Although the health of India's people has improved significantly since Independence some sixty years ago, the country's original health agenda still remains unfinished. At the same time new diseases are on the rise:  Health Improvements since Independence:  ·        Average life expectancy rose from 44 to 63 between 1960 and 2002 ·        Infant mortality more than halved to 68 per thousand ·        Total fertility declined to 2.9 children per woman ·        Progress was made in the control of major communicable diseases.  Unfinished Health Agenda: Despite these gains, a high proportion of the population continues to suffer and die from easily preventable diseases. Fertility rates outstrip those in most Asian countries, and maternal mortality is high. Of particular concern is the health of India’s children, whose well being will determine the extent of India’s much-awaited demographic dividend. These, together with the continuing burden of communicable diseases such as tuberculosis and malaria, constitute the country’s considerable ‘unfinished health agenda’.  New diseases on the rise: At the same time, new health challenges are emerging. The rise in chronic adult diseases such as cardiovascular illnesses and diabetes is stretching the system’s capacity to respond. And, although the prevalence of HIV has recently been lowered to an estimated 0.41% of the population, or approximately 2.45 million individuals, this still poses a very significant burden and requires continued efforts to avoid a devastating, more generalized epidemic.  Key Challenges  - Maternal and Child Health: Despite the largest child-nutrition program in the world, 45 percent of India’s children between the ages of 0-4 are stunted. Since the mid 1990s, the fall in infant and child mortality has slowed and maternal morality remains high. At the current rate of progress, India will not be able to achieve the Millennium Development Goals for health.
. - Stark Disparities: There are stark disparities in people’s health both between and within states. Some states do much better than others with similar levels of resources. Moreover, inequalities in health indicators have been growing since the 1990s, with the northern states displaying the poorest performance. Even within these states, some districts account for a disproportionate share of poor health indicators.
. - Systemic Problems: Health services suffer from systemic problems that limit the efficient use of resources. Government health care delivery is weak and of poor quality, with significant staff absenteeism and inadequate key inputs. This is much worse in the poorer and more populous northern states.
. - Unregulated Private Providers: Faced with inadequate and poor government health services, the bulk of the people’s health spending - 80% - goes to unregulated private providers, many of whom are unqualified. While the government recognizes the potential for public-private partnerships to improve basic health care, innovative partnerships with NGOs and private providers need to be tried and tested to improve the delivery of priority health services.
. - Lack of Adequate Medical Insurance: Only 10 per cent Indians have insurance, and much of it is inadequate. Nearly all private health service providers require families to spend out-of-pocket at the point of service. This leaves people, especially the poor, highly vulnerable. Without adequate financial support, health remains a major cause of financial insecurity and one of the most significant causes of households falling into poverty.
. - Poor Performance of Health Services in States: Although central government schemes drive efforts to improve health outcomes, it is the performance of health services in the states and local governments that determine the actual health outcomes for the people. Better focus is needed to reach the poor in the worst-affected areas.
. - More and Better Public Health Spending Required: The challenge for the government remains how to achieve both more and better public spending on the health sector. There is a need to focus both on accelerating the flow of resources as well as improving governance and accountability in the provision of services.
. - Programs Need Technical Strengthening: Some large-scale programs - for example, malaria control and child undernutrition - need technical strengthening.
Government Initiatives  Recently, the Central Government has focused new energy and attention on the health sector. National health budgets have increased significantly in the last two years and additional resources have been promised. The Government proposes to increase health spending from the current level of a little more than 1 percent of GDP to 2-3 percent.  A National Rural Health Mission (NRHM) was launched in April 2005, and government departments have been reorganized at the national as well as the state level. Efforts are on to address systemic problems in states with the poorest performance.  The NRHM supports a number of novel approaches to improving health outcomes, together with more traditional approaches to strengthen government service delivery. Much will however depend on the effectiveness of efforts to improve human capacities and functioning at the state and local levels.  Some specific new technical strategies to improve outcomes, for example in relation to malaria, child undernutrition, and institutional deliveries, are still at an early stage.  World Bank Support  The World Bank has been lending for health and nutrition in India since the early 1990s. Its priority is to help India to achieve the health MDGs and to reduce the impact of disease on poverty.  Projects  The Bank's lending portfolio is large and diverse. It includes controlling malaria and other vector borne diseases, eradicating polio, controlling TB and HIV/AIDS, and strengthening national programs in reproductive and child health and nutrition, all part of the National Rural Health Mission. Bank projects support: State Health Systems: Projects to improve public health and rural health service delivery in Uttar Pradesh, Karnataka, Tamil Nadu, and Rajasthan. A second generation of state-specific projects will help improve basic health systems in both the government and private sector, increasingly in the worst-off states.Â
 Cross-cutting Health Functions at the National Level:
Food and Drug Capacity Building ProjectÂ
National Disease Surveillance Project
All World Bank loans to the health sector are on concessional terms from the Bank’s soft lending arm – IDA. Repayment is to be made over 35 years with a 10-year grace period. Interest charges are well below 1 percent per annum; these decline as the loan is repaid.
Analysis and Research
The World Bank’s analytic work has contributed to the public policy dialogue in the country, notably with the report on ‘Better Health Systems for India’s Poor’ published in 2000.
 Future PlansÂ
The Bank’s new strategy in the field of health, nutrition, and population, agreed with the Government of India, emphasizes consolidating our program with a tighter geographic focus on the poorer states.
 Bank support will aim to strengthen the coverage and quality of basic health and nutrition services, particularly in the poorer states and on poor and excluded people in the better performing states.  The Bank's work also emphasizes the strengthening of governance in health systems, and the monitoring and evaluations of outcomes. We are currently collaborating with the government to improve governance and capacity in the Ministry of Health and Family Welfare’s focal unit for health sector procurement.  |
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