India's health sector faces several key issues: respective roles of the public and private sectors, budget and resource allocation, management of health services, quality of care, and work force. The Union and state governments are addressing these issues, and the country has embarked on a series of programs to adjust its health strategies, technical paradigms, and appropriate technology, and to improve the performance of its health programs.
Since 1991, the World Bank Group has significantly increased its emphasis on health sector development in India. The Bank has been working to help India reduce the level of mortality, morbidity, and disability through a three-pronged approach. The first is to reduce the burden of the most significant diseases by supporting priority programs with positive externalities. The second is to strengthen the performance of state health systems to deal with the evolving burden of disease by providing more efficient and effective health care. The third is to strengthen essential functions such as food and drug administration capacities. The Bank has also collaborated with the World Health Organization (WHO) and other centers of excellence such as the United States Centers for Disease Control and Prevention, the United States National Institutes of Health, and bilateral agencies in strategy development, technical matters, peer review, project design, and program monitoring.
Through projects to control the spread of AIDS, leprosy, cataract blindness and tuberculosis--and a future project to control malaria--the Government of India is seeking to reduce the burden of the most significant endemic diseases with World Bank Group assistance focusing on high-return investments. Through two Bank Group-assisted projects to support state health systems, the government has also sought to help states improve their health policy environment and access to and quality of services, with particular attention to building institutional capacity, the first-referral level, and services for the poor. This will help establish sustainable health systems that focus on cost-effective programs, and also make sufficient use of the private sector. In the future, the priority will continue to be developing effective and sustainable health systems that can meet the dual demands posed by the growth in non-communicable diseases and peoples' needs for better quality and higher levels of health care.
There are five ongoing projects with the Union and state Ministries of Health and Family Welfare. Three are aimed at critical diseases that constitute current and future burdens on India's health care system, and two are aimed at strengthening the health care system at the state level. The National AIDS Control Project, approved in 1992, supports the government's strategy to initiate a National AIDS Control Program with an IDA credit of US$84 million. The project is a start-up investment intended to launch expanded preventive activities to control HIV transmission. This initial investment will set the stage to mobilize support and assistance from various internal and external sources. The project focuses on metropolitan cities and aims to: promote public awareness and community support; improve blood safety and its use; build capacity for surveillance and clinical management; strengthen control of sexually transmitted diseases; and strengthen the management capacity for HIV/AIDS control. Under the project, regulations have been promulgated to upgrade condom specifications, and policies calling for humane treatment of people with HIV/AIDS were developed. The National Leprosy Elimination Project, approved in 1993, is financed with an IDA credit of US$85 million. The aim of the project is to expand the coverage of the National Leprosy Eradication Program and enhance its effectiveness in preventing disability.
Ultimately, the project aims to enable India to eliminate leprosy as a public health problem by the year 2000 by reducing the disease prevalence to 1 per 10,000. The project is reaching out to underprivileged communities and is expected to benefit directly an estimated 4 million people, of which 2.4 million live below the Government of India's poverty line and of which 1.6 million are women. The project is progressing well and has helped reduce the all-India prevalence rate for leprosy from 19.5 per 10,000 in 1992 to 5.9 per 10,000 in 1996. The Blindness Control Project, financed with an IDA credit of US$117.8 million, was approved in 1994. The project's key objectives are to: improve the quality of cataract surgery; expand service delivery to underserved populations; and reduce the backlog of cataracts by more than 50 percent and incidence by 30 percent in seven selected states: Uttar Pradesh, Madhya Pradesh, Andhra Pradesh, Rajasthan, Maharashtra, Tamil Nadu, and Orissa. The project, which involves both NGOs and the private sector, is working to enhance the quality of service and expand service delivery through new strategies, increased use of modern surgical techniques, and expanded coverage to rural and isolated people. It is also developing skills for eye care by strengthening selected training institutions, upgrading skills of ophthalmic and health personnel, and providing management training to project managers. The project also promotes outreach activities and public awareness through NGOs and community organizations, and is strengthening key institutions at the central, state, and district levels.
In the first two years of the project, the number of surgeries increased by 23 percent. Between July 1995 and June 1996 alone, 1.49 million surgeries were financed under the project; about 60 percent of these operations were performed by or with inputs from NGOs. The Andhra Pradesh First-Referral Health Systems Project was also approved in 1994, and is financed with an IDA credit of US$133 million. The project aims to help the Government of Andhra Pradesh improve efficiency in allocation and use of health resources through policy and institutional development, and improve the quality, effectiveness, and coverage of secondary-level health care to serve better the neediest people. Ultimately, the aim is to improve the health status of the people of Andhra Pradesh, especially the poor and underserved, by reducing mortality, morbidity and disability. The project has also served as a model that can be replicated to reorient the health system in other states in India. The project in Andhra Pradesh set the stage for the State Health Systems II Project, approved in 1996 and financed by an IDA credit of US$350 million.
The project aims to help the Governments of Karnataka, Punjab, and West Bengal put in place a coherent approach to integrating a basic package of preventive and curative health care services. The project has three main activities. First, it will strengthen health care institutions and their ability to deliver services, develop health care policy, and develop surveillance capacity for major communicable diseases and response capabilities.
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