Essential health information available for India in the public domain on the internet

1471-2458-9-208 1471-2458 Research article Essential health information available for India in the public domain on the internet Raban Z Magdalena mrab2647@uni.sydney.edu.au Dandona Rakhi rdandona@med.usyd.edu.au Dandona Lalit dandona@u.washington.edu

School of Public Health and George Institute for International Health, University of Sydney, Sydney, Australia

George Institute for International Health, India, Hyderabad, India

Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA

BMC Public Health 1471-2458 2009 9 1 208 http://www.biomedcentral.com/1471-2458/9/208 19563626 10.1186/1471-2458-9-208 22 10 2008 29 6 2009 29 6 2009 2009 Raban et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Health information and statistics are important for planning, monitoring and improvement of the health of populations. However, the availability of health information in developing countries is often inadequate. This paper reviews the essential health information available readily in the public domain on the internet for India in order to broadly assess its adequacy and inform further development.

Methods

The essential sources of health-related information for India were reviewed. An extensive search of relevant websites and the PubMed literature database was conducted to identify the sources. For each essential source the periodicity of the data collection, the information it generates, the geographical level at which information is reported, and its availability in the public domain on the internet were assessed.

Results

The available information related to non-communicable diseases and injuries was poor. This is a significant gap as India is undergoing an epidemiological transition with these diseases/conditions accounting for a major proportion of disease burden. Information on infrastructure and human resources was primarily available for the public health sector, with almost none for the private sector which provides a large proportion of the health services in India. Majority of the information was available at the state level with almost negligible at the district level, which is a limitation for the practical implementation of health programmes at the district level under the proposed decentralisation of health services in India.

Conclusion

This broad review of the essential health information readily available in the public domain on the internet for India highlights that the significant gaps related to non-communicable diseases and injuries, private health sector and district level information need to be addressed to further develop an effective health information system in India.

Background

Health information and statistics are important for planning, monitoring and improvement of services for the health of populations 1. These are essential for policymakers and programme planners to inform their decisions about what actions to take and what services to provide in order to improve the health of the populations they serve. Though developing countries account for the majority of the global burden of disease, the availability of health information is not adequate in many of these countries 123. The lack of quality health information has become more apparent in recent years with the Millennium Development Goals and demand from international organisations for monitoring and evaluation data on health programmes supported by them 4.

The Government of India in its National Health Policy of 2002 acknowledged the absence of systematic and scientific population health statistics as a major deficiency in India 5. There have been a few recent efforts to strengthen some of the data sources in India 6789. While the data sources themselves require strengthening, it is important that the information generated by them is made available in the public domain in order for it to be utilised by a variety of stakeholders. In this background, as an initial step we reviewed the essential health information readily available in the public domain on the internet for India.

Methods

We reviewed the essential sources of health-related information for India as identified by AbouZahr and Boerma 10. The search strategy included extensive searches of the various websites of the Government of India and the relevant national and international organisations using Google 11 and search of the PubMed literature database 12.

Identification of available data

The ten essential sources of information included in this report are: census; birth and death registration; surveillance and response systems; household surveys; service generated data; mapping of health facilities; behavioural surveillance; national health accounts; financial and management information; and modelling, estimates and projections 10. These information sources provide data at a variety of levels household, patient, health facility, district, state and national. Health research, one of the other essential sources of information 10, was not included in this review as it is a major topic by itself and we have previously reported on health research output from India 13.

As a first step, extensive searches were carried out for the essential sources and their outputs on websites of the government, national health programmes, nongovernmental institutions, and international agencies relevant for the health information system in India. These searches provided further useful links to other relevant websites that provided information on essential sources of population health information in India. In addition, for each essential source a Google search was carried out using "India" AND the essential source related terms. For example, for birth and death registration, the search combinations of "birth registration, death registration, or sample registration system AND India" were used. A similar strategy was used to search PubMed for publications 1990 onwards on essential sources of health information in India. From these various searches, the organisations or programmes that yielded usable information regarding the content, process or outputs of essential sources of health information for India are shown in Table 1.

Table 1

Sources that yielded usable essential health information for India

Organisation

Website

Census of India

http://www.censusindia.gov.in/

Central Bureau of Health Intelligence

http://cbhidghs.nic.in/

Centre for Global Health Research

http://cghr.org/project.htm

Department of Family Welfare

http://mohfw.nic.in/dofw%20website/dofw.htm

Disease Control Priorities Project

http://www.dcp2.org/page/main/Home.html

Jansankhya Sthirata Kosh (National Population Stabilisation Fund)

http://www.jsk.gov.in/

Ministry of Health and Family Welfare

http://mohfw.nic.in/

Ministry of Statistics and Programme Implementation

http://mospi.nic.in/

National AIDS Control Organisation

http://www.nacoonline.org/NACO

National Cancer Registry Programme

http://icmr.nic.in/ncrp/cancer_reg.htm

National Commission on Population

http://populationcommission.nic.in/

National Crime Records Bureau

http://ncrb.nic.in/

National Family Health Survey, India

http://www.nfhsindia.org/index.html

National Institute of Nutrition

http://nnmbindia.org/default.asp

National Polio Surveillance Project

http://www.npspindia.org/

National Programme for the Control of Blindness

http://mohfw.nic.in/default.htm

National Sample Survey Organisation

http://mospi.nic.in/nsso_test1.htm

National Vector Borne Disease Control Programme

http://nvbdcp.gov.in/

Planning Commission

http://planningcommission.nic.in/

Reproductive and Child Health District Level Household and Facility Surveys

http://www.rchiips.org/index.html

Tuberculosis Control in India

http://www.tbcindia.org/home.asp

United Nations Children's Fund – Child info

http://www.childinfo.org/

World Bank – Living Standards Measurement Study

http://go.worldbank.org/WKOXNZV3X0

World Health Organisation World Health Survey

http://www.who.int/healthinfo/survey/en/index.html

World Health Organization India Country Office

http://www.whoindia.org/EN/Index.htm

World Health Organization South East Asia Regional Office

http://www.searo.who.int/

Assessment of available data

For each essential information source, the periodicity of data collection, the information it generated, the geographical level at which this information is reported, and the extent of its availability in the public domain were assessed. Additional searches and reviews were conducted, if needed, of the relevant reports and publications accessible in the public domain to assist with these assessments.

Periodicity was defined as the frequency with which data collection was carried out. The latest year of data collection is reported. The information generated by each essential source was classified into these five categories: mortality and causes of death, morbidity and health status, risk factors, service provision, and health resources 4. Information on health resources was sub-categorised based on whether it was related to infrastructure, human resources or financing 14.

The available information was further assessed to understand how it related to the major causes of disease burden in India as estimated by the Global Burden of Disease Project 15. The rationale for the use of the leading causes of disease burden was based on the idea that relevant health information for these causes at least should be available. All available information produced by the essential sources was examined. Mortality, morbidity, risk factor and service provision information related to the conditions was listed. A risk factor for each condition was considered if it was listed in the major publications examining risk factors or a review of risk factors in India 161718. Service provision indicators considered were the interventions that addressed the risk factors or treatment of a disease or condition.

Geographical level of information reported was assessed for the administrative level for which the information was available: national, state, district or city/town. The extent of availability in the public domain on the internet was rated based on whether all the information produced was freely available including reports, microdata and metadata where appropriate (+++); all types of information was available but with restrictions such as purchase cost (++); only some information was available, for example reports but no microdata (+); or no information was available in the public domain (0). Availability of microdata was not used as a criterion for the documents or sources that dealt with secondary data or were based on other sources.

Results

The findings related to the characteristics of health information for India available from essential sources in the public domain on the internet are summarized in Table 268916192021222324252627282930313233343536373839404142434445464748495051525354555657.

Table 2

Characteristics of essential sources of health information in India, 2008.

Essential source 10

Year started

Periodicity; last year conducted

Category of information

Lowest geographical level

Availability of information in the public domain*

1. Census 19

1872

10 years; 2001

◦ Morbidity & health status

City/town/village

◦ Risk factors

◦ Health infrastructure

2. Birth and death registration

a) National birth and death registration system 202122

1969

Ongoing

◦ Mortality & causes of death

State

◦ Morbidity & health status

b) Sample registration system 623

1969

Ongoing

◦ Mortality & causes of death

State

◦ Morbidity & health status

3. Surveillance and response system

a) HIV Sentinel Surveillance 824

1998

Annual; 2007

◦ Morbidity & health status

District†

b) National Crime Records Bureau "Accidental deaths and suicides in India" 25

1967

Annual; 2007

◦ Mortality & causes of death

State

c) National Cancer Registry Programme 26

1981

Variable; 2003

◦ Mortality & causes of death

City‡

◦ Morbidity & health status

◦ Service provision

d) Integrated Disease Surveillance Project 9

2003

Ongoing

◦ Mortality & causes of death

Not known

◦ Morbidity & health status

e) National Polio Surveillance Project 27

1997

Ongoing

◦ Morbidity & health status

State

+++

f) National Vector Borne Diseases Control Programme 28

Not available

Ongoing

◦ Mortality & causes of death

State

◦ Morbidity & health status

4. Household surveys

a) Reproductive and Child Health District Level Household Surveys 29

1998

4–5 years; 2007/8

◦ Morbidity & health status

District§

+++§

◦ Risk factors

◦ Service provision

b) National Family Health Surveys 30

1990

6–7 years; 2005/6

◦ Mortality

State

+++

◦ Morbidity & health status

◦ Risk factors

◦ Service provision

c) National Sample Survey on household consumer expenditure 31

1972

5 years for large samples (surveys on small samples since 1986/7); 2005/6

◦ Health financing

State

d) National Sample Survey on nutritional intake in India 32

1972

5–6 years; 2004/5

◦ Morbidity & health status

State

◦ Risk factors

e) National Sample Survey on morbidity, health care and the condition of the aged 33

1973

Variable (conducted twice); 2004

◦ Morbidity & health status

State

◦ Risk factors

◦ Service provision

f) World Health Survey 34

2003

Once; 2003

◦ Mortality & causes of death

State||

+++

◦ Morbidity & health status

◦ Risk factors

◦ Service provision

◦ Human resources

g) National Sample Survey on condition of urban slums 35

1976

Variable (conducted thrice); 2002

◦ Risk factors

State

◦ Health infrastructure

h) National Sample Survey on disabled persons in India 36

1981

10–11 years; 2002

◦ Morbidity & health status

State

i) National Sample Survey report on village facilities 37

1950

Variable; 2002

◦ Risk factors

State

◦ Health infrastructure

j) UNICEF Multiple Indicator Survey 38

2000

Once; 2000

◦ Morbidity & health status

State

◦ Risk factors

◦ Service provision

k) National Sample Survey on drinking water, sanitation and hygiene 39

1988

Variable (conducted thrice); 1998

◦ Risk factors

State

l) World Bank Survey of Living Conditions in Uttar Pradesh and Bihar 40

1997/8

Once; 1997/8

◦ Morbidity & health status

State¶

◦ Risk factors

◦ Service provision

m) National Sample Survey on maternal and child health care in India 41

1995/6

Once; 1995/6**

◦ Risk factors

State

◦ Service provision

n) National Sample Survey on consumption of tobacco in India, 1993–94 42

1993/4

Once; 1993/4**

◦ Risk factors

State

5. Service generated data

a) Family Welfare Statistics in India 43

1974

Variable; 2006

◦ Service provision

State

b) Performance of Cataract Surgery under National Programme for Control of Blindness 44

Not available

Ongoing

◦ Service provision

State

c) Revised National Tuberculosis Control Programme 45

1997

Ongoing

◦ Service provision

District††

+++

◦ Health infrastructure

◦ Human resources

6. Mapping of health facilities

a) Bulletin on Rural Health Statistics 46

Not available

Annual; 2007

◦ Health infrastructure

State; some district

◦ Human resources

b) National Health Profile 47

1953

Annual; 2007

◦ Morbidity & health status

State

+++¶¶

◦ Health infrastructure

◦ Human resources

c) WHO "Antiretroviral Therapy Service Map" 48

2006

Once; 2006

◦ Service provision

State

d) Reproductive and Child Health Facility Survey 49

1998

5 years; 2003

◦ Service provision

State

+++‡‡

◦ Health infrastructure

◦ Human resources

e) Jansankhya Sthirata Kosh & National Informatics Centre health maps 50

2007§§

Once; 2001

◦ Health infrastructure

District

+++¶¶

7. Behavioural surveillance

a) NACO Behavioural Surveillance Surveys 51

2001

5 years; 2006

◦ Risk factors

State

◦ Service provision

b) National Nutrition Monitoring Bureau time trend surveys 52

1972

8–13 years; 1996/7

◦ Risk factors

State||||

c) Integrated Disease Surveillance Project 9

2003

Ongoing

◦ Risk factors

Not known

d) Sample Registration System 2353

2001

Ongoing

◦ Risk factors

State

+***

8. National Health Accounts 54

2001/2

3 years; 2004/5†††

◦ Health financing

State

+++

9. Financial and management information

a) Ministry of Health and Family Welfare "Annual Report" 55

Not available

Annual; 2007/8

◦ Health infrastructure

National

+++¶¶

◦ Human resources

◦ Health financing

b) Planning Commission "Five Year Plan" 56

1950

5 years; 2007

◦ Health infrastructure

National

+++¶¶

◦ Human resources

◦ Health financing

c) National Commission on Macroeconomics and Health 57

2005

Once; 2005

◦ Health infrastructure

State

+++¶¶

◦ Human resources

◦ Health financing

10. Modelling, estimates and projections

a) National Commission on Macroeconomics and Health 57

2004

Once; 2005

◦ Mortality & causes of death

National;

+++¶¶

◦ Morbidity & health status

some state

◦ Health infrastructure

◦ Human resources

◦ Health financing

b) Global Burden of Disease and Risk Factors Study 16

1990

Variable; 2002‡‡‡

◦ Mortality & causes of death

National

+++

◦ Morbidity & health status

◦ Risk factors

*Availability of information: +++ means all types of information produced freely available (reports, details, microdata and metadata as applicable), ++ all types available but with restrictions, + means some available (e.g. report or spreadsheet, but no microdata), and 0 means none available.

†At time of writing this paper, district level estimates available for 2006 for HIV prevalence among antenatal clinic attendees and patients with sexually transmitted diseases; estimates of state level population HIV prevalence available for 2007.

‡Only for registry locations; population-based registries at Ahmedabad, Aurangabad, Bangalore, Barshi, Bhopal, Chennai, Delhi, Dibrugarh, Guwahati, Imphal, Kollam, Kolkata, Mizoram, Mumbai, Nagpur, Pune, Sikkim, Silchar, Thiruvananthapuram; hospital-based registries at Bangalore, Chennia, Mumbai, Dibrugarh.

§At the time of writing this paper, reports, metadata and microdata available for district level for 2002–2004 survey; state level reports available for 2007/8 survey.

||Only for the states of Assam, Karnataka, Maharashtra, Rajasthan, Uttar Pradesh, West Bengal; national pooled estimates also available.

¶Only for the states of Uttar Pradesh and Bihar.

**Part of a regular household consumption survey, but these are the only reports on maternal and child health, and tobacco consumption available.

†† District level only for service provision; infrastructure and human resources information available for state level.

‡‡At the time of writing this paper, reports, metadata and microdata available for the 2003 survey.

§§Maps produced in 2007 using 2001 census data.

|||| Only for the states of Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh, West Bengal.

¶¶Only reports available; these are not primary data collection sources, so microdata not expected.

***Some results have been released in the form of a journal publication 53.

†††National Health Accounts for 2004/5 are being computed but the results not available at the time of writing this paper.

‡‡‡Regional estimates for 2004 were made available in 2008.

Periodicity

The periodicity of data collection ranged from on-going (e.g. sample registration system 6), annual (e.g. HIV sentinel surveillance 8) to decennial (census 19) (Table 2). Some data collection under the household surveys 4142, mapping of health facilities 4850 and financial and management information was carried out only once, including a number of international survey programmes 343840 and reports such as the National Commission on Macroeconomics and Health 57.

Information generated

The essential sources generate all five categories of information, i.e. mortality and causes of death, morbidity and health status, risk factors, service provision, and health resources, but to varying degrees (Table 2). Mortality and cause of death information is generated by birth and death registration 620, four surveillance systems 9252628, two household surveys 3034 and modelling 1657. Information on morbidity and health status is generated by the census 19, monitoring of birth and deaths 620, surveillance and response systems 89262728, eight household surveys 2930323334363840, mapping of health facilities 47 and both modelling, estimates and projections sources 1657. Risk factor information is generated by census 19, most household surveys 293032333435373839404142, the behavioural surveillance systems 9515253 and modelling, estimates and projections 16. Service provision information, such as coverage of interventions, is generated by a surveillance and monitoring system 26, household surveys 29303334384041, service generated data 434445, two mapping of health facilities 4849 and one behavioural surveillance system 51.

Information on health system infrastructure is generated by census 19, sources under household surveys 3537, mapping of health facilities 46474950 and financial and management information 555657 (Table 2). Much of this deals with the numbers of public health facilities and the equipment availability in these facilities. Estimates of the number of private sector hospitals and beds have been made in the Planning Commission's Five Year Plan 56.

The National Health Profile 47 and the Report of the National Commission on Macroeconomics and Health 57 provide information on the total number of human resources for health (physicians, nursing staff and other paramedical personnel). The WHO World Health Survey provides the estimates of total numbers of health workers, as assessed by asking respondents if they were employed in the health sector 34. The Bulletin on Rural Health Statistics 46 and the Reproductive and Child Health Facility Survey 49 provide data on the numbers of health workers in public health facilities, including physicians, laboratory workers, nurses and midwives. Revised National Tuberculosis Control Programme provides programme specific data on human resources 45. Information on medical education facilities, such as numbers of medical colleges, is available in the National Health Profile 47, Bulletin on Rural Health Statistics 46, Annual Report of the Ministry of Health and Family Welfare 55, Planning Commission 56, and Report of the National Commission on Macroeconomics and Health 57.

The most comprehensive source of financing information was the National Health Accounts (NHA), completed for the year 2001–2 and is currently underway for 2004–5 54. It provides data on the government and private expenditure on health 54. The other sources of financing information include the National Sample Survey on household consumer expenditure 31, Annual Report of the Ministry of Health and Family Welfare 55, National Health Profile 47, Planning Commission 56 and Report of the National Commission on Macroeconomics and Health 57.

Table 3 shows the available information generated by the essential sources for the leading causes of disease burden in India, other than that generated by the modelling and projections 8192325323334363840414243444548515358596061626364656667. The conditions listed were each estimated to have contributed more than 2% of the total disease burden in India in the year 2002 15. Importantly, the Global Burden of Disease and Risk Factors study provides mortality and morbidity estimates for India for all conditions, some of which are based on modelling and projections as primary data are not available for some conditions. It also provides estimates of the distribution of selected risk factors in the population, again some of which are modelled projections 15.

Table 3

Population health information available in the public domain on the leading causes of disease burden in India.*

Disease or health condition

(% of total DALYs lost in 2002 in India 15)

Category

Information available

Lowest geographical level available

Comments

1. Perinatal conditions

(9.7%)

Mortality

Perinatal mortality rate 23585960†

State

Based on data from sample registration system and large scale household survey ‡ No cause of perinatal death data.

Morbidity & health status

Prevalence of low birth weight 38585961

District

Based on data from large scale household survey‡

Risk factors

Anaemia among women 585962

District

Most estimates based on data from large scale household survey‡

Underweight among women 345859

State

Contraception non-use 38435859606163

District

Birth spacing 585960

State

Number of children ever born 5 or more 5859606163

District

Antenatal care received 33343841435859606163

District

Skilled birth attendance 333438415859606163

District

Low birth weight 38585961

District

Prevalence of postpartum complications 5859606163

District

Service provision

Contraception coverage 38435859606163

District

Most estimates based on data from large scale household survey‡

Antenatal care coverage 33343841435859606163

District

Women receiving iron supplementation 3841435859606163

District

Skilled birth attendance coverage 333438415859606163

District

Postnatal care coverage 3338415859

State

2. Lower respiratory tract infections

(8.5%)

Mortality

None*

Morbidity & health status

Prevalence of cough in children 34385859606163

State

Based on data from large scale household surveys‡

Risk factors

Type of cooking fuel used 1934384058596063

District

Most estimates based on large scale household surveys‡

Tobacco smoking 34425358

State

Childhood underweight 58596062

State

Breastfeeding practices 385859606163

District

Service provision

Treatment of childhood cough 34385859606163

State

Based on data from large scale household surveys‡

3. Ischaemic heart disease

(5.1%)

Mortality

Percent of adult deaths attributed to chest pain 34

National

Estimate based on a small sample of verbal autopsy on sibling deaths§

Morbidity & health status

Self-reported diagnosis with ischaemic heart disease 34

State||

Estimate based on household survey conducted in 6 states||

Self-reported hospitalisations for heart disease 33

National

Risk factors

Prevalence of overweight & obesity 3458

State

Most risk factors have an estimate based on a large scale household survey‡

'Lack of physical activity' measured by household survey conducted in 6 states||

Tobacco & alcohol use 34425358

State

Fruit and vegetable intake 32345859

State

Lack of physical activity 34

State||

Self-reported diagnosis of diabetes 3458

State

Service provision

Self-reported treatment of disease 34

State||

Estimate based on household survey conducted in 6 states||

4. Diarrhoeal diseases (5.1%)

Mortality

Percent of adult deaths attributed to diarrhoea 34

National

Estimate based on a small sample of verbal autopsy on sibling deaths§

Morbidity & health status

Prevalence of diarrhoea in children 34385859606163

State

Most estimates based on data from large scale household surveys‡

Self-reported hospitalisation for diarrhoea 33

National

Risk factors

Access to clean water and sanitation 1933343537383940415859606364

District

Most estimates based on data from large scale household surveys‡

Prevalence of childhood underweight 58596062

State

Vitamin A deficiency in children 38

State

Percentage of children receiving food rich in vitamin A in last 24 hrs 58

State

Breastfeeding practices 385863

District

Service provision

Treatment of childhood diarrhoea 385859606163

State

Most estimates based on large scale household surveys‡

Child vitamin A supplementation 384358596163

District

5. Unipolar depression

(4.9%)

Morbidity & health status

Self-reported diagnosis of depression 34

State||

Estimate based on household survey conducted in 6 states||

Risk factors

Alcohol use 345358

State

Both risk factors estimated by at least one large scale household survey‡

Prevalence of women who experienced childhood sexual abuse 58

National

Service provision

Self-reported treatment coverage 34

State||

Estimate based on household survey conducted in 6 states||

6. HIV/AIDS

(3.4%)¶

Mortality

None*

Morbidity & health status

HIV prevalence 858

State

Estimate based on sentinel surveillance and large scale household survey‡

Risk factors

Unsafe sex 5158

State

Both risk factors estimated by large scale household survey‡ Unsafe sex also estimated by behavioural surveillance

Use of clean injections 58

State

Service provision

Coverage of treatment with antiretrovirals 4865

State

Estimates mostly based on large scale household surveys and behavioural surveillance‡

HIV testing uptake 345158

State

Condom use 345158

State

7. Maternal conditions

(2.9%)

Mortality

Maternal mortality ratio 596066

State

Maternal mortality ratio and cause of death estimates based on sample registration system data

A large scale household survey has also estimated maternal mortality ratio‡

Cause of maternal death 66

National

Percent of total female deaths attributed to maternal conditions 34

National

Morbidity & health status

Prevalence of postpartum complications 58

State

Both estimates based on large scale household survey‡

Prevalence of delivery complications 63

State

Risk factors

Anaemia among women 585962

District

Most estimates based on data from large scale household survey‡

Underweight among women 345859

State

Contraception non-use 38435859606163

District

Birth spacing 585960

State

Number of children ever born 5 or more 5859606163

District

Vitamin A deficiency in pregnant women 586163

National

Antenatal care received 33343841435859606163

District

Skilled birth attendance 333438415859606163

District

Low birth weight 38585961

District

Prevalence of postpartum complications 5859606163

District

Service provision

Contraception coverage 38435859606163

District

Most estimates based on data from large scale household survey‡

Antenatal care coverage 33343841435859606163

District

Women receiving iron supplementation 3841435859606163

District

Skilled birth attendance coverage 333438415859606163

District

Postnatal care coverage 3338415859

State

8. Tuberculosis (2.8%)

Mortality

Percent of adult deaths attributed to tuberculosis 34

National

Estimate based on a small sample of verbal autopsy on sibling deaths§

Morbidity & health status

Self-reported tuberculosis diagnosis 3458596063

State

Most estimates based on large scale household surveys‡

Self-reported hospitalisations for tuberculosis 33

National

Risk factors

Tobacco & alcohol use 34425358

State

Most estimates based on large scale household surveys‡

Type of cooking fuel used 19343840585963

District

Malnutrition 323438586062

District

Service provision

Annualised case detection rate for new smear positive cases 45

District

Most estimates based on tuberculosis surveillance system Self-reported tuberculosis treatment estimates mostly based on large scale household surveys‡

Proportion of new sputum positive out of total new pulmonary cases 45

District

Smear conversion rate 45

District

Treatment success rate 45

District

Self-reported tuberculosis treatment 34585963

State

9. Cerebrovascular disease

(2.5%)

Mortality

Percent of adult deaths attributed to paralysis 34

National

Estimate based on a small sample of verbal autopsy on sibling deaths§

Morbidity & health status

None*

Risk factors

Prevalence of overweight & obesity 3458

State

Most risk factors have an estimate based on a large scale household survey‡

'Lack of physical activity' measured only by household survey conducted in 6 states|

Tobacco & alcohol use 34425358

State

Fruit and vegetable intake 32345859

State

Lack of physical activity 34

State||

Self-reported diagnosis of diabetes 3458

State

Service provision

None

10. Cataract

(2.2%)

Morbidity & health status

Prevalence of blindness 366063

State

Estimates based on both large scale household survey and household survey conducted in 6 states ‡ ||

Previous diagnosis of cataracts 34

State||

Self-reported hospitalisations for cataracts 33

National

Risk factors

Tobacco smoking 34425358

State

Estimates based on of large household surveys, household survey conducted in 6 states and sample registration system ‡ ||

Self-reported diagnosis of diabetes 3458

State

Service provision

Number of cataract operations performed 44

State

Estimates based on household survey conducted in six states and service generated data||

Those with previous diagnosis who have accessed surgery 34

State||

11. Road traffic injuries

(2.1%)

Mortality

Deaths from road traffic injuries 25

State

Estimate based on surveillance

Morbidity & health status

Prevalence of road traffic injury in last one year 34

National

Estimate based on household survey conducted in 6 states ||

Risk factors

Alcohol use 345358

State

Estimates based on both large scale household survey and household survey conducted in 6 states‡ ||

Service provision

Those with previous road traffic injury who had accessed emergency care 34

State||

Estimate based on household survey conducted in 6 states ||

*Other than that generated by modelling and projections

†Only the latest National Family Health Survey provides the perinatal mortality rate specifically, the earlier surveys and the sample registration system give the infant mortality rate.

‡The large scale household surveys include: National Family Health Survey (2005/6 survey sampled 109,041 households), Reproductive and Child Health District Level Household Survey (2002/4 survey sampled 620,107 households), National Sample Survey on morbidity, health care and the condition of the aged (sampled 73,868 households), National Sample Survey on nutritional intake in India (sampled 124,644 households) and United Nations Children's Fund Multiple Indicator Survey (sampled 119,305 households).

§The World Health Survey examined a total of 1954 deaths of which cause of death was attributed to 55% of female and 61% of male deaths.

||The World Health Survey was conducted in six states and state level estimates available only for the states of Assam, Karnataka, Maharashtra, Rajasthan, Uttar Pradesh, West Bengal; national pooled estimates also available; sampled 10,729 households.

¶ The estimated burden of HIV/AIDS in India was reduced recently to about half of the previous estimate based on new population-based data 67; the estimated DALYs lost in 2002 shown in this table is therefore an overestimate.

Mortality information generated by the essential sources other than modelled projections is available to some degree for the leading causes of disease burden in India except lower respiratory tract infections and HIV/AIDS. However, it is not complete for many conditions. For example, the perinatal mortality rate is available but there are no data available on the causes of perinatal death. Additionally, for many of the conditions, the only mortality information available has been generated by the World Health Organisation World Health Survey, which used verbal autopsy for sibling deaths. These estimates have limitations in the detail of the cause of death, the small sample of deaths examined, and the fact that for 46% of female deaths and 40% of male deaths the cause of death was not determined 34. This lack of primary data on mortality is being partly addressed by the addition of verbal autopsy to the sample registration system, which is likely to provide mortality data for all major causes in India 6.

There are more sources generating information on morbidity for maternal and child health and communicable diseases as compared with non-communicable diseases. All of the available morbidity information is sourced from self-reporting of conditions in household surveys. The only exception to this is HIV prevalence. Although, self-reporting of conditions in surveys is problematic, use of biological tests in surveys for the estimation of population prevalence can be tedious for many conditions 4. The use of other sources such as service records can aid to fill some of these gaps, although these estimates are prone to bias 4. As with mortality information, modelled morbidity estimates for India have been produced by the Global Burden of Disease and Risk Factors study 15. Additionally, the National Commission on Macroeconomics and Health produced modelled morbidity estimates for tuberculosis, HIV/AIDS, diarrhoeal diseases, blindness, mental health and cardiovascular disease 57.

Risk factor information is generated by a large number of essential sources in addition to the estimates by the Global Burden of Disease and Risk Factors Study. The majority of this information is generated by household surveys. Information on risk factors is more substantial for perinatal and maternal conditions than for the other conditions. The proposed Integrated Disease Surveillance Project is expected to enhance the risk factor information for non-communicable diseases and injuries, but outputs from this initiative are not available yet 9.

Service provision information is lacking for the leading non-communicable diseases and road traffic injuries. Only one essential source generates information on services for ischaemic heart disease, unipolar depression and road traffic injuries, and these estimates are based on data from a household survey, held in only 6 states in India 34. There is no information on services for cerebrovascular disease.

Overall, there is a significant lack of relevant information on non-communicable diseases and injuries, which now account for a major proportion of the disease burden in India 15. Household surveys are the main source of primary information on the leading causes of disease burden in India. Their main focus is on communicable diseases and maternal and child health. The other essential sources from which information is available on the leading causes of disease burden in India are a surveillance system 8, service generated data 434445, sample registration system 6, behavioural surveillance 5153 and census 19.

Geographical level of information

The majority of information produced by the essential sources is reported at the state level (Tables 2). Census produces information at the town and city level including demographic information, access to clean water, sanitation and use of cooking fuels 19. The National Cancer Registry Programme generates information mainly at the city level 26. The Reproductive and Child Health District Level Household Survey was designed to provide monitoring of the Reproductive and Child Health programme at the district level29. The Bulletin on Rural Health Statistics generates some information at the district level on numbers of public health facilities in each district 46. The Revised National Tuberculosis Control Programme provides performance indicators for the programme at the district level 45.

Availability in the public domain

The availability of the information produced by the essential sources in the public domain on the internet was variable (Table 2). The sources that had all information freely available included the National Polio Surveillance Project 27, Reproductive and Child Health District Level Household Surveys 29, National Family Health Surveys 30, World Health Survey 34, Revised National Tuberculosis Control Programme 45, Reproductive and Child Health Facility Survey 49, national health accounts 54 and the Global Burden of Disease and Risk Factor Study 16. In addition, National Health Profile 47, Jansankhya Sthirata Kosh health maps 50, Ministry of Health and Family Welfare "Annual Report" 55, Planning Commission "Five Year Plan" 56 and the National Commission on Macroeconomics and Health 57 had reports freely available. The sources which required the purchase of microdata include all National Sample Surveys 313233353637394142. Only some information was available for a variety of essential sources, more specifically the census 19, monitoring of births and deaths 620, four surveillance and response systems 8252628, two household surveys 3840, two source of service generated data 4344, two under mapping of health facilities 4648 and three behavioural surveillance systems 515253. The main reason for these sources not scoring well was the non-availability of reports or microdata. For example, the UNICEF Multiple Indicator Survey has a report available, but no microdata. The Integrated Disease Surveillance Project had the lowest score for data available in the public domain.

Discussion

Ready availability of essential health information is imperative for the development of informed and effective systems for improving health of societies. This paper provides a broad overview of the data readily available in the public domain on the internet related to essential health information in India. It highlights a number of issues that need to be addressed to improve the scope and availability of health information in India.

There is a lack of primary data on mortality and cause of death information for the majority of the leading causes of disease burden in India. While there are modelled estimates of causes of death generated by the Global Burden of Disease and Risk Factors project, there are minimal primary data on causes of death. These data would normally be generated by a complete death registration system, which is not present in India. The national birth and death registration system is estimated to cover about half of deaths in India 20. The recent addition of verbal autopsy to the sample registration system is expected to provide all-cause mortality information to some degree in the near future 6. The Integrated Disease Surveillance Project is also expected to contribute to this information, although no data are available yet 9.

There were substantial gaps in the available information on non-communicable diseases and injuries. This is significant as the epidemiological transition is well underway in India. Whereas previously maternal and child conditions and communicable diseases where responsible for the majority of the disease burden, more recently the rising burden of non-communicable diseases is being documented in India and is projected to increase 6869. While there is still need for information on maternal and child conditions and communicable diseases, there is also now additional need for information on non-communicable diseases and injuries. There have been some recent efforts to address this gap. The Integrated Disease Surveillance Project is planned to include surveillance of risk factors for non-communicable diseases and information on road traffic accidents 9. The sample registration system is also expected to contribute information on a number of non-communicable disease risk factors 6.

Information on the health infrastructure and human resources is not complete as it focuses primarily on the public health system, while in the most recent National Family Health Survey 65% of the households in India reported seeking health care from the private sector 58. Information is available for the public health system at all levels of health care including primary care and detailed distribution of human resources is also available. However, information available on the private health sector is restricted to the number of hospital beds and estimates of the number of entire health workforce. These estimates of the total number of health workers are inadequate 70 and do not allow a good understanding of the distribution of the health workers within the private sector.

The lowest level for which the majority of the information generated by the essential sources is available is the state level. Although this information is useful, there is are wide variations between districts within the states. For example, the districts of Agra and Rampur in the state of Uttar Pradesh (population 184 million 19) have literacy rates of 63% and 39% respectively 19. In the state of Andhra Pradesh, 69% of the villages in West Godavari district have a medical facility whereas only 46% of the villages have a medical facility in Chittoor district 19. Therefore, information at the lower administrative levels is especially important in a large country like India. Furthermore, with the emphasis on decentralisation of health services in India 57, district level information is needed. The introduction of the Reproductive and Child Health District Level Household Surveys recognises this need, however these surveys only monitor maternal and child health 29. It should be noted that there may be information available at the district level to administration and management officials, which has not been captured in this review as it is not readily available in the public domain.

The availability in the public domain of the information generated by the essential sources varied. The ready availability of health information, including primary data, informs a range of actions to improve population health and the health system and thus there is an increasing momentum for it to be available in the public domain 3. There are some considerations which need to be taken into account when making data available in the public domain, one of which is maintaining confidentiality. The availability of data sets in the public domain from over 150 demographic and health surveys, including those for India, demonstrates that this is feasible 3.

A limitation of our analysis is that it covers information on the essential sources readily available in the public domain on the internet. However, as stated above, the ready availability of information generated by the health information system is crucial for use by all stakeholders to efficiently improve population health. Therefore, the findings in this paper are significant in highlighting what health information is readily available in the public domain in India and what is not, which would help bring attention to the major deficiencies that exist currently. Although we did extensive web searches for the essential sources of health information that were available in the public domain, it is possible that we could have missed some sources that were not readily available. However, it seems unlikely that this would have led to a substantially different message from this paper.

One of the essential sources, health research, was not examined in this paper 10. The contribution of research to health information cannot be overstated as it often fills gaps in the information generated by the other sources and can guide conceptual development of health policy and systems 71.

All essential sources of health information complement each other to together produce a full picture of the health of a population. Thus a coordinated overall approach should be taken when strengthening health information systems, taking into account all essential sources. This will aid the effective use of scarce resources 4. It has been suggested that streamlining of surveys and careful planning of a national survey programme will ensure all priority health topics are covered and costs minimised by avoiding duplication 4. For example, there is overlapping information produced by a variety of sources on reproductive and child health in India. If this were streamlined the resources saved could be utilised to generate the basic health information that is missing for non-communicable diseases and injuries.

The essential sources and the information they produce are just one component of a national health information system. The policy and leadership environment, infrastructure, the information dissemination and utilisation are the other important aspects of a national health information system 72. A comprehensive framework for the assessment of all these components has recently been developed by the WHO Health Metrics Network 73. The findings reported in this paper provide an initial broad understanding of the essential health information readily available in the public domain in India. Further detailed understanding of the major gaps identified would be needed in order to develop strategies to address them for strengthening the health information system of India.

Conclusion

This broad overview of the essential health information readily available in the public domain on the internet for India identified several weaknesses such as the lack of information on non-communicable diseases and injuries, primary data on causes of death, the private health sector and district level information. While some recent initiatives will help enhance the health information system of India, a systematic approach is needed to develop a streamlined system that addresses the critical gaps. Further nuanced assessment of the gaps in the health information system of India is needed in order to inform its further development.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

MZR, RD and LD contributed to the design of this research, analysis and interpretation, and approved the final version of the paper. This research contributed to the Master of International Public Health Honours thesis by MZR at the University of Sydney which was supervised by RD and LD. All authors read and approved the final manuscript.

Monitoring global health: time for new solutions Murray CJ Lopez AD Wibulpolprasert S BMJ 2004 329 1096 1100 526127 15528624 10.1136/bmj.329.7474.1096 Stumbling around in the dark Anonymous Lancet 2005 365 1983 10.1016/S0140-6736(05)66671-8 15954215 Health metrics and evaluation: strengthening the science Murray CJ Frenk J Lancet 2008 371 1191 1199 10.1016/S0140-6736(08)60526-7 18395581 Health statistics now: are we making the right investments? Boerma JT Stansfield SK Lancet 2007 369 779 786 10.1016/S0140-6736(07)60364-X 17336655 National Health Policy 2002: India Government of India New Delhi: Government of India 2002 http://health.nic.in/NRHM/Documents/National_Health_policy_2002.pdf Prospective study of one million deaths in India: rationale, design, and validation results Jha P Gajalakshmi V Gupta PC Kumar R Mony P Dhingra N Peto R PLoS Med 2006 3 e18 1316066 16354108 10.1371/journal.pmed.0030018 Integrated disease surveillance – a key step to improve public health in India Thakur J Indian Journal of Community Medicine 2006 31 215 216 HIV Sentinel Surveillance and HIV Estimation in India 2007 – A Technical Brief National AIDS Control Organisation New Delhi: Ministry of Health and Family Welfare, Government of India 2008 http://www.nacoonline.org/upload/NACO%20PDF/HIV%20Sentinel%20Surveillance%202006_India%20Country%20Report.pdf Integrated Disease Surveillance Project World Health Organisation India Country Office http://www.whoindia.org/EN/Section3/Section108/Section197.htm Health information systems: the foundations of public health AbouZahr C Boerma T Bull World Health Organ 2005 83 578 583 2626318 16184276 Google http://www.google.com.au/ PubMed National Library of Medicine, National Institutes of Health U.S.A http://www.ncbi.nlm.nih.gov/PubMed/ The lack of public health research output from India Dandona L Sivan YS Jyothi MN Bhaskar VS Dandona R BMC Public Health 2004 4 55 539252 15563377 10.1186/1471-2458-4-55 World Health Statistics 2008 World Health Organisation Geneva: WHO 2008 http://www.who.int/whosis/whostat/2008/en/index.html Global burden of disease estimates: Death and DALY estimates for 2002 by cause for WHO member states World Health Organisation http://www.who.int/healthinfo/global_burden_disease/en/index.html Lopez A Mathers C Ezzati M Jamison D Murray CJL (Eds) Global Burden of Disease and Risk Factors Washington: The World Bank & Oxford University Press 2006 Jamison D Breman J Measham A Alleyne G Claeson M Evans D Jha P Mills A Musgrove P (Eds) Disease Control Priorities in Developing Countries Washington: The World Bank & Oxford University Press 2006 Risk factors for the major causes of disease burden in India Omune B Master of International Public Health (Honours) Thesis Sydney; University of Sydney, School of Public Health 2008 Census of India Registrar General and Census Commissioner http://www.censusindia.gov.in/ Mortality Statistics in India 2006: Status of Mortality Statistics Reporting in India Kumar A Raut D Gupta P Singh U New Delhi: Central Bureau of Health Intelligence, Government of India 2007 http://www.cbhidghs.nic.in/writereaddata/mainlinkfile/File976.pdf Report of the Working Group on Registration of Births, Deaths, Marriages National Commission on Population New Delhi: National Commission on Population, Government of India http://populationcommission.nic.in/RPM_Report.htm#cor1 India: death reporting, medical certification of death, and mortality studies World Health Organisation, South East Asia Regional Office http://www.searo.who.int/LinkFiles/2007_Paper_3._India_Death_Reg_25_Feb_07.pdf Vital Statistics: Sample Registration System Registrar General and Census Commissioner – Government of India http://www.censusindia.gov.in/Vital_Statistics/SRS/Sample_Registration_System.aspx Annual HIV Sentinel Surveillance Country Report 2006 National Institute of Health and Family Welfare, National AIDS Control Organisation New Delhi: Government of India 2007 http://www.nacoonline.org/upload/NACO%20PDF/HIV%20Sentinel%20Surveillance%202006_India%20Country%20Report.pdf Accidental Deaths and Suicides in India, 2007 National Crime Records Bureau New Delhi: Ministry of Home Affairs, Government of India 2008 http://ncrb.nic.in/ADSI2007/home.htm National Cancer Registry Programme Indian Council of Medical Research, Government of India http://icmr.nic.in/ncrp/cancer_reg.htm National Polio Surveillance Project National Polio Surveillance Project, Government of India, a World Health Organisation http://www.npspindia.org/ National Vector Borne Disease Control Programme Directorate General of Health Services, Government of India http://www.nvbdcp.gov.in/home.htm District Level Household and Facility Survey (Reproductive and Child Health Project) International Institute for Population Sciences – India http://www.rchiips.org/index.html National Family Health Survey, India International Institute for Population Sciences – India http://www.nfhsindia.org/index.html Household Consumer Expenditure in India, 2005–06; NSS 62nd Round (July 2005–2006) National Sample Survey Organisation New Delhi: Ministry of Statistics and Programme Implementation, Government of India 2008 http://mospi.nic.in/rept%20_%20pubn/ftest.asp?rept_id=523&type=NSSO Nutritional Intake in India, 2004–2005; NSS 61st Round (July 2005–June 2005) National Sample Survey Organisation New Delhi: Ministry of Statistics and Programme Implementation, Government of India 2007 http://mospi.nic.in/rept%20_%20pubn/ftest.asp?rept_id=513&type=NSSO Morbidity, Health Care and the Condition of the Aged; NSS 60th Round (January-June 2004) National Sample Survey Organisation New Delhi: Ministry of Statistics and Programme Implementation, Government of India 2006 http://mospi.nic.in/rept%20_%20pubn/ftest.asp?rept_id=507&type=NSSO World Health Survey 2003, India: Health System Performance Assessment International Institute for Population Sciences, World Health Organisation Mumbai: International Institute for Population Sciences & WHO 2006 http://www.whoindia.org/LinkFiles/WHS-India_Health_System_Performance_Assessment_Book.pdf Condition of Urban Slums – Salient Features; NSS 58th Round (July – December 2002) National Sample Survey Organisation New Delhi: Ministry of Statistics and Programme Implementation, Government of India 2003 http://mospi.nic.in/rept%20_%20pubn/ftest.asp?rept_id=486&type=NSSO Disabled Persons in India; NSS 58th Round (July – December 2002) National Sample Survey Organisation New Delhi: Ministry of Statistics and Programme Implementation, Government of India 2003 http://mospi.nic.in/rept%20_%20pubn/ftest.asp?rept_id=485&type=NSSO Report on Village Facilities; NSS 58th Round (July-December 2002) National Sample Survey Organisation New Delhi: Ministry of Statistics and Programme Implementation, Government of India 2003 http://mospi.nic.in/rept%20_%20pubn/ftest.asp?rept_id=487&type=NSSO Multiple Indicator Survey – 2000 Department of Women and Child Development – Government of India, and United Nations Children's Fund India Summary Report. New Delhi: UNICEF 2001 http://www.childinfo.org/files/india.pdf Drinking Water, Sanitation and Hygiene in India; NSS 54th Round (January – June 1998) National Sample Survey Organisation New Delhi: Ministry of Statistics and Programme Implementation, Government of India 1999 http://mospi.nic.in/rept%20_%20pubn/ftest.asp?rept_id=449&type=NSSO Living Standards Measurement Study: India – Uttar Pradesh and Bihar, 1997/98 World Bank http://go.worldbank.org/9HNA9X3710 Maternal and Child Health Care in India; NSS 52nd Round (July 1995 – June 1996) National Sample Survey Organisation New Delhi: Ministry of Statistics and Programme Implementation, Government of India 1998 http://mospi.nic.in/rept%20_%20pubn/ftest.asp?rept_id=445&type=NSSO Consumption of Tobacco in India; NSS 50th Round (July 1993 – June 1994) National Sample Survey Organisation New Delhi: Ministry of Statistics and Programme Implementation, Government of India 1998 http://mospi.nic.in/rept%20_%20pubn/ftest.asp?rept_id=427&type=NSSO Family Welfare Statistics in India – 2006 Ministry of Health and Family Welfare New Delhi: Ministry of Health and Family Welfare, Government of India 2007 http://mohfw.nic.in/dofw%20website/FWSII%20-%202006/Book.pdf National Programme for Control of Blindness Directorate General of Health Services, Government of India http://mohfw.nic.in/default.htm Tuberculosis Control India Directorate General of Health Services – Government of India http://www.tbcindia.org/home.asp Bulletin on Rural Health Statistics in India Ministry of Health and Family Welfare New Delhi: Government of India 2007 http://mohfw.nic.in/Bulletin%20on%20RHS%20-%20March,%202007%20-%20PDF%20Version%5CTitle%20Page.htm National Health Profile 2007 Central Bureau of Health Intelligence New Delhi: Government of India 2008 http://cbhidghs.nic.in/index2.asp?slid=987&sublinkid=698 Public health mapping and GIS map library World Health Organisation http://gamapserver.who.int/mapLibrary/app/searchResults.aspx India Facility Survey International Institute for Population Sciences Mumbai: International Institute for Population Sciences 2005 http://www.rchiips.org/pdf/rch2/National_Facility_Report_RCH-II.pdf District level health facility GIS maps and indices Jansankhya Sthirata Kosh (National Population Stabilisation Fund) – India http://www.jsk.gov.in/district_health.asp National behavioural surveillance survey 2006 National AIDS Control Organisation – Government of India http://www.nacoonline.org/Quick_Links/Publication/ME_and_Research_Surveillance/Reports_and_Surveys/National_BSS_20062/ National Nutrition Monitoring Bureau: Activities National Institute of Nutrition of India http://nnmbindia.org/activites.html A nationally representative case-control study of smoking and death in India Jha P Jacob B Gajalakshmi V Gupta PC Dhingra N Kumar R Sinha DN Dikshit RP Parida DK Kamadod R N Engl J Med 2008 358 1137 1147 10.1056/NEJMsa0707719 18272886 National Health Accounts World Health Organisation India Country Office http://www.whoindia.org/EN/Section2/Section232_1261.htm Publications Ministry of Health and Family Welfare – Government of India http://mohfw.nic.in/index.htm Five year plans Planning Commission, Government of India http://planningcommission.nic.in/plans/planrel/fiveyr/welcome.html Report of the National Commission on Macroeconomics and Health National Commission on Macroeconomics and Health New Delhi: Ministry of Health and Family Welfare, Government of India 2005 http://mohfw.nic.in/reports/reports/Report_on_NCMH/ReportoftheNationalCommission.pdf National Family Health Survey (NFHS-3), 2005–06: India International Institute for Population Sciences, Macro International Mumbai: International Institute for Population Sciences & Macro International 2007 1 http://www.nfhsindia.org/NFHS-3%20Data/VOL-1/India_volume_I_corrected_17oct08.pdf National Family Health Survey (NFHS-2), 1998–99: India International Institute for Population Sciences, ORC Macro Mumbai: International Institute for Population Sciences and ORC Macro 2000 http://www.nfhsindia.org/india2.html National Family Health Survey (MCH and Family Planning), India 1992–93 International Institute for Population Sciences Bombay: International Institute for Population Sciences 1995 http://www.nfhsindia.org/india1.html Reproductive and Child Health Project Rapid Household Survey (Phase I & II), 1998–1999 International Institute for Population Sciences Mumbai: International Institute for Population Sciences 2001 http://www.rchiips.org/pdf/rch1/National_Report_RCH-1.pdf Nutritional Status of Children and Prevalence of Anaemia Among Children, Adolescent Girls and Pregnant Women – District Level Household Survey on Reproductive and Child Health, India, 2002–2004 International Institute for Population Sciences Mumbai: International Institute of Population Sciences 2006 http://www.rchiips.org/pdf/rch2/National_Nutrition_Report_RCH-II.pdf District Level Household Survey (DLHS-2), 2002–04: India International Institute for Population Sciences Mumbai: International Institute for Population Sciences 2006 http://www.rchiips.org/PRCH-2.html Slums in India; NSS 49th Round, January – June 1993 National Sample Survey Organisation New Delhi: Ministry of Statistics and Programme Implementation 1997 http://mospi.nic.in/rept%20_%20pubn/ftest.asp?rept_id=417&type=NSSO Publications: Treatment care and support National AIDS Control Organisation – Government of India http://www.nacoonline.org/Quick_Links/Publication/Treatment_Care__Support/ Sample Registration System Maternal Mortality in India, 1997–2003: Trends, Causes and Risk Factors Registrar General New Delhi: Registrar General and Centre for Global Health Research University of Toronto 2006 http://www.health.mp.gov.in/Maternal_Mortality_in_India_1997-2003.pdf Drop of HIV estimate for India to less than half Dandona L Dandona R Lancet 2007 370 1811 1813 10.1016/S0140-6736(07)61756-5 18061043 Responding to the threat of chronic diseases in India Reddy KS Shah B Varghese C Ramadoss A Lancet 2005 366 1744 1749 10.1016/S0140-6736(05)67343-6 16291069 Chronic diseases now a leading cause of death in rural India – mortality data from the Andhra Pradesh Rural Health Initiative Joshi R Cardona M Iyengar S Sukumar A Raju CR Raju KR Raju K Reddy KS Lopez A Neal B Int J Epidemiol 2006 35 1522 1529 10.1093/ije/dyl168 16997852 Not enough here... Too many there... Health Workforce in India World Health Organisation New Delhi: WHO India 2007 http://www.whoindia.org/LinkFiles/Human_Resources_Health_Workforce_in_India_-_Apr07.pdf Conceptualizing health policy Dandona L Natl Med J India 2002 15 226 231 12296481 Assessing the National Health Information System – An Assessment Tool. Version 4.00 Health Metrics Network, World Health Organisation Geneva: WHO 2008 http://www.who.int/healthmetrics/tools/Version_4.00_Assessment_Tool.pdf Framework and Standards for Country Health Information Systems Health Metrics Network, World Health Organization Geneva: WHO 2008 http://www.who.int/healthmetrics/documents/hmn_framework200803.pdf

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