1. Health of Mothers and Children

Scaling up reproductive, maternal, newborn, child and adolescent health services beyond the traditional set of mother and child issues. Emphasis will be put on improving access for difficult-to-reach people to high-quality, certified and supervised services supported by training and controls. WHO intends to use a gender-awareness approach for accelerating the achievement of MDGs 4 and 5, by synchronizing with the government in its effort to pay preferential attention in India to: (i) adolescent health, linked to nutrition¸ the cultural aspects of early marriage and inter-generational issues; (ii) home based care of the newborn and postnatal care (related to breastfeeding); and (iii) management of low birth weight related to the capacity of nurses and midwives.

Care of the pregnant woman, the mother and the newborn in primary health care facilities and hospitals will be subject to well-designed protocols focusing on equity and quality. For example, the number of deliveries under the supervision of skilled birth attendants will be substantially increased. Child and adolescent nutrition and related health issues will be addressed by the government by means of both upstream measures (e.g. government subsidies and school activities) and downstream activities (i.e. regular medical and nursing supervision) and subject to specific follow-up throughout the country. WHO will support the mandates and activities of the government and other developmental partners (civil society and private sector players) paying attention to avoid duplication of effort and maximize returns.

Better information systems, tracking resources and oversight will be promoted in accordance with the ten precise recommendations of the “Accountability Commission on Mother and Child” chaired by the Tanzanian President, the Canadian Prime Minister and WHO’s Director-General, and of which India’s Honourable Minister of Health and Family Welfare is a member. Significant steps will be taken in particular to support (i) integrated use of Information and Communication Technology (ICT) to improve the registration of births, deaths and causes of death combining data from facilities, administrative sources and surveys, and (ii) disaggregate the indicators on reproductive, maternal and child health, for gender and other equity considerations for the purpose of monitoring progress. WHO will also provide technical and policy support to the government aimed at reducing the gap between states in terms of health outcomes, with a specific aim of contributing to the reduction of selective gender abortion, increasing girls’ attendance at school, raising female literacy rates and improving the gender equality, a critical social determinant of health. 

2. Combined Morbidity

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

First, there will be continued commitment to the fight against CDs under the new circumstances, for example, vector-borne diseases are acquiring an increasingly urban rather than rural-related profile due to specific rapid urbanization patterns and water-borne diseases require more robust inter-sectoral work in collaboration with municipal governments and urban developers, among others.

Second, there will be a massive scaling up of upstream (that is, addressing broad determinants of health) and downstream approaches (addressing the symptoms of diseases and immediate needs of patients) to fight cardiovascular, cerebrovascular and metabolic diseases, cancer, mental illnesses and other NCDs in India. Inter-sectoral actions aimed at reducing the risks of contracting NCDs will be combined with effective health services to reduce death and disability once the diseases have started and the risk of acquiring the disease – for example, by diminishing exposure to tobacco and other addictive substances, decreasing consumption of salt, sugar and fat, increasing physical activity and increasing access to effective services, all socially influenced factors.

Third, it is foreseeable that new service modalities of primary health care and hospital care will emerge. WHO will support the government in designing approaches to minimize the catastrophic impact of repeated costly visits to health-care facilities and repeated tests, especially under OOP payment conditions, for those who suffer co-morbidities. At the moment, for example, almost half of Indian families with a member affected by cancer already experience catastrophic spending and a quarter of all families are pushed into poverty as a consequence of the disease. This will be a highly demanding change from the viewpoint of health service facilities and human resources.

The National Commission on Macroeconomics and Health has already identified the delay in introducing changes as being responsible for an unduly high toll in terms of mortality, morbidity and disability in India. If the majority of the population is to be served, enormous innovative efforts in terms of networking delivery arrangements, technologies, health workforce skills and training modalities, among others, will be needed in the coming years to overcome the challenges identified

3. Transitioning Services

De-verticalizing polio, AIDS and TB programmes and transitioning WHO service delivery components in them to regular government structures run by district, state and central authorities, as the public health system of India now has more than sufficient knowledge, organizational capacity, resources and service delivery mechanisms.

In fact, all the improvements proposed under Strategic Priorities 1 and 2 in the field of financing, regulation, governance, access to medicines, strengthened surveillance, monitoring and evaluation and research, will face their acid test in the fight against the combination of CDs and NCDs in the next decade. No doubt, however, that management of AIDS and TB and the efforts for certified eradication of polio, will remain a major issue for India for a number of years to come. Sustaining results in these areas now requires a gradual, phased “transfer strategy” of WHO services to the national, state and local authorities with the sine qua non condition that no erosion of effectiveness occurs during the transition period. Such transition strategy will be developed through a consultative process.

Both the Government of India and WHO want to see more emphasis being placed on augmenting a healthy public policy combined with the much needed cross-sectional services for tackling diseases through the continuum of care. Population services (including improvement of dietary habits, promoting patient self-management, implementation of no-tobacco rules, public health inspection services which are critical for fighting food-borne and water-borne diseases, and laboratory support for STI diagnosis) need to be scaled up and the same applies to preventative primary health care interventions, combined in turn with effective emergency and regular services as well as highly complex individual/personal services. Once more, a gender-related balance will be paramount here.

In summary, WHO’s service delivery in polio, AIDS and TB has to continue for as long as necessary according to country needs, but it should take into account the lessons learnt and have exit in mind. A shift from focusing on polio to routine immunization, for example, in the context of maintaining polio-free status and achieving 90% reduction in measles mortality (baseline 2000) by 2013 has to be accompanied by a timetable for transferring WHO work to the government authorities at all levels. The same applies to relevant objectives in the case of TB (e.g. integration with general health systems, with emphasis on access to drug-resistant TB diagnosis and treatment, integrated TB/HIV services, and improving the engagement of all care providers).

In the case of AIDS, technical and normative support needs to continue, including operational guidelines for integrating health service elements, such as quality assurance of clinical services, ensuring long-term retention of patients on antiretroviral therapy, preventing parent-to-child transmission within the NRHM, updating antiretroviral therapy to consolidate the progress achieved in the last six years and strengthening linkages with community services, monitoring of the development of HIV drug resistance, and reducing HIV transmission among members of the most-at-risk population. At the same time, the above priority services should be increasingly incorporated under regular service schemes linked to universal coverage and delivered by well trained staff and properly licensed facilities.

In the coming six years WHO will maintain its technical support while increasingly focusing on policy advice and strategic work.