Antabuse testing

antabuse testing

KEY TRENDS 

• Globally 12% of all deaths among adults aged 30 years and over were attributed to tobacco as compared with 16% in India, 17% in Pakistan and 31% in Bangladesh @ 

• A recent study illustrated the economic impact of Non-Communicable Diseases (NCDs) in India by estimating that if NCDs like: heart disease, cancer, diabetes, chronic respiratory conditions, and other NCDs were “eliminated”, the country’s 2004 GDP would have been 4 to 10 percent greater##

• The share of out-of-pocket household health expenditures on NCDs in India increased from 32 percent to 47 percent between 1995–1996 and 2004. Moreover, 40 percent of these expenditures were financed by borrowing and sales of assets, increasing the household’s financial vulnerability##

• In Gujarat, India, 50% of women feel they need the permission of their husband or parent-in-law before taking their sick child to a doctor###

• Only 10% Indians have some form of health insurance, mostly inadequate***

• Hospitalized Indians spend on an average 58% of their total annual expenditure*** 

• Over 25% of hospitalized Indians fall below poverty line because of hospital expenses***

• Infant mortality continues to decline, dropping from 68 in 1998-99 to 57 in 2005-06 per thousand births*

• In NFHS-III, 62% of women with two daughters and no sons say they want no more children, compared with 47% in NFHS-II*

• Forty-five percent of women ages 20-24 were married before the legal age of marriage of 18 years during NFHS III (2005-06), compared with 50% during NFHS II (1998-99)*

• Kerala, Maharashtra, Himachal Pradesh and Tamil Nadu that account for 18.8% of the country's population have health indicators similar to those in more developed middle-income countries such as Venezuela, Argentina and Saudi Arabia**

@ WHO Global Report: Mortality Attributable to Tobacco (2012), http://whqlibdoc.who.int/publications/2012/9789241564434_eng.pdf 

http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/Peer-Reviewed-Publications/WBDeepeningCrisis.pdf 

* National Family Health Survey III (2005-06), http://www.nfhsindia.org/nfhs3.html  

** Report of the Independent Commission on Development and Health in India (2008), Voluntary Health Association of India

*** Ministry of Health and Family Welfare,

http://mohfw.nic.in/NRHM/Documents/Mission_Document.pdf 

### A Fair Chance at Life: Why Equity Matters for Children (2010), Save the Children

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According to WHO Global Report: Mortality Attributable to Tobacco (2012), http://whqlibdoc.who.int/publications/2012/9789241564434_eng.pdf: 

• Globally 12% of all deaths among adults aged 30 years and over were attributed to tobacco as compared with 16% in India, 17% in Pakistan and 31% in Bangladesh. 

• In India, the death rate from non-communicable diseases (NCDs) [1096 per 100,000 population] was about 3.3 times that for communicable diseases [336 per 100,000]. Tobacco was responsible for 9% of all NCDs as compared with 2% of all communicable disease related deaths. 

• The death rate due to tobacco in Indian men was 206 [per 100,000 men aged 30 years and over] as compared with 13 [per 100,000 women aged 30 years and over] for women. The proportion of deaths attributable to tobacco was almost 12% for men and 1% for women in India.    

• Within the NCDs, ischaemic heart disease accounted for 329 deaths per 100,000 population aged 30 years and over, with 5% of these deaths attributed to tobacco in India. Cancer of the trachea, bronchus and lung accounted for 16 deaths per 100,000 population but with 58% of these deaths attributed to tobacco. 

• Within the communicable disease group, deaths attributed to tobacco accounted for 5% of all lower respiratory infection deaths and 4% of all tuberculosis deaths in India.  

• The regions with the highest proportion of deaths atrributable to tobacco are the Americas and the European regions where tobacco has been used for a longer period of time. 

• 71% of all lung cancer deaths globally are attributable to tobacco use. 42% of all chronic deaths globally are attributable to tobacco use. 

• Direct tobacco smoking is currently responsible for the death of about 5 million people worldwide each year with many deaths occuring prematurely. An additional 600,000 people are estimated to die from the effects of second-hand smoke.

• In next 2 decades, the annual death from tobacco globally is expected to rise to over 8 million, with more than 80% of those deaths projected to occur in low-and middle-income countries. 

• If effective measures are not urgently taken, tpbacco could in the 21st century kill over 1 billion people worldwide. Tobacco kills more than tuberculosis, HIV/ AIDS and malaria combined.

According to the report titled The Growing Danger of Non-Communicable Diseases: Acting Now to Reverse Course, September, 2011, The World Bank, http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/Peer-Reviewed-Publications/WBDeepeningCrisis.pdf:    

•    Heart disease, cancer, diabetes, chronic respiratory conditions, and other non-communicable diseases (NCDs) increasingly threaten the physical health and economic security of many lower-and middle-income countries.

•    The change in mortality and disease levels will be particularly substantial in Sub-Saharan Africa, where NCDs will account for 46 percent of all deaths by 2030, up from 28 percent in 2008, and in South Asia, which will see the share of deaths from NCDs increase from 51 to 72 percent during the same period. More than 30 percent of these deaths will be premature and preventable. These lower-income countries will, at the same time, continue to grapple with the widespread prevalence of communicable diseases such as HIV, malaria, tuberculosis, and mother and child conditions, and so face a “double burden” of disease not experienced by their wealthier counterparts.

•    The potential cost of NCDs to economies, health systems, households and individuals in middle- and lower-income countries is high. In many middle- and lower-income countries, NCDs are affecting populations at younger ages, resulting in longer periods of ill-health, premature deaths and greater loss of productivity that is so vital for development.

•    Much of the rise in NCDs in developing countries is attributable to modifiable risk factors such as physical inactivity, malnutrition in the first thousand days of life and later an unhealthy diet (including excessive salt, fat, and sugar intake), tobacco use, alcohol abuse, and exposure to environmental pollution.

•    Country evidence suggests that more than half of the NCD burden could be avoided through effective health promotion and disease prevention programs that tackle such risk factors. Particularly effective at very low costs are measures to curb tobacco, such as taxes, as indicated in the “WHO Framework Convention on Tobacco Control”, and to reduce salt in processed and semi processed foods.

•    By 2030, cancer incidence is projected to increase by 70 percent in middle-income countries and 82 percent in lower-income countries.

•    While increases in NCD-related mortality and ill-health in part reflect countries’ successes in extending lives and curbing communicable diseases, a significant part of the increase is a result of modifiable risk factors, many of which are linked to modernization, urbanization, and lifestyle changes.

•    The rise of NCDs amongst younger populations may jeopardize many countries’ “demographic dividend”, including the economic benefits expected to be generated during the period when a relatively larger part of the population is of working age. Instead, these countries will have to contend with the costs associated with populations that are living with longer episodes of illhealth.

•    Cardiovascular disease is already a major cause of death and disability in South Asia, where the average age of first-time heart attack sufferers is 53 compared to 59 in the rest of the world.

•    A recent study illustrated the economic impact of NCDs in India by estimating that if NCDs were “eliminated”, the country’s 2004 GDP would have been 4 to 10 percent greater.

•    The share of out-of-pocket household health expenditures on NCDs in India increased from 32 percent to 47 percent between 1995–1996 and 2004. Moreover, 40 percent of these expenditures were financed by borrowing and sales of assets, increasing the household’s financial vulnerability. NCDs also increase the risk of households incurring “catastrophic” health costs. In South Asia, the chance of incurring catastrophic hospitalization expenditures was 160 percent higher for cancer patients and 30 percent higher for those with cardiovascular diseases than it was for those with a communicable disease requiring hospitalization .

•    Because of their specific characteristics, NCDs affect adults—often in their productive years, require costly long term treatment and care, and often are accompanied by some degree of disability. Therefore, they could potentially have greater socio-economic impact than other health conditions. Increased NCD levels can: reduce labor supply and outputs, increase costs to employers (from absenteeism and higher health care coverage costs), lower returns on human capital investments, reduced domestic consumption and lower tax revenues, as well as increased public health and social welfare expenditures.

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According to the report titled: AIDS at 30: Nations at the crossroads (2011), which has been brought out by UNAIDS,
http://www.unaids.org/en/resources/unaidspublications/2011/#c_60139:  

•    The number of people living with HIV was around 34 million worldwide in 2010.

•    There were 2.6 million new HIV infections worldwide in 2009.

•    Between 1981 and 2000, the number of people living with HIV rose from less than one million to an estimated 27.5 million [26–29 million].

•    Low- and middle-income countries accounted for 95% or more of the global HIV burden by 1998.

•    While less than 1% of adults in South Africa were living with HIV in 1990, 16.1% were living with HIV a decade later. During the same period, adult HIV prevalence rose from less than 1% to 24.5% in Lesotho, and from 3.5% to 26% in Botswana.

•    Half of HIV infections in Eastern Europe and Central Asia in 2010 were due to drug users sharing needles.

•    Clinical trials show that male circumcision reduces the chance of men becoming HIV-positive by about 60%.

•    Beginning in 2005, a series of randomized controlled trials in sub-Saharan Africa found that circumsising adult men reduced their risk of infection by about 60%.

•    Scientific knowledge about HIV expanded steadily in the years 1981–2000. The virus was identified in 1983, and the first serologic test became available in 1985. In the 1990s, studies demonstrated in developed and low- and middle-income countries the possibility of significantly lowering the risk of vertical transmission.

•    Today, 94% of countries (162 of 172 countries reporting) have national HIV strategic plans, up from 87% in 2006. The coordination of national responses also improved during the epidemic’s third decade. Two out of three (67%) countries in 2010 reported having a single HIV monitoring and evaluation system, up from 46% in 2006, although country reports cite insufficient coordination of diverse partners as a continuing challenge to national responses.

•    According to the latest UNGASS reports, AIDS expenditures in 2009 totalled US$ 1.07 billion. Estimates based on the methodology suggested by the Commission on AIDS in Asia indicate that US$ 3.3 billion is needed for a targeted response across the region.

•    There was a significant increase in investment in the HIV response in low- and middle-income countries between 2001 and 2009, with total expenditure rising nearly 10-fold, from US$ 1.6 billion to US$ 15.9 billion.

•    Public and private domestic resources accounted for 52% of total spending on HIV programmes in low- and middle-income countries in 2009, but many low-income countries remain heavily dependent on external financing. In 56 countries, international donors supply at least 70% of HIV resources. This pattern potentially encourages the emergence of new global inequities, as millions of people in sub-Saharan Africa now rely on external donors on a daily basis for the drugs and services that keep them alive.

•    The UNAIDS Domestic Investment Priority Index, a formula that accounts for total HIV burden and government resources, shows that eight of 14 countries in West and Central Africa, six of 16 countries in Eastern and Southern Africa, and all but four countries in Asia were allocating inadequate resources to HIV in  2009.

•    According to research from nine countries under the People Living with HIV Stigma Index, 53% of Rwandans living with HIV have been verbally insulted, 33% of rural Zambians living with HIV have experienced physical violence, and 65% of Rwandans living with HIV have lost a job or income opportunity. Furthermore, women living with HIV from various countries report abuses of their sexual and reproductive health and rights. Nearly 20% of women in Namibia who participated in discussions and interviews with the International Community of Women Living with HIV (ICW), reported that they had been coerced or forced into sterilization. Such deep-seated social ostracism and discriminatory actions discourage people from being tested for HIV or seeking other needed services.

•    Among young women in South Africa, experience of intimate partner violence increases the odds of becoming infected with HIV by 11.9%, while gender inequality within a relationship increases the risk by 13.9%, according to a study reported in The Lancet in 2010.

•    According to the UNAIDS Global Report 2010, the proportion of countries reporting programmes to address stigma and discrimination increased from 39% in 2006 to 92% in 2010, although a budget for these programmes was in place in less than half of these countries.

•    More than 56 countries have laws that specifically criminalize HIV transmission or exposure, with the majority of prosecutions reported in high-income countries. As of April 2011, 47 countries, territories and areas imposed some form of restriction on the entry, stay and residence of people living with HIV. However, in a more positive development, China, Namibia and USA lifted their HIV-related travel restrictions in 2010, while Ecuador and India clarified that no such restrictions were in place.

•    In 116 countries, territories and areas, some aspect of sex work is criminalized. Seventy-nine countries and territories worldwide criminalize consensual same-sex sexual relations, including 85% of countries in Eastern and Southern Africa, 81% in the Middle East and North Africa, and 69% in the Caribbean.

•    Thirty-two countries have laws that allow for the death penalty for drug-related offences, and 27 provide for the compulsory detention of people who use drugs, often without due process or minimum standards of detention or treatment. Such laws, as well as abusive law enforcement and poor access to legal services, deter individuals from seeking needed services, increase their vulnerability to becoming HIV-positive, and intensify their social isolation.

•    As of December 2010, an estimated 6.6 million people in low- and middle-income countries were receiving antiretroviral therapy, an increase of 1.4 million from a year earlier. Between 2001 and 2010, the number of people receiving antiretroviral treatment rose nearly 22-fold, a vivid illustration of the power of international solidarity, innovative approaches and people-centred responses.

•    In sub-Saharan Africa the number of people receiving antiretroviral treatment in 2010 increased by 31%; in the Middle East and North Africa, that figure was 21%.

•    As of December 2009, seven countries had already reached at least 80% of treatment-eligible individuals with antiretroviral treatment. Eighteen countries reported treatment coverage of at least 60%.

•    Since its emergence in 1996, highly active anti retroviral therapy has saved an estimated 14.4 million life years worldwide as of December 2009. Although 54% of life-years saved between 1995 and 2009 were in Western Europe and North America, where antiretroviral therapy has long been available, 3.7 million life-years have been saved in sub-Saharan Africa. The pace of reducing morbidity and mortality in sub-Saharan Africa has accelerated since 2005 as a result of dramatic programme scale-up.

•    In 2009, nearly one in five people (18%) who started antiretroviral therapy in low- and middle-income countries were no longer in care 12 months later.

•    At present, more than 95% of patients on treatment are on first-generation antiretroviral medicines, the majority of which are off-patent. As drug resistance increases over time, more patients will require second- and third-generation medicines. Most of these more recent medicines will remain under patent protection for years to come, resulting in potentially drastic increases in treatment costs. This can be alleviated to a large extent by making use of the flexibilities of public health related TRIPS (trade-related aspects of intellectual property rights). In March 2011, UNAIDS, WHO and UNDP issued a policy brief calling on all countries to use TRIPS flexibilities to lower costs and improve access to HIV treatment. By 2005, five years after affordable means of preventing vertical transmission became available, only 15% of HIV-positive pregnant women in low- and middle-income countries received antiretroviral prophylaxis.

•    More than 50% of pregnant women who tested positive for HIV in 2010 were assessed for their eligibility to receive antiretroviral therapy for their own health. These gains in reducing vertical transmission have helped to reduce childhood mortality. The number of children newly infected with HIV in 2009 (370 000 [230 000–510 000]) was 26% lower than in 2001.

•    According to the most recent population-based surveys in low- and middle-income countries with available data, only 24% of young women and 36% of young men responded correctly when asked five questions about HIV prevention methods and popular misconceptions about HIV transmission. Young women tend to be less likely than young men to be aware of the prevention benefits of consistent condom use. When prompted, 74% of young males in DHS surveys knew that using a condom helps to prevent HIV infection, while only 49% of young females knew the right answer. Some 78% of young males also knew that having a single, faithful partner lowers the risk of HIV infection, compared to only 59% of young females.

•    In 14 countries where HIV prevalence exceeds 2% and where nationally representative data are available, more than 70% of men and women who had high-risk sex in the past year report not using a condom the last time they had sex.

•    Globally, HIV prevalence levels above those reported in the general population have been documented among men who have sex with men (MSM), transgender people, people who inject drugs (IDUs), and sex workers.

•    According to the most recently available data, the proportion of countries reporting that they conduct systematic surveillance of HIV among key populations increased between 2008 and 2010: for sex workers, from 44% to 50%; for MSM, from 30% to 36%; while among IDUs it remained stable at 28%.

•    An estimated 20% of the 15.9 million IDUs worldwide are living with HIV. This statistic underscores the world’s failure to put the lessons of harm reduction to use. In at least 69 countries where injecting drug use has been documented, no programme to provide even sterile needles and syringes exists.

•    The epidemic among MSM communities is a worldwide phenomenon, with 63 out of 67 countries reporting in 2009 a higher HIV prevalence among MSM compared with the general population.

•    At least 79 countries, territories and areas have laws against male–male sexual contact, including some that authorize the death penalty.

•    Among 56 countries reporting in both 2008 and 2010, median condom use with the most recent client reached 84%, with a range from about two thirds to nearly 100%.

•    According to recent estimates, HIV is a leading cause of pregnancyrelated deaths, accounting for about 11% of all maternal deaths in 2008.

•    HIV-positive newborns have about a 50% risk of death before age two in the absence of treatment.

•    In 2009, HIV accounted for 2.1% (1.2–3.0%) of under-five deaths in low- and middle-income countries, a decline from 2.6% (1.6–3.5%) in 2000.

•    In sub-Saharan Africa, HIV was responsible for 3.6% (2.0–5.0%) of all deaths in children under five in 2009. Here, too, striking achievements are evident, as the HIV share of all under-five deaths has sharply fallen from the 5.4% (3.3%–7.3%) reported in 2000.

•    Universal access to effective prevention, diagnosis and treatment for HIV-related tuberculosis (TB) could prevent up to one million TB deaths in people living with HIV between now and 2015, but the world is falling far short of this target.

•    Only 28% of TB patients globally knew their HIV status in 2009, and only 5% of people living with HIV were screened for TB. Although early initiation of antiretroviral therapy significantly reduces the risk of death among HIV-positive people with TB, only 37% of these HIV-positive TB patients got HIV therapy in 2009.

•    According to data compiled by WHO, 10 countries accounted for more than 69% of all people with HIV-related TB in 2009.

•    25% of all TB deaths are in people with HIV, and there are one million cases of TB in people with HIV a year.

•    Between 2001 and 2009, global HIV incidence steadily declined, with the annual rate of new infections falling by nearly 25%.

•    Above-average declines in HIV incidence have occurred in sub-Saharan Africa and in South and South-East Asia, while Latin America and the Caribbean and Oceania regions experienced more modest reductions of less than 25%.

•    Rates of new infections have remained relatively stable in East Asia, Western and Central Europe, and North America. HIV incidence has steadily increased in the Middle East and North Africa, while in Eastern Europe and Central Asia, a decline in new infections was reversed mid-decade, with incidence rising slightly from 2005 to 2009.

•    Coverage of services to prevent new child infections increased from 15% in 2005 to 54% in 2009. The HIV incidence rate declined by more than 25% between 2001 and 2009. Antiretroviral treatment coverage is increasing.

•    Some 22.5 million people now live with HIV in Africa. The majority (60%) are women and girls. HIV prevalence is as high as 25% in some countries, and the rate of people becoming newly infected outpaces treatment access. Of the 16.6 million children globally who have lost one or both parents to an AIDS-related illness, 14.9 million are in Africa.

•    The Asia Pacific region has made significant progress in controlling HIV’s spread. The number of people living with HIV has remained stable for the past five years and estimated new infections are 20% lower than in 2001. Thailand, Cambodia and certain parts of India have turned their epidemics around by providing quality services to their key populations at higher risk.

•    In 2009, median reported prevention coverage for people who inject drugs was 17%; for men who have sex with men 36.5%; and for female sex workers 41%. Programmes in key affected populations to prevent transmission to intimate sexual partners are severely lacking.

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Please click the following link in order to know the Trends in Maternal Mortality: 1990 to 2008 Estimates developed by WHO, UNICEF, UNFPA and The World Bank:

http://www.im4change.org/hunger-hdi/mdgs-113.html
 

According to A Fair Chance at Life: Why Equity Matters for Children (2010), which has been prepared by Save the Children,
http://www.reliefweb.int/rw/rwb.nsf/db900sid/MCOI-88ZMGL//full_report.pdf: 

• In 2000, the world’s governments committed themselves to make a two-thirds reduction in the child mortality rate by 2015 – the fourth of eight United Nations Millennium Development Goals (MDGs). But with five years to go before the target date, the world is collectively off track to reach MDG 4. Just 40% of the necessary progress has been achieved so far, and in three-quarters of countries the goal will be missed on current trends. 

• The child mortality rate at a global level has fallen by just 28% since the MDG baseline year of 1990, far short of the 67% reduction required to meet the goal. Less than 30% of countries are making equitable progress towards MDG 4.

• Ghana, Mozambique, Niger, Egypt, Indonesia, Bolivia and Zambia have made equitable progress in reducing child mortality. Chad, Congo, Kenya, South Africa and Zimbabwe have actually seen increases in their child mortality rates since 1990.

• In sub-Saharan Africa, close to one child in seven still dies before their fifth birthday. Although the mortality rate in sub-Saharan Africa has fallen, high fertility levels mean that the absolute number of child deaths in the region has increased since 1990, from 4.2 to 4.6 million.

• Almost all child deaths – 99% – happen in the developing world. A person born in sub-Saharan Africa can expect to live, on average, 52 years. In western Europe, life expectancy is 80 years. The life expectancy rates in sub-Saharan Africa today have not been seen in Europe since the beginning of the 20th century. In 40 developing countries, children have less chance of living to the age of five than a person in the UK has of living to the age of 65.

• Sri Lanka – with a per capita income of $1,790 – has a child mortality rate of 13, less than half the level in Guatemala, which has a per capita income of $2,680. Gabon has an equivalent per capita income to Argentina, but a child mortality rate of 57, almost four times higher.

• In India, high levels of selective abortion contribute to skewed male-to-female birth ratios. Son preference in India and China can result in high mortality among girls because they are not adequately breastfed or given the same access to medical treatment. A study of 4,000 children aged between one and two in India found that the likelihood of girls being fully vaccinated was five percentage points lower than that for boys. In Gujarat, India, 50% of women feel they need the permission of their husband or parent-in-law before taking their sick child to a doctor.

• High child mortality, illness and malnutrition can be a brake on economic and social development. Children who are sick and undernourished, especially in the first two years of life, often pay a life-long and irreversible price in terms of physical stunting and reduced cognitive ability.

• On the positive side, of the 68 ‘Countdown to 2015’ countries (which together account for 97% of maternal and child deaths worldwide), 60 have reduced child mortality since 1990. A recent study found that the rate of reduction has accelerated since 2000, compared with the period from 1990 to 2000.

• Of the 68 ‘Countdown to 2015’ priority countries, only 19 are on-track to reach MDG 4. Eleven more are making faster-than-average progress, but still not enough progress to achieve MDG 4 by 2015.

• It is estimated that children under five make up 85% of those who die as a result of climate change; 44% of child deaths happen in countries considered fragile; and nearly 70% of the countries with the highest child mortality burden are currently experiencing or have experienced armed violence in the last two decades.

• Inadequate care before birth and during delivery contributes to 40% of child deaths. Even babies who survive the neonatal period (up to 28 days) have greatly reduced chances of surviving beyond the age of five if their mothers die, in part because they are less likely to receive adequate nutrition and healthcare.

• Although the percentage of stunted children decreased globally from 40% to 27% between 1990 and 2010, the number of stunted children is projected to increase in many areas. In Africa, the number of stunted children is estimated to have increased from 45 million in 1990 to 60 million in 2010.

• Undernutrition among pregnant women in developing countries leads to one in six infants being born with low birth weight, which not only carries a high risk of neonatal death, but can also permanently damage long-term cognitive and physical development.

• Infectious diseases accounted for an estimated 68% of the 8.8 million child deaths in 2008, with pneumonia accounting for 18% and diarrhoea for 15% of the global total. More than 40% of deaths from pneumonia and diarrhoea take place in sub-Saharan Africa, where 42% of people lack access to an improved water source, and almost 70% are without adequate sanitation.

• Improved drinking water sources and proper sanitation are crucial to reducing child deaths from diarrhoea, while an estimated 45% of cases could be prevented by simple hand washing with soap.

• If women and men had equal status, it is estimated that the proportion of underweight children below the age of three years would fall by 13 percentage points globally.

According to Women on the Front Lines of Health Care, State of the World's Mothers 2010, http://www.savethechildren.in/files/SOWM2010_FullReport_email.pdf:

• Every year, 50 million women in the developing world give birth with no professional help and 8.8 million children and newborns die from easily preventable or treatable causes.

• Worldwide, there are 57 countries with critical health workforce shortages, meaning that they have fewer than 23 doctors, nurses and midwives per 10,000 people. Thirty-six of these countries are in sub-Saharan Africa. Making up for these shortages would require an additional 2.4 million doctors, nurses and midwives.

• Thirty-six of the countries with critical health worker shortages are in sub-Saharan Africa, which has 12 percent of the world’s population, 25 percent of the global burden of disease, and only 3 percent of the world’s health workers. South and East Asia have 29 percent of the disease burden and only 12 percent of the health workers.

• 41 percent of the child deaths occur among newborn babies in the first month of life.

• 99 percent of child and maternal deaths occur in developing countries where mothers and children lack access to basic health-care services.

• 250,000 women’s lives and 5.5 million children’s lives could be saved each year if all women and children had access to a full package of essential health care.

• Every year 8.8 million children die before reaching age 5.

• Every year 343,000 women lose their lives due to pregnancy or childbirth complications.

• An additional 4.3 million health workers are needed in developing countries to help save lives and meet the health-related Millennium Development Goals.

• The eleventh annual Mothers’ Index helps document conditions for mothers and children in 160 countries – 43 developed nations and 117 in the developing world – and shows where mothers fare best and where they face the greatest hardships.

• European countries – along with New Zealand and Australia – dominate the top positions while countries in sub-Saharan Africa dominate the lowest tier.

According to Performance Audit-Report No. 8 of 2009-10,

http://www.cag.gov.in/html/reports/civil/2009_8_PA/execsummary.pdf:

• This is the latest and an extremely significant report on the status and performance of the National Rural Health Mission (NRHM) all over India providing clues for areas of concern and immediate action. Some of the salient features are as follows:

• The performance audit on implementation of the NRHM was conducted during April-December 2008 in the Ministry of Health and Family Welfare, State Health Societies (SHS) of 33 States/UTs, District Health Societies (DHS) of 129 districts and 2369 health centres at block and village levels covering the period from 2005-06 to 2007-08.

• The NRHM initiated decentralised bottom-up planning. This, however, had been hindered by non-completion of household and facility surveys and State specific perspective plans. In nine States, district level annual plans were not prepared during 2005-08 and in 24 States/UTs block and village level annual plans had not been prepared at all.

• Village level health and sanitation committees were still to be constituted in nine States. The Rogi Kalyan Samitis (RKS) formed at many health centres, aiming at community ownership of healthcare delivery systems, were characterised by weak or absent grievance redressal mechanisms, outreach and awareness generation efforts.

• No RKS in any State/UT received all the stipulated central grants. In 13 States/UTs, the Samiti failed to generate internal resources, while in the remaining States no mechanism existed to monitor the generation of a third of the RKS funds from internal resources as prescribed.

• The participation of Non-Governmental Organisations (NGOs) in the Mission’s activities had not been facilitated and their contribution towards capacity building and service delivery was not effectively monitored. 71 per cent of the districts countrywide were yet to be covered under the Mother NGO scheme.

• During the period 2005-06 to 2007-08, the total outlay/expenditure on the NRHM was Rs. 24,151.45 crore. During the first two years the Centre was contributing 100 per cent of the funds. Thereafter, the States were to contribute 15 per cent of funds during the 11th Five Year Plan (2007-12). However, many of the States were yet to contribute their share to the Mission and this issue needs to be addressed.

• Many high focus States where diseases are endemic and health indicators poor, were however, receiving relatively lesser central grants, as high unspent balances of previous years remained, indicating that capacity building needs to be focused on.

• Basic facilities (proper buildings, hygienic environment, electricity and water supply etc.) were still absent in many existing health centres with many Primary Health Centres (PHCs) and Community Health Centres (CHCs) being unable to provide guaranteed services such as inpatient services, operation theatres, labour rooms, pathological tests, X-ray facilities and emergency care etc.

• While contract workers have been engaged to fill vacancies, there are still shortages of specialist doctors at CHCs, adequate staff nurses at CHCs/PHCs and Auxiliary Nursing Midwife (ANMs)/ Multi-purpose Worker (MPWs) at Sub Centres.

• In nine States, the stock of essential drugs, contraceptives and vaccines adequate for two months consumption as required under norms were not available in any of the test checked PHCs and CHCs.

• Despite holding two National Immunisation Days, six Special National Immunisation Days (and additional rounds in selected districts of Bihar and Uttar Pradesh), 1640 new polio cases had been detected in 17 States/UTs during 2005-08.

According to ‘Diarrhoea: Why children are still dying and what can be done?’ (2009),

http://whqlibdoc.who.int/publications/2009/9789241598415_eng.pdf:

• Diarrhoea is defined as having loose or watery stools at least three times per day, or more frequently than normal for an individual. Though most episodes of childhood diarrhoea are mild, acute cases can lead to death and other complications.

• The leading cause of diarrhea is lack of sanitation and safe drinking water and the life threatening disease is very easily curable with simple tablets and rehydration. (An estimated 88 per cent of diarrhoeal deaths worldwide are attributable to unsafe water, inadequate sanitation and poor hygiene.)

• Most pathogens that cause diarrhoea share a similar mode of transmission – from the stool of one person to the mouth of another.

• In India, under-five mortality rate (per 1000 live births) was 69 during 2008. The number of under-five deaths was 18,30,000 during 2008. The percentage of children under-five with diarrhoea receiving ORS packet during 2005-2008 was 26%.

• Nearly, nine million children under five years of age die each year. Diarrhoea is second only to pneumonia as the cause of these deaths.

• Reducing these deaths depends largely on delivering life-saving treatment of low-osmolarity oral rehydration salts (ORS) and zinc tablets to all children in need.

• Examples of rehydrating fluids include cereal-based drinks made from a thin gruel of rice, maize, potato or other readily available low-cost grain or root crop the family has at home. Breastmilk is also an excellent drink for fluid replacement and should continue to be given to infants with diarrhoea simultaneously with other oral rehydration solutions.

• According to the latest available figures, an estimated 2.5 billion people lack improved sanitation facilities, and nearly one billion people do not have access to safe drinking water. These unsanitary environments allow diarrhoea-causing pathogens to spread more easily.

• Globally, 1.2 billion people practise open defecation, 83 per cent of whom live in 13 countries

• Together, pneumonia and diarrhoea are responsible for an estimated 40 per cent of all child deaths around the world each year.

• Nearly 1 in 4 people in developing countries were practising indiscriminate or open defecation in 2006.

• Nearly one in five child deaths – about 1.5 million each year – is due to diarrhoea. It kills more young children than AIDS, malaria and measles combined.

• Between 1990 and 2006, the proportion of the developing world’s population using an improved drinking water source rose from 71 per cent to 84 per cent. Still, almost 1 billion people lack access to improved drinking water sources, and many households do not treat or safely store their household water supplies.

• The prevention package highlights five main elements that require a concerted approach in their implementation. The package includes: a) rotavirus and measles vaccinations, b) promotion of early and exclusive breastfeeding and vitamin A supplementation, c) promotion of handwashing with soap, d) improved water supply quantity and quality, including treatment and safe storage of household water, and e) community-wide sanitation promotion.

• Mortality from diarrhoea has declined over the past two decades from an estimated 5 million deaths among children under five to 1.5 million deaths in 2004

• Africa and South Asia are home to more than 80 per cent of child deaths due to diarrhoea

• Improving sanitation facilities has been associated with an estimated median reduction in diarrhoea incidence of 36 per cent across reviewed studies.

• Interventions to improve water quality at the source, along with treatment of household water and safe storage systems, have been shown to reduce diarrhoea incidence by as much as 47 per cent.

• Diarrhoea often leads to stunting in children due to its association with poor nutrient absorption and appetite loss.

• Breastmilk contains the nutrients, antioxidants, hormones and antibodies needed by a child to survive and develop.

• Undernourished children are more likely to suffer from diarrhoea and its consequences, which, in turn, increases their chances of worsening nutritional status. Today, 129 million children under the age of five in the developing world are underweight for their age. Together, Africa and South Asia account for more than 80 per cent of total underweight children (25 per cent and 57 per cent, respectively). About 40 per cent of children under five years of age are stunted in Africa, and nearly half in South Asia.

• Only 37 per cent of infants in developing countries are exclusively breastfed for the first six months of life.

• Boys and girls are equally likely to receive ORS to treat diarrhoea. Children in urban areas (39 percent) are more likely to receive ORS than those living in rural areas (31 per cent). Similarly, children from the wealthiest families are 1.5 times as likely to receive ORS to treat their diarrhoea as the poorest children

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According to the World Health Statistics 2009,

http://www.who.int/mediacentre/factsheets/fs290/en/index.html: 

• The proportion of under-nourished children under five years of age declined from 27% in 1990 to 20% in 2005.

• Some 27% fewer children died before their fifth birthday in 2007 than in 1990.

• Maternal mortality has barely changed since 1990.

• One third of 9.7 million people in developing countries who need treatment for HIV/AIDS were receiving it in 2007.

• MDG target for reducing the incidence of tuberculosis was met globally in 2004.

• 27 countries reported a reduction of up to 50% in the number of malaria cases between 1990 and 2006.

• The number of people with access to safe drinking-water rose from 4.1 billion in 1990 to 5.7 billion in 2006. About 1.1 billion people in developing regions gained access to improved sanitation in the same period.

• Globally, the proportion of children under five years of age suffering from under-nutrition, according to WHO Child Growth Standards, declined from 27% in 1990 to 20% in 2005. But, the progress is uneven, and an estimated 112 million children are underweight.

• Globally, the number of children who die before their fifth birthday has been reduced by 27% from 12.5 million estimated in 1990 to 9 million in 2007. This reduction is due to a combination of interventions, including the use of insecticide-treated mosquito nets for malaria, oral rehydration therapy for diarrhoea, increased access to vaccines for a number of infectious diseases and improved water and sanitation. But pneumonia and diarrhoea continue to kill 3.8 million children aged under five each year, although both conditions are preventable and treatable.

• The global maternal mortality ratio of 400 maternal deaths per 100 000 live births in 2005 has barely changed since 1990. Every year an estimated 536 000 women die in pregnancy or childbirth. Most of these deaths occur in sub-Saharan Africa where the maternal mortality ratio is 900 per 100 000 births and where there has been no measurable improvement since 1990. A woman in Africa may face a 1-in-26 lifetime risk of death during pregnancy and childbirth, compared with only 1 in 7300 in the developed regions. 1 There are, however, signs of progress in some countries in Asia and Latin America and the Caribbean.

• The percentage of adults living with HIV worldwide has remained stable since 2000 but there were an estimated 2.7 million new infections during 2007. Moreover, deaths are increasing in parts of Africa, particularly eastern and southern Africa. The use of antiretroviral therapy has increased; in 2007, about 1 million more people living with HIV received the treatment. That means one third of the estimated 9.7 million people in developing countries who need the treatment were receiving it.

• The MDG target for reducing the incidence of tuberculosis was met globally in 2004. Since then, incidence has continued to fall slowly. Thanks to early detection of new cases and effective treatment using the WHO-recommended DOTS treatment strategy, treatment success rates have been consistently improving, with rates rising from 79% in 1990 to 85% in 2006. Multi-drug resistant tuberculosis is a challenge in countries, such as those of the former Soviet Union, while the lethal combination of HIV and tuberculosis is an issue particularly for sub-Saharan African countries.

• Efforts to control malaria are beginning to pay off with significant increases in the proportion of children sleeping under insecticide-treated mosquito nets. Although it is still too early to register the global impact, 27 countries – including five in Africa – have reported a reduction of up to 50% in malaria cases between 1990 and 2006. In 2006, the number of cases was estimated to be 250 million globally.

• Progress has been made in treating neglected tropical diseases that affect some 1.2 billion people. For example, only 9585 cases of dracunculiasis (guinea-worm disease) were reported in the five countries where the disease is endemic, compared with an estimated 3.5 million reported in 20 such countries in 1985.

• The number of people with access to safe drinking water rose from an estimated 4.1 billion in 1990 to 5.7 billion in 2006. But 900 million people still had to rely on water from what are known as unimproved sources, for example surface water or an unprotected dug well.

• Since 1990, an estimated 1.1 billion people in developing regions have gained access to improved sanitation. In 1990, just under 3 billion people had access to sanitation. Their number rose to more than 4 billion by 2006. Yet, in 2006 some 2.5 billion did not have access to improved sanitation and 1.2 billion had to practise open defecation.

• Although nearly all developing countries publish an essential medicines list, the availability of medicines at public health facilities is often poor. Surveys in about 30 developing countries show that availability of selected medicines at health facilities was only 35% in the public sector and 63% in the private sector. Lack of medicines in the public sector often means patients have no choice but to purchase them privately or do without treatment.

According to National Family Health Survey-III (2005-06),

http://pib.nic.in/release/release.asp?relid=31835:

NFHS III reports declining status of nutrition amidst women

• The NFHS III paints a mixed picture of India’s overall reproductive health status. Women are having fewer children and infant mortality has dropped in the seven-year period since the last NFHS survey in 1998-99.

• Anaemia and malnutrition are still widespread among children and adults. And, in an unusual juxtaposition, more adults, especially urban women, are overweight or obese than they were seven years ago.

Trend in Family Planning and Fertility

• Fertility has continued to decline since NFHS-2, dropping to an average of 2.7 children from 2.9 children. Ten states, mostly in Southern India, have reached replacement level or below replacement level fertility.

• While son preference remains a barrier to more rapid decline in fertility, an increasing number of women who have only daughters say that they want no more children. In NFHS-3, 62% of women with two daughters and no sons say they want no more children, compared with 47% in NFHS-2.

• Declining fertility could be attributed largely to women’s increased use of contraception. For the first time ever, more than half of currently married women in India are using contraception, and their use of modern contraceptive methods increased from 43% to 49% between NFHS-2 and NFHS-3.

• A rise in the average age at marriage is also contributing to the drop in fertility. Forty-five percent of women ages 20-24 were married before the legal age of marriage of 18 years, compared with 50% seven years earlier. This shift in age at marriage also influences the median age at first birth, which increased by six months to 19.8 years.

Half of Women Lack Proper Care during Pregnancy and Delivery

• Infant mortality continues to decline, dropping from 68 in 1998-99 to 57 in 2005-06 per thousand births.

• There were particularly notable drops in the infant mortality rate in Bihar, Goa, Haryana, Jammu and Kashmir, Meghalaya, Orissa, Punjab, Rajasthan, Tamil Nadu, and Uttar Pradesh.

• Overall, there was only a marginal improvement in full vaccination coverage, with 44% of children ages 12-23 months receiving all recommended vaccinations, up from 42% seven years earlier.

• Substantial improvements in coverage have been made in all vaccinations except DPT, which did not change at all between NFHS-2 and NFHS-3.

• Gains are particularly evident for polio vaccination coverage, but nearly one-quarter of children age 12-23 months did not receive three recommended doses.

• Progress in vaccination coverage varies markedly among the states. In 11 states, there has been a substantial deterioration in full immunization coverage in the last seven years, due to a decline in vaccination coverage for both DPT and polio.

• Large decline were seen in Maharashtra, Mizoram, Andhra Pradesh, and Punjab. On the other hand, there was major improvement in full immunization coverage in Bihar, Chhattisgarh, Jharkhand, Sikkim, and West Bengal. Other states with marked improvements in full immunization coverage were Assam, Haryana, Jammu and Kashmir, Madhya Pradesh, Meghalaya, and Uttaranchal.

• Diarrhoea continues to be a major health problem for many children.  Although knowledge about Oral Rehydration Salts (ORS) for the treatment of diarrhoea is widespread among mothers, only 58% of children with diarrhoea were taken to a health facility, down from 65% seven years earlier.

• There has been a rise in the number of dispensaries and hospitals, nursing personnel and doctors (including primary health care centers) in between 1991 and 2005/06, as could be deciphered from the table below.

Trends in health care infrastructure

Source: Economic Survey 2007-08, http://indiabudget.nic.in/es2007-08/chapt2008/chap106.pdf

According to the Ministry of Health and Family Welfare
(http://mohfw.nic.in/NRHM/Documents/Mission_Document.pdf):

• Public health expenditure in India has declined from 1.3% of GDP in 1990 to 0.9% of GDP in 1999. The Union Budgetary allocation for health is 1.3% while the State's Budgetary allocation  is 5.5%.

• Union Government contribution to public health expenditure is 15% while States contribution about 85%

• Vertical Health and Family Welfare Programmes have limited synergisation at operational levels.

• There exists lack of community ownership of public health programmes impacts levels of efficiency, accountability and effectiveness.  

• There exists lack of integration of sanitation, hygiene, nutrition and drinking water issues.

• There are striking regional inequalities.

• Population Stabilization is still a challenge, especially in States with weak demographic indicators.

• Curative services favour the non-poor: for every Re.1 spent on the poorest 20% population, Rs.3 is spent on the richest quintile.

• Only 10% Indians have some form of health insurance, mostly inadequate

• Hospitalized Indians spend on an average 58% of their total annual expenditure

• Over 40% of hospitalized Indians borrow heavily or sell assets to cover expenses

• Over 25% of hospitalized Indians fall below poverty line because of hospital expenses

According to the Report of the Independent Commission on Development and Health in India, or the ICDHI, ("Governance of the Health Sector in India: Has the state abdicated its role?", Voluntary Health Association of India, New Delhi, 2008):

• The report analyses the current mess in the public health system and suggests ways in which to deal with it. It focuses mainly on governance and funding of public healthcare in the country.

• The report points out huge regional imbalances in both the process and outcome indicators for health. While the average health status for the country as a whole is poor, and per capita spending on health also low by international standards, there are sharp differences across the states.

• Kerala, Maharashtra, Himachal Pradesh and Tamil Nadu that account for 18.8% of the country's population have health indicators similar to those in more developed middleincome countries such as Venezuela, Argentina and Saudi Arabia. At the other end of the spectrum are the BIMARU-plus states (Bihar, Jharkhand, Madhya Pradesh, Rajasthan, Uttar Pradesh, Orissa and Assam) that comprise nearly 42% of the population and whose indicators are close to those in sub-Saharan Africa and other low-income countries such as Sudan, Nigeria and Myanmar.

• States with poor health outcomes also spend less on public health -- a mere 7.5% of total health expenditure, or Rs 84 per capita, in Uttar Pradesh.

• Shortage of doctors is also a problem. The availability of graduate allopathic doctors in the country as a whole is only 0.6 per thousand population. They are concentrated in the south and in more developed states (Punjab has more than five times the availability of Uttar Pradesh). They are also present in larger numbers in urban areas over rural areas.

• Medical colleges too are unevenly spread: the four southern states have 63% of the colleges and 67% of the seats. The states with the biggest shortfalls in medical personnel are predictably the BIMARU states along with Jharkhand, Chhattisgarh, the northeastern states, Orissa and Haryana.

• Quality of service provided is also poor. The statutory councils for doctors, nurses, dentists and others are almost dysfunctional. So people are forced to turn to private health services, and, in the poorer states, impoverished people are made to pay because government provision is unavailable or inadequate. Thus, in the poorest states, illnesses involving hospitalisation are more likely to deplete poor families' finances. The report cites National Sample Survey Organisation (NSSO) data to show that in Bihar and Uttar Pradesh, more than one-third of those who were hospitalised fell into poverty on account of medical expenditure.

• The cost of private healthcare, which the poor are forced to resort to, has also gone up in recent times. According to the National Sample Survey Organisation, urban hospitalisation costs increased by 126% between 1995-96 and 2003-04, while rural hospitalisation costs increased by 78%. The ICDHI report notes that one-fifth of the population that is just above the poverty line will automatically slip into poverty if they face even one serious health crisis.

• The increase in the cost of therapeutic drugs has been particularly steep. On average, some 75% of health expenditure is on drugs, rising to 90% in Orissa and almost the same in Rajasthan, Bihar, Himachal Pradesh and Uttar Pradesh. In no state was the ratio less than 61%, indicating clearly that the health system is "over-medicalised".

• The new patent regime, lack of adequate regulation of Indian drug manufacturers, and a lax drug policy that allows non-essential, irrational and even hazardous drugs to proliferate are some of the reasons for the high price of drugs.

• The worst performing states in terms of implementing the National Rural Health Mission (NRHM) are: UP, Jharkhand and Assam.