva Economic Adviser, MoH&FW Dr Ashok Dayalchand Director, Institute of Health Management, Pune Dr Ashok Kumar Deputy Director General & Director, Central Bureau of Health Intelligence (CBHI), MoH&FW Dr Ashok Kumar Das Professor & Med. Supdt., Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry Dr Athula Kahandaliyanage Director, Sustainable Development & Healthy Environments, WHO Regional Office for South East Asia

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Mr Atul Kumar Director's Representative, Sasakawa India Leprosy Foundation Dr Avdhesh Kumar Assistant Director General (International Health), Directorate General of Health Services (DGHS), MoH&FW Dr B Ramesh Babu Managing Director, Prevent India, Hyderabad Ms Bharti Abhijeet Tripathi Country Director's Representative, KfW Entwicklungsbank, New Delhi Ms Bhavna Mukhopadhyay Executive Director, Voluntary Health Association of India (VHAI), New Delhi Mr Biju Prabhakar Mission Director, NRHM, Government of Kerala, Thiruvananthapuram Dr Bruce Aylward WHO Assistant Director-General for Polio, Emergencies and Country Collaboration Dr CAK Yesudian Dean & Professor, School of Health System Studies, Tata Institute of Social Sciences (TISS), Mumbai Prof Charles F Gilks Country Coordinator, Joint United Nations Programme on HIV/AIDS (UNAIDS) Ms Cristina Albertin Representative, United Nations Office on Drugs and Crime (UNODC) Dr D Bachani Deputy Director General (Non-Communicable Diseases), DGHS, MoH&FW Dr DC Jain Deputy Director General (Mental Health and National Urban Health Mission, DGHS, MoH&FW Dr DC Katoch Joint Adviser (AYUSH), Dept. of AYUSH, MoH&FW Dr DCS Reddy Former Technical Officer, WHO Country Office for India

Dr DD Sharma Joint Secretary, Dept. of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH), MoH&FW Dr DK Sharma Medical Superintendent, All India Institute of Medical Sciences, New Delhi Dr DK Shukla Indian Council of Medical Research, Dept. of Health Research, MoH&FW Dr DL Ravindra Reddy Hon'ble Minister, Medical & Health, Government of Andhra Pradesh, Hyderabad Dr DR Rai Honorary Secretary General, Indian Medical Association (IMA), New Delhi Dr David Evans Director, Health Systems Financing, WHO headquarters Mr Deepak L Xavier Manager - Research, Oxfam – India, New Delhi Mr Deepak Thapa Office of Internal Oversight Services, WHO headquarters Dr Devi Shetty Chairman, Narayana Hrudayalaya Hospitals, Bengaluru Dr Dhirendra Kumar Professor and Additional Dean (Academic), Institute of Health and Management Research, Jaipur Ms Dianne Arnold Director, Administration & Finance, WHO Regional Office for South East Asia Dr Dileep Mavalankar Professor of Public Health Management, Indian Institute of Management, Ahmedabad Mr Dinesh Trivedi Hon'ble Former Union Minister of State, Health & Family Welfare, Government of India Dr Devesh Gupte Chief Medical Officer (TB), Revised National Tuberculosis Control Programme (RNTCP), DGHS, MoH&FW

Dr Farah Ahmed Research Officer (Unani), Dept. of AYUSH, MoH&FW Dr Flavia Burtreo WHO Assistant Director-General, Family, Women's & Children's Health Fr Frederick D'Souza Assistant Executive Director, Caritas India, New Delhi Ms Frederika Meijer Country Director, United Nations Population Fund (UNFPA) Dr G Gururaj Professor and Head, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru Dr GK Sharma Deputy Director General (Medical), DGHS, MoH&FW Dr GNV Brahmam Deputy Director and Head, National Institute of Nutrition (NIN), Hyderabad Mr G Narayan Director (Bureau of Planning), MoH&FW Mr GR Khetarpal Deputy Secretary, MoH&FW Dr GS Sonal Addl. Director, National Vector Borne Disease Control Programme (NVBDCP), DGHS, MoH&FW Mr G Sudhir Special Chief Secretary, Government of Andhra Pradesh, Hyderabad Dr GV Rao Country Director, Orbis International, Gurgaon Dr GVS Murthy Director, Indian Institute of Public Health, Hyderabad Dr Gayatri Mahendroo Director, National Accreditation Board for Hospitals & Healthcare Providers (NABH), New Delhi Ms Gayatri Mishra Director (Hospitals & IEC – Information, Education and Communication), MoH&FW

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Dr Geetanjali Sharma Technical Officer, International Union against TB & Lung Diseases (IUATLD), South-East Asia Office, New Delhi Mr Ghulam Nabi Azad Hon'ble Union Minister of Health & Family Welfare, Government of India Dr H Sudharsan Founder & Honorary Secretary, Karuna Trust, Bengaluru Dr Hamid Jafari Former Project Manager, National Polio Surveillance Project, WHO Country Office for India Dr Henri van den Hombergh Chief – Health, UNICEF, India Dr Indrani Gupta Professor, Health Policy Research Unit, Institute of Economic Growth, New Delhi Ms Indu Capoor Director, Centre for Health Education, Training & Nutrition Awareness (CHETNA), Ahmedabad Dr JS Thakur Former Technical Officer, WHO Country Office for India Mr Jagbir Sodhi Director, Life and Health, Swiss Re, India Dr Jagdish Prasad Director General of Health Services, MoH&FW Ms Jahnabi Goswami President, Indian Network for People Living with HIV/AIDS (INP+), Chennai Mr James Lattimer Programme Management Officer, WHO Regional Office for South East Asia Ms Jaya Bhagat Director Finance, National Rural Health Mission, MoH&FW Ms Jaya Shrivastava Social Worker, Jagori, New Delhi Mr Joaquin GonzalezAleman Chief, Social Policy, Planning, Monitoring & Evaluation, UNICEF, India and Technical Chair of the UNDAF Task Force

Mr Johnson J Edayaranmula Executive Director, Indian Alcohol Policy Alliance, New Delhi Mr Joseph Kutzin Coordinator, Health Financing Policy, WHO headquarters Ms Jyotsna Govil Honorary Additional Secretary, Indian Cancer Society, New Delhi Mr K Chandramouli Former Secretary, Health & Family Welfare, MoH&FW Mr KR Kishore Principal Secretary Health & Family Welfare, Govt. of Andhra Pradesh, Hyderabad Dr K Raghavendra Scientist G & Director, National Institute of Malaria Research, ICMR, New Delhi Prof Dr K Srinath Reddy President, Public Health Foundation of India (PHFI), New Delhi Mr K Srinidhi Section Officer (International Health), MoH&FW Dr K Srinivasan Dean & Team, St. Johns Research Academy, Bengaluru Mr Keshav Desiraju Special Secretary (Health), MoH&FW Ms Kimberly Allen Health Specialist, UNICEF Dr Krishna Rao Health Systems Specialist, PHFI, New Delhi Mr Krishnan Ramachandran Chief Operating Officer, Apollo Munich Health Insurance, India Mr LC Goyal Additional Secretary (Medicines) & Director General, CGHS (Central Government Health Services), MoH&FW Dr LS Chauhan Director, National Centre for Disease Control, New Delhi

Ms Lalitha Iyer Advisor, Norway India Partnership Initiative Secretariat, United Nations Office for Project Services (UNOPS) Dr Lembit Rago Coordinator, Quality Assurance and Safety of Medicines, WHO headquarters Mr Lokesh Gupta Manager, Rotary International, Polio-Plus, India Mr Lokesh Kumar Mission Director, NRHM, Dept. of Health & Family Welfare, Government of Andhra Pradesh, Hyderabad Mr Luke Joshua Samson Executive Director, Sanctuary for Health & Reconnection to Animals and Nature (SHARAN), New Delhi Dr MM Rao Director, National Institute of Ayurvedic Pharmaceutical Research (NIAPR), MoH&FW, Patiala Dr MS Jawahar Scientist F, Tuberculosis Research Centre, Chennai Dr Madhur Gupta Technical Officer, WHO Country Office for India Lt Gen Mandeep Singh Director General Hospital Services (Armed Forces), Office of the Director General AFMS, New Delhi Mr Manish Jain Director (Health Policy), Johnson and Johnson, India Dr Manoj K Das Director Projects, India-CLEN (Clinical Epidemiology Network) Program Evaluation Network, New Delhi Dr Margaret Chan WHO Director-General Dr Maria J Santamaria Hergueta Office of Internal Oversight Services, WHO headquarters Dr Marie-Andrée Romisch-Diouf Head, Department of Country Focus, WHO headquarters Dr Mario Raviglione Director, Stop TB department, WHO headquarters

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Mr Markus Ruck Senior Social Security Specialist, International Labour Organization (ILO) Dr Maureen Birmingham WHO Representative to Thailand Dr Maya Mascarenhas Program Officer – Health, Mysore Resettlement and Development Agency (MYRADA), Bangalore Ms Meena Sehgal Technical Expert, The Energy and Resources Institute (TERI), New Delhi Ms Meera Mishra Country Coordinator, International Fund for Agriculture Development (IFAD) Ms Michele Vanderlanh Smith Coordinator, Staff Development & Learning, WHO Regional Office for South East Asia Ms Mihoko Tamamura Country Director, World Food Programme (WFP) Prof Mohandas K Mallath Director, Centre for Cancer Epidemiology, Tata Memorial Centre, Mumbai Dr Monir Islam Director, Health Systems Development, WHO Regional Office for South East Asia Dr NC Saxena Member, National Advisory Council & Former Member, Planning Commission of India Dr NK Sethi Former Advisor (Health), Planning Commission of India Dr NS Dharmshaktu Deputy Director General, DGHS, MoH&FW Mr N Shrikanth Chief Executive Officer, Aarogyashri, Government of Andhra Pradesh, Hyderabad Dr Nata Menabde WHO Representative to India Dr Narayan Devadasan Director, Institute of Public Health, Bengaluru

Ms Neeraja Kulkarni Analyst, United Nations Development Assistance Framework (UNDAF), UNRC office Ms Neeta Vinay Director, Programme Operations, International AIDS Vaccine Initiative (IAVI) Dr PK Nag Director, National Institute of Occupational Health (NIOH), Ahmedabad Dr PK Nayak Deputy Commissioner (Training), DGHS, MoH&FW Dr PK Prabhakar Assistant Commissioner (Child Health), DGHS, MoH&FW Mr PK Pradhan Secretary, Health & Family Welfare, MoH&FW Mr P Sukumar Executive Director, Comprehensive Health Insurance Agency of Kerala, Thiruvananthapuram Dr PV Ramesh Former Principal Secretary Health & Family Welfare, Govt. of Andhra Pradesh, Hyderabad Dr Panna Choudhary Consultant Pediatrician, Indian Academy of Pediatricians (IAP), New Delhi Dr Paul Francis Technical Officer, WHO Country Office for India Dr Paul White Spatial Epidemiologist, Food and Agricultural Organization (FAO) Dr Pauline Harvey Director, Division of Global HIV/AIDS Center for Global Health, Centers for Disease Control and Prevention Dr Pawan Labhasetwar Head, Geo-environment Management Division, National Environmental Engineering Research Institute, Nagpur Dr Poonam Khetrapal Singh WHO Deputy Regional Director, Regional Office for South East Asia

Dr Po-Lin Chan Technical Officer, WHO Country Office for India Dr Prabal K Sen Professor (Economics), Xavier Labour Relations Institute (XLRI), Jamshedpur Prof Dr Prabhakaran Dorairaj Executive Director, Centre for Chronic Disease Control, New Delhi Mr Pradeep Diwan Administrative Officer, WHO Country Office for India Dr Pradeepa Guha Sr. Scientist & Head, Research Operations, Madras Diabetes Research Foundation, Chennai Dr Prathap Tharyan Associate Director, South Asian Cochrane Network & Centre, Christian Medical College & Hospital, Vellore Ms Pratibha Sivasubramanian Senior Legal Officer, HIV/AIDS Unit, Lawyers Collective, New Delhi Mr Praveen Shrivastava Former Director, Monitoring & Evaluation Division, MoH&FW Dr Priya Balu Study Director, HLEG-UHC Secretariat, PHFI, New Delhi Dr Punam Bajaj Accreditation Officer, National Accreditation Board for testing & calibration Laboratories (NABL) Dr RD Ravindran Chairman, Aravind Eye Care System, Madurai Dr RK Srivastava Former Director-General Health Services, MoH&FW Dr R Rukmani Director In-Charge, Food Security, MS Swaminathan Research Foundation, Chennai Dr Rajendra S Shukla Joint Secretary (Public Health), MoH&FW Mr Rajesh Bhatia Director (Statistics-Surveys), MoH&FW

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Dr Rakesh Kumar Indian Public Health Association (IPHA), Kolkata Mr Rajat Goyal Director, International AIDS Vaccine Initiative (IAVI) Dr Rajiv Sadanandan Principal Health Secretary, Government of Kerala, Thiruvananthapuram Mr Rajiv Shaw Project Director, Sanctuary for Health and Reconnection to Animals and Nature (SHARAN), New Delhi Prof Raman Kutty Achutha Menon Institute of Public Health, Thiruvananthapuram Dr Raman Sardana Secretary, Hospital Infection Society of India (HISI), New Delhi Mr Ramana Reddy Health Secretary, Government of Karnataka, Bengaluru Dr Ramesh Babu Manager – Direct Projects, Evangelical Fellowship of India Commission on Relief (EFICOR), New Delhi Dr Ranadeb Biswas Director Professor & Head, Preventive & Social Medicine, All India Institute of Hygiene & Public Health, Kolkata Mr Ravindra Putter Director (Control of Communicable Diseases / Vector Borne Diseases), MoH&FW Mr Reg Mills Chief Security Adviser, United Nations Department of Safety and Securities (UNDSS) Dr Reuben Samuel Technical Officer, WHO Country Office for India Dr Reuben Swamickan National Coordinator, Catholic Bishops' Conference of India Coalition for AIDS & Related Diseases, New Delhi Ms Richa Shankar Senior Manager – Program Development, Population Services International (PSI), New Delhi

Dr Richard Laing Technical Officer, Rational Drug Use, Department of Medicines Policy and Standards, WHO headquarters Mr Robert Yates Health Economist, Health Systems Financing, WHO Geneva Mr Rolf Schmachtenberg Country Director's Representative, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), India Mr S Selvakumar Mission Director, NRHM, Government of Karnataka, Bengaluru Dr S Vivek Adhish Professor, National Institute of Health & Family Welfare (NIHFW), New Delhi Dr Sajan Kumar Director, National Rural Health Mission, MoH&FW Dr Sakthivel Selvaraj Health Economist, PHFI, New Delhi Dr Samir Chaudhuri Director, Child in Need Institute (CINI), Kolkata Dr Samlee Plianbangchang WHO Regional Director for South East Asia Dr Sampath Krishnan Technical Officer, WHO Country Office for India Dr Sangay Thinley Director, Family Health and Research, WHO Regional Office for South East Asia Mr Sanjay Prasad Director, International Health, MoH&FW Dr Sanjeev Upadhyay Project Officer, Health, UNICEF, Hyderabad Prof Satish Kumar Dean, School of Public Health, SRM University, Kanchipuram Ms Shakuntala Gamlin Joint Secretary, MoH&FW

Dr Sharat Chauhan Private Secretary to Hon'ble Minister of Health & Family Welfare Dr Shashi Khare Consultant & Head of Microbiology, National Centre for Disease Control, Delhi Ms Shivangi Rai Senior Legal Officer, HIV/AIDS Unit, Lawyers Collective, New Delhi Ms Sonam Yangchen Rana Head, United Nations Office for Project Services (UNOPS) Dr Srikant Tripathy Scientist F, National AIDS Research Institute (NARI), Pune Dr Stephen Moses Country Project Director & Team, Karnataka Health Promotion Trust, Bengaluru Dr Stephen Sosler Deputy project manager, National Polio Surveillance Project, WHO Country Office for India Dr Sujeet Singh Additional Director (Public Health), Dept. of Parasitic Diseases, National Centre for Disease Control, Delhi Dr Sujit Bhattacharya Senior Scientist, National Institute of Science, Technology & Development Studies, New Delhi Dr Sulabha Parasuraman Professor, International Institute for Population Sciences, Mumbai Dr Suman Kanungo Scientist B, National Institute of Cholera and Enteric Diseases (NICED), Kolkata Dr Sumit Majumdar Fellow, Institute for Human Development, New Delhi Dr Sunil Bahl Deputy project manager, National Polio Surveillance Project, WHO Country Office for India Dr Sunita Abraham Deputy Medical Coordinator, Medecins Sans Frontieres – Operational Centre Brussels (MSF-OCB), New Delhi

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Ms Sunita Godara Founder & Director, Health Fitness Trust, New Delhi Dr Suresh K Mohammed Director (Reproductive and Child Health), MoH&FW Dr Surinder Singh Drug Controller General of India Mr T Gangadharan Programme Assistant, WHO Country Office for India Dr T Sundararaman Executive Director, National Health Resource Centre, New Delhi Dr Tannaz J Birdi Deputy Director, The Foundation for Medical Research, Mumbai Mr Tarun Vij Country Program Leader – India, PATH (Program for Appropriate Technology in Health), New Delhi

Ms Ute Schumann Attache, Development Cooperation, European Commission Dr Vijay Kumar Aruldas General Secretary, Christian Medical Association of India (CMAI), New Delhi Dr Vijay Kumar Edward Director, Health & HIV/AIDS Initiatives, World Vision, Chennai Dr Vimlesh Purohit Technical Officer, WHO Country Office for India Dr Vineet Munish Gill Technical Officer, WHO Country Office for India Dr Vinod K Paul Professor, Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi

Ms Virginia Swezy Deputy project manager, National Polio Surveillance Project, WHO Country Office for India Dr Vishwa Mohan Katoch Secretary, Department of Health Research & Director General – Indian Council of Medical Research, MoH&FW Dr Mrs Y Srilakshmi Commissioner, Health & Family Welfare, Government of Andhra Pradesh, Hyderabad Dr Yujwal Raj Programme Officer (Surveillance), National AIDS Control Organization, Dept. of AIDS Control, MoH&FW

The staff of the WHO Country Office for India contributed in many different ways to the development of this strategy

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