Health Reporting

By Vinay Sukhdeve
Chapter 1

World Health Organization

WHO redirects here. For other uses, see Who (disam- a resolution passed on the subject, Alger Hiss, the Sec-
biguation). retary General of the conference, recommended using a
declaration to establish such an organization. Dr. Sze and
The World Health Organization (WHO) is a other delegates lobbied and a declaration [2] passed calling
for an international conference on health. The use of
specialized agency of the United Nations that is con-
cerned with international public health. It was established the word world, rather than international, emphasized
the truly global nature of what the organization was seek-
on 7 April 1948, headquartered in Geneva, Switzerland. [3]
The WHO is a member of the United Nations Develop- ing to achieve. The constitution of the World Health
Organization was signed by all 51 countries of the United
ment Group. Its predecessor, the Health Organization,
was an agency of the League of Nations. Nations, and by 10 other countries, on 22 July 1946.[4]
It thus became the rst specialised agency of the United
The constitution of the World Health Organization had Nations to which every member subscribed.[5] Its consti-
been signed by 61 countries on 22 July 1946, with the tution formally came into force on the rst World Health
rst meeting of the World Health Assembly nishing on Day on 7 April 1948, when it was ratied by the 26th
24 July 1948. It incorporated the Oce international member state.[6] The rst meeting of the World Health
d'hygine publique and the League of Nations Health Or- Assembly nished on 24 July 1948, having secured a bud-
ganization. Since its creation, it has played a leading role get of US$5 million (then GBP1,250,000) for the 1949
in the eradication of smallpox. Its current priorities in- year. Andrija Stampar was the Assemblys rst president,
clude communicable diseases, in particular HIV/AIDS, and G. Brock Chisholm was appointed Director-General
Ebola, malaria and tuberculosis; the mitigation of the ef- of WHO, having served as Executive Secretary during
fects of non-communicable diseases; sexual and repro- the planning stages.[3] Its rst priorities were to control
ductive health, development, and aging; nutrition, food the spread of malaria, tuberculosis and sexually transmit-
security and healthy eating; occupational health; sub- ted infections, and to improve maternal and child health,
stance abuse; and driving the development of reporting, nutrition and environmental hygiene. Its rst legislative
publications, and networking. act was concerning the compilation of accurate statistics
[3]
The WHO is responsible for the World Health Report, a on the spread and morbidity of disease. The logo of the
leading international publication on health, the worldwide World Health Organization features the Rod of Asclepius
[7]
World Health Survey, and World Health Day (7 April of as a symbol for healing.
every year). The head of WHO is Margaret Chan.
The 2014/2015 proposed budget of the WHO is about
US$4 billion.[1] About US$930 million are to be provided
1.1.2 Operational history
by member states with a further US$3 billion to be from
voluntary contributions.[1] IT established an epidemiological information service via
telex in 1947, and by 1950 a mass tuberculosis inocula-
tion drive (using the BCG vaccine) was under way. In
1955, the malaria eradication programme was launched,
1.1 History although it was later altered in objective. 1965 saw the
rst report on diabetes mellitus and the creation of the
1.1.1 Establishment International Agency for Research on Cancer. WHO
moved into its headquarters building in 1966. The
During the 1945 United Nations Conference on Interna- Expanded Programme on Immunization was started in
tional Organization, Dr. Szeming Sze, a delegate from 1974, as was the control programme into onchocerciasis
China, conferred with Norwegian and Brazilian delegates an important partnership between the Food and Agri-
on creating an international health organization under the culture Organization (FAO), the United Nations Devel-
auspices of the new United Nations. After failing to get opment Programme (UNDP), and World Bank. In the

2
1.1. HISTORY
Three former directors of the Global Smallpox Eradication Pro-
gramme read the news that smallpox had been globally eradi-
cated, 1980
following year, the Special Programme for Research and
Training in Tropical Diseases was also launched. In 1976,
the World Health Assembly voted to enact a resolution
on Disability Prevention and Rehabilitation, with a fo-
cus on community-driven care. The rst list of essential
medicines was drawn up in 1977, and a year later the am-
bitious goal of health for all was declared. In 1986,
WHO started its global programme on the growing prob-
lem of HIV/AIDS, followed two years later by additional
attention on preventing discrimination against suerers
and UNAIDS was formed in 1996. The Global Polio
Eradication Initiative was established in 1988.[8]
In 1958, Viktor Zhdanov, Deputy Minister of Health for
the USSR, called on the World Health Assembly to un-
dertake a global initiative to eradicate smallpox, resulting
in Resolution WHA11.54.[9] At this point, 2 million peo-
ple were dying from smallpox every year. In 1967, the
World Health Organization intensied the global small-
pox eradication by contributing $2.4 million annually
to the eort and adopted a new disease surveillance
method.[10][11] The initial problem the WHO team faced
was inadequate reporting of smallpox cases. WHO estab-
lished a network of consultants who assisted countries in
setting up surveillance and containment activities.[12] The
WHO also helped contain the last European outbreak in
Yugoslavia in 1972.[13] After over two decades of ght-
ing smallpox, the WHO declared in 1979 that the disease
had been eradicated the rst disease in history to be
eliminated by human eort.[14]
In 1998, WHOs Director General highlighted gains in
child survival, reduced infant mortality, increased life ex-
pectancy and reduced rates of scourges such as small-
pox and polio on the ftieth anniversary of WHOs found-
ing. He, did, however, accept that more had to be done
to assist maternal health and that progress in this area
had been slow.[15] Cholera and malaria have remained
problems since WHOs founding, although in decline for
a large part of that period.[16] In the twenty-rst cen-
3
tury, the Stop TB Partnership was created in 2000, along
with the UNs formulation of the Millennium Develop-
ment Goals. The Measles initiative was formed in 2001,
and credited with reducing global deaths from the disease
by 68% by 2007. In 2002, The Global Fund to Fight
AIDS, Tuberculosis and Malaria was drawn up to im-
prove the resources available.[8] In 2006, the organization
endorsed the worlds rst ocial HIV/AIDS Toolkit for
Zimbabwe, which formed the basis for a global preven-
tion, treatment and support plan to ght the AIDS pan-
demic.[17]
1.1.3 Overall focus
The WHOs Constitution states that its objective is the
attainment by all people of the highest possible level of
health.[18]
WHO fullls its objective through its functions as de-
ned in its Constitution: (a) to act as the directing and
co-ordinating authority on international health work (b)
to establish and maintain eective collaboration with
the United Nations, specialized agencies, governmen-
tal health administrations, professional groups and such
other organizations as may be deemed appropriate (c)
to assist Governments, upon request, in strengthening
health services (d) to furnish appropriate technical as-
sistance and, in emergencies, necessary aid upon the re-
quest or acceptance of Governments (e) to provide or as-
sist in providing, upon the request of the United Nations,
health services and facilities to special groups, such as
the peoples of trust territories (f) to establish and main-
tain such administrative and technical services as may
be required, including epidemiological and statistical ser-
vices (g) to stimulate and advance work to eradicate epi-
demic, endemic and other diseases (h) to promote, in co-
operation with other specialized agencies where neces-
sary, the prevention of accidental injuries (i) to promote,
in co-operation with other specialized agencies where
necessary, the improvement of nutrition, housing, san-
itation, recreation, economic or working conditions and
other aspects of environmental hygiene (j) to promote co-
operation among scientic and professional groups which
contribute to the advancement of health (k) to propose
conventions, agreements and regulations, and make rec-
ommendations with respect to international health mat-
ters and to perform.
WHO currently denes its role in public health as
follows:[19]
providing leadership on matters critical to health
and engaging in partnerships where joint action is
needed;
shaping the research agenda and stimulating the gen-
eration, translation and dissemination of valuable
knowledge;[20]
4 CHAPTER 1. WORLD HEALTH ORGANIZATION

setting norms and standards and promoting and United Nations Childrens Fund (UNICEF), as well as
monitoring their implementation; smaller organizations. It works to immunize young chil-
dren and prevent the re-emergence of cases in countries
articulating ethical and evidence-based policy op- declared polio-free.[26]
tions;

providing technical support, catalyzing change, and

building sustainable institutional capacity; and
monitoring the health situation and assessing health
trends.
1.1.4 Communicable diseases
The 20122013 WHO budget identied 5 areas among
which funding was distributed.[21] Two of those ve ar-
eas related to communicable diseases: the rst, to reduce
the health, social and economic burden of communica- 1.1.6 Environmental health
ble diseases in general; the second to combat HIV/AIDS,
malaria and tuberculosis in particular.[21]
In terms of HIV/AIDS, WHO works within the UNAIDS
network and considers it important that it works in align-
ment with UNAIDS objectives and strategies. It also
strives to involve sections of society other than health
to help deal with the economic and social eects of the
disease.[22] In line with UNAIDS, WHO has set itself
the interim task between 2009 and 2015 of reducing the
number of those aged 1524 years who are infected by
50%; reducing new HIV infections in children by 90%;
and reducing HIV-related deaths by 25%.[23]
Although WHO dropped its commitment to a global
malaria eradication campaign in the 1970s as too am-
bitious, it retains a strong commitment to malaria con-
trol. WHOs Global Malaria Programme works to keep
track of malaria cases, and future problems in malaria
control schemes. WHO is to report, likely in 2015, as to
whether RTS,S/AS01, currently in research, is a viable
malaria vaccine. For the time being, insecticide-treated
mosquito nets and insecticide sprays are used to prevent
the spread of malaria, as are antimalarial drugs partic-
ularly to vulnerable people such as pregnant women and
young children.[24]
WHOs help has contributed to a 40% fall in the num-
ber of deaths from tuberculosis between 1990 and 2010,
and since 2005, it claims that over 46 million people
have been treated and an estimated 7 million lives saved
through practices advocated by WHO. These include en-
gaging national governments and their nancing, early
diagnosis, standardising treatment, monitoring of the
spread and impact of tuberculosis and stabilising the drug
supply. It has also recognised the vulnerability of victims
of HIV/AIDS to tuberculosis.[25]
WHO aims to eradicate polio. It has also been success-
ful in helping to reduce cases by 99% since the Global
Polio Eradication Initiative was launched in 1988, which
partnered WHO with Rotary International, the US Cen-
ters for Disease Control and Prevention (CDC) and the
1.1.5 Non-communicable diseases
Another of the thirteen WHO priority areas is aimed at
the prevention and reduction of disease, disability and
premature deaths from chronic noncommunicable dis-
eases, mental disorders, violence and injuries, and visual
impairment".[21][27]
The WHO estimates that 12.6 million people died as a
result of living or working in an unhealthy environment
in 2012 this accounts for nearly 1 in 4 of total global
deaths. Environmental risk factors, such as air, water and
soil pollution, chemical exposures, climate change, and
ultraviolet radiation, contribute to more than 100 diseases
and injuries. This can result in a number of pollution-
related diseases.
1.1.7 Life course and life style
WHO works to reduce morbidity and mortality and
improve health during key stages of life, including
pregnancy, childbirth, the neonatal period, childhood
and adolescence, and improve sexual and reproductive
health and promote active and healthy aging for all
individuals.[21][28]
It also tries to prevent or reduce risk factors for health
conditions associated with use of tobacco, alcohol, drugs
and other psychoactive substances, unhealthy diets and
physical inactivity and unsafe sex".[21][29][30]
WHO works to improve nutrition, food safety and food
security and to ensure this has a positive eect on public
health and sustainable development.[21]
1.1.8 Surgery and trauma care
The WHO promotes road safety as a means to reduce
trac-related injuries.[31]
WHO has also worked on global initiatives in surgery, in-
cluding emergency and essential surgical care,[32] trauma
care,[33] and safe surgery.[34] The WHO Surgical Safety
Checklist is in current use worldwide in the eort to im-
prove patient safety.[35]
1.1. HISTORY 5

1.1.9 Emergency work 1.1.11 Governance and support

The remaining two of WHOs thirteen identied policy
The World Health Organizations primary objective in
areas relate to the role of WHO itself:[21]
natural and man-made emergencies is to coordinate
with Member States and other stakeholders to reduce
avoidable loss of life and the burden of disease and to provide leadership, strengthen governance and
disability.[21] foster partnership and collaboration with countries,
the United Nations system, and other stakeholders
On 5 May 2014, WHO announced that the spread of in order to fulll the mandate of WHO in advancing
polio is a world health emergency outbreaks of the dis- the global health agenda"; and
ease in Asia, Africa and the Middle East are considered
extraordinary.[36][37] to develop and sustain WHO as a exible, learn-
On 8 August 2014, WHO declared that the spread of ing organization, enabling it to carry out its mandate
Ebola is a public health emergency; an outbreak which more eciently and eectively.
is believed to have started in Guinea, has spread to other
nearby countries such as Liberia and Sierra Leone. The Partnerships
situation in West Africa is considered very serious.[38]
The WHO along with the World Bank constitute the
core team responsible for administering the International
Health Partnership (IHP+). The IHP+ is a group of part-
ner governments, development agencies, civil society and
1.1.10 Health policy others committed to improving the health of citizens in
developing countries. Partners work together to put inter-
national principles for aid eectiveness and development
WHO addresses government health policy with two cooperation into practice in the health sector.[44]
aims: rstly, to address the underlying social and eco-
The organization relies on contributions from renowned
nomic determinants of health through policies and pro-
scientists and professionals to inform its work, such as
grammes that enhance health equity and integrate pro-
the WHO Expert Committee on Biological Standardiza-
poor, gender-responsive, and human rights-based ap-
tion,[45] the WHO Expert Committee on Leprosy,[46] and
proaches and secondly to promote a healthier environ-
the WHO Study Group on Interprofessional Education &
ment, intensify primary prevention and inuence public
Collaborative Practice.[47]
policies in all sectors so as to address the root causes of
environmental threats to health.[21] WHO runs the Alliance for Health Policy and Sys-
tems Research, targeted at improving health policy and
The organization develops and promotes the use of
systems.[48]
evidence-based tools, norms and standards to support
member states to inform health policy options. It over- WHO also aims to improve access to health research
sees the implementation of the International Health Reg- and literature in developing countries such as through the
[49]
ulations, and publishes a series of medical classications; HINARI network.
of these, three are overreaching reference classica-
tions": the International Statistical Classication of Dis-
eases (ICD), the International Classication of Function- Public health education and action
ing, Disability and Health (ICF) and the International
Each year, the organization marks World Health Day and
Classication of Health Interventions (ICHI).[39] Other
international policy frameworks produced by WHO in- other observances focusing on a specic health promotion
clude the International Code of Marketing of Breast-milk topic. World Health Day falls on 7 April each year, timed
Substitutes (adopted in 1981),[40] Framework Conven- to match the anniversary of WHOs founding. Recent
tion on Tobacco Control (adopted in 2003)[41] and the themes have been vector-borne diseases (2014), [50]
healthy
Global Code of Practice on the International Recruitment ageing (2012) and drug resistance (2011).
of Health Personnel (adopted in 2010).[42] The other ocial global public health campaigns marked
In terms of health services, WHO looks to improve gov- by WHO are World Tuberculosis Day, World Immu-
ernance, nancing, stang and management and the nization Week, World Malaria Day, World No Tobacco
availability and quality of evidence and research to guide Day, World Blood Donor Day, World Hepatitis Day, and
policy making. It also strives to ensure improved access, World AIDS Day.
quality and use of medical products and technologies.[21] As part of the United Nations, the World Health Orga-
WHO - working with donor agencies and national govern- nization supports work towards the Millennium Devel-
ments - can improve their use of and their reporting about opment Goals.[51] Of the eight Millennium Development
their use of research evidence.[43] Goals, three reducing child mortality by two-thirds, to
6 CHAPTER 1. WORLD HEALTH ORGANIZATION

reduce maternal deaths by three-quarters, and to halt and The WHO regularly publishes a World Health Report, its
begin to reduce the spread of HIV/AIDS relate directly leading publication, including an expert assessment of
to WHOs scope; the other ve inter-relate and have an a specic global health topic.[64] Other publications of
impact on world health.[52] WHO include the Bulletin of the World Health Organiza-
tion,[65] the Eastern Mediterranean Health Journal (over-
seen by EMRO),[66] the Human Resources for Health
1.1.12 Data handling and publications (published in collaboration with BioMed Central),[67] and
the Pan American Journal of Public Health (overseen by
[68]
The World Health Organization works to provide the PAHO/AMRO).
needed health and well-being evidence through a variety
of data collection platforms, including the World Health
Survey covering almost 400,000 respondents from 70 1.2 Structure
countries,[53] and the Study on Global Ageing and Adult
Health (SAGE) covering over 50,000 persons over 50
The World Health Organization is a member of the
years old in 23 countries.[54] The Country Health Intelli-
United Nations Development Group.[69]
gence Portal (CHIP), has also been developed to provide
an access point to information about the health services
that are available in dierent countries.[55] The informa-
tion gathered in this portal is utilized by the countries
1.2.1 Membership
to set priorities for future strategies or plans, implement,
monitor, and evaluate it.
The WHO has published various tools for measuring and
monitoring the capacity of national health systems[56]
and health workforces.[57] The Global Health Observa-
tory (GHO) has been the WHOs main portal which pro-
vides access to data and analyses for key health themes
by monitoring health situations around the globe.[58]
The WHO Assessment Instrument for Mental Health Sys-
tems (WHO-AIMS), the WHO Quality of Life Instru-
Countries by World Health Organization membership status
ment (WHOQOL), and the Service Availability and
Readiness Assessment (SARA) provide guidance for data
collection.[59] Collaborative eorts between WHO and As of 2015, the WHO has 194 member states: all of them
other agencies, such as through the Health Metrics Net- Member States of the United Nations except for the Cook
work, also aim to provide sucient high-quality infor- Islands and Niue.[70] (A state becomes a full member of
mation to assist governmental decision making.[60] WHO WHO by ratifying the treaty known as the Constitution
promotes the development of capacities in member states of the World Health Organization.) As of 2013, it also
had two associate members, Puerto Rico and Tokelau.[71]
to use and produce research that addresses their national
needs, including through the Evidence-Informed Policy Several other countries have been granted observer status.
Palestine is an observer as a national liberation move-
Network (EVIPNet).[61] The Pan American Health Orga-
nization (PAHO/AMRO) became the rst region to de- ment recognised by the League of Arab States under
United Nations Resolution 3118. The Holy See also at-
velop and pass a policy on research for health approved
in September 2009.[62] tends as an observer, as does the Order of Malta.[72] In
2010, Taiwan was invited under the name of "Chinese
On 10 December 2013, a new WHO database, known Taipei".[73]
as MiNDbank, went online. The database was launched
on Human Rights Day, and is part of WHOs Quali- WHO Member States appoint delegations to the World
tyRights initiative, which aims to end human rights vio- Health Assembly, WHOs supreme decision-making
lations against people with mental health conditions. The body. All UN Member States are eligible for WHO mem-
new database presents a great deal of information about bership, and, according to the WHO web site, other
mental health, substance abuse, disability, human rights, countries may be admitted as members when their ap-
and the dierent policies, strategies, laws, and service plication has been approved by a simple majority vote of
[70]
standards being implemented in dierent countries. [63] the World Health Assembly.
It also contains important international documents and In addition, the UN observer organizations International
information. The database allows visitors to access the Committee of the Red Cross and International Federation
health information of WHO member states and other of Red Cross and Red Crescent Societies have entered
partners. Users can review policies, laws, and strategies into ocial relations with WHO and are invited as ob-
and search for the best practices and success stories in the servers. In the World Health Assembly they are seated
eld of mental health.[63] alongside the other NGOs.[72]
1.2. STRUCTURE
1.2.2 Assembly and Executive Board
WHO Headquarters in Geneva
The World Health Assembly is the legislative and
supreme body of WHO. Based in Geneva, it typically
meets yearly in May. It appoints the Director-General
every ve years, and votes on matters of policy and -
nance of WHO, including the proposed budget. It also re-
views reports of the Executive Board and decides whether
there are areas of work requiring further examination.
The Assembly elects 34 members, technically qualied
in the eld of health, to the Executive Board for three-
year terms. The main functions of the Board are to carry
out the decisions and policies of the Assembly, to advise
it and to facilitate its work.[74]
1.2.3 Regional oces
Regional oces and regions of the WHO:
Africa; HQ: Brazzaville, Congo
Americas; HQ: Washington, DC, USA
Eastern Med.; HQ: Cairo, Egypt
Europe; HQ: Copenhagen, Denmark
South East Asia; HQ: New Delhi, India
Western Pacic; HQ: Manila, Philippines
The regional divisions of WHO were created between
1949 and 1952, and are based on article 44 of WHOs
constitution, which allowed the WHO to establish a [sin-
gle] regional organization to meet the special needs of
[each dened] area. Many decisions are made at regional
level, including important discussions over WHOs bud-
7
get, and in deciding the members of the next assembly,
which are designated by the regions.[75]
Each region has a Regional Committee, which generally
meets once a year, normally in the autumn. Representa-
tives attend from each member or associative member in
each region, including those states that are not fully recog-
nised. For example, Palestine attends meetings of the
Eastern Mediterranean Regional oce. Each region also
has a regional oce.[75] Each Regional Oce is headed
by a Regional Director, who is elected by the Regional
Committee. The Board must approve such appointments,
although as of 2004, it had never overruled the preference
of a regional committee. The exact role of the board in
the process has been a subject of debate, but the practi-
cal eect has always been small.[75] Since 1999, Regional
Directors serve for a once-renewable ve-year term.[76]
Each Regional Committee of the WHO consists of all the
Health Department heads, in all the governments of the
countries that constitute the Region. Aside from electing
the Regional Director, the Regional Committee is also in
charge of setting the guidelines for the implementation,
within the region, of the health and other policies adopted
by the World Health Assembly. The Regional Committee
also serves as a progress review board for the actions of
WHO within the Region.
The Regional Director is eectively the head of WHO
for his or her Region. The RD manages and/or super-
vises a sta of health and other experts at the regional
oces and in specialized centers. The RD is also the di-
rect supervising authorityconcomitantly with the WHO
Director-Generalof all the heads of WHO country of-
ces, known as WHO Representatives, within the Re-
gion.
1.2.4 People
The head of the organization is the Director-General,
elected by the World Health Assembly.[74] The current
Director-General is Margaret Chan, who was rst ap-
pointed on 9 November 2006[84] and conrmed for a sec-
ond term until the end of June 2017.[85]
WHO employs 8,500 people in 147 countries.[86] In sup-
port of the principle of a tobacco-free work environment
the WHO does not recruit cigarette smokers.[87] The or-
ganization has previously instigated the Framework Con-
vention on Tobacco Control in 2003.[88]
The WHO operates "Goodwill Ambassadors", mem-
bers of the arts, sport or other elds of public life
aimed at drawing attention to WHOs initiatives and
projects. There are currently ve Goodwill Ambassadors
(Jet Li, Nancy Brinker, Peng Liyuan, Yohei Sasakawa
and the Vienna Philharmonic Orchestra) and a further
ambassador associated with a partnership project (Craig
David).[89]
8 CHAPTER 1. WORLD HEALTH ORGANIZATION

1.2.5 Country and liaison oces a total of 473 non-governmental organizations (NGO)
had some form of partnership with WHO. There were
The World Health Organization operates 147 country of- 189 partnerships with international NGOs in formal of-
ces in all its regions.[90] It also operates several liai- cial relations the rest being considered informal in
son oces, including those with the European Union, character.[97] Partners include the Bill and Melinda Gates
United Nations and a single oce covering the World Foundation[98] and the Rockefeller Foundation.[99]
Bank and International Monetary Fund. It also oper-
ates the International Agency for Research on Cancer in
Lyon, France, and the WHO Centre for Health Develop- 1.3 Controversies
ment in Kobe, Japan.[91] Additional oces include those
in Pristina; the West Bank and Gaza; the US-Mexico Bor-
der Field Oce in El Paso; the Oce of the Caribbean 1.3.1 IAEA Agreement WHA 1240
Program Coordination in Barbados; and Northern Mi-
cronesia oce.[92] There will generally be one WHO
country oce in the capital, occasionally accompanied
by satellite-oces in the provinces or sub-regions of the
country in question.
The country oce is headed by a WHO Representative
(WR). As of 2010, the only WHO Representative outside
Europe to be a national of that country was for the Libyan
Arab Jamahiriya (Libya); all other sta were interna-
tional. Those in the Region for the Americas, they are
referred to as PAHO/WHO Representatives. In Europe,
WHO Representatives also serve as Head of Country Of-
ce, and are nationals with the exception of Serbia; there
are also Heads of Country Oce in Albania, the Russian
Federation, Tajikistan, Turkey, and Uzbekistan.[92] The Yablokov (left) and Vassili Nesterenko (farthest right) protest-
WR is member of the UN system country team which is ing in front of the World Health Organization headquarters in
Geneva, Switzerland in 2008.
coordinated by the UN System Resident Coordinator.
The country oce consists of the WR, and several health
and other experts, both foreign and local, as well as the
necessary support sta.[90] The main functions of WHO
country oces include being the primary adviser of that
countrys government in matters of health and pharma-
ceutical policies.[93]

1.2.6 Financing and partnerships

The WHO is nanced by contributions from member

states and outside donors. As of 2012, the largest annual
assessed contributions from member states came from the
United States ($110 million), Japan ($58 million), Ger-
many ($37 million), United Kingdom ($31 million) and
France ($31 million).[94] The combined 20122013 bud- Demonstration on Chernobyl disaster day near WHO in Geneva
get has proposed a total expenditure of $3,959 million, of
which $944 million (24%) will come from assessed con- In 1959, the WHO signed Agreement WHA 1240 with
tributions. This represented a signicant fall in outlaythe International Atomic Energy Agency (IAEA). The
compared to the previous 20092010 budget, adjusting agreement states that the WHO recognises the IAEA as
to take account of previous underspends. Assessed con- having responsibility for peaceful nuclear energy without
tributions were kept the same. Voluntary contributions prejudice to the roles of the WHO of promoting health.
will account for $3,015 million (76%), of which $800 However, the following paragraph adds that whenever
million is regarded as highly or moderately exible fund-
either organization proposes to initiate a programme or
ing, with the remainder tied to particular programmes oractivity on a subject in which the other organization has
objectives.[95] or may have a substantial interest, the rst party shall con-
In recent years, the WHOs work has involved increas- sult the other with a view to adjusting the matter by mu-
ing collaboration with external bodies.[96] As of 2002, tual agreement.[100] The nature of this statement has led
1.3. CONTROVERSIES 9

some pressure groups and activists (including Women in 1.3.5 2009 swine u pandemic
Europe for a Common Future) to believe that the WHO is
restricted in its ability to investigate the eects on human Main article: 2009 u pandemic
health of radiation caused by the use of nuclear power and
the continuing eects of nuclear disasters in Chernobyl In 2007, the WHO organized work on pandemic
and Fukushima. They believe WHO must regain what inuenza vaccine development through clinical trials in
they see as independence.[101][102][103] collaboration with many experts. A pandemic involv-
ing the H1N1 inuenza virus was declared by Director-
General Margaret Chan in April 2009.
1.3.2 Roman Catholic Church and AIDS By the post-pandemic period critics claimed the WHO
had exaggerated the danger, spreading fear and confu-
Main article: Roman Catholic Church and AIDS sion rather than immediate information.[111] Industry
experts countered that the 2009 pandemic had led to un-
precedented collaboration between global health author-
In 2003, the WHO denounced the Roman Curia's health ities, scientists and manufacturers, resulting in the most
departments opposition to the use of condoms, saying: comprehensive pandemic response ever undertaken, with
These incorrect statements about condoms and HIV are a number of vaccines approved for use three months after
dangerous when we are facing a global pandemic which the pandemic declaration. This response was only possi-
has already killed more than 20 million people, and cur- ble because of the extensive preparations undertaken in
rently aects at least 42 million.[104] As of 2009, the during the last decade.[112]
Catholic Church remains opposed to increasing the use
of contraception to combat HIV/AIDS.[105] At the time,
the World Health Assembly President, Guyana's Health 1.3.6 2013-16 Ebola outbreak and reform
Minister Leslie Ramsammy, condemned Pope Benedicts eorts
opposition to contraception, saying he was trying to cre-
ate confusion and impede proven strategies in the bat- Following the 2014 Ebola outbreak in West Africa, the
tle against the disease.[106] organization was heavily criticized for its bureaucracy,
insucient nancing, regional structure, and stang
prole.[113]
1.3.3 Intermittent preventive therapy An internal WHO report on the Ebola response pointed
to underfunding and lack of core capacity in health sys-
The aggressive support of the Bill & Melinda Gates Foun- tems in developing countries as the primary weaknesses
dation for intermittent preventive therapy of malaria trig- of the existing system. At the annual World Health As-
gered a memo from the former WHO malaria chief Akira sembly in 2015, Director General Margaret Chan an-
Kochi.[107] nounced a $100 million Contingency Fund for rapid re-
sponse to future emergencies,[114][115] of which it had re-
ceived $26.9 million by April 2016 (for 2017 disburse-
ment). WHO has budgeted an additional $494 million
1.3.4 Diet and sugar intake for its Health Emergencies Programme in 2016-17, for
which it had received $140 million by April 2016.[116]
Some of the research undertaken or supported by WHO The program was aimed at rebuilding WHO capacity for
to determine how peoples lifestyles and environments direct action, which critics said had been lost due to bud-
are inuencing whether they live in better or worse get cuts in the previous decade that had left the organiza-
health can be controversial, as illustrated by a 2003 tion in an advisory role dependent on member states for
joint WHO/FAO report on nutrition and the prevention on-the-ground activities. In comparison, billions of dol-
of chronic non-communicable disease,[108] which rec- lars have been spent by developed countries on the 2013-
ommended that sugar should form no more than 10% 16 Ebola epidemic and 2015-16 Zika epidemic.[117]
of a healthy diet. The report led to lobbying by the
sugar industry against the recommendation, to which the
WHO/FAO responded by including in the report this 1.3.7 FCTC implementation database
statement: The Consultation recognized that a popula-
tion goal for free sugars of less than 10% of total energy The WHO has a Framework Convention on Tobacco im-
is controversial. It also stood by its recommendation plementation database which is one of the only mech-
based upon its own analysis of scientic studies.[109] In anisms to help enforce compliance with the FCTC.[118]
2014, WHO reduced recommended sugar levels by half However, there has been reports of numerous discrepan-
and said that sugar should make up no more than 5% of cies between it and national implementation reports on
a healthy diet.[110] which it was built. As researchers Homan and Rizvi
10 CHAPTER 1. WORLD HEALTH ORGANIZATION

report As of July 4, 2012, 361 (327%) of 1104 coun-
tries responses were misreported: 33 (30%) were clear
errors (eg, database indicated yes when report indicated
no), 270 (245%) were missing despite countries having
submitted responses, and 58 (53%) were, in our opinion,
misinterpreted by WHO sta.[119]
1.6 Notes and references
[1] Programme budget 20142015 (PDF). who.int. 24 May
2013. Retrieved 23 February 2015.
[2] Sze Szeming Papers, 19452014, UA.90.F14.1, Univer-
sity Archives, Archives Service Center, University of
Pittsburgh.

[3] World Health Organization. The British Medical Jour-

1.4 World headquarters nal. BMJ Publishing Group. 2 (4570): 302303. 7
August 1948. doi:10.1136/bmj.2.4570.302. JSTOR
The seat of the organization is in Geneva, Switzerland. It 25364565.
was dedicated and opened in 1966.
[4] http://whqlibdoc.who.int/hist/chronicles/chronicle_
1947.pdf Chronicle of the World Health Organization,
Vol. I, p. 6-11
1.4.1 Early views
[5] Shimkin, Michael B. (27 September 1946). The World
1.4.2 Views 2013 Health Organization. Science. American Association
for the Advancement of Science. 104 (2700): 281283.
doi:10.1126/science.104.2700.281. JSTOR 1674843.
1.5 See also
[6] Chronicle of the World Health Organization, 1947
(PDF). Retrieved 18 July 2007.
Global health
[7] World Health Organization Philippines. WHO. Re-
Timeline of global health trieved 27 March 2012.

[8] WHO at 60 (PDF). WHO. Retrieved 31 March 2012.

Global Mental Health
[9] Fenner, Frank (1988). Development of the Global
Health For All Smallpox Eradication Programme (PDF). Smallpox and
Its Eradication (History of International Public Health, No.
Health promotion 6). Geneva: World Health Organization. pp. 366418.
ISBN 92-4-156110-6.
Healthy city / Alliance for Healthy Cities, an inter-
national alliance [10] Karel Raka and Smallpox (PDF). Central European
Journal of Public Health. March 2010. Retrieved 17
Health Sciences Online, virtual learning resources November 2010.

[11] Karel Raka The Development of Modern Epidemiol-

High 5s Project, a patient safety collaboration
International Health Partnership
International Labour Organization
Open Learning for Development, virtual learning
resources
Public health
ogy. The role of the IEA (PDF). Central European Jour-
nal of Public Health. March 2010. Retrieved 17 Novem-
ber 2010.
[12] Orenstein, Walter A.; Plotkin, Stanley A. (1999).
Vaccines. Philadelphia: W.B. Saunders Co. pp. ebook.
ISBN 0-7216-7443-7.
[13] BBC History Smallpox: Eradicating the Scourge. Re-
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[14] Anniversary of smallpox eradication. WHO Media Cen-

Sustainable Development tre. 18 June 2010. Retrieved 11 February 2012.
The Partnership for Maternal, Newborn and Child [15] World Health Day: Safe Motherhood (PDF). WHO. 7
Health April 1998. p. 1. Retrieved 31 March 2012.

Tropical disease
WHO Guidelines for drinking-water quality
WHO Pesticide Evaluation Scheme
[16] World Health Organization. Medical Schools and Nurs-
ing Colleges. 2003. Retrieved 31 March 2012.
[17] Zimbabwe launches worlds 1st AIDS training package.
chinaview.cn. 4 October 2006. Retrieved 16 January
2012.

List of most polluted cities in the world by particu- [18] Constitution of the World Health Organization (PDF).
late matter concentration World Health Organization. Retrieved 11 February 2008.
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 1.7. EXTERNAL LINKS 13

[105] Pope claims condoms could make African Aids crisis

worse. The Guardian. 17 March 2009. Retrieved 31
March 2012.
[106] World Health Assembly: Pope Benedict wrong"".
Google News. Agence France-Presse. 21 March 2009.
Retrieved 31 March 2012.
[107] McNeil, Donald G. (16 February 2008). Gates Founda-
tions Inuence Criticized. The New York Times. Re-
trieved 9 February 2012.
[108] Report of a Joint FAO/WHO Consultation. Diet, nutrition
and the prevention of chronic diseases. Geneva: World
Health Organization; 2003 (WHO Technical Report Se-
ries 916).
[109] Mann, Jim (2003). Sugar revisited again (pdf). Bul-
letin of the World Health Organization. 81 (8).
[110] BBC News: WHO: Daily sugar intake 'should be
halved'".
[111] WHO admits errors in handling u pandemic: Agency ac-
cused of overplaying danger of the virus as it swept the
globe. Posted by msnbc.com
[112] Abelina A; et al. (2011). Lessons from pandemic
inuenza A(H1N1) The research-based vaccine indus-
trys perspective (PDF). Vaccine. 29: 11351138.
doi:10.1016/j.vaccine.2010.11.042.
[113] Homan, SJ; Rttingen, JA (February 2014). Split
WHO in two: strengthening political decision-
making and securing independent scientic ad-
vice. Public Health Journal. 128 (2): 188194.
doi:10.1016/j.puhe.2013.08.021. PMID 24434035.
Retrieved 8 July 2015.
[114] Report of the Review Committee on the Role of the In-
ternational Health Regulations (2005) in the Ebola Out-
break and Response (PDF). 13 May 2016. Retrieved 27
May 2016.
[115] WHO Calls For $100 Million Emergency Fund, Doctor
'SWAT Team'".
[116] Reform of WHOs work in health emergency manage-
ment / WHO Health Emergencies Programme (PDF). 5
May 2016. Retrieved 27 May 2016.
[117] WHO Aims To Reform Itself But Health Experts Aren't
Yet Impressed.
[118] http://apps.who.int/fctc/reporting/database
[119] Homan S.J.; Rizvi Z. (2012). WHOs Undermining
Tobacco Control. The Lancet. 380 (9843): 727728.
doi:10.1016/S0140-6736(12)61402-0.

1.7 External links

Ocial website
WHO: Sta regulations and sta rules
World Health Organization on Google+
Chapter 2

Ministry of Health and Family Welfare

The Ministry of Health and Family Welfare is an
Indian government ministry charged with health policy in
India. It is also responsible for all government programs
relating to family planning in India. [1][2]
The Minister of Health and Family Welfare holds cabinet
rank as a member of the Council of Ministers. The cur-
rent minister is Shri. Jagat Prakash Nadda.[3] The Min-
istry regularly publishes the Indian Pharmacopoeia since
1955 through Indian Pharmacopoeia Commission (IPC)
an autonomous body under the ministry for setting of
standards for drugs, pharmaceuticals and healthcare de-
vices and technologies in India.[4]
2.1 Composition
The ministry is composed of four departments: Health
& Family Welfare; Health Research; AIDS Control; and
Ayurveda, Yoga and Naturopathy, Unani, Siddha and
Homoeopathy (AYUSH).[5]
2.1.1 Department of Health
National Mental Health Programme (mental
health)
National Programme for Control of Blindness
(blindness)
National Programme for Prevention and Con-
trol of Deafness (deafness)
National Tobacco Control Programme
(tobacco control)
National Vector Borne Disease Control Pro-
gramme (NVBDCP) (vector-borne disease)
Pilot Programme on Prevention and Con-
trol of Diabetes, CVD and Stroke (diabetes,
cardiovascular disease, stroke)
Revised National TB Control Programme
(tuberculosis)
Universal Immunisation Programme
Medical Council of India
Dental Council of India
Pharmacy Council of India
Indian Nursing Council

The Department of Health deals with health care, in- All India Institute of Speech and Hearing (AIISH),
cluding awareness campaigns, immunisation campaigns, Mysore
preventive medicine, and public health. Bodies under the All India Institute of Physical Medicine and Reha-
administrative control of this department are: bilitation (AIIPMR), Mumbai

National AIDS Control Organisation (NACO) (see Hospital Services Consultancy Corporation Limited
HIV/AIDS in India) (HSCC)
Food Safety and Standards Authority of India
13 National Health Programmes
Central Drugs Standard Control Organization
National AIDS Control Programme (AIDS)
Department Of Aids Control (National AIDS
Control Organisation) (Details About Aids) 2.1.2 Department of Family Welfare
National Cancer Control Programme (cancer)
National Filaria Control Programme The Department of Family Welfare (FW) is responsi-
(lariasis) ble for aspects relating to family welfare, especially in
reproductive health, maternal health, pediatrics, informa-
National Iodine Deciency Disorders Control tion, education and communications; cooperation with
Programme (iodine deciency) NGOs and international aid groups; and rural health ser-
National Leprosy Eradication Programme vices. The Department of Family Welfare is responsible
(leprosy) for:

14
2.2. ALSO READ 15

18 Population Research Centres (PRCs) at six Rashtriya Ayurveda Vidyapeeth, New Delhi
universities and six other institutions across 17 states (RAV)

National Institute of Health and Family Welfare Morarji Desai National Institute of Yoga, New
(NIHFW), South Delhi Delhi (MDNIY)

International Institute for Population Sciences
(IIPS), Mumbai
Central Drug Research Institute (CDRI), Lucknow
Indian Council of Medical Research (ICMR), New
Delhi: founded in 1911, it is one of the oldest med-
ical research bodies in the world
Indian Medicine Pharmaceutical Corporation Lim-
ited (IMPCL), Mohan, Uttaranchal (a public sector
undertaking)
Professional councils
Central Council of Homoeopathy (CCH)
Central Council of Indian Medicine (CCIM)

2.1.3 Department of AYUSH 2.2 Also Read

Main article: AYUSH
Mission Indradhanush

The Department of Ayurveda, Yoga and Naturopa-

thy, Unani, Siddha and Homoeopathy (AYUSH) deals
with ayurveda (Indian traditional medicine), yoga,
naturopathy, unani, siddha, and homoeopathy, and other
alternative medicine systems.
The department was established in March 1995 as the
Department of Indian Systems of Medicines and Ho-
moeopathy (ISM&H). The department is charged with
upholding education standards in the Indian Systems of
Medicines and Homoeopathy colleges, strengthening re-
search, promoting the cultivation of medicinal plants
used, and working on Pharmacopoeia standards. Bodies
under the control of the Department of AYUSH are:
2.3 References
[1] Suspension of anti-diabetes drug takes industry by sur-
prise. The Hindu. June 27, 2013. Retrieved August 1,
2013.
[2] Let the science decide, The Hindu, July 24, 2013, re-
trieved 1 August 2013
[3] National Portal of India : Government : Whos Who
[4] Indian Pharmacopoeia Commission
[5] About Ministry.

Research councils
2.4 External links
Central Council for Research in Ayurveda and
Siddha (CCRAS)
Ocial website
Central Council for Research in Unani
Medicine (CCRUM) Department of Ayurveda, Yoga & Naturopathy,
Unani, Siddha and Homoeopathy (AYUSH), O-
Central Council for Research in Homoeopathy
cial website
(CCRH)
Central Council for Research in Yoga and
Naturopathy (CCRYN)

Educational institutions

National Institute of Ayurveda, Jaipur (NIA)

National Institute of Siddha, Chennai (NIS)
National Institute of Homoeopathy, Kolkata
(NIH)
National Institute of Naturopathy, Pune (NIN)
National Institute of Unani Medicine, Banga-
lore (NIUM)
Institute of Post Graduate Teaching and
Research in Ayurveda, Jamnagar, Gujarat
(IPGTR)
Chapter 3
Health in India
Students educating people about mosquito-borne diseases.
The Constitution of India makes health in India the re-
sponsibility of state governments, rather than the central
federal government. It makes every state responsible for
raising the level of nutrition and the standard of living ofMalnutrition impedes the social and cognitive develop-
its people and the improvement of public health as among
its primary duties. The National Health Policy was en-
dorsed by the Parliament of India in 1983 and updated
in 2002.[1] The National Health Policy is being worked
upon further in 2017 and a draft for public consultation
has been released.[2]
There are great inequalities in health between states. In- school.[10] Also, it reduces the immune defence mech-
fant mortality in Kerala is 12 per thousand live births, but anism, which heightens the risk of infections.[5]
in Assam it is 56.[3]
3.1 Health issues
3.1.1 Malnutrition
Main article: Malnutrition in India
According to a 2005 report, 60% of Indias children
below the age of three were malnourished, which was
greater than the statistics of sub-Saharan African of
28%.[4] It is considered that one in every three malnour-
ished children in the world lives in India. The estimates
varies across the country. It is estimated that Madhya
Pradesh has the highest rate of 50% and Kerala the lowest
with 27%.[5] Although Indias economy grew 55% from
20012006, its child-malnutrition rate only dropped 1%,
lagging behind countries of similar growth rate.[6]
Malnutrition can be described as the unhealthy condition
that results from not eating enough healthy food.[7]
Child malnutrition
Median 2SD of WHO Child Growth Standards
1. NNMB Rural Survey, 200506; NNMB Tribal Sur-
vey, 200809
A well-nourished child is one whose weight and height
measurements compare very well within the standard nor-
mal distribution of heights and weights of healthy chil-
dren of same age and sex.[9]
ment of a child.[6] These irreversible damages result
in lower productivity.[6] As with serious malnutrition,
growth delays hinder a childs intellectual development.
Sick children with chronic malnutrition, especially when
accompanied by anaemia, often suer from a lower learn-
ing capacity during the crucial rst years of attending
Due to their lower social status, girls are far more at risk of
malnutrition than boys their age. Partly as a result of this
cultural bias, up to one third of all adult women in India
are underweight. Inadequate care of these women already
underdeveloped, especially during pregnancy, leads them
in turn to deliver underweight babies who are vulnerable
to further malnutrition and disease.[5]
Forms of malnutrition
Protein-energy malnutrition (PEM), also known as
protein-calorie malnutrition
Iron deciency: nutritional anaemia which can lead
to lessened productivity, sometimes becoming ter-
minal
16
3.1. HEALTH ISSUES 17

Vitamin A deciency, which can lead to blindness the Indian Heart Association and the Medwin Founda-
or a weakened immune system tion were created to raise awareness.[23][24]
Iodine deciency, which can lead to serious mental
or physical complaints 3.1.4 Poor sanitation
Foliate deciency can lead to insucient birth
See also: Water supply and sanitation in India
weight or congenital anomalies such as spina
[10]
bida.
As more than 122 million households have no toilets, and
33% lack access to latrines, over 50% of the population
3.1.2 High infant mortality rate (638 million) defecate in the open.(2008 estimate)[25]
This is relatively higher than Bangladesh and Brazil (7%)
Despite health improvements over the last thirty years, and China (4%).[25] Although 211 million people gained
lives continue to be lost to early childhood diseases, inad- access to improved sanitation from 19902008, only 31%
equate newborn care and childbirth-related causes. More use the facilities provided.[25] Only 11% of Indian rural
than two million children die every year from preventable families dispose of stools safely whereas 80% of the pop-
infections.[11] ulation leave their stools in the open or throw them in
[25]
Approximately 1.72 million children die each year before the garbage. Open air defecation leads to the spread
turning one. The under ve mortality and infant mor- of disease and malnutrition through parasitic and bacte-
[12]
[26]
tality rates have been declining, from 202 and 190 deaths rial infections.
per thousand live births respectively in 1970 to 64 and 50
deaths per thousand live births in 2009.[12][13] However,
this decline is slowing. Reduced funding for immunisa- 3.1.5 Safe drinking water
tion leaves only 43.5% of the young fully immunised.[6]
A study conducted by the Future Health Systems Con- Several million more suer from multiple episodes of di-
sortium in Murshidabad, West Bengal indicates that bar- arrhoea and still others fall ill on account of Hepatitis A,
riers to immunisation coverage are adverse geographic enteric fever, intestinal worms and eye and skin infections [27]
location, absent or inadequately trained health workers caused by poor hygiene and unsafe drinking water.
and low perceived need for immunization.[14] Infrastruc- See also: Water supply and sanitation in India
ture like hospitals, roads, water and sanitation are lack-
ing in rural areas.[15] Shortages of healthcare providers,
Access to protected sources of drinking water has im-
poor intra-partum and newborn care, diarrheal diseases
proved from 68% of the population in 1990 to 88% in
and acute respiratory infections also contribute to the high
[12] 2008.[25] However, only 26% of the slum population has
infant mortality rate.
access to safe drinking water,[26] and 25% of the total
population has drinking water on their premises.[25] This
3.1.3 Diseases problem is exacerbated by falling levels of groundwater
caused mainly by increasing extraction for irrigation.[25]
Diseases such as dengue fever, hepatitis, tuberculosis, Insucient maintenance of the environment around wa-
malaria and pneumonia continue to plague India due to ter sources, groundwater pollution, excessive arsenic and
increased resistance to drugs.[16] In 2011, India devel- uoride[25]in drinking water pose a major threat to Indias
oped a 'totally drug-resistant' form of tuberculosis.[17] health.

HIV/AIDS in India is ranked third highest among coun-

tries with HIV-infected patients. National AIDS Control
Organisation, a government 'Apex Body' is making ef-
forts for managing the HIV/AIDS epidemic in India.[18]
Diarrheal diseases are the primary causes of early child-
hood mortality.[19] These diseases can be attributed to
poor sanitation and inadequate safe drinking water.[20] In-
dia has the worlds highest incidence of rabies.
In 2012 India was polio-free for the rst time in its
history.[21] This was achieved because of the Pulse Polio
programme started in 199596 by the government.[22]
Indians are at particularly high risk for atherosclerosis and
coronary artery disease. This may be attributed to a ge-
netic predisposition to metabolic syndrome and adverse
changes in coronary artery vasodilation. NGOs such as
3.1.6 Female health issues
Main article: Womens health in India
Maternal deaths are similarly high. The reasons for this
high mortality are that few women have access to skilled
birth attendants and fewer still to quality emergency ob-
stetric care. In addition, only 15 per cent of mothers re-
ceive complete antenatal care and only 58 per cent receive
iron or folate tablets or syrup.[11] Womens health in In-
dia involves numerous issues. Some of them include the
following:
Malnutrition : The main cause of female malnu-
18
trition in India is the tradition requiring women to
eat last, even during pregnancy and when they are
lactating.[28]
Breast Cancer : One of the most severe and increas-
ing problems among women in India, resulting in
higher mortality rates.
Maternal Mortality : Indian maternal mortality rates
in rural areas are one of the highest in the world.[28]
3.1.7 Rural health
Rural India contains over 68% of Indias total
population,[29] and half of all residents of rural ar-
eas live below the poverty line, struggling for better
and easy access to health care and services.[30] Health
issues confronted by rural people are many and diverse
from severe malaria to uncontrolled diabetes, from a
badly infected wound to cancer.[31] Postpartum maternal
illness is a serious problem in resource-poor settings and
contributes to maternal mortality, particularly in rural
India.[32] A study conducted in 2009 found that 43.9% of
mothers reported they experienced postpartum illnesses
six weeks after delivery.[33] Furthermore, because of
limited government resources, much of the health care
provided comes from non prots such as The MINDS
Foundation.[34]
3.2 Twelfth Five Year Plan
3.2.1 Strategy
Based on the recommendation of a High Level Experts
Group (HLEG) and other stakeholder consultations, the
key elements of the Twelfth Five Year plan strategy is
outlined. The long term objective of this strategy is to
establish a system of Universal Health Coverage (UHC)
in the country. Following are the 12th plan period strat-
egy:
1. Substantial expansion and strengthening of public
sector health care system, freeing the vulnerable
population from dependence on high cost and often
unreachable private sector health care system.
2. Health sector expenditure by central government
and state government, both plan and non-plan, will
have to be substantially increased by the twelfth ve-
year plan. It was increased from 0.94 per cent of
GDP in tenth plan to 1.04 per cent in eleventh plan.
The provision of clean drinking water and sanita-
tion as one of the principal factors in control of dis-
eases is well established from the history of indus-
trialised countries and it should have high priority in
health related resource allocation. The expenditure
CHAPTER 3. HEALTH IN INDIA
on health should increased to 2.5 per cent of GDP
by the end of Twelfth Five Year Plan.
3. Financial and managerial system will be redesigned
to ensure ecient utilisation of available resources
and achieve better health outcome. Coordinated de-
livery of services within and across sectors, delega-
tion matched with accountability, fostering a spirit
of innovation are some of the measures proposed.
4. Increasing the cooperation between private and pub-
lic sector health care providers to achieve health
goals. This will include contracting in of services
for gap lling, and various forms of eectively
regulated and managed Public-Private Partnership,
while also ensuring that there is no compromise in
terms of standards of delivery and that the incentive
structure does not undermine health care objectives.
5. The present Rashtriya Swasthya Bhima Yojana
(RSBY) which provides cash less in-patient treat-
ment through an insurance based system should be
reformed to enable access to a continuum of com-
prehensive primary, secondary and tertiary care. In
twelfth plan period entire Below Poverty Line(BPL)
population will be covered through RSBY scheme.
In planning health care structure for the future, it
is desirable to move from a 'fee-for-service' mech-
anism, to address the issue of fragmentation of ser-
vices that works to the detriment of preventive and
primary care and also to reduce the scope of fraud
and induced demand.
6. In order to increase the availability of skilled human
resources, a large expansion of medical schools,
nursing colleges, and so on, is therefore is necessary
and public sector medical schools must play a ma-
jor role in the process. Special eort will be made to
expand medical education in states which are under-
served. In addition, a massive eort will be made to
recruit and train paramedical and community level
health workers.
7. The multiplicity of Central sector or Centrally Spon-
sored Schemes has constrained the exibility of
states to make need based plans or deploy their re-
sources in the most ecient manner. The way for-
ward is to focus on strengthening the pillars of the
health system, so that it can prevent, detect and man-
age each of the unique challenges that dierent parts
of the country face.
8. A series of prescription drugs reforms, promotion
of essential, generic medicine and making these uni-
versally available free of cost to all patients in public
facilities as a part of the Essential Health Package
will be a priority.
9. Eective regulation in medical practice, public
health, food and drugs is essential to safeguard peo-
ple against risks and unethical practices. This is es-
pecially so given the information gaps in the health
3.3. SEE ALSO 19

sector which make it dicult for individual to make plan document or HLEG recommendation. In the section
reasoned choices. of National Rural Health Mission (NRHM) in the docu-
ment, the commitment to provide 30- to 50-bed Commu-
10. The health system in the Twelfth Plan will con- nity Health Centres (CHC) per lakh population is miss-
tinue to have a mix of public and private service ing from the main text. It was easy for the government to
providers. The public sector health services need to recruit poor women as ASHA (Accredited Social Health
be strengthened to deliver both public health related Activist) workers but it has failed to bring doctors, nurses
and clinical services. The public and private sectors and specialist in this area. The ASHA workers who are
also need to coordinate for the delivery of a contin- coming from a poor background are given incentive based
uum of care. A strong regulatory system would su- on performance. These people lose many days job un-
pervise the quality of services delivered. Standard dertaking their task as ASHA worker which is not in-
treatment guidelines should form the basis of clini- centivised properly. Even the 12th plan doesn't give any
cal care across public and private sectors, with the solace.[37] To summarise, successive administrative and
adequate monitoring by the regulatory bodies to im- political reforms have conveniently bypassed training cit-
prove the quality and control the cost of care, izens and local bodies to actively participate in healthcare.
In a situation where people are not enabled to identify
poor quality, speak up and debate. There is dire need for
3.2.2 Criticism the health system to ll that role on behalf of the people
and can be easily done by decentralisation of healthcare
The High Level Expert Group report recommends an in- governance.
crease in public expenditure on health from 1.58 per cent
of GDP currently to 2.1 per cent of GDP by the end of the
12th ve-year plan. However, even this is far lower than 3.3 See also
the global median of 5 per cent.[35] The lack of extensive
and adequately funded public health services pushes large Environment of India
numbers of people to incur heavy out of pocket expendi-
tures on services purchased from the private sector. Out HIV/AIDS in India
of pocket expenditures arise even in public sector hos-
pitals, since lack of medicines means that patients have Indian states ranking by institutional delivery
to buy them. This results in a very high nancial burden National Centre for Disease Control (NCDC)
on families in case of severe illness.[36] Though, the 12th
plan document express concern over high out-of-pocket Poverty in India
(OOP) expenditure, it does not give any target or time
frame for reducing this expense . OOP can be reduced Healthcare in India
only by increasing public expenditure on health and by Timeline of healthcare in India
setting up widespread public health service providers.[37]
But the planning commission is planning to do this by reg- Swachh Bharat Abhiyan
ulating private health care providers. It takes solace from
the HLEG report which admits that, the transformation
of Indias health system to become an eective platform 3.4 References
for UHC is an evolutionary process that will span several
years.[38] [1] Jugal Kishore (2005). National health programs of In-
Instead of developing a better public health system with dia: national policies & legislations related to health. Cen-
enhanced health budget, 12th ve-year plan document tury Publications. ISBN 978-81-88132-13-3. Retrieved
2 September 2012.
plans to hand over health care system to private in-
stitutions. The 12th plan document causes concern [2] Ministry of Health and Family Welfare. Draft National
over Rashtriya Swasthya Bhima Yojana being used as a Health Policy 2015. Retrieved 1 April 2015.
medium to hand over public funds to the private sec-
tor through an insurance route. This has also incen- [3] Britnell, Mark (2015). In Search of the Perfect Health Sys-
tem. London: Palgrave. p. 60. ISBN 978-1-137-49661-
tivised unnecessary treatment which in due course will in-
4.
crease costs and premiums. There have been complaints
about high transaction cost for this scheme due to insur- [4] Rie, David (11 October 2009). Indias Malnutrition
ance intermediaries. RSBY does not take into considera- Dilemma. Source: The New York Times 2009. Retrieved
tion state specic variation in disease proles and health 2011-09-20.
needs. Even though these things are acknowledged in
[5] (http://www.unicef.org/india/children_4259.htm)
the report, no alternative remedy is given. There is no
reference to nutrition as key component of health and [6] Robinson, Simon (1 May 2008). Indias Medical Emer-
for universal Public Distribution System (PDS) in the gency. Source: Time US. Retrieved 2011-09-20.
20 CHAPTER 3. HEALTH IN INDIA

[7] (www.merriam-webster.com/dictionary/malnutrition)
[8] http://ninindia.org/DietaryGuidelinesforNINwebsite.pdf
Dietary Guidelines for NIN
[9] (http://www.ajfand.net/Volume6/No1/Mahgoub1420.
pdf)
[10] Child malnutrition.
[31] JSS The Bitter Truth About Rural Health. Jssbi-
laspur.org. Retrieved on 2012-07-17.
[32] Sutherland, T; DM Bishai (2008). Cost-Eectiveness Of
Misoprostol And Prenatal Iron Supplementation As Ma-
ternal Mortality Interventions In Home Births In Rural In-
dia. Int J of Gynecology and Obstetrics. Retrieved 26
May 2012.

[11] FAQs UNICEF.
[12] Childhood Mortality and Health in India (PDF). Source:
Institute of Economic Growth University of Delhi Enclave
North Campus India by Suresh Sharma. Retrieved 2011-
09-20.
[13] Maternal & Child Mortality and Total Fertility Rates
(PDF). Retrieved 2012-02-13.
[14] Kanjilal, Barun; Debjani Barman; Swadhin Mondal;
Sneha Singh; Moumita Mukherjee; Arnab Mandal; Ni-
lanjan Bhor (September 2008). Barriers to access immu-
nisation services: a study in Murshidabad, West Bengal.
FHS Research Brief (3).
[33] Tuddenham, S A; et al. (February 2010). Care seeking
for postpartum morbidities in Murshidabad, rural India.
Int J of Gynecology and Obstetrics. 109 (3): 245246.
doi:10.1016/j.ijgo.2010.01.016. Retrieved 26 May 2012.
[34] What We Do: Our Purpose. The MINDS Foundation.
Retrieved 29 July 2014.
[35] http://www.thehindu.com/business/
where-the-outlook-is-healthy/article3589038.ece
Retrieved from The Hindu on 27 July 2013
[36] http://planningcommission.gov.in/plans/planrel/
12thplan/pdf/vol_3.pdf Retrieved from Planning
commission site on 27 July 2013

[15] Medical and Healthcare Facility Plagued. Source: Ab-
hinandan S, Dr Ramadoss. Retrieved 2011-09-20.
[16] Dengue. Source: Centers for Disease Control and Pre-
vention US. Retrieved 2011-09-20.
[37] T. K. Rajalakshmi. Private leaning. Frontline.
[38] http://planningcommission.nic.in/reports/genrep/UHC_
ExecSummary.pdf Retrieved from Planning Commission
website on 27 July 2013 .

[17] Goldwert, Lindsay. "Totally drug-resistant tuberculosis

reported in India; 12 patients have not responded to TB
medication. New York Daily News 16 January 2012.
[18] HIV/AIDS. Source: UNICEF India. Retrieved 2011-
09-20.
This article incorporates public domain material
from the Library of Congress Country Studies web-
site http://lcweb2.loc.gov/frd/cs/.

[19] Life Expectancy and Mortality in India. Source: The 3.5 External links
Prajnopaya Foundation. Retrieved 2011-09-20.

[20] Health Conditions. Source: US Library of Congress. The State of the Worlds Midwifery India Country
Retrieved 2011-09-20. Prole

[21] India marks one year since last polio case. Al Jazeera,
13 January 2012.
[22] http://india.gov.in/spotlight/spotlight_archive.php?id=
90
Lancet -India: Towards Universal Health Coverage
Indian Healthcare Industry, November 2012 Din-
odia Capital Advisors

[23] Heart Disease is preventable. Indian Heart Foundation.

Retrieved on 2012-07-17.

[24] :: Prevent India 2012, 26 Feb ::. Preventindia.org. Re-

trieved on 2012-07-17.

[25] Water, Environment and Sanitation. Source: UNICEF

India. Retrieved 2011-09-20.

[26] Initiatives: Hygiene and Sanitation. Source: Sangam

Unity in Action. Retrieved 2011-09-20.

[27] What We Do UNICEF.

[28] Chronic hunger and the status of women in India.

[29] . Retrieved on 2015-05-06.

[30] Urban Rural Population of India. Indiafacts.in. Retrieved

on 2012-07-17.
Chapter 4

Infant mortality
0-5
5-10
10-15
15-20
20-25
4.1 Classication
25-30
30-40
40-50

Infant mortality rate (IMR) is the number of deaths of

children less than one year of age per 1000 live births.
The rate for a given region is the number of children dying
under one year of age, divided by the number of live births
50-60
during the year, multiplied by 1,000.[3]
60-70
70-80

Forms of infant mortality:

80-90
90-100
100-110
No data

Infant mortality rates, under age 1, in 2013 Perinatal mortality is late fetal death (22 weeks ges-
tation to birth), or death of a newborn up to one
week postpartum.[3]

Neonatal mortality is newborn death occurring

within 28 days postpartum. Neonatal death is of-
ten attributed to inadequate access to basic medical
care, during pregnancy and after delivery. This ac-
Infant mortality refers to deaths of young children, typ- counts for 4060% of infant mortality in developing
ically those less than one year of age. It is measured by countries.[4]
the infant mortality rate (IMR), which is the number of
deaths of children under one year of age per 1000 live Postneonatal mortality is the death of children aged
births. 29 days to one year. The major contributors to post-
neonatal death are malnutrition, infectious disease,
The leading causes of infant mortality are birth asphyxia, and problems with the home environment.
pneumonia, term birth complications, neonatal infection,
diarrhea, malaria, measles and malnutrition.[1] Many fac-
tors contribute to infant mortality, such as the mothers
level of education, environmental conditions, and polit-
4.2 Causes
ical and medical infrastructure. Improving sanitation,
access to clean drinking water, immunization against Leading causes of congenital infant mortality are malfor-
infectious diseases, and other public health measures can mations, sudden infant death syndrome, maternal com-
help reduce high rates of infant mortality. plications during pregnancy, and accidents and uninten-
tional injuries.[5] Environmental and social barriers pre-
Child mortality is the death of a child before the childs vent access to basic medical resources and thus contribute
fth birthday, measures as the Under-5 Child Mortality to an increasing infant mortality rate; 99% of infant
Rate (U5MR). National statistics sometimes group these deaths occur in developing countries, and 86% of these
two mortality rates together. Globally, ten million infants deaths are due to infections, premature births, compli-
and children die each year before their fth birthday; 99% cations during delivery, and perinatal asphyxia and birth
of these deaths occur in developing nations. injuries.[3] Greatest percentage reduction of infant mor-
Infant mortality rate was an indicator used to monitor tality occurs in countries that already have low rates of
progress towards the Fourth Goal of the Millennium De- infant mortality.[6] Common causes are preventable with
velopment Goals of the United Nations for the year 2015. low-cost measures. In the United States, a primary deter-
It is now a target in the Sustainable Development Goals minant of infant mortality risk is infant birth weight with
for Goal Number 3 (Ensure healthy lives and promote lower birth weights increasing the risk of infant mortal-
well-being for all at all ages).[2] ity. The determinants of low birth weight include socio-

21
22 CHAPTER 4. INFANT MORTALITY

economic, psychological, behavioral and environmental Sudden infant death syndrome

factors.[7]
Main article: Sudden infant death syndrome

4.2.1 Medical
Thousands of infant deaths per year are classied as
Sudden infant death syndrome (SIDS). According to the
Causes of infant mortality that are related to medical con-
Mayo Clinic, SIDS is the unexplained death, usually dur-
ditions include: low birth weight, sudden infant death
ing sleep, of a seemingly healthy baby. Although the di-
syndrome, malnutrition and infectious diseases, includ-
rect cause of SIDS remains unknown, many doctors be-
ing neglected tropical diseases.
lieve that there are several factors that put babies at an in-
creased risk of SIDS, including: babies sleeping on their
Low birth weight stomachs, exposure to cigarette smoke in the womb or
after birth, sleeping in bed with parents, premature birth,
Main article: Low birth weight being a twin or triplet, being born to a teen mother, and
also living in poverty settings. Although the cause is un-
known and currently cannot be explained, doctors have
Low birth weight makes up 6080% of the infant mortal- come to the conclusion that SIDS is most likely to oc-
ity rate in developing countries. The New England Jour- cur between 2 and 4 months and most deaths occur in the
nal of Medicine stated that The lowest mortality rates winter time. Recommended precautions include ensuring
occur among infants weighing 3,000 to 3,500 g (6.6 to that infants sleep on their backs, controlling the temper-
7.7 lb). For infants born weighing 2,500 g (5.5 lb) or ature of the bedroom, employing a crib without toys or
less, the mortality rate rapidly increases with decreasing excess bedding, and breastfeeding.[12]
weight, and most of the infants weighing 1,000 g (2.2 lb)
or less die. As compared with normal-birth-weight in-
fants, those with low weight at birth are almost 40 times Malnutrition
more likely to die in the neonatal period; for infants
with very low weight at birth the relative risk of neonatal Main article: Malnutrition in children
death is almost 200 times greater. Infant mortality due to
low birth weight is usually a direct cause stemming from
other medical complications such as preterm birth, poor Malnutrition frequently accompanies these diseases, and
maternal nutritional status, lack of prenatal care, mater- is a primary factor contributing to the complications of
nal sickness during pregnancy, and an unhygienic home both diarrhea and pneumonia, although the causal links
environments.[3] Along with birth weight, period of ges- and mechanisms remain unclear. Factors other nutrition
tation makes up the two most important predictors of an also inuence the incidence of diarrhea, including socioe-
infants chances of survival and their overall health.[8] conomic status, disruption of traditional lifestyles, access
to clean water and sanitation facilities, age and breast-
According to the New England Journal of Medicine, in feeding status.
the past two decades, the infant mortality rate (deaths
under one year of age per thousand live births) in the Protein energy malnutrition and micronutrient deciency
United States has declined sharply. Low birth weights are two reasons for stunted growth in children under ve
from African American mothers remain twice as high as years old in the least developed countries. Malnutrition
that of white women. LBW may be the leading cause of leads to diarrhea and dehydration, and ultimately death.
infant deaths, and it is greatly preventable. Although it is Millions of women in developing countries are stunted
preventable, the solutions may not be the easiest but ef- due to a history of childhood malnutrition. Womens
fective programs to help prevent LBW are a combination bodies are thus underdeveloped, and their chances of
of health care, education, environment, mental modi- surviving childbirth decrease. Due to underdeveloped
cation and public policy, inuencing a culture support- bodies, the probability of an obstructed pregnancy in-
ing lifestyle.[9] Preterm birth is the leading cause of new- creases. Protein-energy deciency results in low-quality [3]
born deaths worldwide.[10] Even though America excels breastmilk that provides less energy and other nutrition.
past many other countries in the care and saving of pre- Vitamin A deciency can lead to stunted growth,
mature infants, the percentage of American woman who blindness, and increased mortality due to the lack of
deliver prematurely is comparable to those in developing nutrients in the body. Two hundred and fty million
countries. Reasons for this include teenage pregnancy, infants are aected by Vitamin A deciency. Among
increase in pregnant mothers over the age of thirty-ve, women in developing countries, 40% have iron deciency
increase in the use of in-vitro fertilization which increases anemia, which increases maternal and infant mortality
the risk of multiple births, obesity and diabetes. Also, rates, chances of stillbirth, cases of low birth weight ba-
women who do not have access to health care are less bies, premature delivery, and probability of fetal brain
likely to visit a doctor, therefore increasing their risk of damage.[3] One way to prevent Vitamin A deciency is to
delivering prematurely.[11] educate the mother on the many benets of breastfeeding.
4.2. CAUSES 23

Breastmilk is a natural source of Vitamin A, and supplies conditions.[18]

the suckling infant with enough Vitamin A.[13] People who live in areas where particulate matter (PM)
air pollution is higher tend to have more health problems
Infectious diseases across the board. Short-term and long-term eects of
ambient air pollution are associated with an increased
Babies born in low to middle income countries in sub- mortality rate, including infant mortality. Air pollution
Saharan Africa and southern Asia are at the highest risk of is consistently associated with post neonatal mortality
neonatal death. Bacterial infections of the bloodstream, due to respiratory eects and sudden infant death syn-
lungs, and the brains covering (meningitis) are responsi- drome. Specically, air pollution is highly associated
ble for 25% of neonatal deaths. Newborns can acquire with SIDs [19]
in the United States during the post-neonatal
infections during birth from bacteria that are present in stage. High infant mortality is exacerbated because
their mothers reproductive tract. The mother may not newborns are a vulnerable subgroup that is aected by
[20]
be aware of the infection, or she may have an untreated air pollution. Newborns who were born into these en-
pelvic inammatory disease or sexually transmitted dis- vironments are no exception. Women who are exposed
ease. These bacteria can move up the vaginal canal to greater air pollution on a daily basis who are pregnant
into the amniotic sac surrounding the baby. Maternal should be closely watched by their doctors, as well as af-
blood-borne infection is another route of bacterial in- ter the baby is born. Babies who live in areas with less
fection from mother to baby. Neonatal infection is also air pollution have a greater chance of living until their
more likely with the premature rupture of the membranes rst birthday. As expected, babies who live in environ-
(PROM) of the amniotic sac. [14] ments with more air pollution are at greater risk for infant
mortality. Areas that have higher air pollution also have
Seven out of ten childhood deaths are due to infec- a greater chance of having a higher population density,
tious diseases: acute respiratory infection, diarrhea, higher crime rates and lower income levels, all of which
measles, and malaria. Acute respiratory infection such can lead to higher infant mortality rates.[21]
as pneumonia, bronchitis, and bronchiolitis account for
30% of childhood deaths; 95% of pneumonia cases occur The key pollutant for infant mortality rates is carbon
in the developing world. Diarrhea is the second-largest monoxide. Carbon monoxide is a colorless, odorless gas
cause of childhood mortality in the world, while malaria that does great harm especially to infants because of their
[22]
causes 11% of childhood deaths. Measles is the fth- immature respiratory system. Another major pollutant
largest cause of childhood mortality. [3][15]
Folic acid for is second-hand smoke, which is a pollutant that can have
mothers is one way to combat iron deciency. A few detrimental eects on a fetus. According to the Amer-
public health measures used to lower levels of iron de- ican Journal of Public Health, in 2006, more than 42
ciency anemia include iodize salt or drinking water, and 000 Americans died of second hand smoke-attributable
include vitamin A and multivitamin supplements into a diseases, including more than 41 000 adults and nearly
mothers diet.[3] A deciency of this vitamin causes cer- 900 infants ... fully 36% of the infants who died of low
tain types of anemia (low red blood cell count).[16] birth weight caused by exposure to maternal smoking in
utero were Blacks, as were 28% of those dying of res-
piratory distress syndrome, 25% dying of other respira-
4.2.2 Environmental tory conditions, and 24% dying of sudden infant death
syndrome. The American Journal of Epidemiology also
Infant mortality rate can be a measure of a nations health stated that Compared with nonsmoking women having
and social condition.[8][17] It is a composite of a number their rst birth, women who smoked less than one pack
of component rates which have their separate relationship of cigarettes per day had a 25% greater risk of mortality,
with various social factors and can often be seen as an and those who smoked one or more packs per day had a
indicator to measure the level of socioeconomic disparity 56% greater risk. Among women having their second or
within a country.[17] higher birth, smokers experienced 30% greater mortality
than nonsmokers.
Organic water pollution is a better indicator of infant
mortality than health expenditures per capita. Water Modern research in the United States on racial dis-
contaminated with various pathogens houses a host of parities in infant mortality suggests a link between the
parasitic and microbial infections. Infectious disease institutionalized racism that pervades the environment
and parasites are carried via water pollution from animal and high rates of African American infant mortality.
wastes.[18] Areas of low socioeconomic status are more In synthesis of this research, it has been observed that
prone to inadequate plumbing infrastructure, and poorly African American infant mortality remains elevated due
maintained facilities.[3] The burning of inecient fuels to the social arrangements that exist between groups and
doubles the rate of children under 5 years old with acute the lifelong experiences responding[7]to the resultant power
respiratory tract infections.[3] Climate and geography of- dynamics of these arrangements.
ten play a role in sanitation conditions. For example, the
inaccessibility of clean water exacerbates poor sanitation
24 CHAPTER 4. INFANT MORTALITY

4.2.3 Socio-economic factors Many developing countries rely on foreign aid for basic
nutrition. Transport of aid becomes signicantly more
Social class is a major factor in infant mortality, both his- dicult in times of war. In most situations the average
torically and today. Between 1912 and 1915, the Chil- weight of a population will drop substantially.[28] Expect-
drens Bureau in the United States examined data across ing mothers are aected even more by lack of access to
eight cities and nearly 23,000 live births. They discov- food and water. During the Yugoslav Wars in Bosnia the
ered that lower incomes tend to correlate with higher in- number of premature babies born increased and the av-
fant mortality. In cases where the father had no income, erage birth weight decreased.[27]
the rate of infant mortality was 357% more than that There have been several instances in recent years of sys-
for the highest income earners ($1,250+). Dierences tematic rape as a weapon of war. Women who become
between races were also apparent. African-American pregnant as a result of war rape face even more signi-
mothers experience infant mortality at a rate 44% higher cant challenges in bearing a healthy child. Studies sug-
than average;[23] however, research indicates that socio- gest that women who experience sexual violence before
economic factors do not totally account for the racial dis- or during pregnancy are more likely to experience infant
parities in infant mortality.[7] death in their children.[29][30][31] Causes of infant mortal-
While infant mortality is normally negatively correlated ity in abused women range from physical side eects of
with GDP, there may indeed be some opposing short- the initial trauma to psychological eects that lead to poor
term eects from a recession. A recent study by The adjustment to society. Many women who became preg-
Economist showed that economic slowdowns reduce the nant by rape in Bosnia were isolated from their home-
amount of air pollution, which results in a lower infant towns making life after childbirth exponentially more
mortality rate. In the late 1970s and early 1980s, the re- dicult.[32]
cessions impact on air quality is estimated to have saved
around 1,300 US babies.[24] It is only during deep reces-
sions that infant mortality increases. According to Nor- 4.2.5 Medicine and biology
bert Schady and Marc-Franois Smitz, recessions when
GDP per capita drops by 15% or more increase infant Developing countries have a lack of access to aordable
mortality.[25] and professional health care resources, and skilled per-
sonnel during deliveries.[3][26] Countries with histories of
Social class dictates which medical services are avail- extreme poverty also have a pattern of epidemics, en-
able to an individual. Disparities due to socioeconomic demic infectious diseases, and low levels of access to ma-
factors have been exacerbated by advances in medi- ternal and child healthcare.[33]
cal technology. Developed countries, most notably the
United States, have seen a divergence between those liv- The American Academy of Pediatrics recommends
ing in poverty who cannot aord medical advanced re- that infants need multiple doses of vaccines such
sources, leading to an increased chance of infant mortal- as diphtheria-tetanus-acellular pertussis vaccine,
ity, and others.[17] Haemophilus inuenzae type b (Hib) vaccine, Hepatitis
B (HepB) vaccine, inactivated polio vaccine (IPV), and
pneumococcal vaccine (PCV). Research was conducted
by the Institute of Medicine's Immunization Safety Re-
4.2.4 War view Committee concluded that there is no relationship
between these vaccines and risk of SIDS in infants. This
In policy, there is a lag time between realization of a prob- tells us that not only is it extremely necessary for every
lems possible solution and actual implementation of pol- child to get these vaccines to prevent serious diseases,
icy solutions.[26] Infant mortality rates correlate with war, but there is no reason to believe that if your child does
political unrest, and government corruption.[3] receive an immunization that it will have any eect on
their risk of SIDS.[34]
In most cases, war-aected areas will experience a sig-
nicant increase in infant mortality rates. Having a war
taking place where a woman is planning on having a baby
4.2.6 Economics
is not only stressful on the mother and fetus, but also has
several detrimental eects. Political modernization perspective, the neo-classical
However, many other signicant factors inuence infant economic theory that scarce goods are most eectively
mortality rates in war-torn areas. Health care systems in distributed to the market, say that the level of political
developing countries in the midst of war often collapse. democracy inuences the rate of infant mortality. De-
Attaining basic medical supplies and care becomes in- veloping nations with democratic governments tend to
creasingly dicult. During the Yugoslav Wars in the be more responsive to public opinion, social movements,
1990s Bosnia experienced a 60% decrease in child im- and special interest groups for issues like infant mortal-
munizations. Preventable diseases can quickly become ity. In contrast, non-democratic governments are more
epidemic given the medical conditions during war.[27] interested in corporate issues and less so in health is-
4.2. CAUSES 25

sues. Democratic status eects the dependency a nation Cultural inuences and lifestyle habits in the United
has towards its economic state via export, investments States can account for some deaths in infants through-
from multinational corporations and international lending out the years. According to the Journal of the American
institutions.[33] Medical Association the post neonatal mortality risk (28
Levels of socioeconomic development and global inte- to 364 days) was highest among continental Puerto Ri-
gration are inversely related to a nations infant mortal- cans compared to babies of the non-Hispanic race. Ex-
ity rate.[3][35] Dependency perspective occurs in a global amples of this include teenage pregnancy, obesity, dia-
capital system. A nations internal impact is highly in- betes and smoking. All are possible causes of premature
births, which constitute the second highest cause of in-
uenced by its position in the global economy and has
adverse eects on the survival of children in developing fant mortality.[11] Ethnic dierences experienced in the
United States are accompanied by higher prevalence of
countries.[18] Countries can experience disproportionate
eects from its trade and stratication within the global behavioral risk factors and sociodemographic challenges
that each ethnic group faces.[8]
system.[36] It aids in the global division of labor, distorting
the domestic economy of developing nations. The depen-
dency of developing nations can lead to a reduce rate of Gender favoritism
economic growth, increase income inequality inter- and
intra-national, and adversely aects the wellbeing of a na- Historically, males have had higher infant mortality rates
tions population. A collective cooperation between eco- than females. The dierence between male and female
nomic countries plays a role in development policies in infant mortality rates have been dependent on environ-
the poorer, peripheral, countries of the world.[33] mental, social, and economic conditions. More speci-
These economic factors present challenges to govern- cally, males are biologically more vulnerable to infections
ments public health policies.[18] If the nations ability to and conditions associated with prematurity and develop-
raise its own revenues is compromised, governments will ment. Before 1970, the reasons for male infant mortality
lose funding for its health service programs, including were due to infections, and chronic degenerative diseases.
services that aim in decreasing infant mortality rates.[33] However, since 1970, certain cultures emphasizing males
Peripheral countries face higher levels of vulnerability to has led to a decrease in the infant mortality gap between
the possible negative eects of globalization and trade in males and females. Also, medical advances have resulted
relation to key countries in the global market.[18] in a growing number of male infants surviving at higher
rates than females due to the initial high infant mortality
Even with a strong economy and economic growth (mea- rate of males.[39]
sured by a countrys gross national product), the advances
of medical technologies may not be felt by everyone, Genetic components results in newborn females being bi-
lending itself to increasing social disparities.[17] ologically advantaged when it comes to surviving their
rst birthday. Males, biologically, have lower chances of
surviving infancy in comparison to female babies. As in-
4.2.7 Cultural fant mortality rates saw a decrease on a global scale, the
gender most aected by infant mortality changed from
High rates of infant mortality occur in developing coun- males experiences a biological disadvantage, to females
[39]
tries where nancial and material resources are scarce facing a societal disadvantage. Some developing na-
and there is a high tolerance to high number of infant tions have social and cultural patterns that reects adult
deaths. There are circumstances where a number of de- discrimination to favor boys over girls for their future po-
veloping countries to breed a culture where situations of tential to contribute to the household production level. A
infant mortality such as favoring male babies over female countrys ethnic composition, homogeneous versus het-
[3]
babies are the norm. In developing countries such as erogeneous, can explain social attitudes and practices.
Brazil, infant mortality rates are commonly not recorded Heterogeneous level is a strong predictor in explaining
[35]
due to failure to register for death certicates.[37] Fail- infant mortality.
ure to register is mainly due to the potential loss of time
and money and other indirect costs to the family.[37] Even
Birth spacing
with resource opportunities such as the 1973 Public Reg-
istry Law 6015, which allowed free registration for low- Birth spacing is the time between births. Births spaced
income families, the requirements to qualify hold back at least three years apart from one another are associ-
individuals who are not contracted workers.[37] ated with the lowest rate of mortality. The longer the
Another cultural reason for infant mortality, such as what interval between births, the lower the risk for having any
is happening in Ghana, is that besides the obvious, like birthing complications, and infant, childhood and mater-
rutted roads, there are prejudices against wives or new- nal mortality.[4][40] Higher rates of pre-term births, and
borns leaving the house. [38] Because of this it is making low birth weight are associated with birth to conception
it even more dicult for the women and newborns to get intervals of less than six months and abortion to preg-
the treatment that is available to them and that is needed. nancy interval of less than six months. Shorter inter-
26
vals between births increase the chances of chronic and
general under-nutrition; 57% of women in 55 developing
countries reported birth spaces shorter than three years;
26% report birth spacing of less than two years. Only
20% of post-partum women report wanting another birth
within two years; however, only 40% are taking necessary
steps such as family planning to achieve the birth intervals
they want.[4]
Unplanned pregnancies and birth intervals of less than
twenty-four months are known to correlate with low
birth weights and delivery complications. Also, women
who are already small in stature tend to deliver smaller
than average babies, perpetuating a cycle of being
underweight.[3][4][40]
Education
The mothers educational attainment and literacy are cor-
related with age of rst pregnancy, and probability that
the mother attain prenatal and postnatal care. Mothers
with a secondary education have a higher probability of
waiting until a later age to get pregnant. Once pregnant,
they are also more likely to get prenatal and postnatal
care, and deliver their child in the presence of a skilled
attendant. Women who nish at least a primary-level ed-
ucation have improved nutrition, medical care, informa-
tion access, and economic independence. Infants reap
benets such as healthy environments, improved nutri-
tion, and medical care. Mothers with some level of edu-
cation have a higher probability to breastfeeding.[3][18][35]
The duration of breastfeeding has the potential to inu-
ence the birth space.[40] Women without any educational
background tend to have children at an earlier age, thus
their bodies are not yet mature enough to carry and de-
liver a child.[3]
4.3 Prevention
Millennium Development Goals were created to improve
the health and well being of people worldwide. Its fourth
goal is to decrease the number of mortalities within the
infant and childhood population by two thirds, a decrease
from 95 to 31 deaths per 1000.[3] Countries slow to abide
by the Millennium Development Goal by 2015 are pro-
jected to have diculty in reaching goal four.[26]
4.3.1 Public health
Reductions in infant mortality are possible in any stage of
a countrys development.[6] Rate reductions are evidence
that a country is advancing in human knowledge, social
institutions and physical capital. Governments can reduce
the mortality rates by addressing the combined need for
education (such as universal primary education), nutri-
tion, and access to basic maternal and infant health ser-
CHAPTER 4. INFANT MORTALITY
vices. A policy focus has the potential to aid those most at
risk for infant and childhood mortality allows rural, poor
and migrant populations.[26]
Reducing chances of babies being born at low birth
weights and contracting pneumonia can be accomplished
by improving air quality. Improving hygiene can prevent
infant mortality. Home-based technology to chlorinate,
lter, and solar disinfection for organic water pollu-
tion could reduce cases of diarrhea in children by up
to 48%.[3][15][18] Improvements in food supplies and
sanitation has been shown to work in the United States
most vulnerable populations, one being African Amer-
icans. Overall, womens health status need to remain
high.[17]
Simple behavioral changes, such as hand washing with
soap, can signicantly reduce the rate of infant mortality
from respiratory and diarrheal diseases.[41] According to
UNICEF, hand washing with soap before eating and after
using the toilet can save more lives of children than any
single vaccine or medical intervention, by cutting deaths
from diarrhea and acute respiratory infections.[42]
Future problems for mothers and babies can be pre-
vented. It is important that women of reproductive age
adopt healthy behaviors in everyday life, such as taking
folic acid, maintaining a healthy diet and weight, being
physically active, avoiding tobacco use, and avoiding ex-
cessive alcohol and drug use. If women follow some
of the above guidelines, later complications can be pre-
vented to help decrease the infant mortality rates. Attend-
ing regular prenatal care check-ups will help improve the
babys chances of being delivered in safer conditions and
surviving.
Focusing on preventing preterm and low birth weight de-
liveries throughout all populations can help to eliminate
cases of infant mortality and decrease health care dispar-
ities within communities. In the United States, these two
goals have decreased infant mortality rates on a regional
population, it has yet to see further progress on a national
level.[8]
4.3.2 Medical treatments
Technological advances in medicine would decrease the
infant mortality rate and an increased access to such tech-
nologies could decrease racial and ethnic disparities. It
has been shown that technological determinants are in-
uenced by social determinants. Those who cannot af-
ford to utilize advances in medicine tend to show higher
rates of infant mortality. Technological advances has, in
a way, contributed to the social disparities observed to-
day. Providing equal access has the potential to decrease
socioeconomic disparities in infant mortality.[17] Specif-
ically, Cambodia is facing issues with a disease that is
unfortunately killing infants. The symptoms only last 24
hours and the result is death. As stated if technological
advances were increased in countries it would make it eas-
4.4. DIFFERENCES IN MEASUREMENT 27

ier to nd the solution to diseases such as this.[43] 37-county area.[44]

4.3.3 Cultural changes

4.4 Dierences in measurement
Educated females practice a healthier lifestyle. The more
educated a woman is the more likely she is to seek
out care, give birth in the presence of a skilled atten-
dant, breastfeed, and understand the consequences of
HIV/AIDS.[3] Improving womens health and social sta-
tus is one way to ameliorate infant mortality.[4] Status Infant mortality rate
(per 1000 births)
should rise for females seeking out education.[35] Provid- 160-185
135-160
ing women access to family planning centers can educate 110-135
85-110
60-85
mothers on how to plan ahead for their families. Edu- 35-60
10-35
cational means can also teach mothers on the benecial 2-10
No data
Data Year: 2012
health practices such as breastfeeding. Government rec-
ognizing birth space as a possible health intervention is Mortality rates, under age 5, in 2012[45]
now working towards making aordable contraception
available.[40]

4.3.4 Economic/Social policies

Granting women employment raises their status and au-
tonomy. Having a gainful employment can raise the per-
ceived worth of females. This can lead to an increase in
the number of women getting an education and a decrease
in the number of female infanticide.[35] In the social mod-
ernization perspective, education leads to development.
Higher number of skilled workers means more earning Infant mortality rate by region
and further economic growth. According to the eco-
nomic modernization perspective, this is one type eco-
nomic growth viewed as the driving force behind the in-
crease in development and standard of living in a country.
This is further explained by the modernization theory-
economic development promotes physical wellbeing. As
economy rises, so do technological advances and thus,
medical advances in access to clean water, health care fa-
cilities, education, and diet. These changes may decrease
infant mortality.[33][35]
Economically, governments could reduce infant mortal-
ity by building and strengthening capacity in human re-
sources. Increasing human resources such as physicians,
nurses, and other health professionals will increase the
number of skilled attendants and the number of peo- Life expectancy at birth by region
ple able to give out immunized against diseases such as
measles. Increasing the number of skilled professionals is The infant mortality rate correlates very strongly with,
negatively correlated with maternal, infant, and childhood and is among the best predictors of, state failure.[46] IMR
mortality. Between 1960 and 2000, the infant mortality is therefore also a useful indicator of a countrys level of
rate decreased by half as the number of physicians in- health or development, and is a component of the physical
creased by four folds.[26] With the addition of one physi- quality of life index.
cian to every 1000 persons in a population, infant mortal- However, the method of calculating IMR often varies
ity will reduce by 30%. widely between countries, and is based on how they de-
In certain parts of the U.S., specic modern programs aim ne a live birth and how many premature infants are born
to reduce levels of infant mortality. An example of one in the country. Reporting of infant mortality rates can
such program is the 'Healthy Me, Healthy You' program be inconsistent, and may be understated, depending on a
based in Northeast Texas. It intends to identify factors nations live birth criterion, vital registration system, and
that contribute to negative birth outcomes throughout a reporting practices.[47] The reported IMR provides one
28 CHAPTER 4. INFANT MORTALITY

statistic which reects the standard of living in each na- level. However, as mentioned before, these es-
tion. Changes in the infant mortality rate reect social and timates minimize errors and maximize the con-
technical capacities of a nations population.[6] The World sistency of trends along time.[53]
Health Organization (WHO) denes a live birth as any in-
fant born demonstrating independent signs of life, includ- Another challenge to comparability is the practice of
ing breathing, heartbeat, umbilical cord pulsation or def- counting frail or premature infants who die before the
inite movement of voluntary muscles.[48] This denition normal due date as miscarriages (spontaneous abortions)
is used in Austria, for example.[49] The WHO denition or those who die during or immediately after childbirth
is also used in Germany, but with one slight modication: as stillborn. Therefore, the quality of a countrys docu-
muscle movement is not considered to be a sign of life.[50] mentation of perinatal mortality can matter greatly to the
Many countries, however, including certain European accuracy of its infant mortality statistics. This point is re-
states (e.g. France) and Japan, only count as live births inforced by the demographer Ansley Coale, who nds du-
cases where an infant breathes at birth, which makes their biously high ratios of reported stillbirths to infant deaths
reported IMR numbers somewhat lower and increases in Hong Kong and Japan in the rst 24 hours after birth, a
their rates of perinatal mortality.[51] In the Czech Repub- pattern that is consistent with the high recorded sex ratios
lic and Bulgaria, for instance, requirements for live birth at birth in those countries. It suggests not only that many
are even higher.[52] female infants who die in the rst 24 hours are misre-
Although many countries have vital registration systems ported as stillbirths rather than infant deaths, but also that
and certain reporting practices, there are many inaccu- those countries do not follow WHO recommendations for
[54]
racies, particularly in undeveloped nations, in the statis- the reporting of live births and infant deaths.
tics of the number of infants dying. Studies have shown Another seemingly paradoxical nding, is that when
that comparing three information sources (ocial reg- countries with poor medical services introduce new medi-
istries, household surveys, and popular reporters) that the cal centers and services, instead of declining, the reported
popular death reporters are the most accurate. Popu- IMRs often increase for a time. This is mainly because
lar death reporters include midwives, gravediggers, cof- improvement in access to medical care is often accom-
n builders, priests, and othersessentially people who panied by improvement in the registration of births and
knew the most about the childs death. In developing deaths. Deaths that might have occurred in a remote
nations, access to vital registries, and other government- or rural area, and not been reported to the government,
run systems which record births and deaths, is dicult might now be reported by the new medical personnel or
for poor families for several reasons. These struggles facilities. Thus, even if the new health services reduce
force stress on families, and make them take drastic mea- the actual IMR, the reported IMR may increase.
sures in unocial death ceremonies for their deceased
infants. As a result, government statistics will inaccu- Collecting the accurate statistics of infant mortality rate
rately reect a nations infant mortality rate. Popular could be an issue in some rural communities in devel-
death reporters have rst-hand information, and provided oping countries. In those communities, some other al-
this information can be collected and collated, can pro- ternative methods for calculating infant mortality rate
vide reliable data which provide a nation with accurate are emerged, for [37] example, popular death reporting and
death counts and meaningful causes of deaths that can be household survey. The country-to-country variation in
measured/studied. [37] child mortality rates is huge, and growing wider despite
the progress. Among the worlds roughly 200 nations,
UNICEF uses a statistical methodology to account for re- only Somalia showed no decrease in the under-5 mortal-
porting dierences among countries: ity rate over the past two decades.The lowest rate in 2011
was in Singapore, which had 2.6 deaths of children un-
UNICEF compiles infant mortality country der age 5 per 1,000 live births. The highest was in Sierra
estimates derived from all sources and meth- Leone, which had 185 child deaths per 1,000 births. The
ods of estimation obtained either from stan- global rate is 51 deaths per 1,000 births. For the United
dard reports, direct estimation from micro data States, the rate is eight per 1,000 births.[55]
sets, or from UNICEFs yearly exercise. In or- Infant mortality rate (IMR) is not only a group of statistic
der to sort out dierences between estimates but instead it is a reection of the socioeconomic develop-
produced from dierent sources, with dier- ment and eectively represents the presence of medical
ent methods, UNICEF developed, in coordi- services in the countries. IMR is an eective resource
nation with WHO, the WB and UNSD, an es- for the health department to make decision on medical
timation methodology that minimizes the er- resources reallocation. IMR also formulates the global
rors embodied in each estimate and harmonize health strategies and help evaluate the program success.
trends along time. Since the estimates are not The existence of IMR helps solve the inadequacies of the
necessarily the exact values used as input for other vital statistic systems for global health as most of
the model, they are often not recognized as the vital statistic systems usually neglect the infant mor-
the ocial IMR estimates used at the country tality statistic number from the poor. There are certain
4.4. DIFFERENCES IN MEASUREMENT 29

amounts of unrecorded infant deaths in the rural area as 4.4.2 Russia

they do not have information about infant mortality rate
statistic or do not have the concept about reporting early Until the 1990s, Russia and the Soviet Union did not
infant death.[37] count, as a live birth or as an infant death, extremely pre-
mature infants (less than 1,000 g, less than 28 weeks ges-
tational age, or less than 35 cm in length) that were born
alive (breathed, had a heartbeat, or exhibited voluntary
4.4.1 Europe and America
muscle movement) but failed to survive for at least seven
days.[63] Although such extremely premature infants typ-
The exclusion of any high-risk infants from the denomi- ically accounted for only about 0.5% of all live-born chil-
nator or numerator in reported IMRs can be problematic dren, their exclusion from both the numerator and the de-
for comparisons. Many countries, including the United nominator in the reported IMR led to an estimated 22%
States, Sweden and Germany, count an infant exhibiting 25% lower reported IMR.[64] In some cases, too, perhaps
any sign of life as alive, no matter the month of gestation because hospitals or regional health departments were
or the size, but according to United States some other held accountable for lowering the IMR in their catchment
countries dier in these practices. All of the countries area, infant deaths that occurred in the 12th month were
named adopted the WHO denitions in the late 1980s or transferred statistically to the 13th month (i.e., the sec-
early 1990s,[56] which are used throughout the European ond year of life), and thus no longer classied as an infant
Union.[57] However, in 2009, the US CDC issued a re- death.[65][66]
port that stated that the American rates of infant mortality
were aected by the United States high rates of prema-
ture babies compared to European countries. It also out-
lined the dierences in reporting requirements between 4.4.3 Brazil
the United States and Europe, noting that France, the
Czech Republic, Ireland, the Netherlands, and Poland do In certain rural developing areas, such as northeastern
not report all live births of babies under 500 g and/or Brazil, infant births are often not recorded in the rst
22 weeks of gestation.[58][59][60] However, the dierences place, resulting in the discrepancies between the infant
in reporting are unlikely to be the primary explanation mortality rate (IMR) and the actual amount of infant
for the United States relatively low international rank- deaths. Access to vital registry systems for infant births
ing. Rather, the report concluded that primary reason for and deaths is an extremely dicult and expensive task
the United States higher infant mortality rate when com- for poor parents living in rural areas. Government and
pared with Europe was the United States much higher bureaucracies tend to show an insensitivity to these par-
percentage of preterm births. There are a number of fac- ents and their recent suering from a lost child, and pro-
tors which may account for this higher rate of preterm duce broad disclaimers in the IMR reports that the infor-
births, which include obesity or poor prenatal care. mation has not been properly reported, resulting in these
discrepancies. Little has been done to address the un-
derlying structural problems of the vital registry systems
in respect to the lack of reporting from parents in rural
areas, and in turn has created a gap between the ocial
and popular meanings of child death.[37] It is also argued
that the bureaucratic separation of vital death recording
from cultural death rituals is to blame for the inaccuracy
of the infant mortality rate (IMR). Vital death registries
often fail to recognize the cultural implications and im-
portance of infant deaths. It is not to be said that vital
registry systems are not an accurate representation of a
regions socio-economic situation, but this is only the case
if these statistics are valid, which is unfortunately not al-
ways the circumstance. Popular death reporters is an
Regional dierences in the reporting of life births. SOURCE:
NCHS/National Vital Statistics System for U.S. data and Euro- alternative method for collecting and processing statistics
pean Perinatal Health Report on infant and child mortality. Many regions may benet
from popular death reporters who are culturally linked
[61] to infants may be able to provide more accurate statis-
tics on the incidence of infant mortality.[37] According
The U.S. National Institute of Child Health & Human to ethnographic data, popular death reporters refers to
Development (NICHD) has made great strides in lower- people who had inside knowledge of anjinhos, including
ing U.S. infant mortality rates.[62] Since the institute was the grave-digger, gatekeeper, midwife, popular healers
created the U.S. infant mortality rate has dropped 70%, etc. all key participants in mortuary rituals.[37] By
in part due to their research. combining the methods of household surveys, vital reg-
30 CHAPTER 4. INFANT MORTALITY

istries, and asking popular death reporters this can in- while both LDCs and MDCs made signicant reductions
crease the validity of child mortality rates, but there are in infant mortality rates, reductions among less developed
many barriers that can reect the validity of our statistics countries are, on average, much less than those among the
of infant mortality. One of these barriers are political more developed countries.
economic decisions. Numbers are exaggerated when in- A dierence of almost 100 times separate countries
ternational funds are being doled out; and underestimated with the highest and lowest reported infant mortality
during reelection.[37] rates. The top and bottom ve countries by this measure
The bureaucratic separation of vital death reporting and (taken from The World Factbook's 2012 estimates[70] ) are
cultural death rituals stems in part due to structural shown below.
violence.[67] Individuals living in rural areas of Brazil Yet one has to keep in mind that according to Guillot,
need to invest large capital for lodging and travel in order Gerland, Pelletier and Saabneh birth histories, however,
to report infant birth to a Brazilian Assistance League of- are subject to a number of errors, including omission of
ce. The negative nancial aspects deters registration, as deaths and age misreporting errors. Not to say this in-
often individuals are of lower income and cannot aord formation is incorrect, but to be aware that in other coun-
such expenses.[37] Similar to the lack of birth reporting, tries the numbers may not be fully accurate due to those
families in rural Brazil face dicult choices based on al- reasons.[71]
ready existing structural arrangements when choosing to
report infant mortality. Financial constraints such as re-
liance on food supplementations may also lead to skewed 4.5.2 In the United States
infant mortality data.[37]
In developing countries such as Brazil the deaths of im- The infant mortality rate in the U.S. decreased by 2.3% to
poverished infants are regularly unrecorded into the coun- a historic low of 582 infant deaths per 100,000 live births
tries vital registration system; this causes a skew statisti- in 2014.[72]
cally. Culturally validity and contextual soundness canIn the 1850s, the infant mortality rate in the United States
be used to ground the meaning of mortality from a sta- was estimated at 216.8 per 1,000 babies born for whites
tistical standpoint. In northeast Brazil they have accom-
and 340.0 per 1,000 for African Americans, but rates
plished this standpoint while conducting an ethnographic
have signicantly declined in the West in modern times.
study combined with an alternative method to survey in-This declining rate has been mainly due to modern im-
fant mortality.[37] These types of techniques can develop
provements in basic health care, technology, and med-
quality ethnographic data that will ultimately lead to a
ical advances.[73] In the last three decades, infant mor-
better portrayal of the magnitude of infant mortality in
tality overall has also decreased considerably. In the
the region. Political economic reasons have been seen to
last century, the infant mortality rate has decreased by
skew the infant mortality data in the past when governor
93%.[8] Overall, the rates have decreased drastically from
Ceara devised his presidency campaign on reducing the 20 deaths in 1970 to 6.9 deaths in 2003 (per every 1000
infant mortality rate during his term in oce. By usinglive births). In 2003, the leading causes of infant mortal-
this new way of surveying, these instances can be mini-ity in the United States were congenital anomalies, disor-
mized and removed, overall creating accurate and sound ders related to immaturity, SIDS, and maternal compli-
data.[37] cations. Babies born with low birth weight increased to
8.1% while cigarette smoking during pregnancy declined
to 10.2%. This reected the amount of low birth weights
4.5 Epidemiology concluding that 12.4% of births from smokers were low
birth weights opposing to 7.7% of such births from non-
smokers.[74] According to the New York Times, the main
4.5.1 Global trends reason for the high rate is preterm delivery, and there was
a 10% increase in such births from 2000 to 2006. Be-
See also: List of countries by infant mortality rate tween 2007 and 2011, however, the preterm birth rate has
decreased every year. In 2011 there was a 11.73% rate
For the world, and for both less developed countries of babies born before the 37th week of gestation, down
(LDCs) and more developed countries (MDCs), IMR de- from a high of 12.80% in 2006.[75]
clined signicantly between 1960 and 2001. According Economic expenditures on L&D and neonatal care are
to the State of the Worlds Mothers report by Save the relatively high in the United States. A conventional birth
Children, the world IMR declined from 126 in 1960 to averages 9,775 USD with a C-section costing 15,041
57 in 2001.[69] USD.[76] Preterm births in the U.S. have been estimated
However, IMR was, and remains, higher in LDCs. In to cost 51,600 USD per child, with a total yearly cost
2001, the IMR for LDCs (91) was about 10 times as of 26.2 billion USD.[77] Despite this spending, several
large as it was for MDCs (8). On average, for LDCs, reports state that infant mortality rate in the United
the IMR is 17 times as higher than that of MDCs. Also, States is signicantly higher than in other developed
4.6. HISTORY 31

nations.[7][78][79] Estimates vary; the CIAs World Fact-

book ranks the U.S. 55th internationally in 2014, with a
rate of 6.17, while the UN gures from 2005-2010 place
the U.S. 34th.
Aforementioned dierences in measurement could play
a substantial role in the disparity between the U.S. and
other nations. A non-viable live birth in the U.S. could
be registered as a stillbirth in similarly developed nations
like Japan, Sweden, Norway, Ireland, the Netherlands,
and France thereby avoiding the infant death classi-
cation altogether.[80] Neonatal intensive care is also more
likely to be applied in the U.S. to marginally viable in- Data indicating the IMR disparity between non-Hispanic white
fants, although such interventions have been found to in- mothers and non-Hispanic black mothers in the United States
crease both costs and disability. A study following the from 2000-2010.
implementation of the Born Alive Infant Protection Act
of 2002 found universal resuscitation of infants born be-
tween 2023 weeks increased the neonatal spending bur-
4.6 History
den by 313.3 million while simultaneously decreasing
quality-adjusted life years by 329.3.[81] The leading causes of infant mortality have changed over
time. Unpasteurized milk was the leading cause of in-
The vast majority of research conducted in the late 20th fant mortality late in the 19th century.[86] Pasteurization
and early 21st century indicates that African-American of milk cut infant mortality by around 3/4. [86]
infants are more than twice as likely to die in their rst
year of life than are white infants. Although following a
decline from 13.63 to 11.46 deaths per 1000 live births
from 2005 to 2010, non-Hispanic black mothers contin-
4.7 Society and culture
ued to report a rate 2.2 times as high as that for non-
Hispanic white mothers.[82] At some point the improved 4.7.1 Other meanings
rate of 11.46 still places U.S. non-Hispanic black mothers
was on par with Russia, which ranked 66th internation- In reliability engineering, infant mortality refers to the
ally few years ago, but recently improved to 6.1 deaths failures that occur in the rst part of the bathtub curve.
per 1000 live births.[83]
Contemporary research ndings have demonstrated that
nationwide racial disparities in infant mortality are linked 4.8 See also
to the experiential state of the mother and that these
disparities cannot be totally accounted for by socio- List of countries by infant mortality rate
economic, behavioral or genetic factors.[7] The Hispanic
paradox, an eect observed in other health indicators, Related statistical categories:
appears in the infant mortality rate, as well. Hispanic
mothers see an IMR comparable to non-Hispanic white
Perinatal mortality only includes deaths between the
mothers, despite lower educational attainment and eco-
foetal viability (22 weeks gestation) and the end of
nomic status. A study in North Carolina, for exam-
the 7th day after delivery.
ple, concluded that white women who did not complete
high school have a lower infant mortality rate than black Neonatal mortality only includes deaths in the rst
college graduates.[84] According to Mustillos CARDIA 28 days of life.
(Coronary Artery Risk Development in Young Adults)
study, self reported experiences of racial discrimination Postneonatal mortality only includes deaths after 28
were associated with pre-term and low-birthweight deliv- days of life but before one year.
eries, and such experiences may contribute to black-white
Child mortality includes deaths within the rst ve
disparities in prenatal outcomes.[85] Likewise, dozens of
years after birth.
population-based studies indicate that the subjective, or
perceived experience of racial discrimination is strongly
associated with an increased risk of infant death and with
poor health prospects for future generations of African 4.9 References
Americans.[7]
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4.10 External links
Child and infant mortality estimates for all countries
- website by UNICEF

[76] Rosenthal, Elisabeth (June 30, 2013) American Way of

Birth, Costliest in the World. The New York Times

[77] 12Societal Costs of Preterm Birth in Preterm Birth:

Causes, Consequences, and Prevention. Institute of
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Birth and Assuring Healthy Outcomes; Behrman RE, But-
ler AS (eds.). Washington (DC): National Academies
Press (US); 2007.

[78] Oestergaard MZ (2011). Neonatal mortality lev-

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[79] Stareld B (2000). Is US health really the best

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doi:10.1001/jama.284.4.483. PMID 10904513.
Chapter 5

Malnutrition in India

The World Bank estimates that India is one of the high- sequently, new born infants are unable to get adequate
est ranking countries in the world for the number of chil- amount of nutrition from their mothers.
dren suering from malnutrition. The prevalence of un-
Deciencies in nutrition inict long-term damage to both
derweight children in India is among the highest in the individuals and society. Compared with their better-fed
world, and is nearly double that of Sub Saharan Africa peers, nutrition-decient individuals are more likely to
with dire consequences for mobility, mortality, produc- have infectious diseases such as pneumonia and tuber-
tivity and economic growth.[1] culosis, which lead to a higher mortality rate. In addi-
The 2015 Global Hunger Index (GHI) Report ranked In- tion, nutrition-decient individuals are less productive at
dia 20th amongst leading countries with a serious hunger work. Low productivity not only gives them low pay that
situation. Amongst South Asian nations, it ranks third be- traps them in a vicious circle of under-nutrition,[9] but
hind only Afghanistan and Pakistan with a GHI score of also brings ineciency to the society, especially in In-
29.0 (serious situation).[2] dia where labour is a major input factor for economic
India is one of the fastest growing countries in terms of production.[10] On the other hand, over-nutrition also has
population and economics, sitting at a population of 1.2 severe consequences. In India national obesity rates in
billion and growing at 1.5%1.7% annually (from 2001 2010 were 14% for women and 18% for men with some
2007).[3][4] Indias Gross Domestic Product growth was urban areas having rates as high as 40%.[11] Obesity
9.0% from 2007 to 2008; since Independence in 1947, causes several non-communicable diseases such as car-
its economic status has been classied as a low-income diovascular diseases, diabetes, cancers and chronic respi-
country with majority of the population at or below the ratory diseases.[9]
poverty line.[5] Subodh Varma, writing in The Times of India, states that
Though most of the population is still living below the Na- on the Global Hunger Index India is on place 67 among
tional Poverty Line, its economic growth indicates new the 80 nations having the worst hunger situation which
opportunities and a movement towards increase in the is worse than nations such as North Korea or Sudan.
prevalence of chronic diseases which is observed in at 25% of all hungry people worldwide live in India. Since
high rates in developed countries such as United States, 1990 there has been some improvements for children
Canada and Australia. The combination of people liv- but the proportion of hungry in the population has in-
ing in poverty and the recent economic growth of India creased. In India 44% of children under the age of 5
has led to the co-emergence of two types of malnutrition: are underweight. 72% of infants and 52% of married
undernutrition and overnutrition.[6] women have anaemia. Research has conclusively shown
that malnutrition during pregnancy causes the child to
Malnutrition refers to the situation where there is an un- have increased risk of future diseases, physical retarda-
balanced diet in which some nutrients are in excess, lack- tion, and reduced cognitive abilities.[12]
ing or wrong proportion. Simply put, we can categorise
it to be under-nutrition and over-nutrition. Despite In-
dias 50% increase in GDP since 1991,[7] more than one
third of the worlds malnourished children live in India.
Among these, half of them under 3 are underweight and
a third of wealthiest children are over-nutriented.[8]
5.1 Nutritional trends of various
Some of the major causes for malnutrition in India is Eco-
nomic inequality. Due to the low social status of some demographic groups
population groups, their diet often lacks in both quality
and quantity. Women who suer malnutrition are less
Many factors, including region, religion, and caste aect
likely to have healthy babies. In India, mothers gener-
the nutritional status of Indians. Living in rural areas also
ally lack proper knowledge in feeding children. Con-
contribute to nutritional status.[13]

35
36 CHAPTER 5. MALNUTRITION IN INDIA

5.1.1 Socio-economic status Punjab, Kerala, and Delhi also face the highest rate of
overweight and obese individuals.[13]
In general, those who are poor are at risk for under-
nutrition,[14] while those who have high socio-economic
status are relatively more likely to be over-nourished. 5.1.3 Religion
Anaemia is negatively correlated with wealth.[13]
When it comes to child malnutrition, children in low- Studies show that individuals belonging to Hindu, Jain or
income families are more malnourished than those in Muslim backgrounds in India tend to be more malnour-
[19]
high-income families. Some cultural beliefs that may ished than those from Sikh or Christian backgrounds.
lead to malnutrition is religion. Among these is the inu-
ence of religions, especially in India are restricted from
consuming meat. Also, other Indians are strictly ve- 5.2 Management
gan, which means, they do not consume any sort of an-
imal product, including dairy and eggs. This is a seri-
ous problem when inadequate protein is consumed be- The Government of India has launched several programs
cause 56% of poor Indian household consume cereal to to converge the growing rate of under nutrition children.
consume protein. But unfortunately, the type of pro- They include ICDS, NCF, National Health Mission.
tein that cereal contains does not parallel to the pro-
teins that animal product contain (Gulati, 2012).[15] Chil-
dren of Muslim households and those belonging to sched- 5.2.1 Midday meal scheme in Indian
uled castes or tribes also face higher rates of malnour- schools
ishment. This phenomenon is most prevalent in the ru-
ral areas of India where more malnutrition exists on an The Indian government started midday meal scheme on
absolute level. Whether children are of the appropri- 15 August 1995. It serves millions of children with fresh
ate weight and height is highly dependent on the socio- cooked meals in almost all the Government run schools
economic status of the population.[16] Children of fam- or schools aided by the government fund.
ilies with lower socio-economic standing are faced with
Apart from this Food for Life Annamrita run by ISKCON
sub-optimal growth. While children in similar communi-
Food Relief Foundation and the Akshaya Patra Founda-
ties have shown to share similar levels of nutrition, child
tion run the worlds largest NGO-run midday meal pro-
nutrition is also dierential from family to family depend-
grammes, each serving freshly cooked plant-based meals
ing on the mothers characteristic, household ethnicity
to over 1.3 million school children in government and
and place of residence. It is expected that with improve-
government-aided schools in India. These programmes
ments in socio-economic welfare, child nutrition will also
are conducted with part subsidies from the Government
improve.[17]
and partly with donations from individuals and corpo-
rations. The meals served by Food for Life Annamrita
and Akshaya Patra complies with the nutritional norms
5.1.2 Region given by the government of India and aims to eradicate
malnutrition among children in India. Food for Life An-
Under-nutrition is more prevalent in rural areas, again namrita is the premier aliate of Food for Life Global
mainly due to low socio-economic status. Anaemia for http://www.ffl.org the worlds largest free food relief net-
both men and women is only slightly higher in rural ar- work, with projects in over 60 countries.
eas than in urban areas. For example, in 2005, 40% of
women in rural areas, and 36% of women in urban areas
were found to have mild anaemia.[13] 5.2.2 Integrated child development scheme
In urban areas, overweight status and obesity are over
three times as high as rural areas.[13] The government of India started a program called
In terms of geographical regions, Madhya Pradesh, Integrated Child Development Services (ICDS) in 1975.
Jharkhand, and Bihar have very high rates of under- ICDS has been instrumental in improving the health of
nutrition. States with lowest percentage of under- mothers and children under age 6 by providing health and
nutrition include Mizoram, Sikkim, Manipur, Kerala, nutrition education, health services, supplementary food,
Punjab, and Goa, although the rate is still considerably and pre-school education. The ICDS program is one of
higher than that of developed nations. Further, anaemia the largest in the world. It reaches more than 34 million
is found in over 70% of individuals in the states of Bi- children ages 06 years and 7 million pregnant and lac-
har, Chhattisgarh, Madhya Pradesh, Andhra Pradesh, Ut- tating mothers.
tar Pradesh, Karnataka, Haryana, and Jharkhand. Less Other programs impacting under-nutrition include the
than 50% of individuals in Goa, Manipur, Mizoram, and National Midday Meal Scheme, the National Rural
Kerala have anaemia.[18] Health Mission, and the Public Distribution System
5.3. NATIONAL HEALTH MISSION 37

(PDS). The challenge for these programs and schemes is UNICEF since 1949 and is now in the fth decade of co-
how to increase eciency, impact, and coverage. operation for assisting most disadvantaged children and
Bal Kuposhan Mukta Bihar (BKMB) is a campaign their mothers. Traditionally, UNICEF has been support-
launched by Department of Social Welfare, government ing India in a number of sectors like child development,
of Bihar in 2014. The campaign is based on ve Cs: womens development, urban basic services, support for
community based convergent services, health, education,
nutrition, water & sanitation, childhood disability, chil-
communication for behaviour change dren in especially dicult circumstances, information
and communication, planning and programme support.
capacity building
India was a member of the UNICEF Executive Board till
communitys access to tangibles and intangibles 31 December 1997. The board has 3 regular sessions
and one annual session in a year. Strategies and other
community participation and important matters relating to UNICEF are discussed in
those meetings. A meeting of Government of India and
collective approach. UNICEF ocials was concurred on 12 November 1997
to nalise the strategy and areas for programme of coop-
The multi-pronged strategy shows that a health issue eration for the next Master Plan of operations 19992002
like malnutrition can be tackled with the help of be- which is to synchronise with the Ninth Plan of Govern-
[21]
hviour change communication (BCC) and other social ment of India.
aspects.[20]

5.3 National Health Mission

5.2.3 National Childrens Fund
5.3.1 National Rural Health Mission
The National Childrens Fund was created during the In-
ternational Year of the Child in 1979 under the Chari- The National Rural Health Mission of India mission was
table Endowment Fund Act, 1890. This Fund provides created for the years 20052012, and its goal is to im-
support to the voluntary organisations that help the wel- prove the availability of and access to quality health care
fare of kids. by people, especially for those residing in rural areas, the
poor, women, and children.
5.2.4 National Plan of Action for Children The subset of goals under this mission are:

India is a signatory to the 27 survival and development Reduce infant mortality rate (IMR) and maternal
goals laid down by the World Summit on children 1990. mortality ratio (MMR)
In order to implement these goals, the Department of Provide universal access to public health services
Women & Child Development has formulated a National
Plan of Action on Children. Each concerned Central Prevent and control both communicable and non-
Ministries/Departments, State Governments/U.Ts. and communicable diseases, including locally endemic
Voluntary Organisations dealing with women and chil- diseases
dren have been asked to take up appropriate measures Provide access to integrated comprehensive primary
to implement the Action Plan. These goals have been healthcare
integrated into National Development Plans. A Monitor-
ing Committee under the Chairpersonship of Secretary Create population stabilisation, as well as gender and
(Women & Child Development) reviews the achievement demographic balance
of goals set in the National Plan of Action. All concerned
Revitalize local health traditions and mainstream
Central Ministries/Departments are represented on the
AYUSH
Committee.
Finally, to promote healthy life styles
15 State Govts. have prepared State Plan of Action on
the lines of National Plan of Action specifying targets for
The mission has set up strategies and action plan to meet
1995 as well as for 2000 and spelling out strategies for
all of its goals.[22]
holistic child development.

5.2.5 United Nations Childrens Fund 5.4 Sanitation

Department of Women and Child Development is the Despite of economic growth in India, Indias hunger is
nodal department for UNICEF. India is associated with still worse than North Korea or Sudan. And a child raised
38
in India is more likely to be malnourished than Somalia.
Various studies suggest that the biggest reason for Indias
malnutrition is poor sanitation. Because of poor sanita-
tion situation, more children in India than North Korea,
Sudan and Somalia are exposed to bacteria. The bacteria
sickens them, and make it hard for children to consume
nutrients, which results in malnutrition. 620 million peo-
ple in India dont have a toilet in their house and they use
public toilet or just outside. In addition, the air quality
in India is among the worst in the world. As India de-
veloped, the more wastes India produce. And it leads to
more poor sanitation. UNICEF is recognizing the poor
sanitation as one of the reasons for malnutrition. In 2012,
UNICEF made a report that malnutrition is based entirely
on lack of the food. But now, UNICEF and many chari-
table organizations are saying that poor sanitation is one
of the biggest reasons of malnutrition. Currently, the In-
dia government is working to solve malnutrition problem
by making more foods. But a lot of authorities in India
are saying they should change their plan for malnutrition
based on sanitation problem.
5.5 See also
India State Hunger Index
Obesity in India
General:
Malnutrition
Health in India
5.6 Further reading
Measham, Anthony R.; Meera Chatterjee (1999).
Wasting away: the crisis of malnutrition in India.
World Bank Publications. ISBN 0-8213-4435-8.
5.7 References
[1] World Bank Report. Source: The World Bank (2009).
Retrieved 2009-03-13. World Bank Report on Malnutri-
tion in India
[2] 2015 Global Hunger Index Report (PDF). International
Food Policy Research Institute (IFPRI).
[3] World Development Indicators Google Public Data Ex-
plorer. line feed character in |title= at position 29 (help)
[4] World Bank Report. Source: The World Bank 2009.
Retrieved 2009-11-25. India Country Overview 2009
[5] World Bank Report. Source: The World Bank 2009.
Retrieved 2009-11-25. India Country Overview 2009
CHAPTER 5. MALNUTRITION IN INDIA
[6] Journal of the American Medical Association. Source:
JAMA 2004. Retrieved 2009-11-26. The global burden
of chronic diseases
[7] The Indian exception. The Economist. 31 March 2011.
Retrieved 13 February 2012.
[8] Putting the smallest rst. The Economist. 23 September
2010. Retrieved 13 February 2012.
[9] Turning the tide of malnutrition (PDF). World Health
Organization. Retrieved 14 February 2012.
[10] A call for reform and action. The World Bank. Re-
trieved 14 February 2012.
[11] India in grip of obesity epidemic. The Times of India.
12 November 2010. Retrieved 14 February 2012.
[12] Superpower? 230 million Indians go hungry daily, Sub-
odh Varma, 15 Jan 2012, The Times of India,
[13] NFHS-3 Nutritional Status of Adults. Retrieved 2009-
11-26.
[14] Kanjilal, B; et al. (2010). Nutritional Status of Chil-
dren in India: Household Socio-Economic Condition as
the Contextual Determinant. Int J for Equity in Health.
9: 19. doi:10.1186/1475-9276-9-19.
[15] Gulati, A., Ganesh-Kumar, A., Shreedhar, G., & Nan-
dakumar, T. (2012). Agriculture and malnutrition in In-
dia. Food And Nutrition Bulletin, 33(1), 7486
[16] HUNGaMA Survey Report (PDF). Naandi foundation.
Retrieved 1 February 2012.
[17] Kanjilal, Barun; Mazumdar, Mukherjee, Rahman (Jan-
uary 2010). Nutritional status of children in India:
household socio-economic condition as the contextual de-
terminant. International Journal for Equity in Health. 9:
1931. doi:10.1186/1475-9276-9-19. Cite uses depre-
cated parameter |coauthors= (help)
[18] NFHS-3 Nutritional Status of Children. Retrieved
2009-11-26.
[19] Nutrition and Anaemia (PDF). Retrieved 2009-11-26.
[20] A campaign to end malnutrition in Bihar. www.
ideasforindia.in. Retrieved 2015-10-09.
[21] Child Development Website. Source: Child Develop-
ment programmes site (2009). Archived from the original
on 6 December 2008. Retrieved 2009-03-14. Programs
to address malnutrition in India
[22] National Rural Health Mission (PDF). Source: National
Rural Health Mission (20052012). Retrieved 2009-11-
26.
5.8 External links
Malnutrition in India: shame on humanity
India: Malnutrition Report World Bank
5.8. EXTERNAL LINKS 39

Child Malnutrition In India Report

Addressing the Food Insecure and malnutirition in

the Delhi/NCR Region
Chapter 6
Healthcare in India
The private sector is the dominant healthcare provider in research budget in Indian pharmaceutical companies is
India.[1] oriented at developing processes for synthesising drugs,
rather than drug development.
6.1 Health care system
The private healthcare sector is responsible for the major-
ity of healthcare in India. Most healthcare expenses are
paid out of pocket by patients and their families, rather
than through insurance. This has led many households to
incur Catastrophic Health Expenditure (CHE) which can
be dened as health expenditure that threatens a house-
holds capacity to maintain a basic standard of living.[2]
One study found that over 35% of poor Indian house-
holds incur CHE and this reects the detrimental state
in which Indian health care system is at the moment.[2]
With government expenditure on health as a percentage
of GDP falling over the years and the rise of private health
care sector, the poor are left with fewer options than be-
fore to access health care services.[2] Private insurance
is available in India, as are various through government-
sponsored health insurance schemes. According to the
World Bank, about 25% of Indias population had some
form of health insurance in 2010.[3] A 2014 Indian gov-
ernment study found this to be an over-estimate, and
claimed that only about 17% of Indias population was
insured.[4] Public healthcare is free for those below the
poverty line.[5]
Penetration of health insurance in India is low by interna-
tional standards. Also private health insurance schemes,
which constitute the bulk of insurance schemes availed by
the population, do not cover costs of consultation or med-
ication. Only hospitalisation and associated expenses are
covered. India has typically addressed concerns pertain-
ing to pricing of medication through indirect but more
pragmatic means such as tax sops for medical expenses
and patent law. Indian patent law only protects formula-
tion and not the composition of a drug. This means that
generic drugs that typically become available after the
patent protections aorded to a drugs original developer
expire, are available in India much earlier. Indian phar-
maceutical companies routinely re-engineer processes for
manufacturing generic drugs to make medication avail-
able at much lower costs.[6][7] Accordingly, most of the
40
Plans are currently being formulated for the development
of a universal health care system in India, which would
provide universal health coverage throughout India.
6.1.1 Public and private healthcare
According to National Family Health Survey-3, the pri-
vate medical sector remains the primary source of health
care for 70% of households in urban areas and 63% of
households in rural areas.[8] Reliance on public and pri-
vate health care sector varies signicantly between states.
Several reasons are cited for relying on private rather than
public sector; the main reason at the national level is poor
quality of care in the public sector, with more than 57%
of households pointing to this as the reason for a prefer-
ence for private health care.[8] Most of the public health-
care caters to the rural areas; and the poor quality arises
from the reluctance of experienced health care providers
to visit the rural areas. Consequently, the majority of
the public healthcare system catering to the rural and re-
mote areas relies on inexperienced and unmotivated in-
terns who are mandated to spend time in public health-
care clinics as part of their curricular requirement. Other
major reasons are distance of the public sector facility,
long wait times, and inconvenient hours of operation.[8]
The study conducted by IMS Institute for Healthcare In-
formatics in 2013, across 12 states in over 14,000 house-
holds indicated a steady increase in the usage of private
healthcare facilities over the last 25 years for both Out
Patient and In Patient services, across rural and urban
areas.[9]
Following the 2014 election which brought Prime Minis-
ter Narendra Modi to oce, Modis government unveiled
plans for a nationwide universal health care system known
as the National Health Assurance Mission, which would
provide all citizens with free drugs, diagnostic treatments,
and insurance for serious ailments.[10] In 2015, imple-
mentation of a universal health care system was delayed
due to budgetary concerns.[11]
6.2. QUALITY OF HEALTHCARE
6.1.2 Rural Health
A community health centre in Kerala.
The National Rural Health Mission (NRHM) was
launched in April 2005 by the Government of India. The
goal of the NRHM was to provide eective healthcare to
rural people with a focus on 18 states which have poor
public health indicators and/or weak infrastructure.[12] It
has 18,000 ambulances and a workforce of 900,000 com-
munity health volunteers and 178,000 paid sta.[13]
Only 2% of doctors are in rural areas - where 68% of the
population live.[1] High levels of undernutrition among the urban poor
6.1.3 Urban Health
The National Urban Health Mission as a sub-mission of
National Health Mission was approved by the Cabinet
on 1 May 2013. It aims to meet health care needs of
the urban population with the focus on urban poor, by
making available to them essential primary health care
services and reducing their out of pocket expenses for
treatment.[14]
Rapid urbanisation and disparities in urban India:
Indias urban population has increased from 285 million
in 2001 to 377 million (31%) in 2011. It is expected to
increase to 535 million (38%) by 2026 (4). The United
Nations estimates that 875 million people will live in In-
dian cities and towns by 2050. If urban India were a sepa-
rate country, it would be the worlds fourth largest country
after China, India and the United States of America. Ac-
cording to data from Census 2011, close to 50% of urban
dwellers in India live in towns and cities with a population
of less than 0.5 million, while the four largest urban ag-
glomerations Greater Mumbai, Kolkata, Delhi and Chen-
nai are home to 15% of Indias urban population.[15]
Child Health, Survival Disparities in Urban India
Analysis of National Family Health Survey Data for
200506 (the most recent available dataset for analysis)
shows that within Indias urban population the under-
ve mortality rate for the poorest quartile eight states,
41
the highest under-ve mortality rate in the poorest quar-
tile occurred in UttarPradesh (110 per 1,000 live births),
Indias most populous state, which had 44.4million ur-
ban dwellers in the 2011 census[16] followed by Rajasthan
(102), Madhya Pradesh (98), Jharkhand (90) and Bihar
(85), Delhi (74), and Maharashtra (50). The sample for
West Bengal was too small for analysis of under-ve mor-
tality rate. In Uttar Pradesh was four times that of the
rest of the urban populations in Maharashtra and Mad-
hya Pradesh. In Madhya Pradesh, the under-ve mortal-
ity rate among its poorest quartile was more than three
times that of the rest of its urban population.[17]
Maternal Health car Disparities in Urban India
Among Indias urban population, one should note the
much lower proportion of mothers receiving maternity
care among the poorest quartile; only 54 per cent of preg-
nant women had at least three ante-natal care visits com-
pared to 83 per cent for the rest of the urban population.
Less than a quarter of mothers within the poorest quar-
tile received adequate maternity care in Bihar (12 per-
cent), and UttarPradesh (20 percent),and less than half
in Madhya Pradesh (38 percent), Delhi (41 percent), Ra-
jasthan (42 percent), and Jharkhand (48 percent). Avail-
ing three or more ante-natal check-ups during pregnancy
among the poorest quartile was better in West Bengal (71
percent), Maharashtra (73 percent).[17]
For Indias urban population in 200506, 54 percent of
children were stunted, and 47 percent underweight in the
poorest urban quartile, compared to 33 percent and 26
percent, respectively, for the rest of the urban population.
Children under ve years being stunted was particularly
high among the poorest quartile of the urban populations
in Uttar Pradesh (64 percent), Maharashtra (63 percent),
Bihar (58 percent), Delhi(58 percent), Madhya Pradesh
(55 percent), Rajasthan (53 percent), and slightly better
in Jharkhand (49 percent). Evenin the better-performing
states close to half of the children under-ve were stunted
among the poorest quartile, being 48 percent in West
Bengal respectively.[17]
High levels of stunted growth and being under-weight for
age among the urban poor in India points to repeated in-
fections,depleting the childs nutritional reserves, owing
to sub-optimal physical environment. It is also indicative
of high levels of food insecurity among this segment of
the population. A study carried out in the slums of Delhi
showed that 51% of slum families were food insecure.[18]
6.2 Quality of healthcare
In major urban areas, the quality of medical care is close
to and sometimes exceeds rst-world standards. Indian
healthcare professionals have the advantage of working in
a very biologically active region exposing them to treat-
ment regimens of various kinds of conditions. The qual-
42
ity and amount of experience is arguably unmatched in
most other countries. Despite limited access to high end
diagnostic tools in rural areas, healthcare professions rely
on extensive experience in rural areas. However non-
availability of diagnostic tools and increasing reluctance
of qualied and experienced healthcare professionals to
practice in rural, under-equipped and nancially less lu-
crative rural areas is becoming a big challenge.[19] al-
though rural medical practitioners are highly sought after
by residents of rural areas as they are more nancially af-
fordable and geographically accessible than practitioners
working in the formal public health care sector.[20] But
there are incidents were doctors were attacked and even
killed in rural India [21] In 2015 the British Medical Jour-
nal published a report by Dr Gadre, from Kolkata, ex-
posed the extent of malpractice in the Indian healthcare
system. He interviewed 78 doctors and found that kick-
backs for referrals, irrational drug prescribing and unnec-
essary interventions were commonplace.[22]
6.3 Private Healthcare
With the help of numerous government subsidies in
the 1980s, private health providers entered the market.
Opening up of the market in the 90s gave further im-
petus to the development of the private health sector
[23]
in India. Most of the healthcare capacity added after
2005 has been in the private sector, or in partnership with
the private sector.
Private healthcare providers in India typically oer high
quality treatment at reasonable costs. Narayana Health
plans to conduct heart operations at a cost of $800 per [14] NUHM. Retrieved 6 May 2015.
patient.[24] [15] Agarwal, Siddharth (2014-10-31). Making the Invisible
6.4 See also
Health in India
Timeline of healthcare in India
Medical tourism in India
Swachh Bharat Abhiyan
6.5 References
[1] Britnell, Mark (2015). In Search of the Perfect Health Sys-
tem. London: Palgrave. p. 59. ISBN 978-1-137-49661-
4.
[2] Catastrophic Health Expenditure and Poor in India:
Health Insurance is the Answer?" (PDF).
[3] https://www.worldbank.org/
en/news/feature/2012/10/11/
government-sponsored-health-insurance-in-india-are-you-covered
CHAPTER 6. HEALTHCARE IN INDIA
[4] Puja Mehra. Only 17% have health insurance cover.
The Hindu.
[5] Modis ambitious health policy may dwarf Obamacare.
Quartz.
[6] George T. Haley; Usha C.V. Haley (2012). The ef-
fects of patent-law changes on innovation: The case
of Indias pharmaceutical industry. Technological
Forecasting and Social Change. 79 (4): 607619.
doi:10.1016/j.techfore.2011.05.012.
[7] Hepatitis C suerer imports life-saving drugs from In-
dia. 20 August 2015.
[8] International Institute for Population Sciences and Macro
International (September 2007). National Family Health
Survey (NFHS-3), 200506 (PDF). Ministry of Health
and Family Welfare, Government of India. pp. 436440.
Retrieved 5 October 2012.
[9] Ramya Kannan (30 July 2013). More people opting for
private healthcare. Chennai, India: The Hindu. Re-
trieved 31 July 2013.
[10] Indias universal healthcare rollout to cost $26 billion.
[11] Aditya Kalra (27 March 2015). Exclusive: Modi govt
puts brakes on Indias universal health plan. Reuters In-
dia.
[12] Umesh Kapil and Panna Choudhury National Rural
Health Mission (NRHM): Will it Make a Dierence? In-
dian Pediatrics Vol. 42 (2005): 783
[13] Britnell, Mark (2015). In Search of the Perfect Health Sys-
tem. London: Palgrave. p. 60. ISBN 978-1-137-49661-
4.
Visible. Rochester, NY: Social Science Research Net-
work.
[16] Oce of the Registrar General and Census Com-
missioner (2011). Population Census of India 2011
Accessed 9-10-016http://www.census2011.co.in/census/
state/uttar+pradesh.html
[17] Agarwal, Siddharth (2011-04-01). The state of ur-
ban health in India; comparing the poorest quartile to
the rest of the urban population in selected states and
cities. Environment and Urbanization. 23 (1): 1328.
doi:10.1177/0956247811398589. ISSN 0956-2478.
[18] Agarwal, Siddharth; Sethi, Vani; Gupta, Palak; Jha,
Meenakshi; Agnihotri, Ayushi; Nord, Mark (2009-08-
04). Experiential household food insecurity in an urban
underserved slum of North India. Food Security. 1 (3):
239250. doi:10.1007/s12571-009-0034-y. ISSN 1876-
4517.
[19] India.
[20] Kanjilal, B; et al. (June 2007). A Parallel Health Care
market: Rural Medical Practitioners in West Bengal, In-
dia (PDF). FHS Research Brief. 02. Retrieved 30 May
2012.
6.5. REFERENCES 43

[21] Assaults on public hospital sta by patients and their rel-

atives: an inquiry. Indian journal of medical ethics. Re-
trieved 2016-10-20.

[22] Fox, Hannah (8 April 2015). I've seen rst-hand how

palliative care in India is compromised by privatisation.
The Guardian. Retrieved 19 April 2015.

[23] Baru,Rama V(2010): Public Sector Doctors in an Era of

Commercialisation in Sheikh and A George(ed)Health
Providers in India, on the Frontlines of Change(New
Delhi: Routledge)81-96.

[24] Britnell, Mark (2015). In Search of the Perfect Health Sys-

tem. London: Palgrave. p. 58. ISBN 978-1-137-49661-
4.
44 CHAPTER 6. HEALTHCARE IN INDIA

6.6 Text and image sources, contributors, and licenses

6.6.1 Text
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stemeier, Theresa knott, Nerd~enwiki, Glenn, Dietary Fiber, Poor Yorick, Nikai, Andres, Tristanb, Jiang, GCarty, Samuel~enwiki, Pizza
Puzzle, Hashar, Timwi, Radiojon, Joy, Jusjih, Hajor, Bearcat, Robbot, Tomchiukc, Naddy, Postdlf, Sverdrup, Rasmus Faber, Mr-Natural-
Health, Moink, Kd4ttc, GerardM, Profoss, Dhodges, Ruakh, Davidcannon, DocWatson42, Harp, Tom harrison, HangingCurve, Zigger,
Everyking, Snowdog, Gamaliel, Paploo, Jfdwol, Gadum, Andycjp, Bact, Geni, Formeruser-81, Quadell, Antandrus, Beland, CaribDigita,
OwenBlacker, Sharavanabhava, Bodnotbod, AndrewTheLott, Gscshoyru, Qiq~enwiki, Neutrality, Mschlindwein, Janneok~enwiki, Zondor,
Chris Howard, Freakofnurture, Shipmaster, Rich Farmbrough, KittySaturn, YUL89YYZ, Paul H, Bender235, Aecis, El C, Hayabusa future,
Shanes, Art LaPella, Bobo192, AnyFile, Foobaz, Jojit fb, Rajah, HasharBot~enwiki, ADM, Jumbuck, Alansohn, Qwe, Rd232, Monado,
Kurieeto, Eukesh, Mysdaao, Alinor, Xsharksx, Wtmitchell, Velella, Zantastik, Vcelloho, Evil Monkey, Grenavitar, TheAznSensation,
Versageek, TheCoee, Adrian.benko, Bobrayner, Georgia guy, MamaGeek, Guy M, Ahleong, Commander Keane, Astrowob, Tabletop,
Smmurphy, SCEhardt, Splungist, Davidl53, Prashanthns, Rad Racer, Palica, Graham87, Magister Mathematicae, Chun-hian, Ketiltrout,
Drbogdan, Rjwilmsi, Mayumashu, Koavf, , SpNeo, FlaBot, Themalau, Naraht, Vsion, RexNL, Parutakupiu, Steven-
fruitsmaak, Chobot, Jaraalbe, Parallel or Together?, Gwernol, The Rambling Man, YurikBot, Wavelength, RobotE, Gyre, Kafziel, Brand-
meister (old), RussBot, John Quincy Adding Machine, Severa, CFIF, Pseudomonas, Wimt, Deivo, Veledan, Drgregmartin, Howcheng,
RUL3R, Danlaycock, Tyrath, Jpeob, Cassius1213, Lt-wiki-bot, Closedmouth, GraemeL, Vicarious, Fram, Ordinary Person, JLaTondre,
Chris1219, Rathfelder, GrinBot~enwiki, Roke, Jkpjkp, SkerHawx, DVD R W, robot, Sintonak.X, SmackBot, FocalPoint, F, Un-
yoyega, Jacek Kendysz, Midway, Delldot, Eskimbot, Kelw, Edgar181, Mauls, Gilliam, Portillo, Ohnoitsjamie, Cmelbye, MalafayaBot,
Rlevse, Brideshead, Can't sleep, clown will eat me, AntiVan, Shalom Yechiel, , Greenshed, Bolivian Unicyclist, Sun-
darBot, DinosaursLoveExistence, Khukri, Jiddisch~enwiki, Vyborskaya, Aaronlai, Marc-Andr Abrock, Matthew hk, Kukini, Ohconfu-
cius, SashatoBot, Kuru, John, Demicx, The alliance, Gobonobo, NewTestLeper79, Stevendavy, Neovu79, Ckatz, JHunterJ, Tasc, Maksim
L., Waggers, Dcyer, Hogyn Lleol, Elb2000, Iridescent, Muhaidib, Sam Li, CapitalR, Harlan wilkerson, Adambiswanger1, Courcelles,
Coeezombie, Tawkerbot2, Raphael1, CmdrObot, BeenAroundAWhile, Illudin, Mig11, THF, Goatchurch, Godardesque, Musicalanto-
nio, CMG, Themightyquill, Cydebot, Procrastinator supreme, Mato, Anonymi, Danorton, Anthonyhcole, Bigjake, Rehcsif, Lindsay658,
Lo2u, Thijs!bot, Crockspot, Qwyrxian, Bchaln, Newton2, RickinBaltimore, NigelR, Strongriley, Nick Number, Escarbot, AntiVandalBot,
WinBot, Majorly, Luna Santin, Fayenatic london, Minggieming, CNicol, Flubrain, Snali, Aille, Sonicsuns, The Transhumanist, Ph.eyes,
Cindery, Bongwarrior, VoABot II, Mclay1, Kajasudhakarababu, Siapa luh?~enwiki, Recurring dreams, APB-CMX, Theroadislong, Indon,
28421u2232nfenfcenc, Prester John, Valerius Tygart, Mannerheimo, Pvosta, Karol007, Pauly04, MartinBot, Gandydancer, RP88, R'n'B,
CommonsDelinker, Lilac Soul, Francis Tyers, Morrad, J.delanoy, Trusilver, Silverxxx, Qatter, Jerry, Ian.thomson, Tokyogirl79, Svidrillion,
Koven.rm, Gurchzilla, ParaDoctoral, Sd31415, C1010, B.nadeau89, ScooterK, Wavemaster447, BookSquirrel, KylieTastic, Dr.Kerr,
LongLiveTaiwan, Jarry1250, Andy Marchbanks, Permafrost, Blood Oath Bot, CardinalDan, Idioma-bot, Funandtrvl, Rajasekhar1961,
VolkovBot, Thomas.W, Johnfos, ABF, Epson291, Philip Trueman, TXiKiBoT, WatchAndObserve, Rei-bot, ClintonKu, Guillaume2303,
Live STSS, Yilloslime, Broadbot, PDFbot, Vgranucci, CO, Eubulides, Epgui, Starlite89, Yk Yk Yk, Teh romaoer, Galuboo, Doc James,
AlleborgoBot, Kehrbykid, Weeman12342, Enkyo2, SieBot, Techtonic, BotMultichill, ToePeu.bot, Gerakibot, Dawn Bard, Caltas, Ham-
ster X, LeadSongDog, Cwwwang, Bentogoa, Flyer22 Reborn, Abnn, Buttons, Lightmouse, RW Marloe, Ruthdarlow, Nancy, DragonZero,
Dr.Golovenko~enwiki, Analizer, TaerkastUA, HMNSecretariat, Denisarona, Into The Fray, Atif.t2, Ricklaman, ClueBot, Shyamdash,
PipepBot, The Thing That Should Not Be, Arakunem, Drmies, Der Golem, Worldwidegrid, Naacats, Pras, Namazu-tron, Ashashyou, Ex-
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DumZiBoT, Kerres, Lseidlein, Je Wilges, XLinkBot, Pichpich, Cph003, SilvonenBot, Vegas949, Raso mk, MystBot, Zodon, Good Ol-
factory, Johnkatz1972, Saracottler, Gigoachef, Tayste, Wegely, Addbot, Shayer, Katrnuss~enwiki, CurtisSwain, Non-dropframe, Binary
TSO, Fgnievinski, Ronhjones, D0762, Zarcadia, Douglas the Comeback Kid, SoSaysChappy, Chamal N, CarsracBot, Lihaas, Favonian,
SamatBot, Numbo3-bot, David.naumann, Tide rolls, Verbal, Azulrey, Samuel Pepys, LuK3, Artichoke-Boy, Middayexpress, Luckas-
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mon the Likable, Odlaw, Materialscientist, Citation bot, OllieFury, David.scully93, Gothic325, ArthurBot, Bagumba, Quebec99, Xqbot,
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choBot, Corruptcopper, Omnipaedista, Annalise, RibotBOT, Bellerophon, Doulos Christos, GhalyBot, LincolnSt, Shadowjams, Fres-
coBot, Paine Ellsworth, Tobby72, Oldlaptop321, Mistakender, Megasonic58, 19401201Schooner, Glanhawr~enwiki, Grandiose, Ogre-
Bot, Neilpw1, Mitchkatie, I dream of horses, Elockid, HRoestBot, 10metreh, Yyomo, Foxhound66, Jschnur, Ichladegoatsehoch, Mathi-
aseu, Serols, Styleguide, Mathetic, FoxBot, TobeBot, Trappist the monk, , Acara44, Smartchick656, Teotax, Woodlot, Tal
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Rocketrod1960, Zhu Wuneng, ClueBot NG, Derfel73, CocuBot, LogX, This lousy T-shirt, Intermittentgardener, Jamie Guth, Rossi101,
HiKucing, O.Koslowski, , Runehelmet, Widr, Guptan99, Spiral999, 4cecz4, Theopolisme, Helpful Pixie Bot, Mizuzu, Som999,
WNYY98, BG19bot, Petrarchan47, John Cummings, MusikAnimal, Educate.mali, Marcocapelle, Jeancey, Beenelse4, MrBill3, Kate-
Woodhouse, TrangHo KWS, Polmandc, Dianaruttman1, Whym, TracyK123, Etck, Jelicavesic, Fylbecatulous, Ehr1Ros2, Sophia Maigr,
Vanobamo, CynicalTurtle, Sceebaby, ChrisGualtieri, Popopo8776, Wolmfn, Haejelee, Jshsfrt, Lisaachoi, Lugia2453, NightShadow23,
ClaireKairys, Reatlas, Omarash1999, OMAR ASHRAF 1999, Epicgenius, Hendrick 99, Darkcritic, RaphaelQS, Ashleyleia, Jackie845,
IM-yb, Antdogg000, JustBerry, Rubarizwan, Quenhitran, Kind Tennis Fan, Inaaaa, Noyster, Bond127, MidwestCuttlesh, Lowe D. C.
Clog, Cogito ero sum, Door Dow Win 345, Landryrobison, 7Sidz, Abgar eabe ghu, Melcous, Patient Zero, Slyspockthefox, Confetideral,
Lorely20, Riceissa, Newt82, Trackteur, Leroy2311, Rbnewell, Khamissk, Shiva767, Crazyman103, CormacKavalier, T1Biscuit, Mdfaulks,
Pravinsondulkar, Cursedwaes, Wikipedian No, 203434, Rnass083, Ravi.mandalia, Rabrabrab, Xl peep man lx, TaqPol, Parabolist, Ba-
cLuong, MoreTomorrow, Glee6061, Ericchan22, Lwedekind, Hsh0887, Obertan84, Tianyjohnson531, Endofyear, THAKUR SAHIL
SINGH, Faridsabet, Hazelnuterie, GlobalStrategy, Slocatsecretariat, Xevp5qw4, Barbara (WVS), Adwill16, Talkalotforlife, Grammmarrr,
Gulumeemee, Mabulk, Wikisanchez, Bear-rings, Bender the Bot, Jimmy Beques, Abbas212fge3333, Subbu.subbs and Anonymous: 659

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747958491 Contributors: Neutrality, Arcadian, Toussaint, Dwaipayanc, Ebinviswanath, RussBot, Tachs, SmackBot, Timbouctou, Colonies
6.6. TEXT AND IMAGE SOURCES, CONTRIBUTORS, AND LICENSES 45

Chris, Amartyabag, Shyamsunder, Green Giant, CmdrObot, Cydebot, Nick Number, IndianGeneralist, Ekabhishek, Naniwako, Joshua Is-
sac, Barkeep, Mild Bill Hiccup, Addbot, Yobot, AnomieBOT, Bluerasberry, Hunnjazal, LilHelpa, Gauravsinghal2, Crusoe8181, Diannaa,
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Rsrikanth05, Gsingh, Rmky87, Sarkar112, Zzuuzz, Arundhati bakshi, Rathfelder, NeilN, Jhelleranta, SmackBot, Saravask, Yamaguchi ,
Hmains, Chris the speller, A. B., Shuki, Brijesh cp singh, BullRangifer, Amartyabag, Nishkid64, AThing, Geeteshgadkari, Dl2000, Hu12,
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Chellan, Naniwako, In Transit, Mufka, Madhava 1947, Joshua Issac, BioStu, Cibes, Paanduraam, Calliopejen1, Yintan, Flyer22 Reborn,
Allmightyduck, Boromir123, Aumnamahashiva, 2jaipm, Guyofguts, Invertzoo, Sfan00 IMG, ClueBot, Shyamdash, Suyog 11, Rpammdi,
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AnomieBOT, Jim1138, Ulric1313, Materialscientist, Citation bot, The Creationist, LilHelpa, Nasnema, Anna Frodesiak, RadManCF,
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tria156, PigFlu Oink, SpacemanSpi, Tom.Reding, Loyalist Cannons, Half price, Skyerise, SAMUDAR, Innerklang, Kasiarun, Brian
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LeeLuce, BG19bot, NatalieF25, Snic215, Metricopolus, BPositive, Vastu1706, Devadyuti nag, Mark Arsten, Burn & Trauma Research
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Bethmills, Vwalvekar, Mogism, Delljvc, Shyamznwar, Anshul3Bansal, Faizan, Avi royd, Jasdeepsgill, Msundqvist, Commons sibi, JWNoc-
tis, Words with hope, Bladesmulti, No longer a penguin, Lakun.patra, Drsoumyadeepb, Bilorv, Dad editor, Monkbot, Filedelinkerbot,
Milesjolly1997, Mansukhsurin, Aloks895, Sha5001, Abhishek tiwari ji, Clw212, SonOfSiciliy, RRR89, Padwalshubham, Sanjit Agar-
wal, Dr. Nehak, Absolutelypuremilk, Miller james digi, Drruchig, Satyand200, Capankajsmilyo, AusLondonder, U SAACHI, MBlaze
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bauder, William Avery, SimonP, Hephaestos, Edward, Patrick, Menchi, TakuyaMurata, Jpatokal, Snoyes, Nerd~enwiki, Andres, Rl,
Smack, Raul654, DavidCary, Everyking, Patrick-br, Magentagoddess, Proslaes, Sonjaaa, Antandrus, OverlordQ, Piotrus, Gsociology,
NeonElf, Neutrality, Brother Dysk~enwiki, Rich Farmbrough, YUL89YYZ, Bender235, Jules991, CanisRufus, Clayboy, Imoen, JHarris,
Arcadian, Nk, Leifern, A2Kar, Ogress, Jumbuck, Honeycake, Civvi~enwiki, Atlant, Alberto Chilosi, Axl, Ferrierd, Wyatts, TigerShark,
Carcharoth, Ekem, Bennetto, Graham87, Deltabeignet, Elvey, Rjwilmsi, Joe Decker, Stardust8212, Bubba73, Vsion, Kolbasz, Tedder,
Sharkface217, Bgwhite, Banaticus, YurikBot, Hede2000, Gaius Cornelius, Pseudomonas, NawlinWiki, Voyevoda, Lepidoptera, Mike Ser-
fas, Emijrp, Black-Velvet, Mrgomel, ChipperGuy, AlexD, SmackBot, Meshach, Yoot!!, Bobzchemist, Gilliam, Ohnoitsjamie, Bluebot,
Darth Panda, Jsu~enwiki, Rrburke, SundarBot, Ala.foum, Qmwne235, Lambiam, Gloriamarie, Illythr, Mr Stephen, Ginkgo100, Joseph
Solis in Australia, Flamelai, Zoebrillantes, Tawkerbot2, Sohaiblatif, Bigmak, Chandra friend, NickW557, Penbat, Andrew Delong, Don-
aharr2, Cydebot, Bddmagic, Michaelas10, Gogo Dodo, Alaibot, In Defense of the Artist, Vanished User jdksfajlasd, Thijs!bot, Tmdean,
Headbomb, Marek69, Obiwankenobi, Opelio, QuiteUnusual, Fayenatic london, Mack2, Jirka6, HolyT, JenLouise, SiobhanHansa, Tim
killeen, FaerieInGrey, Magioladitis, Puellanivis, Bongwarrior, Jarekt, Avjoska, Nyttend, Loonymonkey, MartinBot, J.delanoy, 068152,
Altes, Nbauman, Boghog, Athaenara, Vanished user 342562, Barts1a, Tony Stein, Naniwako, Mikael Hggstrm, Asen4life, FJPB, RB972,
Remember the dot, Wikieditor06, Malik Shabazz, Philip Trueman, Leafyplant, Knighttjy, Saturn star, Flamable221, Eubulides, Hallbri-
anh, Gillyweed, Lova Falk, Homunculus 2, Doc James, Bfpage, Laoris, Yintan, Aoxiang, Whiteghost.ink, Crazyeights0875, Grundle2600,
Bentogoa, Flyer22 Reborn, Kotabatubara, Shmoigen, DancingPhilosopher, JustBeCool, Martin H., Ienjoyit89, Jean-Francois Landry, Krox-
bury, Megbrown21, ClueBot, Snigbrook, Bargolus, The Thing That Should Not Be, Mild Bill Hiccup, Headrecar, Pointillist, David Igra,
Dwrcan, Diderots dreams, Dedbaby, Arjayay, SchreiberBike, Audionaut, Tired time, MasterOfHisOwnDomain, J Hazard, Addbot, DOI
bot, Non-dropframe, Binary TSO, Hans de Vries, Fieldday-sunday, CanadianLinuxUser, Jpoelma13, MrOllie, SamatBot, Ehrenkater, Tide
rolls, Lightbot, , Mohsenkazempur, Legobot, Yobot, Pagtwentytwo, Librsh, Beeswaxcandle, Worm That Turned, ChildSurvival,
Eric-Wester, AnomieBOT, 1exec1, Jim1138, Ipatrol, Dinesh smita, Materialscientist, Citation bot, Eumolpo, Calebmday, Ywaz, Venice85,
Intelati, Capricorn42, Smallman12q, Samwb123, Nadaga, Goapples, Schiefenhvel, Citation bot 1, Deadbabiesaregood, Sailorman2439,
Test413, Pinethicket, I dream of horses, Johf, Phoenix7777, Starks Hayter, MichaelJDay, Jerd10, Weedwhacker128, Sebastianblake-
howard, Vdalal, RjwilmsiBot, DexDor, Powerkeys, Ionut Cojocaru, Alexmacpherson, I change crud, John of Reading, Stlouisrams11,
Dcirovic, Ornithikos, Werieth, Samcol1492, Thargor Orlando, Matthewcgirling, Veikk0.ma, H3llBot, Jonathansammy, Samkange, IGeM-
iNix, Coasterlover1994, Ace of Raves, Ssmithso, ClueBot NG, MelbourneStar, Mesoderm, Robertdavis71, Mightymights, Helpful Pixie
Bot, Renzut, Mark Marathon, Shaya88, OMolokaiO, BG19bot, Cripz1, Ronengoldenber, Jami430, Rodaen, Jesbeard, Shaun, BattyBot,
Biosthmors, Allyssa.abacan, Mrt3366, Cyberbot II, Dylan303, Dexbot, Martin on the beach, Webclient101, Mogism, Cerabot~enwiki,
Lugia2453, , Lilacerdadju, Breanna foster10, JillianPeirce3, Caitlingreen79, Mcgillsarah1, Gabbyho, Jason mja, Yca169, Hbellamy,
Hhanamm, Mjtang, MarshKath, Haleysarabrown, MeganShobab, Ajayaja32, Jesskyllo, Chnatko, Nestorchau, Collapse1960, McBenjamin,
Eyesnore, AlwynJPie, EngGerm12, JamesMoose, Tentinator, Daniellehull, Bddpaux, MichaelM777, Sari.lindfors, RikardT, Mynameisnot-
barackobama, Akhilburle, M Tracy Hunter, Monkbot, HollyB4rnes98, Halfhat, Frogie9, ThaNDNman224, Rdcole002, EvMsmile, Emma-
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261
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men Kocjancic, Rich Farmbrough, Bender235, Kwamikagami, Wiki-uk, Amorymeltzer, Woohookitty, Rjwilmsi, Bgwhite, Wavelength,
Gaius Cornelius, SmackBot, Chris the speller, NickPenguin, Ohconfucius, Shyamsunder, Ekabhishek, Barek, Abecedare, Naniwako, Log-
icwiki, Oshwah, Anna Lincoln, Doc James, Munci, Yerpo, Aumnamahashiva, Capitalismojo, Denisarona, Ost316, MatthewVanitas, Tut-
terMouse, Yobot, Ningauble, AnomieBOT, Erik9bot, FrescoBot, Kchaitanya21, Tom.Reding, Ciniuk, SpaceFlight89, Euphoria1611, Bur-
rolito, RjwilmsiBot, Venustas 12, Taimijt, GurjeetKaur13, Dewritech, Your Lord and Master, Kkm010, H3llBot, Netha Hussain, Zugger-
naut, Helpful Pixie Bot, Electriccatsh2, Titodutta, BG19bot, Bmusician, AbhiSuryawanshi, MKar, Billadada, EricEnfermero, Khatchell,
Robertcmiller7, Pbazogh, Acadmica Orientlis, Cyberbot II, Wangkangping3, Abhilashmenon87, ChrisGualtieri, Quinn307, Bethmills,
Dr.srireddyk, Ariulloa, Ginsuloft, LoveEarth42, Monkbot, Nowzer, Aqjiang, Elandut, Dr.Nigamananda Swain, Kaashif alikhan, MBlaze
Lightning, Ssupsw, GreenC bot and Anonymous: 70
46 CHAPTER 6. HEALTHCARE IN INDIA

Healthcare in India Source: https://en.wikipedia.org/wiki/Healthcare_in_India?oldid=750298943 Contributors: Versageek, GnniX,

Rathfelder, JohnCD, Obiwankenobi, Yobot, I dream of horses, Tom.Reding, Kkm010, Alexander Misel, Titodutta, Melcous, KH-1,
ShesLostControlAgain, Capankajsmilyo, AusLondonder, Mrinalchadha07, Wikisanchez, MedgurusOrg, Htrah01ddis, Adorncosmetic and
Anonymous: 7

6.6.2 Images
File:1766_WHO_Headquarters_200.jpg Source: https://upload.wikimedia.org/wikipedia/commons/d/d3/1766_WHO_Headquarters_
200.jpg License: Public domain Contributors: Scanned by Darjac Original artist: Darjac
File:2012_Infant_mortality_rate_per_1000_live_births,_under-5,_world_map.svg Source: https://upload.wikimedia.org/
wikipedia/commons/0/03/2012_Infant_mortality_rate_per_1000_live_births%2C_under-5%2C_world_map.svg License: CC BY-SA
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tors: ? Original artist: ?
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nal artist: ?
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? Original artist: ?
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nal artist: ?
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guidelines (Russian/English) Original artist: Various
6.6. TEXT AND IMAGE SOURCES, CONTRIBUTORS, AND LICENSES 47

File:Flag_of_Sweden.svg Source: https://upload.wikimedia.org/wikipedia/en/4/4c/Flag_of_Sweden.svg License: PD Contributors: ?

Original artist: ?
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Contributors:
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svg License: Public domain Contributors: Flag of the United Nations from the Open Clip Art website. Modications by Denelson83,
Zscout370 and Madden. Ocial construction sheet here.
United Nations (1962) The United Nations ag code and regulations, as amended November 11, 1952, New York OCLC: 7548838. Original
artist: Wilfried Huss / Anonymous
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sa-3.0 Contributors: ? Original artist: ?
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commons/8/87/Image_of_Triangle_Shirtwaist_Factory_fire_on_March_25_-_1911.jpg License: Public domain Contribu-
tors: http://www.ilr.cornell.edu/trianglefire/primary/photosIllustrations/slideshow.html?image_id=746&sec_id=3#screen Orig-
inal artist: Unknown<a href='//www.wikidata.org/wiki/Q4233718' title='wikidata:Q4233718'><img alt='wikidata:Q4233718'
src='https://upload.wikimedia.org/wikipedia/commons/thumb/f/ff/Wikidata-logo.svg/20px-Wikidata-logo.svg.png' width='20'
height='11' srcset='https://upload.wikimedia.org/wikipedia/commons/thumb/f/ff/Wikidata-logo.svg/30px-Wikidata-logo.svg.png 1.5x,
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License: Public domain Contributors: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6301a9.htm Mathews TJ, MacDorman MF.
Infant mortality statistics from the 2010 period linked birth/infant death data set. Natl Vital Stat Rep 2013;62(8). Original artist: Mathews
TJ, MacDorman MF
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File:Patio_of_World_Health_Organization_headquarters_building,_1969.jpg Source: https://upload.wikimedia.org/wikipedia/
commons/6/6b/Patio_of_World_Health_Organization_headquarters_building%2C_1969.jpg License: CC BY-SA 3.0 Contributors: I took
this before leaving my job in Geneva as a record of this beautiful building, strictly for my own use.
Previously published: Never published Original artist: GeorgeLouis
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Clipart Original artist: OpenClipart
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Original artist: ?
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Contributors:
Created from scratch in Adobe Illustrator. Based on Image:Question book.png created by User:Equazcion Original artist:
Tkgd2007
File:Reflecting_pool_and_women_walking_at_World_Health_Organization,_Geneva,_1969.jpg Source: https://upload.
wikimedia.org/wikipedia/commons/d/dc/Reflecting_pool_and_women_walking_at_World_Health_Organization%2C_Geneva%
2C_1969.jpg License: CC BY-SA 3.0 Contributors: I shot this photo in Geneva strictly for my own enjoyment and a souvenir of the
building.
Previously published: Never published Original artist: GeorgeLouis
File:Requirements_for_reporting_a_live_birth,_United_States_and_selected_European_countries,_2004.png Source:
https://upload.wikimedia.org/wikipedia/commons/1/1f/Requirements_for_reporting_a_live_birth%2C_United_States_and_selected_
European_countries%2C_2004.png License: Public domain Contributors: NCHS/National Vital Statistics System for U.S. data and
European Perinatal Health Report Original artist: NCHS
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United_Nations_ZP.svg License: Public domain Contributors: ? Original artist: ?
File:Stairwell_in_World_Health_Organization_headquarters,_Geneva,_1969.jpg Source: https://upload.wikimedia.org/wikipedia/
commons/0/01/Stairwell_in_World_Health_Organization_headquarters%2C_Geneva%2C_1969.jpg License: CC BY-SA 3.0 Contribu-
tors: I took this photo the last day of my work in Geneva so I would have a record of this beautiful building.
Previously published: Never published. Original artist: GeorgeLouis
File:Stamps_of_Germany_(DDR)_1966,_MiNr_1178.jpg Source: https://upload.wikimedia.org/wikipedia/commons/1/18/Stamps_
of_Germany_%28DDR%29_1966%2C_MiNr_1178.jpg License: Public domain Contributors: Eigener Scan und Bearbeitung Original
artist: Hochgeladen von --Nightyer (<a href='//commons.wikimedia.org/wiki/User_talk:Nightflyer' title='User talk:Nightflyer'>talk</a>)
13:21, 19 July 2009 (UTC)
48 CHAPTER 6. HEALTHCARE IN INDIA

File:The_entrance_hall_WHO_HQ,_Geneva.JPG Source: https://upload.wikimedia.org/wikipedia/commons/4/43/The_entrance_

hall_WHO_HQ%2C_Geneva.JPG License: CC BY-SA 3.0 Contributors: Own work Original artist: Thorkild Tylleskar
File:WHO_HQ_main_building,_Geneva,_from_East.JPG Source: https://upload.wikimedia.org/wikipedia/commons/7/73/WHO_
HQ_main_building%2C_Geneva%2C_from_East.JPG License: CC BY-SA 3.0 Contributors: Own work Original artist: Thorkild Tylleskar
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HQ_main_building%2C_Geneva%2C_from_North.JPG License: CC BY-SA 3.0 Contributors: Own work Original artist: Thorkild
Tylleskar
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HQ_main_building%2C_Geneva%2C_from_West.JPG License: CC BY-SA 3.0 Contributors: Own work Original artist: Thorkild
Tylleskar
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HQ_main_building%2C_Geneva_from_South.JPG License: CC BY-SA 3.0 Contributors: Own work Original artist: Thorkild Tylleskar
File:WHO_HQ_main_building,_Geneva_from_Southwest.JPG Source: https://upload.wikimedia.org/wikipedia/commons/4/47/
WHO_HQ_main_building%2C_Geneva_from_Southwest.JPG License: CC BY-SA 3.0 Contributors: Own work Original artist: Thorkild
Tylleskar
File:WHO_HQ_main_entrance,_Geneva.JPG Source: https://upload.wikimedia.org/wikipedia/commons/0/05/WHO_HQ_main_
entrance%2C_Geneva.JPG License: CC BY-SA 3.0 Contributors: Own work Original artist: Thorkild Tylleskar
File:Wappen_Genf_matt.svg Source: https://upload.wikimedia.org/wikipedia/commons/9/9d/Wappen_Genf_matt.svg Li-
cense: Public domain Contributors: ozielle PDF Original artist: Unknown<a href='//www.wikidata.org/wiki/Q4233718'
title='wikidata:Q4233718'><img alt='wikidata:Q4233718' src='https://upload.wikimedia.org/wikipedia/commons/thumb/f/ff/
Wikidata-logo.svg/20px-Wikidata-logo.svg.png' width='20' height='11' srcset='https://upload.wikimedia.org/wikipedia/commons/
thumb/f/ff/Wikidata-logo.svg/30px-Wikidata-logo.svg.png 1.5x, https://upload.wikimedia.org/wikipedia/commons/thumb/f/ff/
Wikidata-logo.svg/40px-Wikidata-logo.svg.png 2x' data-le-width='1050' data-le-height='590' /></a>
File:Wiki_letter_w_cropped.svg Source: https://upload.wikimedia.org/wikipedia/commons/1/1c/Wiki_letter_w_cropped.svg License:
CC-BY-SA-3.0 Contributors: This le was derived from Wiki letter w.svg: <a href='//commons.wikimedia.org/wiki/File:
Wiki_letter_w.svg' class='image'><img alt='Wiki letter w.svg' src='https://upload.wikimedia.org/wikipedia/commons/thumb/6/6c/Wiki_
letter_w.svg/50px-Wiki_letter_w.svg.png' width='50' height='50' srcset='https://upload.wikimedia.org/wikipedia/commons/thumb/6/6c/
Wiki_letter_w.svg/75px-Wiki_letter_w.svg.png 1.5x, https://upload.wikimedia.org/wikipedia/commons/thumb/6/6c/Wiki_letter_w.svg/
100px-Wiki_letter_w.svg.png 2x' data-le-width='44' data-le-height='44' /></a>
Original artist: Derivative work by Thumperward
File:Women_sunning_selves_at_Geneva_headquarters_of_World_Health_Organization,_1969.jpg Source: https:
//upload.wikimedia.org/wikipedia/commons/9/91/Women_sunning_selves_at_Geneva_headquarters_of_World_Health_Organization%
2C_1969.jpg License: CC BY-SA 3.0 Contributors: I took this photo in my nal week of work in Geneva, as a souvenir of this beautiful
building.
Previously published: Never published. Original artist: GeorgeLouis
File:World_Health_Organisation_building_south_face_2.jpg Source: https://upload.wikimedia.org/wikipedia/commons/5/52/
World_Health_Organisation_building_south_face_2.jpg License: GFDL Contributors: Own work Original artist: Yann Forget
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Health_Organisation_regional_offices.svg License: Public domain Contributors: This le was derived from: BlankMap-World6.svg
Original artist: Derfel73; Canuckguy et al.
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World_Health_Organization_Executive_Board_Room.JPG License: CC BY-SA 3.0 Contributors: Own work Original artist: Thorkild
Tylleskar
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World_Health_Organization_membership_status_map.png License: CC BY-SA 3.0 Contributors: Own work Original artist: Alinor at
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