Sweden India

Development Cooperation in

Health, 1960-2013

F R O N T P A G E P I C T U R E : M I D W I V E S S I G N U P F O R T R A I N I N G ( P H O T O : C A R L M Y R É N )

Authored by: Yasmin Zaveri Roy

Senior National Advisor

Embassy of Sweden

November 2013

General description

Sweden’s development aid to India in the health sector dates back to 1960s when

assistance was provided mainly through UN agencies. From the 70s Sweden started

bilateral support to Government programs and in the 90s included direct support to

NGOs. Sweden’s international work in the area of sexual and reproductive health and

rights (SRHR) was the results of UN international conferences in the mid-90s as well

as the Government Bill Shared Responsibility – Sweden’s Policy for Global

Development. When Sweden terminated bilateral aid in 1998 post the nuclear trial by

India, most of the Sida projects were supported through NGOs and multilateral

agencies that focused on SRHR. In 2009, a Memorandum of Understanding on

Healthcare and Public Health was signed between the Government of Sweden and

India and Sida, based on its strategy for partner driven cooperation, supported many

collaborations.

India in the 1960s, photo by Alva Myrdal, Sweden’s first ambassador to India Naresh Dayal, Secretary and, Dr. Anbumani Ramadoss, Minister of Health and

Family Welfare Ministry and Lars-Olov Lindgren, Swedish Ambassador to India

signs the MoU on health in 2009

Health sector

Sweden assisted India’s family planning program from the 1960s after it received

request for aid to the India Population Project (IPP). Initially only limited technical

assistance was provided and from the 70s the aid increased dramatically and

concentrated on large projects that ensured strengthening of the health facilities

through the provision and testing of various alternative approaches in more than

1500 healthcare facilities. The project entailed a very large expansion of the Indian

health infrastructure. The project cost, over a six-year period, was estimated at 152,6

million SEK (31.7 million USD) where IDA financed one third of the project, India

another third and the balance by Sweden. Due to coercive sterilization campaigns and

ethical reasons, Sida decided, in 1979, to withdraw its support to IPP.

Alva Myrdal, Sweden’s first ambassador to India on the Indian countryside in the late 1950s. Photo: Gunnar Myrdal.

From 1978 Sweden supported three National programs on Malaria, Leprosy and TB

control. The support to the National Malaria Eradication Programme (NMEP) lasted

till 1990 (12 years). The support to National Leprosy Eradication Programme (NLEP),

channeled through WHO, was to implement the Multi-drug Treatment Therapy (MDT)

in 18 districts to arrest further transmission of the disease and reduce deformities in

patients. Up to 1993, about one million people were treated that resulted in a sharp

decline of leprosy cases. In due course the NLEP introduced MDT in all endemic

districts of the country. The support to National Tuberculosis Control Programme

(NTP) was mainly for installation of x-ray machines and equipment for TB Centres in

200 districts, as well as for procurement of anti-TB drugs and for providing health

education on short course Chemotherapy.

In 1992 Sweden channeled it support through UNICEF with an allocation of SEK 300

million for the Universal Immunization Program which was later expanded to the

Child Survival and Safe Motherhood Program (CSSM). The aim was to improve the

health status of infants and reduce children and maternal mortality and morbidity.

Reviews and evaluations indicated that the program had succeeded better in

impacting child survival than maternal survival. The percentage of children fully

immunized and those receiving vitamin A prophylactics had increased. A Sida

evaluation of 1995 strongly recommended for a move forward in reproductive health

that endorsed the inclusion of emergency obstetrics and neonatal care as well as

capacity building. The project had been relevant in pushing issues related to maternal

mortality and safe abortion higher up on the national health agenda that lead the

Government to initiate a National program on Reproductive and Child Health.

The Government of India’s Integrated Child Development Scheme (ICDS) offered a

comprehensive package related to education, nutrition, and health to children

between 2–6 years, adolescent girls and supplementary food for children, pregnant

and lactating women. The focus of Swedish support (SEK 167 MSEK from 1989-1999

in four districts of Tamil Nadu) was on quality improvement and innovative activities.

The support covered around 4,500 anganwadi centres catering to 100,000 children (6

months-2 years) for feeding, 154,000 (3-6 years) for pre-schooling, 70,000 pregnant

and nursing mothers for health training and nutrious supply, and 17,000 adolescent

girls for vocational skill training.

An external evaluation1 of the Sida support revealed the project had reached a high

proportion of eligible beneficiaries’ and achieved positive effects regarding young

child nutrition with significant reduction in sever e malnutrition and increased

attendance in primary schools, particularly by girls. Some of the innovations such as

the preschool teaching methodology and the adolescent girls’ scheme had been

incorporated in the national ICDS program, by the World Bank and other state

governments.

1 ‘Reaching out to children in poverty, The Integrated Child Development Services in Tamilnadu, India’ – Sida

Evaluation 00/2

Children in Rajasthan in the 1960s, photo: Alva Myrdal

From 2005-2010, a network of 10 NGOs received Sida supported that covered 180

villages in seven districts in Rajasthan. The project, Integrating Social Support for

Reproductive and Child Health and Rights received technical assistance from

International Maternal and Child Health (IMCH), Uppsala University. An external

evaluation stated that the project, through community mobilization and sensitizing

the local self-government institutions, created demand for maternal and child health

services. On the other hand it also facilitated the health delivery service system that

responded adequately to the community needs. The end line survey noted significant

changes e.g. increased institutional deliveries from 41% to 89%, full immunization

coverage among children, enabled girls to discuss sensitive issues like RTI/STI,

puberty, HIV/AIDS etc. attendance of girls in middle and secondary schools increased

followed by delay in marriage age.

Midwifery training 2013, in the Midwifery Strengthening Project (see below). Photo: Carl Myrén

The Midwifery Strengthening Project, implemented since 2005, was collaboration

between Swedish and Indian institutions2 that aimed to contribute to India’s efforts

to reduce maternal and child mortality and morbidity. The main objective was to

make available trained and skilled midwifery teachers and service providers, develop

district models of midwifery-based maternal and newborn care, enhance

management capacity and advocate for midwifery teaching and profession.

The project succeeded in achieving a number of results3 viz. increased visibility of

midwifery at policy level; created evidence at district level for strengthening

midwifery skills to reduce maternal and infant mortality; skilled nurse-midwives were

available in labour rooms; five states improved labour rooms; and developed

modules, curriculum and teachers’ guide for midwifery teaching at four Centers of

Advanced Midwifery Training established within the government nursing colleges in

three states.

The project Develop a Multi-sectoral Approach Model for Sustainable Health and

Development implemented from 2005-09 was inclusive of health, education, social

welfare, agriculture, biotechnology and information & communication technology to

2 The collaborative institutes consisted of Academy for Nursing Studies, Society of Midwives in India,

Trained Nurses’ Association of India, White Ribbon Alliance for Safe Motherhood, India, Indian Institute

of Management, Ahmedabad and on the Swedish side, Karolinska Institute and the Swedish Association

of Midwives. 3 ‘Strengthening Midwifery and Emergency Obstetric Care (EmOC) Services in India, Sida Review 2010:09

enhance the nutritional status and women's health and empowerment. The Pravara

Institute of Medical Sciences in Loni, Maharashtra collaborated with Linköping

University, Skövde and the County Council of Östergotland, Sweden. The project

trained health functionaries to upgrade their skills based on the Swedish pattern of

primary health care. Six rural health centres were upgraded to serve 45,000 general

patients, 4,000+ ante natal mothers and 16,000+ children and adolescents. Seven e-

health centres were established in the project villages and five mobile clinics provided

outreach services.

The project Increase Access to Comprehensive Abortion Care in the Public Health

System was implemented by a consortium of organizations4 in India and Sweden from

2006-2009. The goal of the project was to increase access to legal, safe, and

comprehensive abortion services, including post abortion family planning services, in

the public health system with a focus on the rural poor. The project piloted a model

for comprehensive abortion care (CAC) service delivery in two selected districts in

Maharashtra and Rajasthan.

The second phase of the project (2010-13) was implemented by Ipas and

IMCH/Uppsala University with an aim to create aim to create a sustainable CAC model

by strengthening training capacities and facilitating safe abortion service delivery in

the public sector health system in the states of Maharashtra, Madhya Pradesh and

Assam.

4 Ipas, Population Council, Center for Enquiry into Health and Allied Themes, Federation of Obstetric and

Gynecological Societies of India, Family Planning Association of India, Society of Midwives, India, and the

International Unit of Maternal Child Health, Uppsala University.

Wall painiting indicating three key abortion messages – safe, easy and legal. Photo: Consortium for Safe Abortions

Another collaboration between Karolinska Institute and Action Research and Training

for Health (ARTH) aimed to contribute to reduction of maternal mortality in Rajasthan

by introducing a simplified regime for Medical Abortion services through the public

health system.

Marie Klingberg Allvin, Karolinska Institute with Rajasthan women. Phot: ARTH - Karolinska

The MAMTA-RFSU institutional twinning project on Adolescent/Young People’s

Sexual and Reproductive Health and Rights, from 1999-2009 with a total of SEK 40

million, was implemented in three phases - evolving strategies, strengthening services

and consolidating. RFSU provided technical inputs on sensitive issues related to

gender and sexuality education, sexual diversities (LGBT), clinical services for men

having sex with men (MSM) and media advocacy. During the project period, three

external evaluations were undertaken that confirmed the good results achieved,.

MAMTA contributed to Government of India’s planning of national strategies on

adolescent health

Campaign against early child marriage 2007. Photo: MAMTA

MAMTA developed partnership with Lund University (2008-13) to conduct National

Training Program on Youth Friendly Health Services in India (see picture opposite

page), and from 2010 the National Institute of Health and Family Welfare entered the

collaboration. The aim was to strengthen capacity of public health facilities by training

key personnel to deliver youth friendly health services for 10-24 years age group and

support the implementation of the Government of India’s Adolescent Reproductive

and Sexual Health (ARSH) program.

National Training Programme on Youth Friendly Health Services 2011. Photo: MAMTA

With an aim to integrate lifestyle related concerns in youth health and development,

Lund University and MAMTA had developed a partnership project with the State

Health Mission of the State of Himachal Pradesh. The project Develop District Design

for Mainstreaming Adolescent Reproductive and Sexual Health and Non-

Communicable Conditions in Youth Friendly Health Services was implemented 2012-

13 with SEK 3.6 million.

Prevention and Control of Antibiotic Resistance was a collaborative project of mutual

interests between the Swedish Institute for Communicable Disease Control (SMI) and

the Indian National Centre for Disease Control (NCDC). The project aimed to improve

antibiotic use through increased surveillance, monitoring and guidelines for rational

use and improved measures of hygiene awareness. Exchange visits by both agencies

resulted in concretizing collaborative areas and methods. Sida contribution of SEK

3 238 580 was provided to SMI only.

The India-Swedish collaboration in the field of alcohol between the Swedish National

Institute of Public Health (SNIPH) and the Public Health Foundation of India (PHFI)

with Sida contribution of SEK 1 440 627 aimed to address and recommend a

comprehensive alcohol policy framework for the Indian Government. The

intervention was a process oriented approach that involved policy review and

consultations. The partners had collated and analyzed excise policies to look at taxes

and manufacturing, retail/wholesale policy regimes and constituted research core

group from India and Sweden.

Meeting in the India-Swedish collaboration in the field of alcohol project, see text above. Photo: SNIPH

The project Protection of working people from health and productivity risks due to

workplace heat exposure and the links to climate change was collaboration between

Umeå University and Sri Ramachandra University. The collaboration aimed to

contribute towards a better understanding of heat prevention approaches and

technologies needed to reduce heat exposures and facilitate locally adapted

preventive interventions.

HIV/AIDS

Sida provided technical and financial assistance to Mumbai Municipal Corporation,

Maharashtra through WHO GPA (1992-95). The project aimed towards reducing

transmission of STDs and HIV among sex workers and their clients of Kamathipura and

Khetwadi districts of Greater Mumbai Municipal area. This project was the first

intervention for HIV prevention among sex workers in India funded by an external

agency in collaboration with the National AIDS Prevention Control Program,

Government of India. Follow up to an Evaluation and Reprogramming Mission in

1995, Sida extended direct support to the project from 1997 onwards, renamed as

AIDS STD Health Action (ASHA) project. An external evaluation5 revealed that the

project had reached 5000 women in prostitution periodically and about 20,000 male

clients and addressed issues related to stigma and discrimination. As a result, a

decreasing trend in STD cases was witnessed in the project area. Through the

outreach and services, the project had influenced and forged collaborations with

community based organizations.

In response to the high prevalence of drug use and HIV/AIDS in the northeastern

states, 5 NGOs (three NGOs in Manipur and one in Nagaland and Assam) were

5 AIDS, STD Health Action Project in Mumbai, India – An Evaluation of ASHA’; Sida Evaluation – 00/28

provided technical and financial assistance by Sida from 1993-2000. The projects

aimed to undertake outreach intervention to reduce the risk of HIV transmission

among injecting drug users (IDUs) and their sexual partners. The harm reduction

approach that prevents further spread of HIV/AIDS, was the first intervention in the

country that marked a strategic shift from the abstinence model. The project was able

to motivate users to adopt safer practices through needle exchange and provided

friendly spaces such as drop-in-centres for users to gather without fear, and the

community stigma was thus reduced.

From 2005-2010 Sida supported the Joint Program on HIV and AIDS Prevention and

Care in the North East through UNAIDS to,

develop regional capacity for an integrated response to STI/HIV and AIDS care

and support services,

improve quality to develop state specific innovative interventions, and

establish efficient management and co-ordination.

Positive networks were strengthened through the establishment of Northeast

Regional Network of Positive people. The network established 50 Mother’s Groups in

five districts of Assam and identified 22 positive speakers and 50 women leaders. The

women leaders were trained to manage programs at the district level.

The project Legal intervention in HIV/AIDS and related contexts in India was

supported during 2003-2008 with SEK 16.5 million. Implemented by Lawyers

Collective HIV/AIDS Unit the project provided legal advice, advocacy, and build

capacity of legal and paralegal personnel and filed litigation for people living with

HIV/AIDS and those affected by the epidemic. One of the most evident achievements

had been to spearhead the development of National HIV/AIDS Bill which was a

request for technical assistance by the Government of India. When the Indian Patent

Ordinance got passed in 2004, the campaign for affordable medicines and treatment

increased and resulted in amendments/revisions in the Patents Act in March 2005.

Conference in Stockholm, Sweden, 22 May 2013: Prince Daniel of Sweden, Shri. Ghulam Nabi Azad, Minister of Health

and Family Welfare India, Göran Hägglund Minister for Health and Social Affairs, Sweden.

The journey continues…

The Swedish development cooperation to India came to an end in December 2013. It

had been a long and interesting journey of India-Sweden health cooperation. Today

the two countries share a new form of cooperation that is based on mutual benefit

and knowledge exchange. The Memorandum of Understanding is very active and

proving to be an excellent platform to build partnerships and continue to promote

India-Sweden the health cooperation. Since it’s signing, six Joint Working Group

meetings have been held and the two sides have identified prioritized areas of

cooperation. A number of high level interactions and delegations in both directions

have taken place and collaborations established between public agencies and

businesses.

Inaugural session of the Indo-Swedish Health Week 2010, where ministers from both Sweden and India participated.