India has made substantial gains in its health status in the last six decades. However, despite significant reductions in mortality and fertility, a number of challenges remain. With one-sixth of the world’s population and one-third of the world’s poor, India’s economic and social progress is critical to achieving universal Millennium Development Goals. India’s population is now 1.2 billion and projected to grow to 1.6 billion by 2050, overtaking China by 2030.

More than 800 million people, or 75.6 percent of the population, live on less than $2.00 per day. This segment of the population lacks education, workforce skills, social capital, and access to the primary health care and basic infrastructure that would allow them to benefit from India’s economic growth. Approximately 1.9 million children die before their fifth birthday every year. The sex ratio at birth and gender differential in under-five mortality continues to be skewed against girls. Approximately 67,000 mothers die each year due to complications during pregnancy and childbirth. About 30 million couples have an unmet need for contraception. Almost half of Indian children under the age of five suffer from chronic malnutrition, with about 70 percent anemic. Indoor air pollution, caused by traditional cook stoves, contributes to morbidity and mortality, primarily affecting women and children.

Tuberculosis (TB) remains the most common disease in India, killing more than 1,000 people per day. Every year, TB results in 300,000 children leaving schools, 100,000 women being rejected from their families, and approximately $3 billion in economic costs to society. There are an estimated 2.27 million persons living with HIV/AIDS in India (third highest in the world), with over 90 percent of them unaware of their status. India’s urban poor, who live in cramped, low-quality housing with limited sanitation and poor access to affordable quality health care, experience widespread illiteracy and social isolation. Their health indicators are much worse than urban averages and similar to or worse than those of rural populations.

In India, health expenditure is 4.1 percent of the GDP and the government spends 3.7 percent of that on health care. The private sector is predominant in India’s healthcare picture, accounting for nearly three-fourths (73.8 percent) of health expenditures.

Despite increases in the Government of India’s (GOI) health budget, India’s investment in the health and nutrition sector remains relatively low. Technical and operational capacity limitations continue to hinder India’s ability to provide effective delivery of basic service.

USAID’S RESPONSE

USAID supports programs and technical assistance in coordination with the GOI’s flagship health programs (including the National Rural Health Mission and the National AIDS Control Program) to help India achieve a sustainable population; integrate health services and nutrition to improve maternal, newborn, and child health; stem global disease threats, including HIV/AIDS, polio and TB; and strengthen capacity to deliver water and sanitation services.

In line with U.S. President Barack Obama’s Global Health Initiative and GOI priorities, USAID envisions that its technical cooperation, coupled with resources from the GOI and the private sector, will continue to catalyze India’s ability to improve the health system and increase access for its vulnerable populations to quality health care.

On September 30, 2010, USAID and the GOI signed a Health Partnership Program Agreement, which lays out a new five-year approach to strengthen the health system to address health needs of vulnerable populations through integrated activities.

KEY ACCOMPLISHMENTS

USAID health partnership with the GOI began in 1958. Among our many achievements and contributions, our collaboration has strengthened:

• Evidence-based decision making for policies and programs;

• Capacities of public health systems and Indian organizations;

• Private sector involvement for improved public health outcomes; and

• Development of innovative models for improved health delivery.

Evidence-based decision making for policies and programs: The 2005-2006 National Family Health Survey (NFHS-3), coordinated by USAID in partnership with the GOI and other donors, drew the attention of policymakers to poor nutrition and immunization levels in India. NFHS-3 data has been used for the formulation of India’s Eleventh Five-Year Plan, is monitoring progress of the GOI’s Reproductive and Child Health program, accelerating universalization of the Integrated Child Development Services Scheme, as well as triggering the introduction of a National Urban Health Mission.

HIV/AIDS: USAID implements HIV/AIDS prevention, care, and treatment as part of the President’s Emergency Plan for AIDS Relief (PEPFAR). PEPFAR efforts in India include HIV prevention in high prevalence states and among high risk groups; work to ease the suffering of children affected by or infected with the disease; care and support to those affected; and, involvement with the private sector to help stem the spread of HIV/AIDS on a broader scale. In Tamil Nadu, where USAID has been supporting HIV/AIDS activities since 1995, there has been a dramatic impact with overall HIV prevalence reduced by half. Initiatives developed through USAID programs have contributed to the current National AIDS Control Program, such as development of a policy addressing HIV/AIDS orphans.

Family Planning: The use of and access to family planning spacing methods has increased more in Uttar Pradesh, a focus state for USAID family planning program, than in most states not receiving USAID support. Further, data from within the state suggests that use of modern contraception increased nearly twice as fast from 1992 to 2005 in areas where USAID projects were active than where USAID was not active in the state. Capitalizing on the GOI’s momentum to revitalize use of long-term contraceptive spacing methods, specifically the Intra Uterine Device (IUD), in 2006, USAID supported initial master training and revision of the GOI IUD guidelines for twelve states. This initiative has been scaled up nationwide, with recent state data indicating an increase in the number of trained providers for the IUD and the number of institutions providing IUD insertions. The monthly statistics report show an estimated 4.9 percent increase in IUD use.

Tuberculosis: High-level technical expertise from USAID is bolstering the GOI’s National Tuberculosis Control Program. Assistance focuses on priorities such as: sustaining and improving the quality of Directly Observed Therapy-Short Course for Tuberculosis, a globally recognized strategy for TB control; expanding services for diagnosis and treatment of multi-drug resistant TB; and, strengthening linkages between TB and HIV/AIDS services and control activities. USAID’s help has resulted in intensified case-finding for TB in HIV counseling and testing centers in high HIV prevalence states, and strengthened state-level intermediate reference laboratories.

Malnutrition: USAID’s food aid support to the GOI’s Integrated Child Development Services scheme has helped to change the GOI program’s focus from three- to six-year-old children to children under two years, who are most in need of nutrition supplementation. USAID’s innovative and viable strategies have been incorporated into standardized government protocols to address malnutrition through food supplements. USAID also serves as the secretariat for the Coalition for Sustainable Nutrition Security in India, a network of high-level political leaders committed to ending malnutrition in India launched in 2008. Coalition members work together to influence policy and program decisions at the national and state levels to achieve sustainable nutrition security in India.

Private sector involvement for improved public health outcomes: Recognizing the Indians’ overwhelming use of the private sector as the primary source for health care service delivery and the recent recognition by the public sector that it alone cannot meet the health needs of all Indians, USAID prioritizes public-private partnerships (PPPs) as a major theme across the entire health portfolio. The GOI and other donors recognize USAID as a leader in the PPP arena. USAID support helped define the strategic framework of PPPs for the $8.5 billion, national Reproductive Child Health-2 program. USAID’s support demonstrated that a variety of PPPs are possible, including contracting-in, contracting-out, social marketing, social franchising, fractional franchising, demand-side financing, and partnerships with the commercial sector.

Newborn and Child Health: USAID policy advocacy efforts contributed to the 2009 revision of the GOI’s newborn and child health and nutrition policy, strategy, and operational guidelines, which will help to further reduce infant and child morbidity and mortality.

Urban Health: USAID’s support in urban health programming influenced GOI policies to increasingly target the health needs of the urban poor. Urban health issues increasingly have received more attention and have been integrated into government plans and activities.