Category Archives: water

Fighting the tide

This post by Kathleen Dominique from the OECD Environment Directorate is part of the Wikiprogress series on ‘Water‘ and the ‘Environment‘. 

Preparing for the water-related impacts of climate change

Headlines of record‑breaking water-related disasters around the world – whether flood or drought – are a sign of things to come. AsLord Stern recently warned, the extreme weather events witnessed in many parts of the world reflect “a pattern of global change that it would be very unwise to ignore”. Recently, the UK and French floods have been in the news, but flooding is just one type of natural disaster and in fact, if you look at 2012 data from Munich Re, floods account for less than 13% of economic losses from natural hazards compared to 59% for storms and 16% for forest fires and droughts – hence the need to think broadly about water security.
Water-related impacts are one of the main ways that we are seeing and feeling the effects of climate change. We can expect more torrential rains, floods and droughts in many areas. Events that were once considered “exceptional circumstances” are now becoming commonplace.
The cost of impacts of these events can be substantial and are set to rise in the future. According to data gathered in a recent OECD survey on water and climate change adaptation, flood risk is projected to increase significantly across the UK. Annual damage to UK properties due to flooding from rivers and the sea currently totals around GBP 1.3 billion. For England and Wales alone, the figure is projected to rise to between GBP 2.1 billion and GBP 12 billion by the 2080s, based on future population growth and if no adaptive action is taken.
A recent OECD review of actions governments are taking to prepare for water-related impacts of climate change found that nearly all OECD countries ranked extreme events (floods and droughts) among their primary concerns. This comprehensive review of policies for water and climate change adaptation is one way that the OECD has been tracking progress on preparing for a more risky and more uncertain future.

At the OECD, we recommend governments undertake a robust assessment of risks – and that’s somewhere we’re seeing progress. In fact, it’s one of the most active areas of climate change adaptation in OECD countries. This is positive – but this evidence base then needs to spur action. Governments need to determine what is an “acceptable level” of risk by balancing the benefits and costs of taking pre-emptive action. On the one hand, nobody wants to have their property flooded, but on the other, completely eliminating flood risk is often not possible and a high-level of protection is very costly. Once an acceptable level of risk has been set, governments need to explore the options open to them, and that includes sharing responsibility between the public and private sectors when investing in infrastructure, devising insurance schemes, as well as in emergency response.  
As we expect to see more severe weather events around the world, we need to understand that anticipation can avoid future costs. For example, the European Commission’s Joint Research Centre estimates that EUR 1 invested in flood protection can result in EUR 6 of avoided damage costs. Investments in early warning systems and emergency preparedness have significantly reduced casualties in Hurricane-prone countries. Austria and Germany made smart investments in flood defences after floods in 2002, and that served them well when water levels rose again last year.
However, sometimes avoiding risks altogether is cheaper than building infrastructure to protect against them. Protection measures are not only about building hard infrastructure but we can use innovative architecture and landscape solutions – such as “green roofs”, “blue belts” or restored wetlands – so that nature is part of the solution.
That said, since we can’t predict the exact timing or magnitude of weather events, it’s very hard to get the timing and investment level right when taking preventative action. At a time when many governments are working under tight budget constraints, it’s even more vital that investments are well-thought out. The most cost-effective approaches to climate change adaptation are the most flexible and forward-looking ones, and the OECD has recommended a range of policy tools and investment approaches. This includes infrastructure design and financing techniques that can be scaled up or down over time, as needed. 

To see what OECD countries are doing to help prepare, check out

Transparency and governance in the land sector: two sides of the same coin?

This blog, written by ODI’s Anna Locke, discusses land governance and transparency definitions, initiatives and key lessons. The post is part of Wikiprogress‘ spotlight on governance
Land transparency has been on the public agenda again since the G8 summit in June this year. Two events in the same week in October showcased the issue: the Open Government Partnership annual summit in London (which publicised the recent Open Government Guide on Land), and the Global Soil Week conference in Berlin, which dedicated a session to partnerships for responsible land governance – an issue that is rarely discussed by soil scientists. 

A couple of things hit me from these recent discussions. First, the public discussion has broadened from land transparency to land governance. The G8 communique published in June does not refer to a land transparency initiative as such but talks about ‘global activities to improve land tenure governance’. 

Transparency served as an immediate umbrella to bring together different initiatives in a very short time in the run-up to the G8 summit 2013 but seems to have been a launch pad rather than the end point. Similarly, the Open Government Guide on Land focuses on land governance while acknowledging the need for transparency, participation and accountability at the heart of open government. 

I welcome this broader agenda as it provides more of a framework to see how transparency can effect meaningful change.

However, at the risk of being pedantic on this issue (I have form on this– see my blog on the World Bank conference) once again, I want to pin down the terms of the debate and look at the underlying assumptions. It is important to make sure that we are all talking about the same thing, particularly as we prepare for an ODI Roundtable on the whole issue of Land Transparency in December.

First, definitions

What is land governance? The Open Government Guide on Land defines it as a series of processes, including recognition, registration and enforcement of land tenure rights, land-use administration, management planning and taxation, information provision and dispute resolution.

It then identifies the elements that characterise good governance: governments should help to ensure that these processes are ‘clear, transparent and fair… [with] human rights of citizens protected’; that they include‘accountable decision-making about how best to use land… improving the openness’[of those processes, I assume]; and that they ensure ‘consultation with those potentially affected by changes… [which] can help communities and households protect their rights’. 

The Guide suggests the Land Governance Assessment Framework (LGAF) mechanism launched by the World Bank as the main reference point for a baseline evaluation of the state of land governance. The LGAF measures governance in five thematic areas: legal and institutional framework; land use planning, management and taxation; management of public land; public provision of land information; and dispute resolution and conflict management. In turn, the main reference point for the LGAF is the World Bank’s definition of governance as the ‘manner in which public officials and institutions acquire and exercise the authority to shape public policy and provide public goods and services’. 

I would be more specific on two things. Yes, the discussion of land governance highlights the issue of how institutions can carry out the work of land titling, registration and administration. But it also needs to look at how they take and implement decisions on land – who takes part in decisions on land allocation, use and management, and how different interests in competing social and economic functions of land are reconciled. That goes beyond consultation. Indeed, it goes to the heart of the political economy of decision-making and the power relations that are involved. This is recognised implicitly in the Open Government Guide in its recommendation for participatory land and resource use planning. 

And what is the role of the private sector in all of this? Does the shift (back?) from transparency to governance mean a refocusing on governments, instead of the broader private sector actors targeted under pre-G8 discussions? These have been targeted directly through efforts to increase contract disclosure and public provision of information on holdings.

Second, what is the relationship that is assumed between transparency and governance? 

The G-8 Communique talks about the Voluntary Guidelines on the Responsible Governance of Tenure as ‘providing global policy guidance for good land governance and transparency’. So are they of equal importance or does one feed into the other?

The Open Government Guide takes the transparency of processes as a central element that feeds into governance (openness and accountability are others). The LGAF recognises the role of transparency in promoting better governance in the land sector, particularly in land-use restrictions, valuations, expropriation, the transfer of public to private land and in levying fees for different services provided by governments. Its emphasis on the provision of information, particularly through registries and cadastres, is the starting point for transparency in any form. 

The work of ODI (ADP,PoGo) and others, such as Global Witness, on transparency reveals a growing recognition of the importance of transparency for good governance. But it also shows that transparency is not enough, on its own to achieve the standard of governance in the land sector that we are striving for. This was also acknowledged in the Berlin discussions in October.

So, what can we take away from this? I see three key lessons.
  1. Yes, the shift to a broader perspective on land governance is useful. But we need to acknowledge areas of agreement and difference on what we mean by governance, particularly in the presence of conflicting interests in land processes, and recognise the role of the private sector. 
  2. We need to be clear about the role of transparency in promoting good governance – transparency and governance are not two sides of the same coin although progress on one depends on progress in the other. 
  3. And finally, let’s carry the debate on the pathways from transparency to accountability to meaningful change into the debate on governance. This means talking about the content, timing and transmission of information; mechanisms and timescales to ensure meaningful participation and consultation; and getting accurate indicators that measure impact, not just processes.
All of these will issues were discussed at the ODI Roundtable on Land Transparency at ODI on 10 December 2013.

– Anna Locke
*The blog first appeared on 20 November 2013 on the ODI blog site
This post features the author’s personal view and does not represent the view of ODI.    

Sanitation in schools

This blog, written by Wikichild co-ordinator Melinda Deleuze, is a part of the Wikiprogress September spotlight on “Education and skills“. Also, in conjunction with the OECD’s 2013 World Water Week, the post discusses the need for improved water and sanitation in schools and various organizations’ efforts.
It is important to focus on improving school’s sanitation standards, because children are often the most vulnerable to diseases, according to Children also take new ideas and habits back to their homes and families, increasing programs’ impact. 
Only 49% of schools around the world provide drinking water to its pupils and 11% of schools provide water for handwashing. In Kenya, although 63% of schools provided drinking water, only 27% had treated water. Also, while 63% of schools in Kenya have handwashing water available to its students, only 8% of schools have soap. Studies show that handwashing with soap can reduce the risk of diarrheal disease by more than 42% (Curtis and Caincross, 2003). 
Over the past few years, multiple organizations have been working hard to increase the number of schools with drinking water, sanitation facilities and handwashing stations. According to the Sanitation and Water for All project update (April 2013), in the past year, Nigeria mobilized private sector resources for provision of WASH facilities in over 700 schools.
Sustaining and Scaling School Water, Sanitation and Hygiene Plus Community Impact (SWASH+), also known as “WASH in schools”, is a project established to identify, develop, and test innovative approaches to school-based water, sanitation and hygiene in Kenya. Funded by the Bill and Melinda Gates Foundation and the Global Water Challenge, the project has been running since 2006 with the help of CARE, Emory University’s Center for Global Safe Water, the Government of Kenya, Kenya Water for Health Organisation,, and SANA. SWASH+ has worked in 185 primary schools in four districts in Nyanza Province, gathering data, learning about challenges and testing solutions for school water, sanitation and hygiene (WASH). SWASH+ provides a base package, which includes:
  1. Provision of water for drinking in safe storage containers
  2. Daily treatment of drinking water with an appropriate technology
  3. Provision of water for handwashing
  4. Daily provision of soap
After the 5-year project, SWASH+ found that:
  • Absenteeism is significantly reduced among girls, with an average of 6 days fewer absences per year.
  • There was a 45% overall reduction of ascaris, and an even greater decrease among girls. Also, the intensity of hookworm infection significantly declined among boys.
  • Unfortunately, there were higher quantities of E. coli bacteria on pupils’ hands who received hygiene, water treatment and sanitation facilities. A study by the European Journal of Tropical Medicine and International Health (2009) found that only 32% of Kenyans wash their hands after fecal contact.
Sapling handwashing, Malawi. Photo: Plan Malawi
Another program working towards increasing drinking water, sanitation facilities and handwashing stations in schools is the Pan African School Led Total Sanitation (SLTS) program. This program is targeting 742 schools in 6 sub-Saharan countries (i.e. Sierra Leone; Ethiopia; Uganda; Kenya; Zambia; Ghana; Niger; Malawi). In each country, the SLTS program follows the same process to facilitate the necessary activities to trigger the schools’ and communities’ progress:
  1. Discuss with the government’s Health and Education sectors, plan at different levels and reach an agreement;
  2. Train teachers who then train students how to use the school latrine and surrounding water and sanitation areas, as well as playing games which help internalize sanitation and hygiene concerns;
  3. Register households for monitoring;
  4. Conduct a school sanitation campaign, cleaning the whole school compound;
  5. Group community into Development Units and establish these groups’ meeting places and times (meetings take place at schools);
  6. Establish a committee of six for each Development Unit who facilitate discussion and prepare a report;
  7. Monitor progress with these reports.
The SLTS program’s 5-year period runs through next year (2014), and this process can be reviewed and changed before the next Pan Africa program begins.
Water and sanitation needs to improve in schools in order to increase school attendance among girls and decrease sickness among all children. Top-down and bottom-up forces are needed to help children become more educated and safer around the world. 

Week in Review

Hello Wikiprogress followers and welcome to this Week in Review! This week’s highlights include a UN report on human rights in the context of the post-2015 agenda, an update from UNICEF on global progress on sanitation and drinking water and an Oxfam report on risk and poverty reduction.
Released this week, the UN’s Who will be Accountable? – Human Rights and the Post-2015 Development Agendacalls on countries to ensure that the post-2015 development agenda focuses on equality, social protection and accountability, noting that one billion people around the world are still living in poverty. 
“The rise of inequality has severely undermined the achievements of the Millennium Development Goals, or MDGs,” UN Spokesman, 21st May 2013

The “OECD E-Government Review of Egypt” assesses Egyptian e-government policies and implementation, and makes recommendations for future actions. The report highlights Egypt’s progress and proposes that to enhance the use of ICTs in the public sector Egypt should undertake a number of measures. Find out more!

No Accident – Resilience and the Inequality of Risk – This report from Oxfam stipulates that governing bodies and aid agencies must challenge the politics and power at the heart of the increasing effects of climate change, growing inequality and people’s vulnerability to disasters. Oxfam highlights the increasing threat of various major external risks and points out that the majority of these are actively dumped on poor people, with women bearing the brunt because of their social, political and economic status. 

Progress on Sanitation and Drinking Water – 2013 Update – UNICEF’s annual report card presents country, regional and global estimates on improvements (or lack of them) in access to drinking water and sanitation. According to the publication, the world will not meet the MDG sanitation target of 75% and if current trends continue, it is set to miss the target by more than half a billion. To find out more about sanitation inequality, read our recent Progblog article on the subject.  
The right poverty measure for post-2015 – is part of a series of blogs that debate how a post-2015 framework ought to measure poverty. This article by Stephan Klasen, Professor of development economics and empirical economic research at the University of Göttingen, puts forward a proposal for internationally coordinated national poverty measurement. 

Thanks for checking in – we are pleased to inform you that our theme of the month in June will be Environment so we look forward to bringing you articles, blogs and Week in Reviews related to the subject in the coming weeks!

The Wikiprogress Team

From the Bottom to the Top: One Step to Improving Global Sanitation

This article by Robbie Lawrence, Wikichild Coordinator, considers how global sanitation can be improved in the context of the International Federation of Red Cross’s ‘Getting the Balance Right’ report. This is part of the Wikiprogress #Health Series. 
“Communities in rural areas and urban settlements must be empowered to increase their resilience through access to safe water, improved sanitation and effective hygiene promotion.” Getting the Balance Right, International Federation of Red Cross, 2013

This post follows on from Wednesday’s blog on the dangers of diarrhoea by focusing on the disease’s chief causation: poor sanitation. Currently 3.4 million people die each year from water, sanitation and hygiene-related causes ( An estimated 2.5 billion do not have access to basic sanitation and 1.1 billion of those people practice open defecation. This is not only degrading but a severe health risk as fecal matter-oral transmitted diseases cause at least 1.5 million deaths per year in children under the age of five (Getting the Balance Right). As Gary White and Matt Damon so bluntly put it, by the time you’ve read this paragraph, another child will have died from something that is eminently preventable.  
In the same way that inequality has reared its head in the post-2015 discussions, forcing global leaders to consider how poverty reduction might be carried out more equitably in the future, it is evident that we need to address water and sanitation issues. The “Progress on Drinking Water and Sanitation 2012” report by the WHO and UNICEF highlights that, although the MDG target of halving the number of people globally without access to improved water source will be fulfilled by the MDG 2015 deadline, the target for sanitation is unlikley to be met.  
More often than not aid donors and development agencies have aimed at providing clean and safe water supplies rather than making sanitation a priority. As it stands, sanitation only receives 12 percent of global aid put towards combatting water and sanitation related issues. In the short term this trajectory make sense, since water is usually in more immediate demand, however, if diarrhoea and other hygiene related illnesses are to be dealt with, access to sanitation facilities must be increased. The ‘Getting the balance right’ report emphasizes that ‘neither water nor sanitations is more important: both elements are required to maintain and improve health and dignity.’ argues that the inability of philanthropic efforts to efficiently deal with the problem of poor sanitation has been a problem in the past. Even the money that has gone towards solving the issue has largely missed the goal of providing relief for those most in need. The organization recognized that if local communities were to make progress, independent of donors, then they must be viewed and view themselves as the owners of the project. Community ownership is the linchpin of’s philosophy. Without an active engagement from communities from the start of a project to its completion there is a strong likelihood that previously entrenched social norms such as public defecation will continue.
The ‘Getting the Balance Right’ report delivers a similar message, and uses a number of examples of community-based initiatives that have succeeded in improving sanitation. In Eritrea, a country where only three percent of its rural population has access to sanitation, the IFRC and the EU implemented a program focused on mobilizing and educating women in hygiene knowledge that reached a total of 145,000 people in 120 villages. By empowering these local women and providing them with  information, the program motivated them to become promoters of sanitation within their own communities. The website also lists various bottom to the top initiatives that have shown remarkable success rates. An Emory University review of a community based ventures in Lempira, Honduras reported that 100 per cent of the project sites were still operational after 10 years with 98 per cent of respondents satisfied with the system.
Since poor sanitation is now firmly in the crosshairs of policy makers and aid groups, it seems that the and IRFC have laid out a fairly effective framework for combating the problem. Changing intrinsic social norms from the routes of a community appears a far more effective means of catalyzing change than large, trickle down cash injections. The flow of international water aid must of course be rebalanced towards sanitation, but organizations, governments and NGOs need to go further and ensure that it reaches the right groups and individuals. The stark reality of IRCF’s report brings to light the vital role that sanitation plays in human health and dignity:  
“Let us speak clearly; the single largest cause of human illness globally is faecal matter. A society – regardless of how many clinics or water supply points it has – can never be healthy is human waste is not safely disposed of.” Getting the Balance Right

Robbie Lawrence

Childhood Pneumonia and Diarrhoea KILLS!

This article, by Ousmane Aly Diallo, Wikiprogress Africa Advisor, is part of the Wikiprogress Health Series. Wikiprogress Africa aims to  provide a platform for knowledge sharing on measuring progress and well-being in an Africa context. 

We know what works against pneumonia and diarrhoea – the two illnesses that hit the poorest hardest. Scaling up simple interventions could overcome two of the biggest obstacles to increasing child survival, help give every child a fair chance to grow and thrive, Anthony Lake, UNICEF Executive Director.

The Lancet recently published a series of papers on Childhood Pneumonia and Diarrhoea in collaboration with the Aga Khan University of Pakistan, in April 2013.  The series demonstrates that it is possible to eradicate the prevalence of these two diseases among children through a comprehensive strategy involving all the stakeholders and highlights the barriers that have enabled children’s death from it.

Pneumonia and diarrhoea are low in incidence in the developed world but remain serious health concerns in the developing world. Childhood Pneumonia and Diarrhoea are particularly lethal in the developing world; nearly 90% of the children who died from these diseases are from Sub-Saharan Africa and South Asia, according to a recent World Health Organization report.

Assessing  the global burden of childhood pneumonia and diarrhoea in the world,  Walker and Alii’s paper show that these two diseases remain the leading infectious causes of death in children younger than 5 years, and caused an estimated 700 000 and 1·3 million deaths, respectively, in 2011. 

According to the study, more than half of the burden (56% of severe episodes of diarrhoea and 64% of severe episodes of pneumonia) is upon 15 countries and among this category, 10 of them are Sub-Saharan Africa’s ones: Angola, Burkina Faso, Democratic Republic of the Congo, Ethiopia, Kenya, Mali, Niger, Nigeria, Tanzania, and Uganda. Most of these deaths could have been prevented through vaccines and other means of prevention according to this study. Besides, undernourishment constitutes another obstacle to these children’s survival. Any program to tackle childhood pneumonia and diarrhoea should include a facet on improving child nutrition.

Lack of national leadership in the fight against these diseases and a lack of financial resources are important bottlenecks. This, coupled with the inadequate training of health workers, and a lack of health indicators, are key obstacles that need to be addressed to lower the morbidity rate of pneumonia and diarrhoea among children and to improve their survival rates, for these authors.

The second paper on “Interventions to address deaths from childhood pneumonia and diarrhoea…” shows that scaled interventions could save 95% of diarrhoea and 67% of pneumonia deaths in younger children (under 5 years) by 2025. But to reach that goal, the emphasis must be put on community-level healthcare as it is the best way to reach the most exposed populations. 

This series show that childhood pneumonia and diarrhoea are serious health concerns in many developing countries, particularly in Sub-Saharan Africa, but that they could be eradicated through prevention (immunisation campaigns) and effective intervention. In its subject and objectives, this series echoes the recent publication by the World Health Organization and UNICEF, the Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea. This plan aims to reduce by 75% (with 2010 levels as reference) the incidence of severe pneumonia and diarrhoea, as well as the death from both these diseases among children under-five. It also aims for a 40% reduction in the global number of children under five who are stunted since undernutrition is one of the key risk factor for children suffering from pneumonia and diarrhoea. There’s a global commitment to ending child death from preventable diseases and these two Lancet publications show that this objective is reachable if all means are galvanised.

Childhood diarrhoea and pneumonia are deadlier in low-income countries of Sub-Saharan Africa and South Asia than in the developed world. Closing the gap is one of the ultimate aims of the Lancet series as shown through different models, it is an objective that is within our reach.

To find out more about Wikiprogress Africa, click here

Ousmane Aly DIALLO
(Wikiprogress Africa Advisor)

India’s Health-Issues and Challenges

Public health is squarely a state responsibility and particularly so in a developing country. It has to go hand-in-hand with sanitation, drinking water, health education and disease prevention.

The challenges facing India’s health sector are mammoth. They will only multiply in the years ahead. Surprisingly many of the challenges are neither a result of the paucity of resources nor of technical capacity. These hurdles exist because of a perception that the possible solutions may find disfavour with voters or influential power groups.
The first malady has been the utter neglect of population stabilisation in states where it matters the most.
The second is the monopoly that an elitist medical hierarchy has exercised for over 60 years on health manpower planning. The result has given a system where high-tech speciality services are valued and remunerated far higher than the delivery of public health services. The latter ironically touches the lives of millions.
Related to this is the third big challenge — how to make sure that doctors serve the growing needs of the public sector when the working conditions are rotten, plagued by overcrowding, meagre infrastructure and a virtual absence of rewards and punishments.

Divergent Attitudes to Birth Control.

In the aftermath of the 1975 Emergency and the odium of forced sterilisations, the emphasis on population control shrivelled in most of North India. While countries like Korea and Iran which then had fertility rates far higher than ours, embraced the joys of planned parenthood, India dodged the subject. In 1994 the country adopted a target free policy and the states were encouraged to implement a “cafeteria approach” while supplying contraceptives.
However the southern states of Kerala and Tamil Nadu unlike the rest of the country went full force to make family planning their top-most priority. No matter which party came to power, political support was there in abundance. In the mid- eighties the programme was spearheaded by no less than the state Chief Secretary of Tamil Nadu, Mr.T V Anthony, (nick-named Tubectomy-Vasectomy Anthony) which speaks for itself. With enthusiastic politicians, civil servants and doctors joining hands, Kerala and Tamil Nadu reduced fertility rates to equalise European levels. That was more than 20 years ago. Meanwhile, North India (where most of the emergency driven sterilizations had taken place) recoiled from the very mention of family planning- a mind-set that persists even to this day.

The Challenge of Reducing Maternal and Infant Mortality

There is a clear correlation between the health of the mother and maternal and infant mortality. In the northern states more than 60% of the girls and boys (respectively) are married well before the legal ages of 18 and 21. The repercussions of early pregnancy and child birth have not even dawned on the pair when they wed. The first child arrives within the year when most adolescent girls are malnourished, anaemic and poorly educated. With no planned spacing between the births, another child is born before the young mother has rebuilt her strength or given sufficient nutrition and mothercare to the first born. These are among the main causes of high deaths of young women and infants. The chart and tables below clearly show the regional difference in maternal, infant and child mortality. Narrowing the gaps poses one of the biggest health challenges.

Regional Variations: Maternal Mortality Ratio* (MMR)

Extract from – Special Bulletin (June, 2011) on Maternal Mortality in India 2007-09 (Sample Registration System) Office of Registrar General, India
*MMR: Maternal deaths per 1,00,000 live births
The regional variations in the deaths of mothers in the states of Uttar Pradesh, Bihar, Jharkhand, Madhya Pradesh, Chattisgarh, Odisha, Rajasthan and Assam show that the percentage of maternal deaths is 6 times higher than in the Southern states.
Source: Special Bulletin on Maternal Mortality in India 2007-09 (SRS, 2011) Office of Registrar General, India and Unicef SOWC, 2011
Taken together the EAG States and Assam account for 62% of the maternal deaths. Schemes for nutrition, supplementary feeding, literacy, the right to education and health care remain hollow expressions without any meaning as long as women (and chiefly adolescents) have no control over pregnancy. Unlike other South and South East Asian countries the use of IUD and injectibles has not taken off in India -nor are these the thrust areas for family planning anywhere in the country. Although long term, reversible methods of preventing pregnancy are available, young mothers and children continue to suffer or die. The challenge lies in bringing the issue to centre –stage and not wait for incremental improvements to take place in the fullness of time. The charts below show the colossal difference that has been achieved by the southern states that invested heavily in family planning (albeit through the adoption of terminal methods like sterilisation which can be avoided today.)
Source: Registrar General of India, Ministry of Home   Affairs (SRS, 2011)
Source: Registrar General of India, Ministry of Home   Affairs (SRS, 2011)

Health Management and Manpower Planning

The second challenge relates to a obsession for exclusivity that has consumed the medical sector for too long. The Councils that regulate education and register the practitioners (Medical Council of India (MCI), Dental Council, Pharmacy Council, Nursing Council) were established with laudable goals- to elect a cross section of doctors and other health professionals democratically and to entrust to them the responsibility for designing and executing professional corses. It was expected that the country’s needs for professional health manpower would be met both qualitatively and quantitatively. But because the Councils were constituted through a political process of elections, the baggage of money, patronage and quid pro quos became a predictable accessory. Today, gaining entry to professional colleges has become highly commercialised-ultimately reflecting in the aspirations of the health fraternity to reap back benefits from huge investments incurred. As the quest to produce specialists and super specialists grows, the production of qualified technical manpower has declined severely creating a mis-match which cannot be corrected by people who work in silos and lack the understanding and vision to think of the country’s health needs in totality.

The Challenge of Establishing NCHRH.

The neglect of public health is one of the fallouts of the elitism that has pervaded medical education. Whereas cities and towns at least have alternatives available- at a price- epidemics and acute illnesses that occur in rural areas often leave people in the hands of fate. The erstwhile elected MCI had relegated public health to the lowest rung of the health hierarchy and the doctors that once decimated dreaded diseases like malaria and smallpox are not to be found. The complement of technical staff, nurses, pharmacists, dentists, lab technicians and operation theatre staff are all in short supply outside the urban areas as the bodies that register them do not work in tandem. More importantly no Council has a stake in health care of any particular state- leave alone the country.
The proposal to set up a National Council for Human Resources in Health (NCHRH), far from being a bureaucratic response was a well thought out strategy having its roots in the recommendations of independent think tanks and expert committees. The rationale for setting up such an umbrella body was to see that the goals of health manpower planning, the prescription of standards, the establishment of accreditation mechanisms and preservation of ethical standards were served in a co-ordinated way, on the lines of structures that operate successfully in other countries.
The Indian Medical Association in particular and doctors in general have been arguing against the need for such a body because they perceive it as a threat to their autonomy and a camouflage for political and bureaucratic meddling. The fact that health manpower planning was simply ignored, that there was a complete lack of coordination between the councils and most important of all the fact that public health had become a low priority have been overlooked in the fire and fury of opposing the NCHRH concept tooth and nail. The challenge today is how to ensure that the health sector produces adequate professionals as required for the primary, secondary and tertiary sectors, both for the public as well as the private sector health facilities. If the NCHRH Bill before the Standing Committee of Parliament does not see light of day, the resurrection of the superseded scam-ridden MCI is a foregone conclusion.
The Challenge of Allopathy and AYUSH.

Public health cannot be run on contract basis and much less be farmed out to private insurance companies and HMOs (Health Management Organisations) as a recent report on Universal Health Coverage seems to suggest. Public health is squarely a state responsibility and particularly so in a developing country. It has to go hand-in-hand with sanitation, drinking water, health education and disease prevention. The National Rural Health Mission (NRHM) which is a public-sector programme has registered an encouraging impact in even the most intractable regions of the country. A UNFPA study has shown that nearly three quarters of all births in Madhya Pradesh and Odisha had been conducted in a regular health facility. The percentage of institutional deliveries in Rajasthan, Bihar in Uttar Pradesh was lower but even so, accounted for almost half the deliveries conducted in those states. Indeed these achievements are immense.

Having said this, institutional deliveries alone cannot be the answer to all the problems that beset the rural health sector. A visit to any interior block or taluka in the Hindi belt states shows that most primary health centres beyond urban limits are bereft of doctors, except sporadically. Some state governments have taken to posting contractual AYUSH*  doctors engaged under NRHM to man the primary health centres. These doctors dispense allopathic drugs, prescribe and administer IV fluids, injections and life-saving drugs, assisted by AYUSH pharmacists and nursing orderlies. This reality must be confronted. If an AYUSH is doctor has been entrusted with the responsibility of running a primary health centre, and found in shape to handle the national programmes, the controversy over what AYUSH doctors can and cannot do must be settled. The trend of AYUSH doctors working in as registrars and second level physicians in private sector hospitals, clinics, and nursing homes is wide-spread in states like Uttar Pradesh, Maharashtra, and Punjab; so also in Delhi and Mumbai. The challenge lies in understanding what can be changed and what cannot be changed, without getting intimidated by protests from Medical Associations that will always protect their turf to retain primacy.

The Challenge of Retaining Doctors.

The most important concern by far is to decide what kind of medical and public health cover is necessary and feasible to be given to people living beyond the bigger towns and cities. If all general duty doctors are making a beeline for post graduation- failing which opting for management, administration and even banking jobs (because cities are better places to live in,) the facts must be faced. Pursuing post-graduation, migrating abroad and prospecting for jobs outside the medical sector cannot be stopped by any Government. But fixed term requirements to stay bonded to the public sector can certainly be insisted upon for state sponsored medical graduates. But equally the working conditions, facilities and remuneration of such doctors should be respectable. In the state of Jammu and Kashmir the compensation given for working in more difficult areas has been graded. Such practical solutions can greatly bolster doctor retention.
At the end of the day, the challenges of the health sector can only be met if doctors, essential drugs and supporting staff are available in the health facilities. The biggest transformation will come if wriggling out of postings and manipulating things through political patrons stops. The doctors will fall in line only if postings are notified through a transparent and fair process and no exceptions whatsoever are allowed. Only the state Chief Ministers and Health Ministers can make this happen. But will they?

*AYUSH refers to Ayurveda, Siddha, Unami and Homeopathy medical systems supported by Yoga . The status of Indian Medicine & Folk Healing can be seen in a publication by the author at ;

Shailaja Chandra will be speaking on Day Two of the 4th OECD World Forum on “Statistics, Knowledge and Policy”



A Better Future for All

This post first appeared on Wikiprogress partner, UNDP’s  Let’s Talk Human Development

In June 2012 world leaders will gather in Rio de Janeiro to seek a new consensus on global actions to safeguard the future of the planet and the right of future generations everywhere to live healthy and fulfilling lives. This is the great development challenge of the 21st century.
The 2011 Human Development Report offers important new contributions to the global dialogue on this challenge, showing how sustainability is inextricably linked to basic questions of equity—that is, of fairness and social justice and of greater access to a better quality of life. Sustainability is not exclusively or even primarily an environmental issue, as this Report so persuasively argues. It is fundamentally about how we choose to live our lives, with an awareness that everything we do has consequences for the 7 billion of us here today, as well as for the billions more who will follow, for centuries to come.
Understanding the links between environmental sustainability and equity is critical if we are to expand human freedoms for current and future generations. The remarkable progress in human development over recent decades, which the global Human Development Reports have documented, cannot continue without bold global steps to reduce both environmental risks and inequality. This Report identifies pathways for people, local communities, countries and the international community to promote environmental sustainability and equity in mutually reinforcing ways.
In the 176 countries and territories where the United Nations Development Programme is working every day, many disadvantaged people carry a double burden of deprivation. They are more vulnerable to the wider effects of environmental degradation, because of more severe stresses and fewer coping tools. They must also deal with threats to their immediate environment from indoor air pollution, dirty water and unimproved sanitation. Forecasts suggest that continuing failure to reduce the grave environmental risks and deepening social inequalities threatens to slow decades of sustained progress by the world’s poor majority— and even to reverse the global convergence in human development.
Major disparities in power shape these patterns. New analysis shows how power imbalances and gender inequalities at the national level are linked to reduced access to clean water and improved sanitation, land degradation and deaths due to indoor and outdoor air pollution, amplifying the effects associated with income disparities. Gender inequalities also interact with environmental outcomes and make them worse. At the global level governance arrangements often weaken the voices of developing countries and exclude marginalized groups.
Yet there are alternatives to inequality and unsustainability. Growth driven by fossil fuel consumption is not a prerequisite for a better life in broader human development terms. Investments that improve equity—in access, for example, to renewable energy, water and sanitation, and reproductive healthcare—could advance both sustainability and human development. Stronger accountability and democratic processes, in part through support for an active civil society and media, can also improve outcomes. Successful approaches rely on community management, inclusive institutions that pay particular attention to disadvantaged groups, and cross-cutting approaches that coordinate budgets and mechanisms across government agencies and development partners.
Beyond the Millennium Development Goals, the world needs a post-2015 development framework that reflects equity and sustainability; Rio+20 stands out as a key opportunity to reach a shared understanding of how to move forward. This Report shows that approaches that integrate equity into policies and programmes and that empower people to bring about change in the legal and political arenas hold enormous promise. Growing country experiences around the world have demonstrated the potential of these approaches to generate and capture positive synergies.
The financing needed for development—including for environmental and social protection—will have to be many times greater than current official development assistance. Today’s spending on low-carbon energy sources, for example, is only 1.6 percent of even the lowest estimate of need, while spending on climate change adaptation and mitigation is around 11 percent of estimated need. Hope rests on new climate finance. While market mechanisms and private funding will be vital, they must be supported and leveraged by proactive public investment. Closing the financing gap requires innovative thinking, which this Report provides.
Beyond raising new sources of funds to address pressing environmental threats equitably, the Report advocates reforms that promote equity and voice. Financing flows need to be channelled towards the critical challenges of unsustainability and inequity—and not exacerbate existing disparities.
Providing opportunities and choices for all is the central goal of human development. We have a collective responsibility towards the least privileged among us today and in the future around the world—and a moral imperative to ensure that the present is not the enemy of the future. This Report can help us see the way forward.

By Helen Clark
Administrator, United Nations Development Programme (UNDP)