Our work in India began almost two decades ago with an HIV prevention initiative called Avahan. We have since expanded our efforts in India to address a wide range health and development challenges, including maternal and newborn health, immunization, family planning, nutrition, and communicable diseases.
All of our health-related efforts and investments in India support the priorities of the Indian government. In partnering with them, we offer our expertise and global experience and an ecosystem of partnerships in service of developing relevant, scalable, and high-impact solutions.
Maternal and newborn health
We believe that improving maternal and newborn health is the key to ensuring that India’s poorest families and communities can benefit from the country’s economic growth.
India has made significant progress in improving maternal and newborn health over the past couple of decades. The maternal mortality rate (MMR) in India declined by 79.6 percent from 1990 to 2018, from 556 per 100,000 live births to 113. The country is now focused on strengthening the quality of care, and working towards reducing the number of maternal deaths to continue on the path towards achieving the MMR goal of 70, under the United Nations Sustainable Development Goals (SDGs).
Given the significant progress India has made in expanding health care resources; training physicians, nurses, and other healthcare providers, developing production capabilities for a wide variety of drugs; and building a globally recognized technology sector, the country is well situated to accelerate improvements in maternal and newborn health by scaling up proven solutions. These include prevention and treatment of newborn and postpartum conditions, prenatal care, hospital-based delivery, immediate and exclusive breastfeeding, and improved routine immunization.
To augment, support and amplify the efforts of state governments of UP and Bihar in rapidly reducing maternal and child mortality, we have built strong partnerships with both state governments. The aim of these partnerships is two fold: to rapidly reduce maternal and infant mortality rates and to develop a detailed blueprint for increasing the efficiency and effectiveness of their state health systems.
We also collaborate with India's Ministry of Health and Family Welfare (MoHFW) in a range of areas, including the quality of intrapartum care, with a focus on respectful maternity care, strengthening skills for emergency obstetric and newborn care (EmONC) and basic emergency obstetrics and newborn care (BEmONC), midwifery-led care, the rollout of the Safe Motherhood Assurance (SUMAN) initiative, quality antenatal care (ANC) in facilities, outreach for improved institutional delivery, and integration of maternal and newborn care at health and wellness centers.
Data and evidence inform our work toward all of these objectives. We also cultivate champions to advance work in these areas, and we assist the state governments of Uttar Pradesh and Bihar with priority national and state initiatives that aim to reduce maternal and newborn mortality--improving availability of comprehensive emergency obstetric and newborn care (CEmONC) at first referral units, strengthening BEmONC through mentoring and capacity-building initiatives, improving quality of intrapartum initiatives such as LaQshya, and strengthening ANC and newborn care.
We also work at the national and state levels to develop operational guidelines and pathways for community engagement, ensure accountability for entitlement payments, and increase demand for and access to quality services through the public health system.
Every year in India, half a million children die due to vaccine-preventable diseases. Nearly 9 million more remain at risk because they are either unimmunized or partially immunized against vaccine-preventable diseases. Vaccines are among the most cost-effective health interventions ever developed, and they can save many of these children’s lives.
We provide support to ministries at the central and state levels to improve coverage of routine immunization, improve equity in access to vaccines, and strengthen the health system through innovative design, development, and data-system provision. We also supplement the MoHFW’s immunization efforts during outbreaks when needed.
In addition, we support India’s Universal Immunization Programme through the entire discovery-development-delivery cycle—from pilot projects to rollout to scale-up—to expand vaccine coverage and ensure equity so even the last child at the last mile has timely access to vaccines.
We work closely with a range of partner organizations in new vaccine development and introduction, expansion of routine immunization coverage, cold chain management, safety surveillance, and research and evidence generation. Through our partnerships with the states of Bihar and Uttar Pradesh, we also work to improve routine immunization as part of our maternal and child health initiatives.
We contribute to the growth of the vaccine industry in India by augmenting the manufacturing capacity of domestic producers, supporting clinical trials, and enabling global technology transfer. This work happens in close collaboration with the Ministry of Science and Technology’s Department of Biotechnology, the Indian Council for Medical Research, local clinical research organizations, international agencies, and the private sector.
Vaccines developed and produced in India have led to the control or elimination of widespread diseases such as rotavirus (Rotavac and Rotasiil) and have included the first typhoid vaccine that is safe for infants as well as vaccines for controlling epidemics (such as MenAfriVac for meningitis, developed by the Serum Institute of India and used in Africa; and Shanchol for cholera, developed by Shantha Biotechnics and used in Haiti). India is now a global supplier of about 70 percent of the vaccines used in low- and middle-income countries, fulfilling the country’s “made in India” dream.
The Ministry of Health and Family Welfare (MoHFW) has been working closely with the state governments, to lead a massive national effort to vaccinate priority populations against COVID-19. With the goal of achieving equitable access to the vaccine in every part of the world, the Foundation, through Gavi’s COVAX Advance Market Commitment, provided funding support to the Serum Institute of India for manufacturing a low-cost vaccine for India as well as other Low and Middle Income Countries. The COVAX program aims to vaccinate roughly 20 per cent of the population in the 92 Advance Market Commitment (AMC) countries. In line with India’s stated commitment to use the country’s vaccine production and delivery capacity to help all of humanity fight the COVID-19 pandemic, the Government of India, under the Vaccine Maitri initiative has provided vaccine assistance to several countries.
Access to information about contraceptive products and services is an integral part of a woman's ability to exercise bodily autonomy. Family planning has also proven to be one of the most effective and affordable ways to improve the health of women and girls. Enabling women to make informed decisions about whether and when to have children reduces maternal and newborn deaths. It also increases educational and economic opportunities for women and leads to healthier families and communities.
In 2016, the MoHFW initiated Mission Parivar Vikas (MPV), a national effort to expand family planning services in 146 districts across seven states: Bihar, Uttar Pradesh, Assam, Chhattisgarh, Madhya Pradesh, Rajasthan, and Jharkhand. MPV has shown that investing in family planning not only reduces death and disability among mothers and children and protects against unintended pregnancies, HIV, and sexually transmitted infections, but it also empowers women and girls by helping them devote more time to their career aspirations and increases family investments in the education and care of children.
Our efforts complement and supplement India’s National Family Planning Programme and aim to strengthen the public health system so it can deliver the full range of high-quality family planning services, especially in Bihar and Uttar Pradesh. We provide strategic support in those states and at the national level to help assess family planning needs, identify barriers to access and funding gaps, and provide technical assistance to improve the quality and availability of family planning services, while constantly working towards expanding contraceptives choices for girls and women and their families. We also support performance monitoring and better data collection, and we help improve coordination among governments and partners.
Our work includes engaging directly with private providers to offer access to quality family planning tools and services and expand the contraceptive choices available to young, low-parity couples. We work through our partners and with community organizations and women’s self-help groups to disseminate accurate information about family planning options, thereby building both the supply and demand sides of family planning.
Many Indian mothers begin pregnancy poorly nourished, which puts them at high risk of having an underweight newborn that is at increased risk of early death, stunting, and poor health throughout life. But proven, cost-effective interventions are available to interrupt this vicious cycle, and India’s political commitment to improving maternal nutrition has never been stronger.
Although India accounts for one of the world’s highest child mortality rates, under-5 mortality fell by an average of 4.5 percent per year from 1990 to 2019, from 3.4 million deaths in 1990 to 824,000 in 2019.
Since 2004, the country has established 1.4 million Anganwadi centers, which provide informal preschool education, basic health care, and nutrition services at the community level. These measures, together with reductions in poverty, improved water and sanitation, and other development gains, led to a decrease in childhood stunting from 48 percent in 2005–2006 to 38.4 percent in 2015–2016. The government’s national nutrition plan, the POSHAN Abhiyaan, aims to cut the stunting rate to 25 percent by 2022.
We support these government nutrition initiatives by demonstrating what is possible when existing interventions are delivered more broadly and by supporting the development and use of new solutions. We focus in particular on maternal, infant, and young child nutrition (MIYCN) interventions—including early and exclusive breastfeeding, complementary feeding, micronutrient supplementation, food fortification, and treatment of children with severe malnutrition—at the state level in Bihar and Uttar Pradesh. We also focus on providing technical assistance for MIYCN interventions at the national level.
India accounts for one in every four cases of tuberculosis (TB) worldwide. TB claims 1,000 lives in India each day and disproportionately affects poorer populations. Beyond the medical consequences, TB can lead to significant financial and social repercussions for patients and their families.
In 2018, Prime Minister Narendra Modi announced India’s goal of eliminating TB by 2025, five years ahead of the global target of 2030. The National TB Elimination Program has been working relentlessly toward this goal by providing universal access to TB care. This includes free TB drugs, easy access to quality services, and direct benefit transfers for nutrition support.
An estimated 70 percent of Indians rely on private providers for outpatient care, so averting TB transmission requires improving private provider engagement in managing the disease—and improving the quality of private health care generally, which is crucial to combating TB.
From 2013 to 2019, the foundation’s Tuberculosis team, in partnership with Indian districts, states, and the National TB Elimination Program, helped develop, demonstrate, and implement effective, scalable models of private provider engagement in TB care. The team has also supported the development of information systems and the deployment of new medication adherence tools, such as 99DOTS and Medication Event Reminder Monitoring Systems (MERMs).
Through pilot projects in the cities of Mumbai, Patna, and Mehsana, we and our partners—including the MoHFW’s Central Tuberculosis Division and WHO India—were able to demonstrate an effective approach for engaging private providers in TB care. This effort provided valuable lessons in disease surveillance, monitoring of coverage and operations, technology integration for more efficient care, and outreach to private providers about the benefits of engaging with the government TB program.
More recently, we have been working with the Central Tuberculosis Division to scale up private provider engagement and deploy new tools and approaches to increase TB notification and strengthen treatment completion. These include direct benefit transfers to patients, treatment coordinators and supporters, and patient-centric digital adherence tools. This work is taking place at the national level and in the states of Bihar, Uttar Pradesh, Rajasthan, Maharashtra, Gujarat, and Madhya Pradesh.
Neglected tropical diseases
In India, as in many lower-income countries, millions of people suffer from infectious diseases that attract little donor funding, largely because those diseases are rare in wealthier countries. These neglected tropical diseases, or NTDs, result in consequences ranging from anemia and blindness to stunting, cognitive impairment, pregnancy complications, and death. In India, we focus in particular on two NTDs, lymphatic filariasis (LF) and visceral leishmaniasis (VL).
India has at least 40 percent of the global burden of LF, a painful and debilitating disease. An estimated 670 million Indians live in LF-endemic areas—272 districts across 16 states and five union territories, and are therefore at risk of contracting the disease.
To combat LF, India has been dispensing two drugs, Diethylcarbamazine and Albendazole, in affected areas since 2007. In 2015, a project we supported discovered that the addition of a third drug, Ivermectin, almost entirely eliminated the LF parasite from a patient’s blood. The MoHFW pilot-tested the new triple-drug regimen, called IDA, in five states, and its safety and efficacy were established.
In 2016, we supported an additional safety and efficacy trial of IDA in Yadgir, Karnataka, in association with the Indian Council of Medical Research’s Vector Control Research Center. In 2018, following the positive trial results, the Indian government rolled out IDA in Arwal, Bihar; Simdega, Jharkhand; Nagpur, Maharashtra; and Varanasi, Uttar Pradesh as part of the national LF elimination program.
We currently support implementation of the LF elimination program in all LF-endemic states in India, including Bihar, Uttar Pradesh, Chhattisgarh, Jharkhand, Maharashtra, Madhya Pradesh, West Bengal, and Odisha.
In addition to our nearly two decades of funding for LF research, we provide technical assistance to the government’s LF surveillance, treatment, and prevention efforts.
We work closely with the Indian government and the states of Bihar, Uttar Pradesh, and Jharkhand to control the transmission of VL through biannual indoor residual spraying in endemic areas.
Although VL cases in India decreased from 45,000 in 2007 to less than 3,200 in 2019, the country felt short of its goal of VL elimination by 2019 by just 37 blocks. All of these were in the worst-affected districts of Bihar and Jharkhand, despite a consistent decline in overall incidence. The challenge with a disease like VL is the lack of epidemiological “stickiness,” which means that even when the case numbers go down, an imminent risk of epidemic remains—as case numbers go down, so does herd immunity, which can lead to a resurgence of the disease.
More effective insecticides, better spray pumps, and an effective single-dose medication have reached unprecedented levels of coverage, and a number of support systems, notably robust information and tracking systems, are well established. Independently assessed indoor insecticide coverage has reached 80 to 90 percent of targeted households in the worst-affected districts of Bihar and Jharkhand, from estimated lows of around 30 to 40 percent in 2013–2014. Effective spraying is possible now that synthetic pyrethroids and Hudson pumps have replaced DDT and stirrup pumps.
The target year for VL elimination in India is now 2023. Reaching this goal will require sustained investments in delivering low-cost, ongoing (and perhaps even perpetual) interventions for vector control, disease surveillance, diagnosis, and treatment.
In 2002, experts projected that the HIV epidemic in India could grow to staggering proportions, with more cases than in any other country. Given this dire prospect, we made our first investment in India that year: a grant for an HIV prevention program called Avahan, which was launched in partnership with community-based organizations and non-governmental organizations.
Avahan focused on sex workers and other high-risk populations in six states with the highest HIV infection rates. Since its launch, and due to the efforts of the government and various partners, HIV infection rates in India have decreased dramatically. Between 2010 to 2017, the government gradually took ownership of the program, as planned, under a memorandum of understanding between the foundation and India’s National AIDS Control Organization.
Avahan is one of the great success stories in national-level response to HIV/AIDS. In October 2013, a study published in The Lancet (Pickles et al.) detailed Avahan’s impact on the HIV epidemic in India, suggesting that about 600,000 infections may have been averted as a result of the program’s interventions over a 10-year period.
India’s certification as a polio-free country in March 2014 marked a major milestone on the path to global polio eradication. India was long considered the most difficult place to end polio due to its population density, high rates of migration, poor sanitation, high birth rates, and low rates of routine immunization. Huge numbers of unvaccinated children lived in crowded slums and remote rural areas. As recently as 2009, India was home to 50 percent of the world’s polio cases.
But the Indian government—with support from international partners, including the World Health Organization, UNICEF, USAID, Rotary International, and our foundation—rolled out a carefully coordinated polio campaign that sent out millions of volunteer vaccination teams to reach 170 million children each year with repeated doses of oral polio vaccine.
In 2011, the last case of polio was reported in India. In 2014, the country was officially declared polio-free, putting the world on course to completely wipe out polio.
Rotavirus and routine childhood immunizations
Rotavirus, the most common cause of diarrhea in children under age 5, is estimated to kill more than 200,000 children each year, including about 78,000 in India. But while India suffers the highest burden of rotavirus in the world, other nations have long had access to a safe, affordable vaccine against this deadly disease.
In India, we have contributed significantly to vaccine development, including support for clinical trials, global technology transfer, and expanded capacity for domestic manufacturing. Beginning with a highly successful children’s vaccine program in Andhra Pradesh in 2001, we have provided funding, technical support, and other assistance to ministries at the national and state levels, including the MoHFW, to improve coverage of routine childhood immunizations. The number of Indian children receiving basic immunizations jumped from 44 percent in 2005–2006 to 62 percent in 2015–2016.
These contributions have also aided India in introducing 10 new vaccines over the past two decades, including the rotavirus vaccine ROTAVAC. Launched in 2016, ROTAVAC was developed as a social innovation project under a public-private partnership. The multicenter Phase III efficacy and safety clinical trial for ROTAVAC was India’s first such vaccine trial. ROTAVAC is now being administered by the government in 25 states, in accordance with India’s goal of providing rotavirus vaccine nationwide by 2022. The vaccine has received WHO prequalification and will soon be available to children in Africa and the rest of Asia.
A meningitis vaccine for Africa
Indian pharmaceutical companies are making important contributions to global health by developing vaccines and drugs that prevent and treat infectious diseases. Among them is MenAfriVac, a high-quality, low-cost meningitis vaccine developed especially for Africa that we worked with Indian and international partners to develop and distribute.
Meningitis affects 25 countries in sub-Saharan Africa. In the 1990s, a major epidemic led to 250,000 cases and 25,000 deaths. The most recent large-scale epidemic occurred in 2009, causing 88,000 suspected cases and more than 5,000 deaths in 14 countries. Since MenAfriVac was launched in Africa, it has reached more than 200 million people and no meningitis epidemics have occurred.