MAXIMIZING POSITIVE SYNERGIES - World Health Organization

INDIA: Exploring how disease-specific
programmes in TB and HIV/AIDS interact
with health systems.
Abstract
Krishna Dipankar Rao 1 , Mathew Sunil George 1 , Aarushi Bhatnagar 1 , Babita Rajkumari 1 ,
Maulik Chokshi 1 , Preeti Kumar 1 and Indrajit Hazarika 1
1 Public Health Foundation of India, New Delhi.
GHIs represent an important recent trend in international health. Several GHIs operate in India
(Global Fund, PEPFAR and GAVI). Global Fund is the biggest contributor to India’s health sector.
The aim of this study is to understand how programmes supported by the Global Fund in India,
National Aids Control Programme (NACP-3) for HIV/AIDS and the Revised National TB Control
Programme (RNTCP) for TB, interact with existing health systems. Key informant interviews and
data from health facilities were collected in three states of India. Findings indicate that the RNTCP
and especially the NACP have great potential for strengthening health systems in several ways: (1)
by placing key staff at health facilities, especially at the periphery, who then function as a resource
for the entire health facility; (2) by strengthening laboratory services, sharing supplies and
resources with labs meant for general patients or providing services for non-programme specific
patients; (3) by improving patient perceptions of public health facilities through the presence of
relatively well-run programmes and creating demand for better quality services. The Global Fund
has also helped to strengthen the presence, voice and capacity of civil society organizations (CSOs)
to participate in national health programmes. Yet, these synergies did not take place at all health
facilities and the RNTCP was more conducive to generating these synergies. Here, three factors
appear to be important: (1) the explicit intention of the programme to strengthen health systems;
(2) the locus of administrative control over programme-specific contractual health workers; and (3)
the locus of administrative control over the programme as a whole.
Background
The largest country in South Asia, India is bordered by Pakistan to the west; China, Nepal, and
Bhutan to the northeast; and Bangladesh and Myanmar to the east. India is home to 1.1 billion
people with an average annual population growth rate of 1.4% [1]. Between 1997 and 2007, its
GDP grew at 6.9% per year on average, making India one of the ten fastest growing economies in
the world [1]. India ranked 132nd out of 179 countries on the UN Human Development Index in
2006 [2]. Premature death and illness due to major environmental health risks - such as a lack of
safe water, vector borne diseases, and agro-industrial chemicals - account for nearly 20% of the
total burden of disease [3]. India's public health spending is low at around 1% of GDP. The
National Rural Health Mission (NRHM), launched in 2005 to strengthen the rural public health
system, aims to increase public spending on health to 2-3% of GDP by 2012 [4]. In 2002, the
Ministry of Health and Family Welfare in India estimated that less than 20% of the population
which seek outpatient services, and less than 45% of that which seek inpatient treatment, make
use of such services in public hospitals [5]. The private health sector in India is growing at a
remarkable rate. In 2005, India ranked among the top 20 of the world's countries in its private
spending. Employers paid for 9% of spending on private care, health insurance 5-10%, and 82%
was from personal funds. More than 40% of all patients admitted to hospital had to borrow
money or sell assets to cover expenses [6].
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