In her exclusive interview with BioSpectrum's Raj Gunashekar, she shares some of her top priorities that she believes needs to be immediately tackled in the current Indian public health scenario.

According to her, India is facing a double burden of both communicable and noncommunicable diseases (NCDs) because of globalization and changing lifestyles.

She observes that prevention and control of neglected tropical diseases (NTDs) contributes significantly towards Millennium Development Goals (MDGs) thereby improving social and economic well-being.

Dr Poonam is also of the opinion that in order to accelerate the health outcomes in India, it must bolster its planning, regulation and monitoring of health services for better oversight and stewardship.

She also adds that WHO uses its regional and global network to enhance bi-lateral collaborations when requested by countries.

Excerpts:

Q: As a newly appointed regional director for WHO South-East Asia Region, what are your top priorities for India in the area of public health?
Dr Poonam Khetrapal Singh: The public health arena is changing fast. My vision is to propose an ambitious '1 by 4' plan.

The '1' refers to a more responsive WHO in the region and the '4' refers to the four strategic areas which are namely addressing the persisting and emerging epidemiological and demographic challenges, promoting universal health coverage and robust health systems, strengthening emergency risk management for sustainable development, and articulating a strong regional voice in the global health agenda.

Q: What are the current healthcare system challenges in India?
There have been very substantial achievements and accomplishments in improving healthcare and health outcomes in India. Investments in health have yielded impressive achievements including in the advancement towards the Millennium Development Goals in reducing child infant mortality and in improving maternal health.

India's challenges include the 'unfinished agenda' of health system modernization including high out-of-pocket expenditures, insufficiency and uneven distribution of staff, service provision (mainly in private hands) and its quality, and a better alignment of regulation with present day needs.

India also has a high burden of disease. While communicable diseases are being addressed along with their determinants such as sanitation, water, and education, we are seeing a transformation of Indian society.

Globalization, urbanization, and changing lifestyles - all these have impacted the health profile of the country. Noncommunicable diseases, the so-called diseases of richer countries and richer societies - have emerged in a big way. India is facing a double burden of diseases, both communicable and noncommunicable diseases.

Noncommunicable conditions such as diabetes and cardiovascular diseases already account for more than half the deaths in India and they are expected to increase in the years to come.

These are big challenges and they cannot be addressed by the health sector alone. It requires the engagement of several other sectors.

In addition, synergies have to be achieved between health promotion, disease prevention, diagnostics, treatment, rehabilitation and supportive interventions to strengthen the Indian health system.

Q: What are your strategies in tackling neglected tropical diseases (NTDs)?
The vision of controlling, eliminating and eradicating neglected tropical diseases has gathered significant momentum over recent years. WHO recommends five strategies for the prevention, control, elimination and eradication of NTDs.

These include preventive chemotherapy, intensified disease management, vector and intermediate host control, veterinary public health at the human-animal interface and provision of safe water, sanitation and hygiene.

The WHO South-East Asia region bears the second highest burden of NTDs
- though not all NTDs are prevalent in the region. Priority NTDs in this region include dengue fever, rabies, leprosy, lymphatic filariasis, Kala-azar, trachoma and yaws. Prevention and control of NTDs contributes significantly to achievement of the MDGs and improve social and economic well-being.

Substantial success has been achieved in eliminating some of NTDs of public health importance in the South-East Asia region in recent past.

WHO will continue to support countries with technical assistance, provision of free drugs, strengthening of health system and augmenting national capacity to combat NTDs.

Q: What role can the Indian government play in its efforts to further
bolster its attempts to address the immediate health issues?
In the recent years, India has enhanced health infrastructure, reduced child and maternal mortality rates and achieved polio free status among other achievements in health.

However, it is important to recognize that India is now experiencing a change in the epidemiological and demographic realities - rapid urbanization, population migration, and non-communicable diseases have now overtaken communicable diseases.

To accelerate the health outcomes India must strengthen planning, regulation and monitoring' of health services in the country for better oversight and stewardship.

Reorganizing health service delivery is another important step. It is well known that private sector plays a dominant role in health service delivery in India, with focus largely upon curative and diagnostic services. The preventive, promotive, and rehabilitative services are limited and mainly available in the public sector.

The re-organization of services should focus on increasing the quantum of all type of services, with higher access and availability of quality health services, developing effective referral linkage and ensuring 'continuity of care' from primary to tertiary care facilities.

In India, public expenditure on health needs will increase because of Out of Pocket (OOP) expenditure for the patient is one of the highest in the world. However, putting more resources in health doesn't always translate to better health outcomes.

There is sufficient evidence that if health outcomes should be improved, the 'cashless access to health services, at all delivery points' would be required. This has been successfully achieved in a number of countries in the recent years.

Some of these approaches are being already considered by the Indian government as part of Universal Health Coverage (UHC) efforts in India. High level and sustained political commitment is critical to achieve the desired health outcomes.

The notional provision of health services have limited value unless those are of acceptable quality. The need for strengthened regulatory mechanism to oversee quality of health care provision, in both public and private sector, is often voiced by many. India has enacted clinical establishment (registration and regulation) Act, 2010, which has been adopted by limited number of states.

If this act is implemented well, it has immense potential to improve quality of health services. Moreover, improving coverage of vast Indian population with good quality services might be a huge challenge and country needs to consider how best to engage and collaborate with a broad range of private providers.

Last but not least, strengthening collaboration between sectors through multiple departments and ministries to deliver much needed public health interventions such as improved water supply and sanitation will go a long way to improve health in India.

Q: Can you tell us something about the Indo-Maldivian healthcare collaboration?
The Indo-Maldivian healthcare collaboration is supported through a regional platform and healthcare initiatives of SAARC (most recent examples, support to newborn care services by provision of equipment, supplies and training).

The Indira Gandhi Memorial Hospital (IGMH) in Male is an example of this collaboration. This tertiary level hospital was established in the 1990s in Male with India's support. This support has continued with India providing assistance to strengthen management, training, exchange of experiences and much more.

India has a number of WHO collaborating centers, and its rich pool of experts is also a source of technical assistance to other countries of WHO South-East Asia region.

Direct bi-lateral collaboration includes committed quota for the Maldivian students in the medical schools in India, in-service training of Maldivian healthcare workforce in India. Moreover, there are other tight relations arranged through public-private channels such as:

* Indian doctors and nurses working as part of the Maldives healthcare
* Diagnostics and treatment of Maldivian patients in the Indian institutions
* Significant proportion of pharmaceutical supplies and essential medicines for Maldives is procured from Indian manufactures

The latter is an avenue where WHO can assist in further strengthening availability of essential medicines in Maldives (and other countries) through effective quantification, diagnosing wastages, providing analysis for maximizing available procurement options and logistics management.

When requested by countries, WHO uses its regional and global network
to enhance bi-lateral collaboration.

Q: Innovation and collaboration is widely talked about in every industry in order to taste phenomenal success today. How do you intend to bring in the healthcare industry, academia, and the government to work together in this endeavor?
Strong health systems must deliver quality preventive, curative and rehabilitative health services.

Public-private partnerships (PPPs) could be a pragmatic way to complement the efforts of the public sector.

The Global Polio Eradication Initiative, with its founding members, WHO, Rotary International, UNICEF and the United States Centers for Disease Control and Prevention (USCDCP), now includes many other partners, such as the Bill and Melinda Gates Foundation, and has become one of the largest public-private partnerships the world has ever known.

It serves as a model of how international, regional, national, local, public and private entities can work closely together to achieve common goals.

Q: Do you think the healthcare community in India needs more awareness and education in addressing serious healthcare issues, especially among the rural population?
Rural populations generally have lower access to healthcare. By improving knowledge, skills and competences of healthcare providers, India would be able to address the issues of quality, responsiveness and equity of services.

As per Rural Health statistics, only 15% PHCs and CHCs conform to IPHS standards. Some recent studies suggest that the adherence to clinical protocols in healthcare providers is low and the retention of knowledge and skills provided through one time training is minimal.

Continued medical education and constant follow up through supportive supervision of health workers is needed at different levels.

While NCDs now contribute to 53% of all deaths in India,, there is an urgent need to upgrade skills of health workers in newer technology and treatments protocols as well as tackling the challenges of emerging diseases.

Health workforce must be trained to identify NCD risk factors, screen for NCDs, and provide treatment and continuity of care.

The existing data suggests that within rural areas, people from lower socio-economic strata are more vulnerable, and lack of preventive care increases their vulnerability.

Polio experience shows us that identification and targeted health interventions in these high-risk populations can yield better health results outcomes.

Q: How do you think we can bridge the gap between theoretical knowledge and practical application in the midst of changing public health scene?
Improving access requires overcoming four main barriers: geographical,
technological, social and financial. These are not insurmountable.

There is untapped opportunity to improve access to health through new
cost-effective technologies. Research, innovation and affordable health technologies need to be encouraged.

Q: How well is India prepared to face an immediate outbreak or an
unprecedented epidemic?
India has gained extensive experience over the past decade in handling several disease outbreaks such as Avian influenza (bird flu) among poultry in the country - with prevention of human cases due to the public health measures put in place; pandemic influenza H1NI (2009); Crimean Congo Hemorrhagic Fever and others.

Building surge capacity in public health laboratory network and infection control initiatives have received significant thrust following some of these events. Multidisciplinary training for preparedness and response has been consistently built over the years and a large number of health care workers have been trained.

Capacity for clinical management of severe respiratory cases requiring ventilator support has also been developed at the level of most districts. The concerned ministries have also developed and deployed comprehensive communication strategies for risk reduction and enhancing community level preparedness.

The Government of India has also ensured adequate stock piles of antibiotics and anti-virals while at the same time preventing indiscriminate use through supply control and special ordinance.

Mathematical modeling capacity for projecting pandemic spread and case surges which was lacking in the public health sector during the last pandemic is also being enhanced in collaboration with various academic institutions.

There is growing recognition that pandemics cannot be managed by the health sector alone and a number of inter-sectoral mechanisms have been instituted such as the Standing Committee on Zoonoses and the Joint Monitoring Group for Influenza, both of which have representation of WHO.

India has a nationwide indicator and event-based surveillance system for identification and verification of disease outbreaks.

Coverage of the hospital sector, especially the private providers by the surveillance system unfortunately remains a key challenge.

Laboratory capacity is also being strengthened across sectors for rapid verification and etiological confirmation of the disease outbreaks. The country also has good experience in handling events at points of entry (ports and airports) and has recently developed contingency plans for handling disease events of international
importance.

Inter-sectoral coordination, which is challenging, is also being strengthened to ensure compliance with requirements of the International Health Regulations (IHR).

The Government of India has demonstrated that it is capable of managing such threats without external assistance by converging resources to the needed areas.

Q: After 44 years, an Indian woman has been elected for the first time
as the WHO's South-East Asia regional director. What kind of different
challenges do you think you will have to face as opposed to others who
held the same position before you?
I take charge as regional director at an important moment in the history of public health and at a critical time in the evolution of WHO. I do so in all humility, knowing full well the challenges that lie ahead.

The public health arena is changing fast. The dominance of communicable diseases, inspite of their continued relevance, stands eroded.

Noncommunicable diseases, Millennium Development Goals, universal health coverage, intellectual property rights, virus sharing, essential and affordable medical products, and the impact of socio-economic and environmental determinants on health are increasingly engaging the time and attention of our health partners.

Q: Recently we celebrated International Women's Day. What will be your
pivotal message for all the Indian women out there, be it home makers, IT professionals, women on company boards, or even a school going girl
child?
To achieve health for all people, we must promote and protect the health of women and girls throughout their lives, not just during the reproductive phase of her life.

A healthy, empowered girl child grows up to be a healthy woman. A healthy other creates a healthy family and a healthy nation.

To realize this vision, women must get equal access to quality, acceptable and affordable health services. This means that our health workforce must be trained and sensitized to be gender sensitive.

Health services and interventions need to be designed to meet women's needs. Only then will we be able to achieve women-centered integrated services and universal health coverage.