Excellent paper worth reading in full;
Lancet 2011; 377: 252?69
Published Online
January 12, 2011
DOI:10.1016/S0140-6736(10)61265-2
India: Towards Universal Health Coverage 1
Continuing challenge of infectious diseases in India
T Jacob John*, Lalit Dandona, Vinod P Sharma, Manish Kakkar
In India, the range and burden of infectious diseases are enormous. The administrative responsibilities of the health
system are shared between the central (federal) and state governments. Control of diseases and outbreaks is the
responsibility of the central Ministry of Health, which lacks a formal public health department for this purpose.
Tuberculosis, malaria, fi lariasis, visceral leishmaniasis, leprosy, HIV infection, and childhood cluster of vaccinepreventable
diseases are given priority for control through centrally managed vertical programmes. Control of HIV
infection and leprosy, but not of tuberculosis, seems to be on track. Early success of malaria control was not sustained,
and visceral leishmaniasis prevalence has increased. Inadequate containment of the vector has resulted in recurrent
outbreaks of dengue fever and re-emergence of Chikungunya virus disease and typhus fever. Other infectious diseases
caused by faecally transmitted pathogens (enteric fevers, cholera, hepatitis A and E viruses) and zoonoses (rabies,
leptospirosis, anthrax) are not in the process of being systematically controlled. Big gaps in the surveillance and response
system for infectious diseases need to be addressed. Replication of the model of vertical single-disease control for all
infectious diseases will not be effi cient or viable. India needs to rethink and revise its health policy to broaden the
agenda of disease control. A comprehensive review and redesign of the health system is needed urgently to ensure
equity and quality in health care. We recommend the creation of a functional public health infrastructure that is shared
between central and state governments, with professional leadership and a formally trained public health cadre of
personnel who manage an integrated control mechanism of diseases in districts that includes infectious and noninfectious
diseases, and injuries
...
Key messages
? Although the burden of infectious diseases has decreased as a result of overall
socioeconomic progress and increasing use of vaccines and antimicrobials in the past
60 years since independence from colonial rule, they still contribute about 30% of the
disease burden in India.
? Only a few infectious diseases are prioritised in the vertical control programmes
managed by the central government, and even among these diseases only the control
of HIV and leprosy seems to be successful but not that of diseases such as tuberculosis,
malaria, and visceral leishmaniasis.
? Infectious diseases that are not in the vertical control programmes are mostly
neglected, with no formal monitoring or control system at the population level.
? Functional integration of vertical programmes and their coordination with the
health-care system, which is managed by state governments, is needed for effi cient
and sustainable reduction of the burden of a wide range of infectious diseases.
? Case-based disease surveillance, generated through health-care personnel in the
public and private sectors, and public health response at the district level, as part of a
functional public health infrastructure, are urgently needed for eff ective control of all
infectious diseases.
? The public sector health-care network is overwhelmed with preventable morbidity
from infectious and other diseases, encouraging growth of largely unregulated private
commercial health care that entails large out-of-pocket expenditures by families.
? For a formal cadre of public health personnel at district, state, and national levels,
reorganisation of the system and adequate training programmes will be necessary to
control infectious diseases and link this eff ort with control of the increasing burden of
non-infectious diseases and injuries that are already major causes of death and
economic loss.
...
Gaps in information gathering
The Public Health Act of 1897 has not been amended (a
draft of the revised act is pending in Parliament); hence
notifi able diseases are generally not reported. A realtime,
effi cient, and inexpensive surveillance of diseases
in districts that are prone to outbreaks and are targeted
for control, in both public and private-sector hospitals,
has been successfully fi eld tested.9,10 It could not be scaled
up because health care is the responsibility of the state,
and outbreak control is mainly the responsibility of the
federal government. Therefore, the Integrated Disease
Surveillance Project, another vertical programme,
supported by the World Bank, was established in 2004. It
is not integrated with other vertical programmes or with
health care, and is virtually ineff ective yet for the control
of infectious diseases.11 Therefore, a badly designed
solution does not achieve the desired result and also
prevents the application of the right solution. WHO?s
Regional Offi ce for South-East Asia reports monthly data
for selected infectious diseases in member countries,
but data from India are often reported as not available.
Civil law requires death registration before cremation
or burial. Rural communities often ignore it; about
70% of deaths happen at home, and more than threequarters
of these without certifi cation of the cause of
death.13 In urban communities, local health departments
register death, but the information is not captured in
the health-care system.14 Autopsies are rarely done,
except when a criminal case is registered. Invaluable
data about frequency, age pattern, and causes of death
are lost. To capture these data, a public health
infrastructure must include all administrative units.
The neglect of the relevant civil law shows the widely
held belief that life events are externally directed and not
changed by human endeavour.
Another potential source of data for infectious diseases
is the diagnostic laboratory. However, primary and
secondary public sector health-care networks have no
access to microbiology laboratories (except for blood and
sputum smears to test for the presence of malarial
parasites and acid-fast bacilli). The Medical Council of
India does not recognise infectious diseases as a
specialty for postgraduate medical education, resulting
in inadequately prepared teachers who seldom use
evidence-based diagnosis of these diseases in
undergraduate teaching, and thereby perpetuate low
demand and supply of laboratory services. Qualityassured
support for microbiology laboratories is
restricted to a few medical-care institutions.15 Antibiotics
are sold over the counter, overused, and misused,
leading to increasing drug resistance.
Estimates of disease burden are thus obtained from
fragmentary databases, mostly generated through
primary health centres that cater to only a small
proportion of people with illnesses. Denominator-based
data are available only from surveillance of polio
infection and yearly surveys of HIV infection. Within
these limitations, the estimates by the Global Burden of
Disease Project (table) suggest a 15-times greater burden
of infectious diseases per person in India than in the
UK in 2004, and that about 30% of the disease burden in
India is attributable to infections.16 These data do not
capture several other infectious diseases of clinical and
public health importance.
...
Creation of public health infrastructure
India, as an emerging world economic leader, needs to
rescue its reputation as a country that provides its people
freedom from the many endemic and outbreak-prone
infectious diseases that impoverish families through loss
of income and out-of-pocket spending on health care.
Families often have to borrow, or occasionally liquidise
their capital assets?eg, selling cattle, land, or even their
homes. Prevention and control of infectious diseases
require a public health infrastructure, a cadre structure,
professional leadership, trained human resources, and
adequate economic investment.1,2
Incrementally adding new programmes will not solve
the fundamental systemic defi ciency. Even the innovative,
highly visible, and generally successful Integrated Child
Development Service Programme (for nutrition, missing
in primary health care), National Rural Health Mission,
and proposed National Urban Health Mission have
severe limitations in terms of public health functions.
Although all such programmes are good in themselves,
none of them can individually or collectively fi ll the void
of an overarching public health infrastructure.
The health system in India has to be modifi ed with a
major focus on public health in addition to the current
focus predominantly on medical care. Instead of
incremental changes, a transformation is essential. The
current national government came to power with the
people?s mandate for stability, continuity, and socioeconomic
development, and promised in its election
manifesto health security for all. Now is therefore the
best time for an overhaul of the health system.
The Calcutta Declaration on Public Health made a plea
to the governments in 2000 to accept the discipline of
public health as an essential requirement and to create
career structures nationally, and in states and districts,3
but this plea has not been acted on. Since the district is
the logical unit for civil administration, so should it be
made the unit for integration of the activities of medical
care and public health. In 1994, in response to an
outbreak of suspected pneumonic plague in Surat city in
western India, the Government of India appointed the
Technical Advisory Committee on Plague, which
identifi ed the urgent national need for trained
epidemiologists to respond to signals gathered through
disease surveillance in districts and that has not
happened.173 A Department of Public Health should be
created that is on a par with other existing departments,
with a government secretary selected from technically
qualifi ed individuals, as was the case for the Department
of Health Research, which was created in 2008.
To cater for the expected need for trained public health
offi cers in districts, states, and the centre, a national public
health service could be designed that is similar to the
Indian civil services, which include administrative, police,
and foreign services. Side by side, the relations and
budget-sharing between states and the centre should also
be re-examined for adequacy and functional effi ciency.
These prescriptions come from our own assessment, but
we do not have the necessary skills to design a specifi c
model, for which wider consultations are obviously
essential. What we have provided is more of a product
description rather than specifi cation for construction. A
change is imperative as discussed in another report in this
Lancet Series.174 A suitable think tank might be created by
the Government of India, such as a National Commission
on Healthcare and Public Health, to help make this need
for transformation a reality.175
There is an alarming and rapidly rising trend in the
burden of and mortality due to lifestyle diseases (noncommunicable,
metabolic, or related to urbanisation) in
India as discussed by Patel and colleagues176 in this Series.
The public health system that learns from the control of
single-pathogen infectious diseases should be able to
address the control of lifestyle diseases that often have
multifactorial causes. If control of infectious diseases is
the primary school of public health, control of lifestyle
diseases is the high school to which we have to progress
in the shortest possible time.
Lancet 2011; 377: 252?69
Published Online
January 12, 2011
DOI:10.1016/S0140-6736(10)61265-2
India: Towards Universal Health Coverage 1
Continuing challenge of infectious diseases in India
T Jacob John*, Lalit Dandona, Vinod P Sharma, Manish Kakkar
In India, the range and burden of infectious diseases are enormous. The administrative responsibilities of the health
system are shared between the central (federal) and state governments. Control of diseases and outbreaks is the
responsibility of the central Ministry of Health, which lacks a formal public health department for this purpose.
Tuberculosis, malaria, fi lariasis, visceral leishmaniasis, leprosy, HIV infection, and childhood cluster of vaccinepreventable
diseases are given priority for control through centrally managed vertical programmes. Control of HIV
infection and leprosy, but not of tuberculosis, seems to be on track. Early success of malaria control was not sustained,
and visceral leishmaniasis prevalence has increased. Inadequate containment of the vector has resulted in recurrent
outbreaks of dengue fever and re-emergence of Chikungunya virus disease and typhus fever. Other infectious diseases
caused by faecally transmitted pathogens (enteric fevers, cholera, hepatitis A and E viruses) and zoonoses (rabies,
leptospirosis, anthrax) are not in the process of being systematically controlled. Big gaps in the surveillance and response
system for infectious diseases need to be addressed. Replication of the model of vertical single-disease control for all
infectious diseases will not be effi cient or viable. India needs to rethink and revise its health policy to broaden the
agenda of disease control. A comprehensive review and redesign of the health system is needed urgently to ensure
equity and quality in health care. We recommend the creation of a functional public health infrastructure that is shared
between central and state governments, with professional leadership and a formally trained public health cadre of
personnel who manage an integrated control mechanism of diseases in districts that includes infectious and noninfectious
diseases, and injuries
...
Key messages
? Although the burden of infectious diseases has decreased as a result of overall
socioeconomic progress and increasing use of vaccines and antimicrobials in the past
60 years since independence from colonial rule, they still contribute about 30% of the
disease burden in India.
? Only a few infectious diseases are prioritised in the vertical control programmes
managed by the central government, and even among these diseases only the control
of HIV and leprosy seems to be successful but not that of diseases such as tuberculosis,
malaria, and visceral leishmaniasis.
? Infectious diseases that are not in the vertical control programmes are mostly
neglected, with no formal monitoring or control system at the population level.
? Functional integration of vertical programmes and their coordination with the
health-care system, which is managed by state governments, is needed for effi cient
and sustainable reduction of the burden of a wide range of infectious diseases.
? Case-based disease surveillance, generated through health-care personnel in the
public and private sectors, and public health response at the district level, as part of a
functional public health infrastructure, are urgently needed for eff ective control of all
infectious diseases.
? The public sector health-care network is overwhelmed with preventable morbidity
from infectious and other diseases, encouraging growth of largely unregulated private
commercial health care that entails large out-of-pocket expenditures by families.
? For a formal cadre of public health personnel at district, state, and national levels,
reorganisation of the system and adequate training programmes will be necessary to
control infectious diseases and link this eff ort with control of the increasing burden of
non-infectious diseases and injuries that are already major causes of death and
economic loss.
...
Gaps in information gathering
The Public Health Act of 1897 has not been amended (a
draft of the revised act is pending in Parliament); hence
notifi able diseases are generally not reported. A realtime,
effi cient, and inexpensive surveillance of diseases
in districts that are prone to outbreaks and are targeted
for control, in both public and private-sector hospitals,
has been successfully fi eld tested.9,10 It could not be scaled
up because health care is the responsibility of the state,
and outbreak control is mainly the responsibility of the
federal government. Therefore, the Integrated Disease
Surveillance Project, another vertical programme,
supported by the World Bank, was established in 2004. It
is not integrated with other vertical programmes or with
health care, and is virtually ineff ective yet for the control
of infectious diseases.11 Therefore, a badly designed
solution does not achieve the desired result and also
prevents the application of the right solution. WHO?s
Regional Offi ce for South-East Asia reports monthly data
for selected infectious diseases in member countries,
but data from India are often reported as not available.
Civil law requires death registration before cremation
or burial. Rural communities often ignore it; about
70% of deaths happen at home, and more than threequarters
of these without certifi cation of the cause of
death.13 In urban communities, local health departments
register death, but the information is not captured in
the health-care system.14 Autopsies are rarely done,
except when a criminal case is registered. Invaluable
data about frequency, age pattern, and causes of death
are lost. To capture these data, a public health
infrastructure must include all administrative units.
The neglect of the relevant civil law shows the widely
held belief that life events are externally directed and not
changed by human endeavour.
Another potential source of data for infectious diseases
is the diagnostic laboratory. However, primary and
secondary public sector health-care networks have no
access to microbiology laboratories (except for blood and
sputum smears to test for the presence of malarial
parasites and acid-fast bacilli). The Medical Council of
India does not recognise infectious diseases as a
specialty for postgraduate medical education, resulting
in inadequately prepared teachers who seldom use
evidence-based diagnosis of these diseases in
undergraduate teaching, and thereby perpetuate low
demand and supply of laboratory services. Qualityassured
support for microbiology laboratories is
restricted to a few medical-care institutions.15 Antibiotics
are sold over the counter, overused, and misused,
leading to increasing drug resistance.
Estimates of disease burden are thus obtained from
fragmentary databases, mostly generated through
primary health centres that cater to only a small
proportion of people with illnesses. Denominator-based
data are available only from surveillance of polio
infection and yearly surveys of HIV infection. Within
these limitations, the estimates by the Global Burden of
Disease Project (table) suggest a 15-times greater burden
of infectious diseases per person in India than in the
UK in 2004, and that about 30% of the disease burden in
India is attributable to infections.16 These data do not
capture several other infectious diseases of clinical and
public health importance.
...
Creation of public health infrastructure
India, as an emerging world economic leader, needs to
rescue its reputation as a country that provides its people
freedom from the many endemic and outbreak-prone
infectious diseases that impoverish families through loss
of income and out-of-pocket spending on health care.
Families often have to borrow, or occasionally liquidise
their capital assets?eg, selling cattle, land, or even their
homes. Prevention and control of infectious diseases
require a public health infrastructure, a cadre structure,
professional leadership, trained human resources, and
adequate economic investment.1,2
Incrementally adding new programmes will not solve
the fundamental systemic defi ciency. Even the innovative,
highly visible, and generally successful Integrated Child
Development Service Programme (for nutrition, missing
in primary health care), National Rural Health Mission,
and proposed National Urban Health Mission have
severe limitations in terms of public health functions.
Although all such programmes are good in themselves,
none of them can individually or collectively fi ll the void
of an overarching public health infrastructure.
The health system in India has to be modifi ed with a
major focus on public health in addition to the current
focus predominantly on medical care. Instead of
incremental changes, a transformation is essential. The
current national government came to power with the
people?s mandate for stability, continuity, and socioeconomic
development, and promised in its election
manifesto health security for all. Now is therefore the
best time for an overhaul of the health system.
The Calcutta Declaration on Public Health made a plea
to the governments in 2000 to accept the discipline of
public health as an essential requirement and to create
career structures nationally, and in states and districts,3
but this plea has not been acted on. Since the district is
the logical unit for civil administration, so should it be
made the unit for integration of the activities of medical
care and public health. In 1994, in response to an
outbreak of suspected pneumonic plague in Surat city in
western India, the Government of India appointed the
Technical Advisory Committee on Plague, which
identifi ed the urgent national need for trained
epidemiologists to respond to signals gathered through
disease surveillance in districts and that has not
happened.173 A Department of Public Health should be
created that is on a par with other existing departments,
with a government secretary selected from technically
qualifi ed individuals, as was the case for the Department
of Health Research, which was created in 2008.
To cater for the expected need for trained public health
offi cers in districts, states, and the centre, a national public
health service could be designed that is similar to the
Indian civil services, which include administrative, police,
and foreign services. Side by side, the relations and
budget-sharing between states and the centre should also
be re-examined for adequacy and functional effi ciency.
These prescriptions come from our own assessment, but
we do not have the necessary skills to design a specifi c
model, for which wider consultations are obviously
essential. What we have provided is more of a product
description rather than specifi cation for construction. A
change is imperative as discussed in another report in this
Lancet Series.174 A suitable think tank might be created by
the Government of India, such as a National Commission
on Healthcare and Public Health, to help make this need
for transformation a reality.175
There is an alarming and rapidly rising trend in the
burden of and mortality due to lifestyle diseases (noncommunicable,
metabolic, or related to urbanisation) in
India as discussed by Patel and colleagues176 in this Series.
The public health system that learns from the control of
single-pathogen infectious diseases should be able to
address the control of lifestyle diseases that often have
multifactorial causes. If control of infectious diseases is
the primary school of public health, control of lifestyle
diseases is the high school to which we have to progress
in the shortest possible time.
Comment