WHO Country Cooperation Strategy 2006-2011 India

WHO
Country Cooperation Strategy

2006-2011
India
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November 2006
ii WHO Country Cooperation Strategy 2006-2011

Contents
Preface .............................................................................................................. v
Message from the Regional Director ................................................................. vi
Acknowledgements ......................................................................................... vii
Abbreviations ................................................................................................. viii
Executive Summary ........................................................................................... x
1. Introduction ............................................................................................... 1
2. Health and Development Challenges .......................................................... 3

Burden of Diseases ................................................................................................ 4
Health Sector ......................................................................................................... 9
Health in the Future ............................................................................................. 14
3. Development Assistance and Partnership .................................................. 17

Overall Trends in Assistance ................................................................................. 17
Sector-Wide Approaches ...................................................................................... 18
Donor Coordination ............................................................................................. 19
4. WHO Global and Regional Policy Directions ............................................ 21

Global Challenges in Health ................................................................................. 21
Global Health Agenda .......................................................................................... 22
Regional Policy Framework .................................................................................. 23
5. WHO Current Policy Framework and Cooperation ................................... 24

Policy Framework and Strategic Directions ........................................................... 24
Current Country Programme and Organization .................................................... 25
Financing the Technical Assistance Activities ......................................................... 26
Decentralisation and State Level Responses .......................................................... 26
India iii
6. Strategic Agenda: Priorities for Cooperation 2006–2011 ........................... 33
Reduce the Burden of Communicable Diseases ................................................... 33
Promote Maternal and Child Health ..................................................................... 35
Scale up Prevention and Control of NCDs ............................................................ 36
Strengthen Health Systems Development ............................................................. 38
7. Implementing the Strategic Agenda........................................................... 45

Responsibility of the Country Team ...................................................................... 45
Support from the Regional Office (SEARO) ........................................................... 47
Support from WHO Headquarters ....................................................................... 47
Risks facing the CCS ............................................................................................. 47
Annexes: Tables, Organizational Charts, CCS Matrix ....................................... 49
iv WHO Country Cooperation Strategy 2006-2011

Preface
The purpose of this country cooperation strategy document (CCS) is to reflect the medium-
term vision of the World Health Organization for its cooperation with India and to elucidate
the strategic framework for such cooperation. The CCS represents a balance between
evidence-based country priorities with Organization-wide strategic orientations and
priorities in order to contribute optimally to national health development. It is the result
of extensive cumulative consultations, both internal and external.
While India is being propelled to a position of international eminence, it faces the
challenge of dealing effectively with unfinished agendas as well as with new emerging
challenges, including those related to globalization. While WHO India Country Office
(WCO) will maintain its technical collaboration in various important areas of work in
the health sector, it intends to scale up its efforts aiming at four strategic objectives,
major components of which are central to the pursuit of the Millennium Development
Goals. The four strategic objectives address the following: (a) communicable and
emerging diseases; (b) maternal and child health; (c) non-communicable diseases and
the formidable rising burden of preventable premature morbidity and mortality; and
(e) health systems development within the national and global environment. Since
India has a lot to offer in contributing to the management and shaping of the policy
environment for health, both inward and outward-looking perspectives have been
taken into consideration.
The CCS elucidates the areas of technical support, including cross-cutting priorities,
such as promoting equity. WCO will support ethical and evidence-based policy and
advocacy positions; monitor health information and database for appropriate decisions;
and support operational studies with special reference to gender, children and vulnerable
populations. The private sector accounts for more than 70 percent of health expenditures.
WCO will support the forging of public-private partnerships and will increase its
outsourcing with centres of excellence, collaborating centres and professional associations.
WCO aims to interact more closely with the states, in coordination with the Union
Ministry, and in support of ongoing decentralization efforts of the Government of India.
WCO will pursue its CCS guided by the mandate, functions and governance of
WHO, and will fulfil its technical support role with passion to serve health development
efforts in India.
Dr S. J. Habayeb
WHO Representative to India
India v
Message from the Regional Director
The collaborative activities of the World Health Organization in the South-East Asia
Region are geared to improve the health status of the population in the Member States.
Though WHO has been contributing as a key catalyst to India’s health policies and
programmes, there is a need for a thorough analysis and discussion of how WHO can
further improve its contribution to health development in India.
The South-East Asia Region was the first Region to promote Country Cooperation
Strategies (CCS) as a process to identify how best WHO can support health development
in our Member States. Over the past six years, all 11 Member States in the Region have
prepared their CCS. In the case of India, though there has never been a formally
published CCS, work has progressed on the basis of a series of drafts. Therefore, the
publication of this CCS for India is a key milestone in the work of WHO in the country.
An analysis of the current health situation and the likely scenario over the next six
years have formed the basis for the priorities outlined in this CCS. We appreciate the
inputs and suggestions from the Ministry of Health, whose official have been the major
collaborators in developing this document. In addition, consultations were held with
various WHO Collaborating Centres in India, which provided valuable suggestions.
Finally, the advice and recommendations of our health development partners in India
were extremely valuable in guiding the development of the CCS. The consultative
process here will help to ensure that WHO’s inputs provide the maximum support to
health development efforts in the country.
To help achieve the objectives of this CCS, we recognize the importance of a
strong WHO Country Office to work closely with key counterparts, keeping in mind
local conditions. Nonetheless, the entire Organization is committed to the work of the
CCS. The staff of the WHO Regional Office will use this CCS in determining regional
priorities and in supporting collaborative activities in India. Furthermore, we will also
seek assistance, as necessary, from WHO headquarters to assist these efforts.
I would like to thank all those who have contributed to developing this Country
Cooperation Strategy, which has the full commitment of the Regional Office. We will
provide our maximum support towards achieving its objectives over the next six years.
Our joint efforts, I am confident, will help in achieving the maximum health benefits for
the people of India.
Samlee Plianbangchang, M.D., Dr.P.H.

01 September 2006 Regional Director
vi WHO Country Cooperation Strategy 2006-2011

Acknowledgements
We acknowledge with sincere thanks the significant inputs of WHO staff at the levels
of the country, the region, and headquarters. We are deeply indebted to the officials of
the Union Government and State Governments; UN, multilateral and bilateral agencies;
collaborating centres; professional associations; civil society; and academic institutions
for their views and valuable advice.
India vii
Abbreviations
AIDS Auto Immuno Deficiency Syndrome
ANM Auxilliary Nurse Midwife
ARI Acute Respiratory Infection
ART Anti Retroviral Treatment
ASHA Accredited Social Health Activist
AYUSH Ayurveda, Yoga, Unani, Siddha and Homeopathy
CCS Country Cooperation Strategy
CHC Community Health Centre
CVD Cardio Vascular Disease
DFID Department For International Development
DLHS District Level Household Survey
DOTS Directly Observed Treatment Short-course
FCH Family and Community Health
FCTC Framework Convention on Tobacco Control
FETP Field Epidemiology Training Programmes
GATS General Agreement on Trade and Services
GAVI Global Alliance for Vaccine Initiative
GDP Gross Domestic Product
GFATM Global Fund for AIDS, TB and Malaria
GOI Government of India
GPW General Programme of Work
GPPPs Global Public-Private Partnerships
GNP Gross National Product
HIV Human Immuno Deficiency Virus
HRH Human Resources for Health
ICC Inter-agency Coordination Committees
IDSP Integrated Disease Surveillance Programme
IEC Information Education Communication
IHR International Health Regulations
IPHS Indian Public Health Standards
IMR Infant Mortality Rate
IMCI Integrated Management of Childhood Illnesses
IMNCI Integrated Management of Newborn and Childhood Illnesses
INC Indian Nursing Council
IT Information Technology
viii WHO Country Cooperation Strategy 2006-2011

LEP Leprosy Elimination
LF Lymphatic Filariasis
MCI Medical Council of India
MDG Millennium Development Goals
MOHFW Ministry of Health and Family Welfare
MPS Making Pregnancy Safer
NACO National AIDS Control Organization
NMH Noncommunicable Diseases and Mental Health
NPSP National Polio Surveillance Programme
NCMH National Commission on Macroeconomics and Health
NCD Noncommunicable Diseases
NCRB National Crime Records Bureau
NFHS National Family Health Survey
NGO Non Governmental Organization
NRHM National Rural Health Mission
ODA Overseas Development Assistance
PHC Primary Health Centre
PLWHA People Living With HIV and AIDS
RBM Roll Back Malaria
RCH Reproductive and Child Health
RGI Registrar General of India
RNTCP Revised National Tuberculosis Control Programme
SARS Severe Acute Respiratory Syndrome
SDE Sustainable Development and Healthy Environment
SEAR South-East Asia Region
SEARO Regional Office for South-East Asia
STEPS Stepwise surveillance of risk factors
SWAp Sector Wide Approach
TRIPS Trade Related Intellectual Property Rights
TFI Tobacco Free Initiative
UIP Universal Immunization Programme
UN United Nations
UNCT United Nations Country Team
UNICEF United Nations Children Fund
UNFPA United Nations Population Fund
UNDAF UN Development Assistance Framework
WCO WHO Country Office
WHO World Health Organization
WR WHO Representative
WTO World Trade Organization
India ix
Executive Summary
This Country Cooperation Strategy (CCS) of WHO’s Country Office (WCO) in India
for the period 2006-2011 forms the basis for undertaking technical assistance in
collaboration with the Government of India, the states, development partners and civil
society. The CCS is WHO’s tool for alignment with national health priorities and for
harmonization with other development partners.
While India is being propelled to a position of international eminence, it faces the

challenge of dealing effectively with unfinished agendas, strengthening of public health
systems, and critical issues of human resources, management, health information and
health sector governance on one hand; and new emerging challenges such as
globalization and a formidable rising burden of preventable premature morbidity and
mortality due to noncommunicable diseases on the other. Since India has much to
offer in contributing to the management and shaping of the global policy environment
for health, both inward and outward-looking perspectives have been taken into
consideration in framing the CCS.
The spectrum of human resource issues in India is vast and complex and is not
limited to health practitioners, but extends to managers, administrative and support
staff and allied health personnel. There are issues of quantity, quality, relevance,
motivation, utilization and distribution. Shortages of human resources in the health
sector are widespread with disproportionate concentration in urban areas. WCO will
work with GOI and its partners in dealing with major issues, notably developing systems
for relevant quality education and training of health workers; supporting them;
enhancing their effectiveness; and tackling health imbalances and inequities.
WCO aligns its strategy with the priorities and evolving needs of the country. It
intends to scale up its efforts in four strategic objectives discussed below and would
adjust its country presence accordingly. Major components within these strategic
objectives are central to the pursuit of the Millennium Development Goals. Concurrently,
WCO will maintain its technical collaboration in numerous other important areas of
work, such as those related to health action in crisis, environmental health, water and
sanitation, but without the enhancement of related country presence capacities. WCO
will support the regional public health initiative while promoting multi-disciplinary
and multi-sectoral approaches. WCO will support healthy public policy. Besides, WCO
would contribute to facilitating the work of the Commission on Social Determinants in
India. WCO will take into consideration paramount cross-cutting priorities, notably
poverty, equity, access, gender, quality assurance and capacity building. The primary
x WHO Country Cooperation Strategy 2006-2011

partnership of WCO is with the Union Ministry of Health and Family Welfare, including
day-to-day liaison with the International Health Division. Also, WCO works closely
with the state governments, centres of excellence, collaborating centres, professional
associations and civil society. Given the fact that 85% of WHO’s regular budget is
allocated to activities at the state level, WCO aims to interact more closely with the
states in support of ongoing decentralization efforts (see Figure 7, page 29).
WCO will implement the CCS, which would be guided by the mandate, functions
and governance of WHO, with a focus on and technical collaboration in critical areas
such as capacity building, advocacy and policy development. Promoting equity and
addressing disparities in the health sector are cross-cutting priorities. WCO will support
ethical and evidence-based policy and advocacy positions; monitor health information
and database for appropriate decisions; and support operational studies with special
reference to gender, children and vulnerable populations. Also, WCO will support
national public health programmes and the National Rural Health Mission (NRHM)
where the government’s inbuilt focus is on rural, underserved areas.
The four main strategic objectives of the CCS are the following:
Reduce the burden of communicable and emerging diseases by enhancing

surveillance and response capacities.
The main thrust areas will be strengthening surveillance and information systems,
and responding to emerging and re-emerging diseases. Towards this, WCO would
continue to extend technical support to strengthen integrated disease surveillance for
epidemic-prone diseases, laboratory diagnostic capabilities, and enhance national and
local capabilities to cope and deal effectively with the threats of newly emerging diseases
like pandemic influenza. WCO will assist in the strengthening of epidemic intelligence
and preparedness and building core capacities for implementation of the revised
International Health Regulations (2005). Through its network of field consultants, WCO
would support better management of diseases of public health importance, such as
tuberculosis and multi-drug resistant TB, polio, communicable childhood diseases,
and leprosy, thus accelerating disease control/ elimination/ eradication efforts. It would
also support improved control strategies for diseases like malaria, JE, dengue, leprosy,
filariasis, kala-azar, HIV/AIDS, including HIV-TB. WCO will provide support for the
whole cycle of disease prevention and control, including technical guidelines, standards
and norms, policies, strategy development, programme planning, monitoring and
evaluation. Support would also be provided for evaluation and introduction of newer
vaccines by the government.
Promote maternal and child health by improving the continuum of care and
strengthening immunization.
WCO will continue to focus attention on provision of skilled birth attendance,
integrated management of newborn & childhood illnesses, adolescent health,
India xi
population stabilization, universal immunization, and nutrition. Through its technical
inputs, WCO will support the National Rural Health Mission and the Reproductive
and Child Health Programme. These programmes provide convergence and an
integrated framework for accelerating the decline in maternal, newborn and child
mortality and morbidity as well as providing accessible and affordable health care to
rural areas and weaker sections of the population, particularly through the promotion
of community level workers and activists, convergence of programmes, and forging
government partnership with other sectors.
Scale up prevention and control of noncommunicable diseases (NCDs) through

support for developing new policies and programmes.
WHO estimates that an additional two percent annual reduction in chronic disease
death rates in India over the next ten years would prevent six million deaths. This
would result in an economic gain equivalent to US$15 billion for the country. Since
the pace of the epidemiological and demographic transition varies between states,
WCO will assist in developing policies and intervention strategies which are flexible so
as to accommodate the differing needs and resources of various states.
Technical support will be provided for NCD risk factor surveillance to make it
sustainable, especially in data management and translation of data into appropriate
policies. Multi-sectoral interventions have maximum effectiveness in primary prevention,
hence WCO plans to advocate and facilitate their development. The WHO Global
Strategy for Diet, Physical Activity & Health provides feasible options for addressing
important risk factors. WCO will continue to provide technical support for the effective
implementation of the provisions of the Framework Convention for the Tobacco Cotrol
(FCTC) and the enforcement of the National Tobacco Control Legislation, including
the strengthening of the National Tobacco Control Cell, establishment of a National
Tobacco Control Programme, and setting up of a Multi-sectoral Coordination Committee
for tobacco control and NCD prevention. Capacity in the area of tobacco control will
be built at the state level through training of relevant state authorities, law enforcement
and, health professionals, and civil society organizations. Technical assistance will also
be provided for implementation of a sustained anti tobacco public awareness campaign
and for expanding the tobacco cessation services to reach the masses through existing
health systems.
WCO will support the development, scaling up and implementation of the national
programmes for diabetes, cardio-vascular disease, stroke and cancer. WCO will support
health system strengthening, including capacity building for addressing NCDs. Health
promotion across the life span will be adopted with emphasis on providing a supportive
environment to promote healthy behaviour. WCO will encourage horizontal integration
across all NCD prevention and control programmes.
xii WHO Country Cooperation Strategy 2006-2011

Strengthen health systems development within the national and global
environment, with a focus on human resources.
WCO will provide technical support to India in its pursuit for improving access, quality
and accountability of the health systems in consonance with the World Health Assembly
Resolution adopted in May 2005 on sustainable health financing, universal coverage,
and social health insurance. Escalating health care costs constitute an important cause
for indebtedness among the poor and middle-income groups, and lead to the
impoverishment of 2.2 percent of the population annually. WCO will assist in increasing
risk pooling, including health insurance and innovative financing initiatives. At
present, the public sector health investment in India is only 0.9 percent of its GDP, one
of the lowest in the world. WCO will promote the evidence base and updated
information on health expenditures through the National Health Accounts System.
Concurrently, WCO will assist in assessing options to facilitate efficiency and decision-
making in channelling funds to priority areas. WCO will support the recommendations
of the National Commission on Macroeconomics and Health.
The private health sector accounts for more than 70 percent of health expenditures.
WCO will support the forging of public-private partnerships, and would assist GOI and
the states to develop mechanisms for regulation which would not discourage needed
investment in the health sector, but which would be rigorous enough to protect the
interests of both patients and providers. In this context, WCO would assist in developing
objectively verifiable service standards, protocols, technology assessments and
accreditation systems which would promote consumer choice and improve
accountability of service providers.
It is self-evident that a coherent policy framework for service provision is needed.

WCO will support the broad spectrum of inputs required for the relentless demands
made for strengthening public health systems with a focus on human resources, health
workforce strategies, evolving needs of sectoral skills and relevant management issues.
WCO will support the creation of health information and database for evidence-
based decisions, including documentation, sharing of lessons and best practices
at various levels: among states, nationally, and at the global level.
In the context of the global policy environment for health, WCO will provide
technical support to India in managing the impact of spill-ins and spill-overs particularly
in international trade agreements and health-related undertakings. WCO will further
strengthen the WTO cell within the Ministry of Health, assist in promoting networks,
technical alliances, information sharing and mobilizing expertise to advise on options
and policy instruments related to international agendas.
Risks
There are three main risks facing the CCS and its strategic objectives: (a) The
effectiveness of WHO technical support and the anticipated impact may remain limited.
India xiii
Ensuring the highest possible standards of quality and credibility of the technical advice
provided would alleviate this risk, which is closely related to the country’s own
implementation capacities. The biennium workplans are intimately linked to the
country’s institutions with the inevitability of mixed outcomes in a vast subcontinent
with large disparities existing among the states. In order to further mitigate related
risks, greater attention would be provided to upstream planning, quality at entry,
thorough assessment of institution-specific implementation capacity, and closer
monitoring. (b) Competing demands and priorities, both within WHO and the country,
as well as unforeseen and unfunded demands, may dilute the focus on priority objectives
and overstretch the capacity of WCO. This would be addressed through advocacy,
persuasion, striving for widespread endorsement and seeking valuable technical support
from SEARO and HQ. (c) Finally, potential resource constraints may hamper the
strengthening of WHO’s country presence and its contributions. Increased outsourcing
to centres of excellence, partnerships, sustained resource mobilization efforts by WCO,
SEARO and HQ, and effective utilization of internal WHO capacities at all levels would
alleviate this risk.
xiv WHO Country Cooperation Strategy 2006-2011

Introduction 1
Given the size of India’s population, its diversity and the burden of disease, the challenge
of attaining good health for the people of India is a daunting one. Since independence,
due to focused action by the Government and civil society, India has made substantial
progress in controlling communicable diseases and reducing child mortality.
The World Health Organization (WHO) has been a partner with the Government
of India (GOI), academic institutions, other United Nations (UN) agencies, development
partners and civil society organizations to realize these goals. This has been managed
through the WHO Country Office, India (WCO); the Regional Office for South-East
Asia (SEARO), New Delhi; and the Head-Quarters of WHO in Geneva. Most of WHO’s
interaction with India is channelled through the WCO in the major clusters of
Communicable Diseases and Disease Surveillance, Family and Community Health,
Noncommunicable Diseases and Mental Health, Health Systems Development, and
Immunization and Vaccine Development. Furthermore, WCO works extensively with
the Government, bilateral agencies and stakeholders in special programmes, which
are Routine Immunization, Disease Surveillance, National Polio Surveillance, Revised
National Tuberculosis Control, Commission on Macroeconomics and Health, HIV/
AIDS Technical Assistance, Leprosy Elimination, Roll Back Malaria, Tobacco Free
Initiative, Lymphatic Filariasis, Knowledge Management and Health Internetwork. The
Country Cooperation Strategy (CCS) endeavours to merge WHO’s global and regional
agendas with India’s national priorities. This second generation CCS was developed by
the WCO team through cumulative consultations with major partners.
The CCS is WHO’s tool for alignment with national health strategies and priorities
as well as for harmonization with other UN agencies working in health and its
development partners. It clarifies the roles and functions of WHO in supporting the
National Health Plan and other national health and development frameworks such as
the poverty reduction strategies, the Sector-wide Approach (SWAp), the National Rural
Health Mission (NRHM) and others. The CCS is an organization-wide reference for
country work, which guides planning, budgeting and resource allocation. It is based
on the health situation in the country, government health policies and plans, work of
key health partners, and on WHO’s own experience in the country as well as its
comparative advantage. The document will become a framework for WHO. It would
assist in mobilizing human and financial resources for strengthening WHO support to
India in order to contribute optimally to national health development.
India 1
The CCS would provide a framework for WCO to build upon its existing country
presence and responsiveness through technical support, skilled staff and strengthened
capacities, establishment of WHO Collaborating Centres and enhanced partnerships.
Besides providing support and advocating the conventional priorities of communicable
diseases and maternal and child health, WCO will step up its role in dealing with
emerging issues of globalisation in reference to trade related agreements and their
impact on health. It would support the reduction of non-communicable disease risk
factors and advocate efficient resource allocations, decentralisation, and public-private
partnerships. Furthermore, it would also promote knowledge management; improve
information systems and infrastructure, and support capacity building. The CCS takes
into consideration the human rights based approach to development and the gender
sensitivity adopted by the UN system. The CCS will contribute to the broader efforts
seeking the achievement of the Millennium Development Goals (MDGs).
This document will form the framework for designing WCO’s collaboration with
the Government of India, civil society and development partners for the period 2006
to 2011 and would contribute to the achievement of good health by the people of
India.
2 WHO Country Cooperation Strategy 2006-2011

Health and Development Challenges 2
With over one billion people, India is the second most populous country in the world,
and accommodates 17 percent of the world’s population in 2.4 percent of the world’s
area. The demographic profile of India’s population is changing and the proportion of
the elderly is increasing significantly. The female-to-male sex ratio in the age group of
0-6 years has decreased from 945 in 1991 to alarming proportion of 927 as of 20011.
One of the major challenges to the health sector is to respond to these demographic
phenomena. Since India is home to diverse socio-cultural groups, the health needs of
the people also vary from region to region.
Census data of 2001 has estimated that 64.8 percent of Indians are literate. The
female and male literacy rates were 53.7 and 75.9 percent, respectively (Annexure –
Table 1). In India, 73.2 percent of rural and 90 percent of urban households have
access to safe drinking water2. As of 2002, 37.7 percent of the population has access to
improved sanitation facilities3.
Since independence, India has pursued a policy of planned economic development

led by the public sector. However, influenced by the transitions in the international
arena, India adopted structural adjustment policies in the 1990s. This emphasized
liberalization of controls on economic activities and greater integration with the global
economy. Consequently, the Indian economy grew at a fast rate though concerns were
raised regarding issues of equity. During the Ninth Five-Year Plan (1997-2002), the
state aimed at improving the living conditions of the poor and increasing employment
opportunities. India is currently implementing the Tenth Five-Year Plan (2002-2007)
that stresses human development by promoting quality of life and access to basic
social services.
India is the 10th largest economy in the world4. The Gross National Product (GNP)
at current prices per capita stood at around Rs. 25,781 (US$ 572) in 2004-5.5 The
Gross Domestic Product (GDP) per capita annual growth rate has been 3.3 percent for
1975–20036 with the current annual growth rate being eight percent. The economy of
1
Census of India 1991 & 2001, Provisional Population Totals: India, Registrar General of India, Ministry of Home
Affairs, GOI.
2
Economic Survey 2005-2006, Ministry of Economic Affairs. Government of India.
3
India – Water Supply & Sanitation, The World Bank, January 2006.
4
World Bank Website http://siteresources.worldbank.org/datastatistics/Resources/GDP.
5
Quick Estimates of National Income, Consumption Expenditure, Saving and Capital Formation 2003-2004, Central
Statistical Organization, Ministry of Statistics & Programme Implementation, GOI.
6
World Development Indicators, 2005, World Bank 2005.
India 3
India has grown steadily in the last few decades and the percentage of poor persons in
the population came down from 47 percent in 1973-74 to 26 percent in the year
20007. Due to focus on improvement in public health and living conditions, a substantial
enhancement in the health status of the people has been witnessed in the last 50 years
(Annexure – Table 2). India’s public health sector, however, has not grown in proportion
to its economic growth (Annexure – Table 3).
To understand the challenges faced by the health sector there is a need to review
issues in the country, such as health sector governance and organization, burden of
disease, occurrence of natural disasters, condition of women and children; as well as
anticipation of issues in the future.
Burden of Diseases
The disease burden for India for all age groups by major causes of death are presented
in Figure 1.
Figure 1: Estimated percentage of deaths (all ages)

in 2005 by cause
Source: http://www.who.int/chp/chronic_disease_report/en/
Women and Children: The past decade witnessed improvement in the health of
women and children in India. With regard to reproductive health, the Government
policies and programmes have shifted from a target-oriented family planning approach
to a broader comprehensive strategy. Pregnancies and deliveries are safer in India
today than they were in the years immediately following independence. Yet the number
of avoidable deaths of mothers and infants in India is still high.
Tenth Five-Year Plan Document, Planning Commission, GOI

7

India’s annual population growth rate is 1.74 percent and contributes to about 20
percent of births worldwide. New technologies have been accepted into every day
sexual and reproductive life, such as new methods of contraception and termination
of pregnancy.
The median age of marriage has been rising in India. Yet 61 percent of all women
(69 percent rural and 41 percent of urban) are married before the age of 16. The
median age at first pregnancy is 19.2 years. Each year in India, roughly 30 million
women experience pregnancy and 27 million have live births8. About 65 percent of
pregnant women receive antenatal care. Of the total pregnant women, only 34 percent
had institutional deliveries and 42 percent received professional medical care. The
maternal mortality ratio, an important indicator of maternal health in India, is estimated
to be 301/100,000 live births9. With an estimated 136,000 deaths, India has the highest
burden of maternal mortality in the world. Forty seven percent of maternal deaths in
rural India are attributed to anaemia and haemorrhage, causes that are very much
avoidable. Abortions are the third leading single cause of maternal mortality, being
responsible for 12 percent of deaths. Regional disparities in maternal and neonatal
mortality are wide. Delays in accessing specialised maternal care happen at all levels,
starting from the decision to seek medical care to reaching a health facility and receiving
timely and quality emergency obstetrics care.
More than one-third of women in India (41 percent rural and 23 percent urban)
are undernourished. Among children, 47 percent are undernourished and 74 percent
are anaemic. Among adolescents, 18 percent are malnourished. Due to lack of
awareness and socio-cultural taboos, only 16 percent of the infants are breastfed soon
after birth and 37 percent on the first day. Only 55 percent of children are exclusively
breastfed up to four months.10
With over 2.4 million under-five annual deaths, India accounts for a quarter of the
global child mortality. The major killers of children are acute respiratory infections,
dehydration due to diarrhoea, measles with accompanying malnutrition, neonatal
diseases and in some areas malaria. The high prevalence of malnutrition contributes to
over 50 percent of child deaths. In recent years, the impressive rate of decline of the
infant mortality rate seen in the decade of the 1980s has slowed down considerably.
There are wide inter and intra state variations in infant and child mortality. A significant
proportion of child deaths (over 40 percent of under-five mortality and 64 percent of
infant mortality) take place in the neonatal period. Apart from infections, other causes
like asphyxia, hypothermia and pre-maturity are responsible.
About one-third of the newborns have a birth-weight less than 2,500 grams (low
birth-weight). A significant proportion of mortality occurs in low birth-weight babies.
8
Health Information of India, DGHS, MOHFW, 2003.
9
Maternal Mortality in India: 1997 – 2003, Trends, Causes and Risk Factors, Registrar General of India, Ministry of
Home Affairs, 2006
10
National Family Health Survey (NFHS-II), 1998-99, IIPS, Mumbai and ORC Macro, 2000.
India 5
Only 47.6 percent of children in the age group of 12–23 months receive all the
vaccinations recommended under the Universal Immunisation Programme (UIP). The
percentage varies from 14 percent in some states to 92 percent in Tamil Nadu. The
three major illnesses that contribute to mortality among children are fever (30 percent),
acute respiratory infection (ARI) (19 percent), and diarrhoea (19 percent).11
There are 225 million adolescents comprising nearly one-fifth (22 percent) of India’s
total population12. Of the total adolescent population, 12 percent belong to the 10-14
years age group and nearly ten percent are in the 15-19 years age group. More than
half of the illiterate currently married females have been married below the legal age
of marriage. Nearly 27 percent of the 1.5 million girls married under the age of 15
years are already mothers13. More than 70 percent girls in the age group of 10-19 years
suffer from severe or moderate anemia14. Nearly 27 percent of married female
adolescents reported unmet needs for contraception15. Most sexually active adolescents
are in their late adolescence. Over 35 percent of all reported HIV infections in India
occur among young people in the age group of 15-24 years, indicating that young
people are highly vulnerable.
The ratio of girls to boys in the age group 0-6 years in India is becoming increasingly
skewed in favour of boys. The child-sex ratio, calculated as the number of girls per
1000 boys in the 0-6 years age group, reported by the 1991 census was 945 girls per
1000 boys. The ratio declined to 927 girls per 1000 boys during the 2001 census.
Cultural, social and economic factors predicate son preference. Neglect of female
children has resulted in substantially higher death rates in girls, which impacts the
child-sex ratio. Pre-natal sex determination is a prelude to abortion of female foetuses.
Communicable Diseases: In India, the communicable disease burden remains

significant. Every year, there are over 1.8 million new cases of tuberculosis and about
370,000 deaths resulting from the disease. Over one and a half million people contract
malaria each year. It is estimated that over 550 million people live in areas endemic to
filariasis are exposed to the risk. As many as 90,000 persons are undergoing treatment
for leprosy. More than five million people were living with HIV in India in 2005 with a
mixed distribution in the country and with higher prevalence in most southern states
and the north-eastern region. The total all India prevalence remains under one percent.
With regard to polio, major strides have been achieved in the country. The number of
affected districts has been reduced from 159 in 2002 to 35 in 2005. The disease is
localized now to two geographical areas in Uttar Pradesh and Bihar. Up to the end of
2005, 66 Acute Flaccid Paralysis (AFP) polio cases were reported in the country, where
polio surveillance is managed by WHO (Annexure – Table 4). Dengue outbreaks have
been reported from all over the country and 378 million persons are at risk from
11
12
Census of India 2001, Provisional Population Totals: India, Registrar General of India, MOH, GOI.
13
Census of India 2001, Provisional Population Totals: India, Registrar General of India, MOH, GOI.
14
District Level Reproductive Health Household Survey, IIPS, 2004.
15

Japanese encephalitis. The resurgence of kala-azar has emphasized the need for
improved case detection, complete treatment, vector surveillance and control. The
global pandemic of SARS and avian flu has also highlighted the threat of new emerging
and re-emerging diseases and the need for regional and global collaboration.
Noncommunicable Diseases: Noncommunicable Diseases (NCDs), especially

Cardiovascular Diseases (CVD), diabetes mellitus, cancer, stroke and chronic lung
diseases have emerged as major public health problems in India, due to an ageing
population and environmentally driven changes in behaviour (Annexure – Table 5).
Premature morbidity and mortality in the most productive phase of life is posing a
serious challenge to Indian society and its economy. It is estimated that in 2005, NCDs
accounted for 5,466,000 (53 percent) of all deaths (10,362,000) in India. The WCO-
ICMR study on NCDs in India has estimated that the burden of Diabetes Mellitus,
Ischeamic Heart Disease and Stroke are 37.8 million, 22.4 million and 0.93 million
respectively. In the age group 30-59 years, NCDs account for a substantial proportion
of mortality as presented in the pie diagram (Figure 2).
Figure 2: Estimated proportion by cause of death

in 30-59 year age group in India-2005
Source: Preventing Chronic Diseases: A vital investment. WHO; Geneva, 2005
The National Cancer Registry Programme estimates that there will be more than
800,000 new cancer cases every year. Tobacco related cancers predominate with cervix
and breast cancers being the leading cancers in women. It has been estimated that in
2005, India lost US$9 billion in national income from premature deaths due to heart
diseases, stroke and diabetes alone. It is projected that over the next 10 years deaths
from NCDs will increase by 18 percent and an estimated 60 million deaths will occur
in this period. India stands to lose US$237 billion over the next decade due to premature
NCD deaths16.
Preventing Chronic Diseases: A vital investment. WHO; Geneva, 2005.

16
India 7
Contrary to popular belief that NCDs are a problem of rich urban males, the poor
have been found to be more vulnerable to chronic diseases because of material
deprivation, psychosocial stress, higher levels of risk behaviour, unhealthy living
conditions and limited access to good quality health care. Once a disease is established,
poor people are more likely to suffer adverse consequences than wealthier people.
This is especially true of women, as they are often more vulnerable to the effects of
social inequality and poverty, and less able to access resources including health care.
Chronic diseases inflict an enormous direct economic burden on the poor, and push
many people and their families into poverty.
The causes of NCDs are universally known and are the same in India as in wealthy
countries. The common causal risk factors are tobacco and alcohol use, unhealthy diet
and physical inactivity. Changes in the population prevalence levels of these factors
can therefore predict future disease burden. The WHO STEPwise approach to
surveillance of NCD risk factors (STEPS) which has been carried out in 5 sites in India
by WCO and ICMR has revealed that only 50 percent of the population aged 15-64
years consumed vegetables daily and 60-80 percent led a sedentary lifestyle. At least
80 percent of premature heart disease, stroke, Type 2 Diabetes and 40 percent of
cancer can be prevented through avoidance of tobacco products and the adoption of
healthy diet and regular physical activity.
Tobacco is the foremost cause of preventable death and disease in the world today.
In India, 47 percent of men and 14 percent of women use tobacco in some form,
resulting in nearly one million premature deaths annually. The total economic cost of
the three major diseases caused by tobacco use in India was Rs. 308 billion (US$7.2
billion) in 2002-0317.
India has played a leading role in the development of the Framework Convention
on Tobacco Control (FCTC) and was one of the first countries to ratify the convention.
This lays the foundation for implementing a range of comprehensive policies.
Mental health and injuries: Apart from chronic NCDs, mental disorders are also
a common form of disability. It is estimated that in the year 2001, 67 million people
with major mental disorders, 20.5 million with common mental disorders and 10.2
million with alcohol dependence problems required services18.
Road traffic injuries every year result in death of more than 100,000 persons, two
million hospitalizations, 7.7 million minor injuries and an estimated economic loss of
55,000 crores of Indian Rupees or nearly 3% of GDP every year.19
Natural Disasters: India is prone to natural disasters such as cyclones, floods and
earthquakes. While floods in the Indo-Gangetic and Brahmaputra plains are annual
17
Report on Tobacco Control in India. Ministry of Health and Family Welfare, Government of India; New Delhi, 2004.
18
Burden of Disease in India, Background Papers, National Commission on Macroeconomics and Health, GOI, 2005.
19
Gururaj G. Road Traffice Injury Prevention in India, NIMHANS Publication No. 56, Bangalore, India 2006.

features, around eight percent of land is vulnerable to cyclone. Around 54 percent of
land is vulnerable to earthquakes, out of which 12 percent areas fall under severe
earthquake zone. Natural disasters in India cause heavy losses - in terms of human life,
mental stress as well as financial loss of property and personal belongings. The average
annual impact from natural hazards in India has been estimated at: mortality – 3,600;
crop area affected – 1.42 million hectares; and property (houses) – 2.36 million dwellings.
The average damage to crops, houses and public utilities from floods during the
period 1935–95 was estimated at Rs. 9,720 million (equivalent to US$216 million)
every year, while the maximum damage was Rs. 46,300 million (equivalent to US$1,030
million) in 1998. In the Orissa super cyclone of 1999, over 10,000 people were killed.
In the Gujarat earthquake of 2001, at least 16,000 people died. The damage has been
estimated at US$4.6 billion. The number of people injured and treated due to the
Gujarat earthquake had been reported to be around 170,000. In the recent tsunami of
2004, which struck the Andaman and Nicobar Islands and the states of Andhra Pradesh,
Kerala, Tamil Nadu and Union Territory of Pondicherry, the estimated death toll was
about 10,000 with around 5,000 persons reported as missing.
Health Sector
Organization: India is a Democratic Republic consisting of 28 States and 7 Union
Territories (directly administered by the Central Government). According to the
Constitution of India, state governments have jurisdiction over public health, sanitation
and hospitals while the Central Government is responsible for medical education.
State and Central Governments have concurrent jurisdiction over food and drug
administration, and family welfare. Even though health is the responsibility of the states,
under the Constitution, the Central Government has been financing the national disease
control, family welfare and reproductive and child health programmes.
India is home to many indigenous systems of medicine, including Ayurveda and

Siddha. Homeopathy, Unani, Naturopathy and various other systems are also widely
practiced. The Government of India and many state governments have taken steps to
formalize and initiate standardization of these systems. These include evolving
pharmacopoeia standards for drugs, upgrading educational standards in indigenous
medicine and in homeopathy colleges in the country and encouraging research on
applicability of these systems to specific diseases. In terms of its organization, the health
sector primarily comprises of the public and private sectors.
Public sector: Government health care services are organised at different levels,
generally corresponding to the organisational structure of the administrative machinery.
The Primary Health Centre (PHC) is the core of the rural health services infrastructure
in India. It has both outpatient and outreach services. These outreach services are
provided by sub-centres and staffed by multipurpose health workers. Inpatient and
more specialised services are provided at the community health centres (CHC). Each
India 9
sub-centre is expected to cater to a population of 5,000; each PHC to a population of
30,000; and a CHC serves a population of 100,000. District hospitals and medical
college teaching hospitals along with specialized institutions provide referral care.
Private sector: India has a large and unregulated private sector, both in formal and
informal sectors. In the formal sector, the private sector accounts for 68 percent of the
hospitals and 64 percent of the beds.20 There are large numbers of informal health
care providers, most of them being less than fully qualified service providers. Adequate
information is not available on the number of informal health care providers. Expenditure
data reveals that more than three-fourths of outpatient curative care services are accessed
through private health care providers.21
Private non-profit sector: The private non-profit sector includes health services
provided by voluntary organizations, charitable institutions, missions, and charitable
trusts among others. Till the mid-1960s, voluntary effort in heath care was confined to
hospital-based care. Later, perhaps inspired by the Chinese experience of a motivated
health cadre delivering care at the community level, models of community health
programmes and decentralized curative services began to receive attention. The National
Health Policy 1983 and 2002 called for expanding the coverage of services through
the non-profit sector to improve access and availability.
The efforts of the non profit organizations in the health sector cover a wide range
of activities and can be classified broadly into:
• Organizations implementing government programmes;
• Organizations running specialized community health integrated programmes
for basic health care delivery and community development;
• Organizations sponsoring health care for blindness control, polio eradication,
management of blood banks, and support during disasters/epidemics;
• Organizations/individuals, health researchers and activists who undertake
applied research in health service delivery, health economics, health education
and play an advocacy role.
According to a rough estimate, more than 7000 voluntary organizations in the
country work in these areas of health care22. Although a systematic documentation of
NGO contribution is lacking, it is obvious that NGOs and non profit institutions could
improve access, quality and equity of services either through direct provision or through
advocacy and other action. The potential of non profit institutions in helping to reach
public health goals have not been fully realized for several reasons, beginning with
their limited size and spatial distribution. The challenge is to find strategies that will
20
Better Health Systems for India’s Poor : Findings, Analysis, and Options, David H. Peters, Abdo S. Yazbeck, et al,
World Bank, 2002.
21
Morbidity and Treatment of Ailments, NSSO 52nd Round, (2001), Dept of Statistics, GOI, New Delhi.
22
India Health Report, Mishra R L, Chatterjee R, Rao S, OUP, 2005.

facilitate a far more substantial participation in the health sector, particularly in poor
performing states and remote areas, and to ensure systems that will keep participation
accountable and transparent.
In India, new public health challenges have emerged from demographic and
epidemiological transitions, environmental degradation, emerging infectious diseases
and anti-microbial resistance. India’s public health infrastructure, however, is unable
to respond to these new challenges as the delivery system is not functioning optimally
and as it is not based on the current needs of the community. The Government in its
National Health Policy 200223, advocated the need for ensuring adequate availability
of personnel with specialization in public health. There is an urgent need to strengthen
public health education in India. The main challenges for public health institutions in
India is to reflect social responsiveness and accountability, develop quality assurance
systems, keep pace with advancing technology and develop an interface with the
community and health care delivery system.
Financing: India spends 4.6 percent of its GDP on health, of this 0.9 percent is
public expenditure and 3.5 percent is private expenditure (Annexure – Table 6 and
Figure 4). The National Health Accounts are estimated within the boundaries shown in
Figure 3. Of the private expenditure, the major financing sources that provide funds
Figure 3: Scope of National Health Accounts with overall

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

23
India 11
Figure 4: Total Health Expenditure in India 2001-02
are households, which account for 72 percent of the total health expenditure incurred
in India. This includes out of pocket payments borne for treating illness of family
members and insurance premium contributed by individuals for enrolling themselves
in various social voluntary health insurance schemes. The remaining sources which
contribute substantially for provision of health care services in the country are State
Governments (13 percent), Central Government (six percent) and the public and private
firms which provide medical benefits to employees and their dependents (five percent).
External support from bilateral and multilateral agencies accounts for two percent of
health expenditure in India (Annexure – Table 7 and Figure 5).
Figure 5: Health Expenditure by Financing Sources – 2001-02

Data reveals that 70 percent of the financial resources are flowing to health care
providers in the for-profit private sector. Another 23 percent of resources are being
spent on public providers. The Ministry of Health and Family Welfare (MOHFW) spends
a sizeable share of its resources on Public Health and RCH programmes, medical
education and research and on specialty hospitals, while the State Departments of
Health and Family Welfare spend substantial share of resources on hospitals (33 percent)
and dispensaries/ PHC/ Sub Centres (17 percent).
Workforce: Human Resources for Health (HRH) are one of the most important
part of a country’s health system. The health system is dependent upon an efficient,
motivated and vibrant health workforce. In the World Health Report 2006, the health
workforce is defined as all people engaged in actions whose primary intent is to enhance
health. There are two types of health workers – health service providers and health
management and support workers.
In India, the HRH can vary from traditional healers to modern health professionals.
The modern sector comprises of trained and qualified doctors of allopathic system, a
range of paramedical professionals and allied personnel such as policy makers, health
planners and managers, researchers and health technologists. The other sector is replete
with the richness of India’s traditional healing systems. Here one finds professionally
trained and qualified practitioners of Ayurvedic, Unani, Siddha and Homeopathy
(AYUSH). There are also less than fully qualified providers and traditional and household
birth attendants amongst others.
Till 2004, 633,108 doctors were registered with various State Medical Councils in
India. This gives a doctor to population ratio of one doctor for every 1676 population
(or 59.7 physicians for 100,000 population). A different picture emerges when one
accounts for AYUSH practitioners. There were 492,550 qualified AYUSH practitioners
registered with the respective councils by the end of 2003. As of March 2003, there
were 839,862 nurses registered with the State Nursing Councils. The nurse to population
ratio as of 2004 is 1:100-200. The nurse to doctor ratio is about 1.3:1 compared to a
ratio of 3:1 in most developed countries. There were also 53,775 dentists registered
with the dental council24. There is inadequate data on those working in the management
or support capacity.
Though medical education in India has been around for a long time, it has not fully
kept pace with the changing disease patterns and advancement of science and technology.
The goal of medical education should be to produce health personnel capable of managing
common problems in realistic health care settings. WHO is supporting medical education
by providing fellowships and also technical assistance to encourage linkages with public
health programmes. The health manpower requirement needs to be forecasted and
appropriate strategies need to be identified. The trend of increasing personnel for high
Financing and Delivery of Health Care Services in India, Background Papers, National Commission on
24
Macroeconomics & Health, GOI, New Delhi, 2005.
India 13
end care has to be reversed, keeping staff free for a broad range of services. Training for
paramedical personnel would require additional emphasis.
Notwithstanding the progress, some of the critical issues that need to be addressed
include availability of HRH, the numerical and distributional imbalances, inadequate
training and capacity building, inefficient skill mix of health personnel, personnel
management issues, lack of support and poor working environment, lack of opportunities
for personnel development and other factors leading to inefficient delivery of care.
Information on HRH is fragmented and difficult to obtain. Hence, there is also a need
to pay attention to HRH policy, planning and management issues in a consistent and
planned manner.
Health in the Future

India is striving to ensure the health of its people by focusing on improving the health
infrastructure, reducing inequity and regional imbalances (especially for the health of
women and children), and alleviating the problems of malnutrition and by forging
partnerships between the various stakeholders. India, under the Tenth Five-Year Plan,
has focused on the following:
• Reorganisation and restructuring of the existing health infrastructure at primary,
secondary and tertiary levels so that they attain the capacity to render health
care services to the population with appropriate referral linkages with each
other;
• Appropriate delegation of power to Panchayat Raj institutions (local self
government) to ensure local accountability of public health care providers;
• Integration of national disease control programmes including supplies
monitoring, Information, Education and Communication (IEC), training and
administrative arrangements;
• Development of an appropriate two-way referral system using information
technology and exploration of alternative systems of health care financing; and
• Clear definition of the role of the various stakeholders – the government, private
and voluntary sectors.
India’s National Health Policy 2002, takes into account new diseases and changes
in medical science since the previous health policy of 1983. It aims to reduce inequities
and regional imbalances in the health sector and to strengthen the primary health care
network all over the country. The achievement of an acceptable, affordable and
sustainable standard of good health and the presence of an appropriate health system
to reduce the burden of diseases are the main thrust of the new health policy.
India’s National Population Policy 2000, places the achievement of demographic

goals in the larger social context. This Policy provides a framework for advancing goals

and prioritising strategies during the next decade for meeting the reproductive and
child health needs of the people of India, and for achieving net replacement levels of
fertility by 2010. It is based on the need to simultaneously address issues of child
survival, maternal health and contraception, while increasing outreach and coverage
of a comprehensive package of reproductive and child heath services by the government,
industry and the non-government sector, all working in partnership with each other.
India’s National Nutrition Policy 1993, advocates for a comprehensive inter-sectoral

strategy for alleviating the different problems of malnutrition and its related deficiencies
and diseases so as to achieve an optimal state of nutrition for all sections of the society,
but with a special priority for women, mothers and children who are vulnerable or “at-
risk”.
National Rural Health Mission: The National Rural Health Mission (NRHM) has
been formed with a view to increasing the expenditure in the health sector from a
current 0.9 percent of GDP to two percent over the next five years and to focus on
Primary Health Care. The Mission has been made operational from April 2005
throughout the country with special focus on 18 states which include: eight Empowered
Action Group States (Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh,
Uttaranchal, Orissa and Rajasthan); eight North-Eastern States (Assam, Arunachal
Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura); Himachal
Pradesh and Jammu & Kashmir.
The main aim of NRHM is to provide accessible, affordable, accountable, effective

and reliable primary health care, especially, to the poor and vulnerable sections of’ the
population. It aims at bridging the gap in rural health care through the creation of a
cadre of Accredited Social Health Activists (ASHAs), improved hospital care measured
through Indian Public Health Standards (IPHS), decentralization of’ programmes to
the district level to improve intra and inter-sectoral convergence, and effective utilization
of resources. Furthermore, the NRHM aims to provide an overarching umbrella to the
existing programmes of Health and Family Welfare, including RCH-II, malaria, blindness,
iodine deficiency, filaria, kala-azar, TB, leprosy and Integrated Disease Surveillance.
The NRHM also addresses issues which are basic determinants of good health
such as safe drinking water, sanitation and hygiene, nutrition and other social
determinants. It promotes greater convergence among related social sector departments
namely, AYUSH, Women & Child Development, Sanitation, Elementary Education,
Panchayati Raj and Rural Development. It seeks to build greater ownership of the
programme among the community through involvement of NGOs and other
stakeholders at National, State, District and Sub-District levels to achieve the goals of
National Population Policy 2000 and National Health Policy 2002.
Globalization issues: Globalization and trade liberalization can affect health directly
and indirectly. Therefore, it is important to take into account the global environment
when developing national and domestic strategies. Countries also need to take into
India 15
account global, regional, and cross-border spill-ins and spill-overs when developing
health policies. Governments have to manage both opportunities and risks that result
due to globalization.
In order to protect the population, MOHFW has to engage externally to mitigate

some of those risks. It requires cooperation with other concerned ministries.
There is a need to consider international policy developments and treaties when

drafting national policy. For instance, the policy changes brought about by the World
Trade Organization (WTO) regime have limited the choices available to nations to
control trade practices that influence the health of their people. Safeguards are available
in different policy instruments and trade agreements. But unless the implications of the
different clauses and sub-clauses of the agreements are understood, public health officials
will not be able to use these safeguard provisions.
The new trade regime, especially the measures related to intellectual property
rights and sanitary and phytosanitary measures, will have a significant impact on health
systems, more since the product patent regime has become obligatory for India since
2005. The impact can be both negative and positive. India would be able to make
effective use of the safeguards that have been inbuilt into the agreement if appropriate
steps are taken.
Trade Related Intellectual Property rights (TRIPS) attempts to balance two

complementary public health goals – making drugs affordable and providing incentives
for developing new drugs. As Indian pharmaceutical companies move up the value
chain, both objectives become relevant for the country. India will also need to explore
how the provisions of TRIPS can be used to enhance public health in developing countries
and work out how India can contribute to it. As the product patent regime has become
applicable, it is necessary to form strategic alliances to have access to the expanding
knowledge base in pharmaceuticals. Indian pharmaceuticals also need support on availing
the exemptions available for purposes of research and clinical trials.
Increasing trade in health services challenges the capability of MOHFW to assess

accurately and respond rapidly to the risks and opportunities for population health.
The definition of trade in services in the Agreement hinges on four types of transactions
or “modes of supply”. These are the cross border supply of services (e.g. telemedicine,
eHealth), consumption of services abroad (patients who travel abroad for medical
treatment), commercial presence (establishment of health facilities in the country
concerned) and presence of natural persons (foreign doctors or nurses who seek to
practice in the countries). Informed and evidence-based approaches are needed to
manage any future effort to liberalize health-related services so as to ensure greater
access to affordable, better quality and effective services, leading to increased choice
for consumers and greater equity in health outcomes.

Development Assistance
and Partnership 3
Development assistance, including loans and grants, contribute a small percentage of

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

The pattern of development assistance to India in the health sector has undergone
major changes. These include changes in the share contributed by different funding
agencies, the method of financial inflow and the nature of programmes being funded.
Until the late 1980s, the major source of external funding in the health sector was the
US government (USAID) followed by UNICEF, the World Bank and WHO (Annexure -
Table 8). But after 1995, the World Bank has emerged as the major external funding
agency for India in addition to the United Kingdom’s Department for International
Development (DFID).
The programmes funded by external assistance have also been changing, reflecting
the evolving needs and shifts in the priority of both donors and the Government of
India. In the initial phase, assistance has focused on malaria control, polio, and family
planning. Currently, the emphasis has shifted to HIV/AIDS, tuberculosis and health
systems development. Reproductive and child health also remains a priority area.
Recent years have also seen the emergence of funding agencies that are not
governments or part of the UN system. Important among these are the Global Alliance
for Vaccine Initiative (GAVI), Global Fund for AIDS, TB and Malaria (GFATM) and the
Bill and Melinda Gates Foundation, in addition to existing agencies such as the Aga
Khan Foundation. These agencies could be expected to further influence the
development assistance scenario in the medium term.
Global Alliance for Vaccines and Immunization: GAVI was formed to harness
the strengths and experiences of multiple partners in immunization. It is an alliance
Human Development Report, Globalization with a Human Face, 1999, UNDP

25
India 17
between the private and public sector, committed to the mission of saving children’s
lives and protecting people’s health through the widespread use of vaccines. GAVI has
been supporting the Hepatitis B pilot project of the Government of India in 14 cities
and 33 districts in Phase I of the project (2002-2006). The funds amounting to US$ 40
million are mainly for supporting procurement of Hepatitis B vaccines and Auto Disable
syringes. WHO will continue to provide technical support to the expansion programme
of Hepatitis B.
Global Fund to Fight AIDS, Tuberculosis and Malaria: GFATM is an independent
public-private partnership, working to increase funding to fight these three diseases in
countries with the greatest need and contribute to poverty reduction as part of the
Millennium Development Goals. The Fund complements existing programmes and
activities.
WHO serves as a member of the Country Coordination Mechanism (CCM) and
provides ongoing technical support to proposal development and monitoring. WHO
also supported the establishment of a secretariat to facilitate the functioning of the CCM.
Bill and Melinda Gates Foundation: This Foundation is guided by the firm belief
that all lives, no matter where they are lived, have equal value. Their global health
mission is to help ensure that lifesaving advances in health are created and shared with
those who need them most. To date, the foundation has committed more than US$6
billion in global health grants to organizations worldwide. The strategy focuses on two
primary areas:
(1) Accelerating access: funding to ensure that existing health interventions and
technologies are made widely available in the developing world; and
(2) Supporting research: funding for basic and clinical research to develop new
vaccines, drugs, and other health tools to fight diseases that cause the greatest
illness and death in developing countries.
In India, around US$200 million were provided to establish Avahan, a national
HIV prevention initiative. WHO will continue to provide technical support for HIV
prevention to Avahan initiative.
The Clinton Foundation HIV/AIDS Initiative India would also be provided with
technical assistance in the area of paediatric HIV/AIDS.
Sector-Wide Approaches
Sector Wide Approaches (SWAps), which came into being in the mid 1990s, are an
important element of the international effort to harmonize and align development
assistance around national policies and strategies. From the beginning, WHO has made
a globally significant contribution to the basic ideas underpinning SWAps at the
conceptual level. For several years WHO provided the secretariat to the Inter-Agency
Group on Sector-wide approaches and Development Cooperation.

In India, the Reproductive and Child Health (RCH) Phase II was developed using
a Sector-wide programme approach. The funding mechanism is flexible and supports
sector policies. While part A of the programme will be funded entirely by the
Government of India, part B will be through a pooled fund from various donor agencies.
Part A will cover basic maintenance of the programme, including salaries of the core
programme staff in the states. It will be released through consolidated state funds and
grant-in aid to some central institutions and will cover the procurement of contraceptives
for social marketing. Part B of the programme will enable the states to design and
implement the RCH programme to suit their specific needs. It will also finance approved
state plans through a flexible pool of funds. This will enhance the quality and scope of
the RCH programme by supporting innovations such as Public Private Partnerships,
demand side financing, and expansion of the programme to the urban poor and other
vulnerable groups.
Starting 2005-06, DFID and the World Bank have agreed to support RCH-II through
pooled financing for five years. The commitment of the World Bank is US$350 million,
DFID’s is British Pound Sterling 265 million and US$25 million by UNFPA for the
common pool. Other development partners such as USAID will also support the
programme through their ongoing projects. The non pooling partners, notably WHO,
will be supporting the initiative under the overall framework of RCH-II programme.
Donor Coordination
Since the share of donor assistance is a small portion of the total health expenditure,
donor and development partner coordination is vital for enhancing the productivity of
development aid. Given the fragmented manner in which funds are channelled and
lack of effective coordination of aid, it often results in duplications and overlap of
activities, distortion of aid through conflicting approaches and schemes, and gaps among
identified need that are not addressed by donors.
Donor and development coordination helps to integrate technical collaboration
and financial aid in line with national priorities. This may be carried out through
mechanisms like Inter-Agency Coordination Committees (ICCs) as is being currently
used in poliomyelitis eradication. ICCs have been recently expanded to include all
immunizations. It can also be carried out through Consultative Group meetings, at
present held on an annual basis for all major donors. The following collaborations
currently exist in the health field:
Expanded Theme Group on HIV/AIDS: The UN Theme Group on HIV/AIDS in
India is an expanded Theme Group, which is co-chaired by the UN Resident
Representative and Government of India. It includes the National AIDS Control
Organization (NACO), bilateral donor agencies and the Indian Network for People
living with HIV/AIDS. It works closely with the government, nongovernmental
organizations, community networks, people living with HIV and AIDS (PLWHA), the
private sector and other partners in generating a well-coordinated and enhanced
response to HIV and AIDS.
India 19
CHARCA: In addition, a joint UN project called ‘CHARCA’ (Coordinated HIV/
AIDS Response through Capacity-building and Awareness), is being implemented in
six districts in partnership with NACO, State AIDS Control Societies, district
administration and services, NGOs, community-based organizations and women’s
groups. Being a member of this group, WCO is actively participating and providing
technical assistance in the implementation of CHARCA.
National Polio Inter-Agency Coordinating Committee: In India, many
organizations take part in immunization activities, each contributing in different ways
with vastly different resources. Much can be gained by coordinating the efforts of
these organizations to avoid duplication and maximize the use of limited resources.
Therefore, in 1995, a national ICC was created to coordinate immunization activities
in general and polio eradication in particular.
The ICC in India has been an effective mechanism in the Intensified Polio Eradication
efforts. It is supported by the Government of India, development partners and UN agencies.
The ICC is coordinated by WHO and has representation from UNICEF, World Bank,
agencies such as USAID, DFID and NGOs such as ROTARY International. WHO
orchestrates polio surveillance and supplemental immunization activities, convenes an
international expert group which advises on strategies, coordinates funding requirements
and mobilization of international support. UNICEF coordinates vaccine procurement
and supply, and provides technical advice on cold chain renewal and maintenance.
ROTARY mobilizes opinion leaders and communities through its extensive nationwide
network. All the partners are committed to supporting the effort until polio is eradicated.
United Nations Development Assistance Framework (UNDAF): In line with the
UN Reforms, the UNDAF for 2008-2012 is currently under preparation. The UNDAF
will be based on the 11th Five Year Plan priority areas highlighted by the Planning
Commission of the Government of India. The UN Country Team (UNCT) as a group
has agreed on the overarching goal of the next UNDAF, i.e. “promoting social, economic,
and political inclusion” with the objective of “capacity development at local level to
improve the quality of life for the most disadvantaged women and girls”.
With the above objective in mind, the India UNDAF will be framed around the
MDGs as these resonate well with the approach to the 11th Five Year Plan. The UNCT has
agreed to set up eight Thematic Working Groups (TWG) to analyze the achievements and
gaps around the MDGs. These are: 1) poverty and hunger, 2) education, 3) gender, 4)
maternal and child health, 5) HIV (and malaria and TB), 6) environment, 7) disaster and 8)
decentralization. The TWGs will perform a situational analysis, including the current
scenario, achievements, gaps, major players and a mapping of who does what in each of
these thematic areas. They will also identify the results at the output level based on the
comparative advantage of the UN agencies working in that sector. WCO is participating
actively in MCH and disaster groups and chairing the work on malaria and TB.

WHO Global and Regional
Policy Directions 4
Global Challenges in Health

The General Programme of Work (GPW) is one of the highest policy documents of
WHO. The 11th GPW (2006-2015) sets out the direction for international public health
for the period of 2006 through 2015. The document notes that there have been
substantial improvements in health over the last 50 years. However, significant challenges
remain, as described in the following four gaps:
Gaps in social justice: Clearly, poverty is a key factor that impedes access to
quality health services. In some countries the life expectancy of the poor is 20 years
lower than other privileged members of society. Poor health and poverty form a vicious
cycle. Other factors that reduce access to services are discrimination by ethnicity or
gender, and women’s health which is often not adequately addressed.
Gaps in responsibility: Health problems today are no longer merely the

responsibility of those working on health, but require positive action by those outside
the health sector. International conflicts and national crises often lead to the disruption
of social services which include health care. Globalization and decisions made regarding
international trade have a direct impact on health, especially in pharmaceuticals and
the movement of health professionals. In many countries Ministries of Health often do
not have the capacity to adequately influence important causes of ill-health outside
the health sector.
Gaps in implementation: Very often the technology to implement cost-effective

interventions to improve health is available. But these are not implemented because of
shortage of funds, lack of human resources or the absence of an effective health system.
Available resources may often be allocated to high-cost curative services and favor
urban areas, leaving inexpensive and effective interventions in rural and remote areas
neglected.
Gaps in knowledge: Global advances in science and technology have improved

the effectiveness and efficiency of medical services and the prevention and treatment
of diseases. However, information about these advances is often not available in many
countries. Also, the lack of information about health conditions, and existing rigidities
in many countries have in turn made it difficult to formulate and manage effective
health policies and interventions. Even operational research for those most in need of
health services is generally not done, thereby reducing the efficiency of key programmes.
India 21
Global Health Agenda
In order to reduce these gaps over the coming ten years, the 11th GPW outlines a
global health agenda consisting of seven priority areas:
• Investing in health to reduce poverty
• Building individual and global health security
• Promoting universal coverage, gender equality, and health-related human rights
• Tackling the determinants of health
• Strengthening health systems and equitable access
• Harnessing knowledge, science and technology
• Strengthening governance, leadership and accountability
The global health agenda is meant for everyone working in the field of health
development. WHO will contribute to this agenda by concentrating on its core functions,
which have been built on the comparative advantages of the Organization. In
accordance with the global health agenda and WHO’s core functions, the Organization
has set the following priorities:
(1) Providing support to countries in moving to universal coverage with effective
public health interventions
(2) Strengthening global health security
(3) Generating and sustaining action across sectors to modify the behavioural,
social, economic and environmental determinants of health
(4) Increasing institutional capacities to deliver core public health functions under
the strengthened governance of ministries of health
(5) Strengthening WHO’s leadership at global and regional levels and supporting
the work of governments at the country level.
WHO’s Core Functions

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

WHO will pursue these priorities through its Medium-term Strategic Plan (2008-
2013) and the biennium budget of the Organization. The Director General of WHO
has clearly put a major focus on the work of the Organization at the country level. The
Regional Offices and Headquarters have been directed to emphasize support for country
work and implement these priorities in Member States, especially where the health
needs are greatest.
Regional Policy Framework

The South-East Asia Region (SEAR) has the second highest population among the six
WHO regions and has the greatest burden of disease. While there has been great
economic development in this region in recent years, the problems of poverty and
poor health remain significant. Many countries have faced health emergencies in the
last decade and the threat of disease outbreaks is ever-present. At the same time, non-
communicable diseases have become an increasingly important cause of morbidity
and mortality in SEAR countries. Therefore, the global policy framework of WHO is
appropriate for the countries of the region, with special attention given on strengthening
the capacity of Member States to support public health interventions.
The South-East Asia Region has always placed a strong emphasis on its work in
Member States. Of the total budget provided to the region, 75 percent is allocated for
countries, the highest of any WHO region. The WHO Regional Director has recently
increased the delegation of authority to country offices to enable them to plan and
implement programmes with a higher degree of independence and to be more
accountable for their work. At the same time, he has emphasized that the Regional
Office staff should give the highest priority to support the work in these countries.
India 23
WHO Current Policy Framework
5 and Cooperation
Policy Framework and Strategic Directions

Article One of the WHO Constitution spells out the mission of WHO: “the attainment
by all peoples of the highest possible level of health”.
Mission Statement of the WCO

Build a strong, proactive, technically excellent and dedicated WHO country team
within a global network; provide leadership in health; and collaborate with
governments, civil society and other partners.
Provide technical expertise in public health through partnerships with the Ministry
of Health and Family Welfare; state and local governments; development and
other partners; and civil society; with focus on:
• Promoting health as a fundamental human right, and working to place health as an
integral part of sustainable socio-economic development for the people of India.·
Proactive and committed leadership in public health, with emphasis on:
– setting norms and standards;
– reducing the burden of excessive morbidity, disability and mortality;
– reducing the risk factors associated with major causes of disease;
– developing health systems to ensure equity in health
– promoting an effective health dimension to development policies in social,
economic and environmental areas.
• Mobilizing, developing and optimally utilizing human and financial resources
and promoting a conducive working environment
In India, WHO has built up a reputation for strong technical skills, neutrality and
commitment to India’s health needs. These have been demonstrated time and again
through successful collaboration between the GOI and WHO. Some of the recent
examples of WHO’s technical support being acknowledged by GOI and other UN
partners include:

• Assistance provided for a quick response to emergencies caused by epidemics
(SARS, avian flu) and natural disasters (Gujarat earthquake, Orissa cyclone and
Tsunami disaster);
• Recognition of WHO’s technical collaboration in programmes such as the
Revised National Tuberculosis Control Programme (RNTCP), polio eradication,
guinea worm eradication, National Cancer Control Programme (NCCP) and
scaling up Anti-Retroviral Treatment (ART) for people living with HIV/AIDS;
• Increased credibility and trust on WHO displayed by the government and the
civil society, such as when India faced the threat of SARS and avian flu;
• Recognition of WHO’s role in the Tobacco Free Initiative; and
• Mobilization of additional resources and better utilization of resources.
Some of the factors that made such increasing recognition possible were:
• The ability of WCO in India to draw on global and regional experience;
• The technical expertise provided by a strong and proactive team at WCO;
• Increasing evidence-based decision-making;
• WHO’s image of neutrality giving WCO an ability to mediate between conflicting
interests; and
• Acceptability of WHO by the government as a valuable partner and
consequently having a close working relationship with it.
Current Country Programme and Organization

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

• Communicable Diseases and Surveillance (CDS)
• Family and Community Health (FCH)
• Noncommunicable Diseases and Mental Health (NMH)
• Health Systems Development (HSD)
• Sustainable Development and Healthy Environment (SDE)
• Immunization and Vaccine Development(IVD)
• Health Action in Crisis (HAC)
India 25
The WHO’s Country Office in India (WCO-India), has the role of providing technical
collaboration and coordinating with GOI, to move forward the national health
development efforts within the corporate policy framework of WHO.
The WCO is organized around Core Programme Clusters. Each of the core clusters
has programmes on diseases (e.g. communicable and non-communicable diseases),
or focuses on a specific area in the health sector (e.g. child and adolescent health,
health system, etc.). The WCO also has special programmes that focus on specific
initiatives, such as the National Polio Surveillance (NPSP), Routine Immunization,
Disease Surveillance, Revised National Tuberculosis Control (RNTCP), Emergency and
Humanitarian Action, National Commission on Macroeconomics and Health (NCMH),
HIV/AIDS Technical Assistance, Leprosy Elimination (LEP), Roll Back Malaria (RBM),
Tobacco Free Initiative (TFI), Lymphatic Filariasis (LF) and Knowledge Management.
The WCO has technical personnel in the above areas; with some of them being stationed
in the field, to provide leadership and to assist in collaboration with other stakeholders.
The nodal ministry for WCO is the Ministry of Health and Family Welfare of the
Government of India. However, all ministries of the GOI, UN agencies, various
development partners and health-related NGOs access technical assistance from WCO.
WCO also partners with designated WHO Collaborating Centres (Map 1) and national
institutes of excellence in the country, mainly for research and capacity building. As
appropriate, WCO may support activities of development partners and selected NGOs
in identified priority areas of the health sector.
Financing the Technical Assistance Activities

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

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

Map 1: WHO Collaborating Centres
India 27
Figure 6: India Workplan Budget Summary 2006-2007
Source: WHO Activity Management System Database, 2006
and material support sensitive to their specific needs. The Indian health system has
sought to address this reality while assigning powers to different tiers of government.
Many functions of public health importance have been assigned to units of local
administration in rural and urban areas. New strategies in RCH II programme and the
National Rural Health Mission have further strengthened decentralized programming
at village and district levels.
Since WCO works in areas of public health importance in India, there has always
been a strong involvement at state and district levels. WCO has worked at generating
information, building capacities, providing technical guidance to states, and at times
directly carrying out operations at state level and below, even in the absence of formal
structures at sub-national levels. The following schematic diagram in Figure 7 represents
the collaborative programme and the relative proportion of resources utilized at the
National and State levels. The work at the state levels are guided and facilitated by the
Central Government.
Most aspects of health systems, especially relating to public health and curative
services, are managed by the states. The core programme clusters of WCO collaborate

Figure 7: Collaborative Programme of WHO India and Government of India
with the states (see Map 2). WCO has collaborated with states to conduct studies on
the efficacy of current methods of financing, creating awareness on alternate financing
routes and build capacities on key issues related to health financing and health insurance.
WCO has also collaborated with MOHFW and state governments to document and
disseminate health sector reforms across the states of India. The following are the main
activities performed at the state level.
Improving guidelines and skills: WCO supports the state drug authorities by
strengthening and improving diagnostic skills for better regulation, developing training
capacities for good clinical and pharmacy practices, elimination of spurious drugs,
developing protocols and guidelines for blood banks, strengthening drug testing
laboratories and developing and disseminating material for consumer information.
Non-communicable Diseases: WCO has helped states which are at an advanced

stage of epidemiological transition to generate data necessary for planning through
NCD risk factor surveillance in the general population and through an industrial
surveillance network. A multicentric study has been carried out to generate the health
profile of the elderly population in ten states. Health promotion has been initiated
through schools and hospitals and IEC materials developed for a healthy lifestyle. The
India 29
mental health survey in 11 states will provide reliable estimates of the burden of mental
health problems. A sustainable community based psychosocial programme was
developed for the tsunami affected populations. Cancer control programmes, cancer
registration, and palliative care programmes have been initiated in 10 states, and the
National Cancer Control Programme has been supported for strategy development,
IEC and training. Cancer ATLAS of India has been developed. States have also been
partnering with Government of India and WCO in scaling up programmes to control
the use of tobacco. The partnership now includes 18 states.
Strengthening environmental health: WCO works on environmental health issues

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

Map 2: WHO’s Work in the States by Core Programme Clusters
India 31
Health promotion: WCO has supported health promotion across the life span
and has initiated health promoting schools in Varanasi and health promoting hospital
in Lucknow. Tobacco cessation clinics have been set up in 18 states. Support has been
provided to cancer detection and prevention programmes in states under the National
Cancer Control Programme. Industrial settings in 10 states have been provided
interventions for health promotion and prevention of NCDs.
Disease control: WCO supports national communicable disease control

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

Strategic Agenda: Priorities for
Cooperation 2006-2011 6
While developing the CCS for India the global and regional priorities have been kept
in view. The GOI has articulated a series of policy and plan documents for the health
sector and the WCO is committed to supporting the efforts of the government in
achieving its goals. Given India’s vast population, the size of the country and resource
constraints, the WCO needs strategic deployment of its resources.
The thrust of WHO support for the period 2006-2011 (outlined below) has been
chosen carefully based on their share in the overall health problem in India; impact of
proposed interventions, and comparative advantages of WHO.
High Priority Areas

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

poverty, equity, access, gender, quality assurance and capacity building. The WCO is
committed, in association with its partners, to making a difference in these areas which
are crucial to improving the health status of the people of India.
Reduce the Burden of Communicable Diseases

Although significant progress has been achieved in the control of communicable diseases
in the country, the existing burden falls mainly on the poor. Therefore, the control of
India 33
communicable diseases remains a major focus for state and central governments as
well as WCO. Current disease control programmes do not give sufficient importance
to the diversity of disease profiles in different parts of the country. Locally appropriate
responses are needed in the national disease control programmes. This would involve
generating reliable epidemiological data for states or regions within bigger states. The
WCO will work with GOI and the states to generate the needed data and develop
capacities to manage state specific responses.
Substantial progress has been made in GOI’s Revised National Tuberculosis Control
Programme (RNTCP), leading to a complete national coverage in 2006. Future challenges
will be to sustain progress and address emerging issues, particularly in multi-drug
resistance. The experience of polio eradication shows that mobilization level is high
when there is a clearly defined goal. WCO will assist in identifying long-term integration
options so that the benefit of the polio surveillance can reach the routine immunization
system and integrated disease surveillance. WCO will continue providing technical
assistance to the government for scaling up the HIV/AIDS response. WCO will assist
the development of capacity in the country for laboratory, clinical and social support,
as well as monitoring and evaluation for antiretroviral treatment. WCO will also support
the government in evaluating and introducing newer vaccines for disease control
programmes while ensuring high coverage with vaccines of high quality.
Strengthen surveillance and information systems: The GOI is implementing the

Integrated Disease Surveillance Programme (IDSP) at the district, state and national
levels with WCO technical support and funding assistance from the World Bank. This
programme is expected to detect, verify and respond rapidly and effectively to outbreaks
and epidemics. Given the geographical size, population and diversity among health
care providers, developing and sustaining such a system is an enormous challenge.
Through its staff and collaborating centres, WCO will also provide support to monitor
and evaluate the functioning of the system so that feedback can be provided to state
and central governments. The WCO-supported Field Epidemiology Training Programmes
(FETP) also come as a complement to IDSP so that epidemiological intelligence is built
to use information for decision-making.
Respond to emerging and re-emerging diseases: The WCO and GOI acted in
unison to respond to emerging diseases such as Severe Acute Respiratory Syndrome
(SARS) and avian flu. In the future, it is probable that new and more virulent forms of
pathogens would emerge. Given the level of connectivity that exists between nations
today, these diseases can be managed optimally only through regional and/or global
co-ordinated efforts.
To detect and monitor the presence of newly emerging diseases, India is

strengthening the surveillance system to international standards, especially the
International Health Regulations. This can be developed as an offshoot of the Disease
Surveillance Programme. WCO will work with GOI to make the early warning systems

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

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

adolescent age group, WCO supported initiatives on adolescent friendly health services
have been started. WCO will continue to support the Adolescent Sexual and
Reproductive Health Strategy that focuses on reorganizing the existing public health
system in order to meet the service needs of adolescents. A core package of services,
including preventive, promotive, curative, counseling services, and training modules
have already been developed. WCO will continue to assist the government with tools,
guidelines and training manuals for working with young people to address their
India 35
nutritional, health and psychosocial needs and to make services available to them in a
friendly manner.
The National Rural Health Mission (NRHM) and RCH-II provide a broad framework
for convergence and for accelerating the decline in maternal, newborn and child
mortality and morbidity through building a skilled workforce, improving quality and
provision of services at all levels, including referral systems, building capacities of
individuals, families and communities and strengthening collaboration with other public
health programmes. The WCO will extend technical assistance to GOI in making the
programme operational. It will also help develop and analyze data on indicators to
assess how close India is to achieving the objectives and sub-objectives of the National
Population Policy, 2000, and MDGs.
Population stabilization: The National Population Policy, 2000, advocated a

holistic, multi-sector approach towards population stabilization. While many regions
of the country have shown signs of stabilization in population growth, this has been
hampered in other parts by the poor capacity and lack of appropriate systems to identify
community needs and plan for their provision.
The WCO will work with MOHFW in collaboration with the centre and state
governments to develop and assess policies appropriate to identified states. New
technologies are being introduced to expand the choices of contraception. WCO will
partner with other UN agencies in assessing these technologies and make appropriate
recommendations. In order to promote evidence based practices, WCO will be working
with the government to update the technical standards and guidelines for family planning
methods and contribute to quality assurance.
Universal Immunization Programme (UIP): This is a government programme to

provide immunization against vaccine preventable diseases. Under the UIP, vaccines
are administered to infants and pregnant women for controlling six vaccine preventable
diseases namely, childhood tuberculosis, diphtheria, pertussis, poliomyelitis, measles
and neonatal tetanus. WCO will provide technical assistance for improving routine
immunization coverage and safety; support capacity building of the National Regulatory
Authority and provide advocacy for new vaccine introduction and vaccine development
Scale up Prevention and Control of NCDs

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

result in an economic gain of US$15 billion for the country. As India is passing through
an epidemiological and demographic transition, the pace of transition varies between
states. WCO will assist in developing policies, intervention strategies and development
of feasible models. The policies will be flexible and accommodate the differing needs
and resources of the states in India.
Surveillance: The WHO Step-wise surveillance for NCD risk factors has been
introduced into the Integrated Disease Surveillance Project in India. The prevalence of
NCD risk factors in the population will serve as indicators for planning and monitoring
of intervention strategies. Technical support will be provided to the NCD risk factor
surveillance to make it sustainable, especially in data management and translation of
data into appropriate policies. Support will be provided for networking cancer centres
and for cancer registries. WCO will support the implementation of the NCD Infobase
in India to provide reliable data on NCDs in the country. Models for surveillance of
Diabetes and Cardiovascular Diseases will be developed.
Health promotion: The WHO Global Strategy for Diet, Physical Activity and Health
provides options for addressing important risk factors for NCDs. WCO will facilitate
the Global School Based Student Health Survey through the Central Board of Secondary
Education, which will provide a basis for school health promotion programmes. Models
for intervention will be developed for workplace settings and will be disseminated.
Health promotion across the life span will be adopted with emphasis on providing a
supportive environment to promote healthy behaviours.
Disease control: WCO will support the development, scaling up and

implementation of the National Programme for diabetes mellitus, cardiovascular diseases
and stroke. Technical support will be provided to the existing and proposed National
Programmes in these areas. The ongoing National Cancer Control Programme will be
strengthened in areas of prevention, early detection and palliative care. Horizontal
integration will be encouraged across all NCD prevention and control programmes.
Emphasis will be maintained on health system strengthening, capacity building of health
personnel, multisectoral involvement and community participation in NCD control.
Tobacco Free Initiative: WHO will provide technical assistance and partner with
GOI for effective implementation of the provisions of the FCTC and the enforcement
of the national tobacco control legislation. This would include strengthening of the
National Tobacco Control Cell, technical support for the establishment of a National
Tobacco Control Programme with adequate funds, and setting up of a Multi-Sectoral
Coordination Committee for tobacco control and NCD prevention.
Capacity in the area of tobacco control will be built at the state level through
training of relevant state authorities, law enforcers, civil society organizations and health
professionals. Technical assistance will also be provided for implementation of a sustained
anti tobacco public awareness campaign and for expanding the tobacco cessation
services to reach the masses through existing health systems.
India 37
Strengthen Health Systems Development
(1) Improve access, quality and accountability

India is one of the 192 Member States that adopted the resolution on “Sustainable
health financing, universal coverage, and social health insurance” at the World Health
Assembly in May 200526. Accordingly, WHO will support the Government of India to
further improve the health financing system with the ultimate goal of attaining universal
coverage, i.e. to ensure all people have access to needed interventions and services
without the risk of financial catastrophe and impoverishment. This will involve a number
of areas and activities:
Advocacy for increasing resources: At present, public sector health investment in

India is around 0.9 percent of its GDP, one of the lowest in the world. Total health
expenditures are also relatively low at 4.63 percent of GDP. Advocating to augment
resources available for the health sector, WCO would focus on: (i) advocacy with
governments at various levels to increase allocation for health sector; (ii) assisting in co-
ordination of external assistance in specific programmes; and (iii) development of
evidence based tools needed to monitor and evaluate projects. WCO will continue
working with GOI in maintaining and updating information on health expenditures
through the National Health Account System.
Channel funds to priority areas: When resources are limited, they ought to be
spent on interventions that offer the greatest possible health improvements. In health
this would translate into activities that would benefit the greatest number, programmes
that benefit the poor, and interventions that are cost-effective. The WCO will advocate
and generate instruments for evaluating interventions on the basis of cost effectiveness,
and decision-making based on such assessments. It would also support the sharing of
information and experiences from other settings.
Increase risk pooling including health insurance: Data from the National Sample
Survey Organisation indicate that escalating health care costs is one of the reasons for
indebtedness not only among the poor but also in the middle-income group. Nearly
2.2 percent people of India are impoverished annually because of high health care
costs. Health insurance is one of the various financing options being considered in
India to decrease indebtedness. Health insurance is the pooling of resources to cover
the costs of future unpredictable health-related events. At present, health insurance
coverage in India is extremely limited, especially outside the formal sector. Health
insurance can help mobilise revenue for the health sector, protect individuals and
households from the risk of medical expenses, and promote efficiency, quality and
equity of health-care services. The WCO would assist in identifying experts who can
provide technical assistance, support capacity building, and facilitate exchange of
World Health Assembly (58.33), Geneva, WHO

26

country experiences and best practices. WCO will also provide technical support to
the development and evaluation of selected innovative financing initiatives.
Support public-private partnership: The private sector which accounts for 70

percent of the health expenditures has some advantages such as flexibility and better
response to patient needs. But access to services is contingent upon ability to pay,
thereby putting adequate private services beyond the reach of the poor. It is possible
to develop a partnership between public and private sectors so as to leverage the
advantages of the private sector and to partner in the national health development
efforts. The WCO will attempt to forge public-private partnerships; analyse and
disseminate strengths and weaknesses; stimulate discussion on the acceptability of
strategies and provide assistance for trying them out in pilot sites.
While engaging with the private sector, it is also necessary to have a regulatory
framework for health care institutions in the public sector. Many states have found it
difficult to develop such a framework due to the presence of conflicting pressure groups.
The WCO will work with GOI and the state governments to develop mechanisms for
regulation that would not discourage the needed investment in the health sector, but
which would be rigorous enough to protect the interests of patients and providers. It is
necessary to have accreditation of health care institutions so that the consumers know
about the quality of care that they are paying for. The WCO will also attempt to develop
systems to ensure the accountability of health care providers to the community.
Regulate framework, standards and technology assessment: While the private

health sector in India has grown, it has done so in an unregulated manner. With patients
more aware of the scope and limitations of health care services, there is a growing
demand for objectively verifiable standards for services. It is in the interest of both the
patients and the service providers to have documented standards for diagnostic,
treatment and referral services. Such standards can be developed either by government
or by professional associations and endorsed by the government. The WCO will assist
in analysing similar standards and protocols in other countries and in assisting GOI and
professional associations to develop them for India.
Health services have benefited from technological advances. However, the business
segment aggressively introduces new technologies which lead to excessive use, wasteful
investments and higher expenditure. There is a limited regulatory framework to govern
the introduction of new technology. The WCO will assist in developing protocols for
assessing technology and make it available to health care providers, government and
civil society organisations.
Document health information for evidence-based decisions: Knowledge is a

vital input in health sector management. Changes in the financing and provisioning
strategies are time consuming and expensive. The probability of a successful outcome
is enhanced if one learns from past experiences. WCO will build capacity through the
following:
India 39
• Documenting best practices and lessons learnt. India has had several significant
successes in the health sector. It is important that these are documented so that
lessons are learnt. WCO will commission a series of documentation projects to
record the significant successes and how they were achieved.
• Generation of data to support evidence-based management. Any reform, with
long term implications, should be based on careful research regarding cost-
effectiveness, welfare implications and sustainability. WCO will support the
generation of such database to support and advocate for reforms, including
documentation of those with access to needed services, and the extent of
catastrophic payments and impoverishment due to out of pocket payment for
health services. WCO will also support evaluation of many initiatives, donor
funded and other wise, in health sector reform which are being attempted in
some states in India.
• Support for operations research on issues relevant to India. The National Health
Policy 2002 aims to increase expenditure on research to one percent of the
total allocation for health by 2005 and to two percent by 2010. There is a need
to identify knowledge gaps and undertake relevant research that is context
specific and resource sensitive. WHO has considerable experience in supporting
research in the health sector. It also has access to expertise available in some of
the best research institutions in the world. WCO will work with GOI and
academic institutions to identify areas of operational research relevant to India
and to provide technical support for researchers.
(2) Improve Effectiveness and Efficiency

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

must be made more effective and health systems management more supportive. Public
health programmes need efficient management to maximize their effectiveness.
Personnel and financial management capacity has to be strengthened, as does
management of such areas as procurement and distribution of supplies and equipment.
WCO will advocate for and assist in building these skills among the health managers,
especially in the public sector at all levels. A team approach to patient care will be
encouraged.
Positioning public health education and approaches: In today’s world of market

economy and trade liberalization, even with the availability of funds and other resources,
public health systems cannot function optimally due to human resources constraints.
Rough estimates suggest that India needs around 10,000 public health professionals.
The shortage is further exacerbated by the lack of skill mix required in today’s public
health worker. Today’s health worker needs “leadership ability, strategic thinking and
planning capacity, flexible management skills and enhanced communication ability”
to cope with the demands of new public health. Training in many of the institutes is
firmly embedded in the biomedical model of health care wherein public health is set
within clinical practice. The curriculum is neither need-based nor objective oriented
with a distinct gap between classroom teaching and practice in the field, unsatisfactory
skill building during under-graduate as well as in post-graduates programmes and with
limited career development opportunities.
WCO will work with GOI and other partners in positioning public health high on
the national agenda. It will work to strengthen the national and regional public health
institutions and departments, develop skill-based trained professionals in public health,
review and revise the curriculum and demonstrate the models of integrated teaching.
It will also support professional development of public health professionals, develop
standards for courses and institutions, facilitate the establishment of accreditation system
and network of institutions, and foster regular interaction among them.
WHO would increase its role as a convenor of centers of excellence to maximize

the effective use of their work and expertise, thus benefiting both India and other
countries.
Nursing and midwifery education and practices: Qualified nurses can contribute
to positive health outcomes such as reducing mortality, morbidity, disability and
promoting healthy lifestyles. In India, nurses and midwives’ contribution to the quality
and efficiency of health service is felt to be insufficient. While the absolute number of
nurse to population or to patient is high compared to other countries, nursing and
midwifery do not receive high recognition from the public. The number of nurses at
the national and state levels for highlighting nursing practice, research, education,
management, planning and policy development is inadequate. Roles and responsibility
of nurses are not clearly defined, and nurses spend most of the time in non nursing
care. Nurses and midwives have limited opportunities for continuing education.
India 41
Considering the existing circumstances, it is evident that the skills of nurses and midwives
are not optimally used.
WCO will work with GOI, the Indian Nursing Council (INC) and other partners in
developing strategic plans that can guide further action to prevent nursing shortage in
specific areas and to increase efficiency in deployment, utilization and development.
WCO will continue to strengthen nursing education by reviewing and revising the
curriculum, and to further advance the standards of nursing education, research and
practice, facilitate the development of quality assurance system, and enhance nursing
autonomy in practice. It will support efforts to strengthen competencies of Auxiliary
Nurse Midwives (ANMs); create advanced nurse practitioners; promote evidence based
practice and nursing research; and contribute to establishing nursing development
programmes. Additionally, WCO will work with INC in strengthening the nursing
management information system.
Moving closer to the States: The states in India differ in the extent and composition
of their public health problems, disease burden, availability of resources and their
management capacity. Recognizing this, the National Health Policy 2002 has
recommended that the responsibility for public health be delegated to units of local
administration, i.e. the Panchayats at rural levels and Municipal bodies in urban areas.
Some states have already passed the facilitative legislation.
This move calls for high quality capacity building at the central, state and local
government levels. To develop state-specific strategies, it is necessary to generate state-
specific data, and build capacity for planning, implementation and monitoring. In
coordination with the centre, the WCO will facilitate state-specific planning by
supporting capacity building at the state level. Systems have to be developed to ensure
that the states and local administration units take action in accordance with national
policies and strategies. In addition, the centre needs to develop a mechanism for
monitoring and quality assurance. The WCO will support this process by providing
technical assistance, documenting best practices from Indian states and other countries,
and supporting pilot initiatives.
The health strategy of each state has to deal with its complexity and diversity
which has been recognised in the NHP. In coordination with the centre, the WCO will
facilitate state-specific planning by supporting capacity building at the state level.
The CCS envisages more strategic technical support to states in India. WCO will
build capacities closer to the states through various approaches:
• assessment of needs for technical support of states with the involvement of
MOHFW. Focus would be on the priority areas identified in the CCS;
• assessment of the available resources within WCO to respond to the states
needs. If such resources are not available at WCO level, the assistance of the

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

To address the risks and opportunities of globalization and the global policy environment
for public health in India , WCO will focus on the following issues:
Managing the impact of spill-ins and spill-overs: WCO will assist the dialogue at
the national level among relevant ministries, including those of health, trade, commerce,
finance and external affairs, in order to facilitate policy coherence and to ensure that
the interests of trade and health are appropriately balanced and coordinated. In the
international trade of health services under GATS, WCO will facilitate ‘evidence-based
approaches’ so that the government can liberalize health services to ensure greater
access to affordable, better quality and effective health services. This will lead to
increased choices for consumers and greater equity in health outcomes. Other specific
areas will include access to drugs and TRIPS, food safety, bilateral and regional
agreements. Support will be provided to manage cross border opportunities or threats
that could affect health, such as new technologies, climate changes, marketing practices,
‘trade in bads’ (such as: illicit drugs, organs, and people trafficking), communicable
diseases, and unsafe food.
Shaping the global agenda: India plays a leading role in shaping the global and
regional agenda in many sectors, such as: trade, commerce, external affairs, as well as
in selected issues in international health such as the FCTC. The potential of India as
well as of other countries such Brazil, Canada, and China to become major actors in
shaping the global health agenda is increasing. Potential areas are:
• Influencing global health governance: new rules in health and in other sectors
influencing health (trade, GATS rules), new institutions and funding mechanisms;
• Export of best practices and knowledge in specific domains: education in health
(cross border e-health to support training of health personnel, and telemedicine);
traditional medicine (AYUSH); universal coverage of primary care in rural areas
(NRHM).
In each of the above areas WCO will work with GOI to build capacity to identify
and manage the impact of both existing and emerging policy regimes. In addition,
WCO will also support relevant research and policy development. To carry out the
above mentioned activities WCO will:
India 43
• Work with Collaborating Centres, Centres of Excellence, and professional
associations and organizations;
• Create networks among the existing centres;
• Facilitate the work of the WTO cell within the MOHFW and with other Ministries
as appropriate;
• Participate and initiate global networks in selected areas of public health, linking
centers of excellence within the Region and outside;
• Support South-South cooperation based on identified best practices, specific
knowledge and strengths; and
• Develop strategic alliances with like-minded countries to better place their
health priorities on the international agenda.

Implementing the Strategic Agenda 7
The CCS will be the strategic framework around which WCO will organise its country
programme. The WCO is committing itself to the priority areas it has listed and will
take all required steps to ensure that outcomes in these are achieved. This could be for
generating support for the CCS goals, accessing technical expertise, as well as generating
resources and adapting the organisation’s structure to suit the requirements of the
CCS. The recent enhancement of delegation of authority to WCO with regard to human
resources, programmes, financial and travel issues would facilitate the implementation
of these strategies.
A key characteristic of the CCS is that its focus areas have been chosen strategically.
The high priority areas where WHO has comparative strengths such as Communicable
Diseases, Maternal and Child Health and Non-Communicable Diseases, will have a
substantial impact on India’s health. The strengthening of the health system and dealing
with globalization issues will emerge as challenges in the future. To achieve results the
WHO organization plans to divide tasks among the Country team, Regional Office
and Headquarters.
Responsibility of the Country Team

Technical Assistance: WHO’s main strength, acknowledged by GOI and other partners,
is its competence to provide technical support. Therefore, WCO needs to make available
high quality technical assistance in sufficient capacity to assist the government and
other partners in reaching targets in the priority areas (Annexure - Table 9). WCO will
continue its existing technical assistance in the areas of Communicable Diseases,
Maternal and Child Health and Non Communicable Diseases. Other priority areas in
Health Systems Development include: policy analysis, systems development,
management, quality assurance, health impact analysis, health financing strategies,
and public health promotion. Some of the areas identified in the CCS such as expertise
related to the globalization issues are new for India. Technical assistance will be provided
through collaborating institutions. There will be increased collaboration and co-
ordination with the Regional Office and Headquarters for technical support. Expertise
will be made available to the government, partners and non-governmental agencies.
Organisational Development and Human Resources: While implementing the

CCS, the WCO will place a greater emphasis on organisational development. The
India 45
WCO will develop overall indicative plans for 2006-2011 and detailed action plans on
a biennial basis. Since human resources would be an important facet in the
implementation of the CCS, the WCO would restructure and strengthen the technical
capacity of the current staffing to meet future demands. Additional human resource
needs would be met either by redeployment, retraining, hiring of new personnel or
outsourcing functions to other institutions where needed. The WCO would place special
emphasis on staff development to strengthen the capacities and capabilities of both
the technical and general staff.
Since the CCS lays emphasis on decentralised decision-making in health, the need
to have a sub-national presence will be felt even more. India is a vast and diverse
nation with highly varying health needs and capacities. The WCO will explore the
options to strengthen its sub-national presence in the long run, in consultation with the
Government of India.
Collaboration and Partnerships: A major component of implementation will be

to strengthen partnerships with other agencies. The WCO would explore ways and
means for increased outsourcing to WHO Collaborating Centres and Centres of
Excellence. It will help facilitate the activities implemented by UN agencies in the
health sector. Synergy exists between activities of many agencies involved in such
areas as safe drinking water, environment impact assessment and foreign trade policies,
amongst others. WCO will leverage the comparative advantages of such centres and
agencies and will seek their support to achieve the objectives of the CCS.
Strengthening Management Capacities: India possesses immense capacity in most

aspects of health care management. The role WCO and other agencies would be to
strengthen capacity in specific areas. The WHO fellowship programme consists of
specially tailored training programmes aligned to national health priorities and human
resource needs. There has been a conscious shift to in-country fellowships as they are
more cost-effective, help use the large pool of training talent available in the country,
and help strengthen national training institutions to become regional and global training
centres. WCO will continue the focus on national institutions and streamline and
redesign the fellowship programme to align it to the technical support needs for
implementing the CCS.
Strengthening information systems and infrastructure: Information is a vital

ingredient in all forms of reform. It is needed for advocacy, evidence-based planning
and designing, monitoring and evaluation of systems. Information can be generated
by documenting experiences in India, synthesizing international experience, and through
operational research and pilot projects. WCO will support generation of information
relevant to health. WCO will disseminate information to relevant stakeholders.
Furthermore, WCO will make efforts to strengthen the office infrastructure in terms of
automation, information technology, space, transport and other facilities for high-quality
outputs.

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

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

Technical support: The HQ staff are expected to provide technical support in specific
areas where they have comparative advantage. Some of these areas include costing of
interventions, cost-effectiveness, innovative financing, non-communicable diseases and
new initiatives in HIV/AIDS treatment. HQ conducts many pilot studies and generates
technical reports, which provide valuable inputs to WCO.
Standards, guidelines and tools: HQ has developed many standards, guidelines

and tools on the basis of its global experience. Examples of areas that would be helpful
to the WCO: tools for costing of different activities, method of estimating financial
burden caused by catastrophic illnesses, multi-drug resistance of ARV medicines,
Integrated Management of Adult Illness, etc.
Resource Mobilization: It is expected that HQ would continue its efforts in

mobilizing resources for India with its effective networking and advocacy capacities.
Risks facing the CCS

There are three main risks facing the CCS and its strategic objectives. The first is related
to the effectiveness of WHO technical support and the possibility that the anticipated
impact would remain limited. Ensuring the highest possible standards of quality and
credibility of the technical advice provided would alleviate this risk. The risk is closely
related to the country’s own implementation capacities and the fact that the biennium
work plans are intimately linked to the country’s institutions. It is inevitable to witness
mixed implementation outcomes in a vast subcontinent such as India with large
India 47
disparities among the states. In order to further mitigate this risk, greater attention
would be provided to upstream planning, quality at entry, realistic expectations,
thorough assessment of institution-specific implementation capacity, identification of
related gaps, effective hands-on-training and closer sustained monitoring.
The second risk concerns competing demands and priorities, both within WHO
and the country, thus diluting the focus on top priority areas and overstretching the
capacity of WCO. This would be addressed through advocacy, persuasion, and seeking
widespread endorsement.
The third risk concerns potential resource constraints that may hamper the
strengthening of WHO’s country presence and its contribution. Efficiency gains and
sustained resource mobilization efforts would alleviate this risk through sustained
resource mobilization efforts by WCO, SEARO and HQ. Also, rather than seeking to
deal with too many areas on its own, WCO will partner more with other UN agencies,
Centres of Excellence and WHO Collaborating Centres. WCO will draw up further
arrangements for outsourcing and making such centres available for providing technical
assistance. Concurrently, attention would be paid to develop the skills and capacities
of such institutions within the states. Linking fellowships with institutions rather than
individuals would be promoted to the extent possible. Also, WCO would enhance
horizontal collaboration across countries in the region, and would seek to leverage the
capacities and support of the regional office and headquarters.

Annexes
Table 1: Selected indicators for India
1
Census of India 2001, Provisional Population Totals: India, Registrar General of India, Ministry of Home Affairs,
GOI.
2
Health Information of India, 2004 & 2005, Central Bureau of Health Intelligence, MOHFW, GOI.
3
Economic Survey 2005-2006, Ministry of Economic Affairs, GOI.
4
National Family Health Survey (NFHS-II), 1998-99, IIPS and ORC Macro, 2000.
5
SRS Bulletin, Registrar General of India, GOI.
6
Registrar General India, 2006.
7
National Health Accounts India, 2001-02, MOHFW, GoI 2005.
8
Annual Report – 2005-2006, Ministry of Health and Family Welfare, GOI.
9
Health Information of India 2005, Central Bureau of Health Intelligence, MOHFW, GOI.
India 49
Table 2: Health indicators
Source: Sample Registration Systems Bulletin, 2004, Provisional Estimates and Census of India,
Registrar General of India, Ministry of Home Affairs, GOI.
Table 3: Public health infrastructure
Source: Health Information of India, 2004 & 2005, Central Bureau of Health Intelligence, Ministry of Health
and Family Welfare, Government of India.
Table 4: Trends in disease pattern
Source: National Health Policy, 2002, Dept. of Health, MOHFW, GOI, 2002;
*National Polio Surveillance Project
Table 5: Estimated number of deaths in India from chronic diseases

in 2005 and projections for 2015
Source: Preventing Chronic Diseases: A Vital Investment. WHO Geneva 2005.

(http://www.who.int/chp/chronic_disease_report/en/)

Table 6: Health expenditure – India, 2001-02
#
As per New Series (Base: 1999-2000) of National Accounts Statistics, CSO dated 28th February, 2006.
US$1.00 = INR46.00
Source: National Health Accounts India, 2001-02, Ministry of Health and Family Welfare, GOI 2005
Table 7: Health expenditure by sources – India, 2001-02
#
Estimate based on data from NHA study on health financing by local bodies undertaken on behalf of MOHFW
$
National Commission on Macroeconomics and Health, MOHFW, 2005
*Estimate based on NHA study on Health Financing by NGOS undertaken on behalf of MOHFW
Source: National Health Accounts India, 2001-02, Ministry of Health and Family Welfare, GOI 2005
US$1.00 = INR46.00
India 51
Table 8: External funding to India for health (2000)
Source: Computed from Misra, R, Chatterjee, R, Rao, S (2003): “India Health Report”, Oxford, New Delhi.
Pp.163, 168- 170,
Table 9: Health resources profile, WHO Country Office – India
* National Professional Officer

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

Organizational Chart – WCO India (Established Posts)
WR
PHA
NPO (P&AO) NPO NPO Medical officer Medical officer

(Med. Epid.) (Sanitary Engineer) ‘3 by 5’ (Epid.)
NPO NPO Medical officer MO Project

Assistant III
NPO (HR) (NMH) (FCH) (TB) Manager (NPSP)
(Prog.)
Assistant III NPO NPO

Assistant Prog. Technical
Clerk I (CDS) (HSD)
(Prog.) Manager Officer (NPSP)
Assistant III NPO NPO

Clerk I (TFI) (TB)
(Fin.)
Assistant II Assistant II
Clerk I (Statistics)
(Fellowships)
Secretary II Driver
Assistant I Driver/
(S&E) Messenger
Assistant I WCO India
India
Driver
(Fin) 19-07-2006
53
Messenger
54
Proposed Organization Chart, WCO Inida, 2006-2011
WR
PHA
NPO (UNDP)
Knowledge Management
MO Epid. MO Epid. MO MO Planning Admin NPO NPO NPO NPO NPO NPO NPO NPO
– Polio TB 3 by 5 Officer Officer SDE EHA Med Enid TB CDS NMH FCH HSD
WHO Country Cooperation Strategy 2006-2011

Asst. Prog. Technical Technical Assistant HR NPO NPO NCD NPO
Manager Officer Officer AO Officer Malaria Surveillance EDM
NPO NPO NPO

Mental Health
Asst III (Prog) Asst (IT) Driver Leprosy
Health Technology
NPO NPO
Asst III (Prog) Secretary II Driver
Tobacco Free
Laboratory
Initiative
Asst III (Prog) Clerk I Driver/Messenger
NPO
Surveillance
Messenger NPO
Asst III (Fin) Clerk I
Nutrtion
Asst II (Fel) Clerk I Support Staff NPO

engaged on STE Adolescent
and SSA basis Health
Asst I (S&E) Clerk I
NPO
Asst I (Fin) Child Health
Indicative chart subject to change based on

evolving circumstances and operations
Country Cooperation Strategy Matrix
Communicable Diseases and Disease Surveillance

Area Challenges Opportunities WHO’s strategy Expected outcomes Partners
1. Reduction of • High mortality and • Significant successes in • Provide technical • Adoption of WHO
Burden of morbidity from eradicating/eliminating assistance to the strategy, technical
Communicable communicable some diseases in the Ministry of Health and operational
Diseases, including diseases, especially entire country or some and Family Welfare advice
strengthening of among the poor. parts of the country and State Health • Technical
surveillance systems • Regional differentials • Political commitment Departments in guidelines, manuals
and responding to in prevalence of towards welfare of the strategy and SOPs of
emerging threats various diseases poor including promise formulation, various diseases
of larger commitments technical and made available to
• Differential type and
to management of operational matters GOI and states
quality of health
care providers communicable diseases • Facilitate access to • Evaluation report of MOHFW, Health
across the country • Existing surveillance information and to new vaccines Departments of
project financed by a international state governments,
• Inadequate and • Capacity building
loan from the World networks and Development
delayed information modules for
available for Bank, Integrated • Support evaluation strategy Partners
outbreak Disease Surveillance and introduction of formulation
management Project (IDSP) new vaccines
• Emergence of new • International Heath • Capacity building at
pathogens in the Regulations available as all level
region as well as a framework for
globally monitoring and early
warning systems
• Better connectivity
across the country,
facilitate the spread
India
of diseases.
55
56
Maternal and Child Health
2a. Reducing Maternal, • Slow decline of • Political commitment • Provide technical • Policy, technical and
Neonatal, Infant, and maternal, neonatal, to supporting poor assistance to the operational guidelines
Child Mortality infant and children women and children Ministry of Health and and training manuals
under 5 year mortality • Clear objectives in the Family Welfare and for quality
rates. National Population State Health Reproductive,
• Socio-economic Policy, 2002 Departments in Maternal, Newborn
determinants of poor strategy formulation, and Child, nutrition
• Huge government
health of women, technical and and Adolescent Health
program to address the
infant and children operational issues in services available and
mother and child
the areas of maternal, accessible
• Non-availability of health issues, such as:
neonatal, infant and • Guidelines and training
required health care Reproductive and Ministries and
child health, nutrition modules for training of
personnel with skills Child Health-2, Janani departments of union
and adolescent health Skilled birth attendants,
and health facilities in Suraksha Yojana and and state governments,
parts of the country to National Rural Health • Focus on strengthening Emergency Obstetrics of Health & Family
WHO Country Cooperation Strategy 2006-2011

address the problem. Mission systems for continuum Care, Adolescent Welfare and also Women
of care, ensuring skilled Friendly Sexual and and Child Development,
• Behaviour towards
attendance at every Reproductive Health Education,
women and girl
birth, and improving available and
child Development partners
quality of Emergency accessible
Obstetric Care WHOCC
• Coverage with Skilled
• Capacity building of attendance and IMNCI MCI and INC
various health expanded Professional Associations
professionals and • Updated curriculum like FOGSI, IAP, NNF,
workers at various and syllabi available IPHA, IAPSM
level, in the area of Civil society
• Annual reports
maternal, neonatal, organisations,
available on progress
infant and child health,
for achieving indicators Media
nutrition and
of NPP, RCH-2 and
adolescent health.
NRHM
Promoting nursing
fraternity
• Support the
government in monitor
progress on achieving
the objectives of the
National Population
Policy, RCH-2 and
NRHM
Maternal and Child Health (continued...)
India
57
Noncommunicable Diseases and Mental Health

Health Systems Development
4a.Improve access, • Limited current • Commitment of the • Develop National • Availability of updated
quality, accountability, government funding, Government to Health Accounts (NHA) NHA
effectiveness and only 0.9% of GDP. increase public health system to support • Advocacy instruments
efficiency of the health • Unregulated health care investment to 2% of advocacy and resource available
system. private providers, GDP management.
• Documentation and
account for 70% of the • In few health Advocacy to increase
information Planning Commission &
health expenditures. programmes, good health allocations and
dissemination on the MOF & MOHFW
High out of pocket outcomes of public- channel funds to
pros and cons of PPP & development partners,
expenditures for health private partnership priority areas
pilot projects initiated NGOs, academic
care lead to (PPP) • Analyze and institutions
• Evaluation of different
impoverishment of • Increased interest from disseminate the
modalities of social Ministry of Rural
population high level government strengths and
insurance made Development, Law and
• Human resources for officials on public weaknesses of public-
available Justice, Health in GOI
health issues: quantity, health and importance private partnerships
• International and state governments,
quality, relevance, skill- of other disciplines that and provide assistance
experience appropriate development partners,
mix (skill in health relate to health, such as for pilot projects
to India made available and academic
management and economics, • Advocacy for social institutions
to health managers
public health), demography, etc. health insurance,
• Various modules MOHFW, state
motivation, utilization, • Growing demand from provide technical
available for capacity governments, UN
distribution the community for assistance for capacity
building agencies, academic
• Ineffective systems to objectively verifiable building.
• Systems for sharing of institutions
ensure accountability of standards of service • Document best
information Ministry of Science and
health care providers to • Efforts to develop practices from other
Technology, Health,
the community, and to regulatory framework countries and states in • Generic manuals
prepared for regulation, development partners,
assess diagnostic and for health technology India and support pilot
accreditation civil society
technology and medical devices initiatives
organizations, and
advancement used in • Assist in coordination • Reports on analysis of academic institutions
health care. among development standards & protocols
partners and GOI for & its relevance to India.
information sharing and • Guidelines on assessing
implementation of appropriateness of
capacity building medical technology
India
initiatives
59
Health Systems Development (continued...)

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ii WHO Country Cooperation Strategy 2006-2011

Message from the Regional Director ................................................................. vi

Acknowledgements ......................................................................................... vii

Abbreviations ................................................................................................. viii

Executive Summary ........................................................................................... x

2. Health and Development Challenges .......................................................... 3

3. Development Assistance and Partnership .................................................. 17

4. WHO Global and Regional Policy Directions ............................................ 21

5. WHO Current Policy Framework and Cooperation ................................... 24

7. Implementing the Strategic Agenda........................................................... 45

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

iv WHO Country Cooperation Strategy 2006-2011

Samlee Plianbangchang, M.D., Dr.P.H.

vi WHO Country Cooperation Strategy 2006-2011

viii WHO Country Cooperation Strategy 2006-2011

While India is being propelled to a position of international eminence, it faces the

x WHO Country Cooperation Strategy 2006-2011

Reduce the burden of communicable and emerging diseases by enhancing

Scale up prevention and control of noncommunicable diseases (NCDs) through

xii WHO Country Cooperation Strategy 2006-2011

It is self-evident that a coherent policy framework for service provision is needed.

xiv WHO Country Cooperation Strategy 2006-2011

2 WHO Country Cooperation Strategy 2006-2011

Since independence, India has pursued a policy of planned economic development

Figure 1: Estimated percentage of deaths (all ages)

Tenth Five-Year Plan Document, Planning Commission, GOI

4 WHO Country Cooperation Strategy 2006-2011

Communicable Diseases: In India, the communicable disease burden remains

6 WHO Country Cooperation Strategy 2006-2011

Noncommunicable Diseases: Noncommunicable Diseases (NCDs), especially

Figure 2: Estimated proportion by cause of death

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

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

8 WHO Country Cooperation Strategy 2006-2011

India is home to many indigenous systems of medicine, including Ayurveda and

10 WHO Country Cooperation Strategy 2006-2011

Figure 3: Scope of National Health Accounts with overall

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

National Health Policy – 2002, MOHFW, GOI, 2002.

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

Figure 5: Health Expenditure by Financing Sources – 2001-02

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

12 WHO Country Cooperation Strategy 2006-2011

Macroeconomics & Health, GOI, New Delhi, 2005.

Health in the Future

India’s National Population Policy 2000, places the achievement of demographic

14 WHO Country Cooperation Strategy 2006-2011

India’s National Nutrition Policy 1993, advocates for a comprehensive inter-sectoral

The main aim of NRHM is to provide accessible, affordable, accountable, effective

In order to protect the population, MOHFW has to engage externally to mitigate

There is a need to consider international policy developments and treaties when

Trade Related Intellectual Property rights (TRIPS) attempts to balance two

Increasing trade in health services challenges the capability of MOHFW to assess

16 WHO Country Cooperation Strategy 2006-2011

Development assistance, including loans and grants, contribute a small percentage of

Overall Trends in Assistance

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

18 WHO Country Cooperation Strategy 2006-2011

20 WHO Country Cooperation Strategy 2006-2011

Global Challenges in Health

Gaps in responsibility: Health problems today are no longer merely the