Previously Completed Projects

The Role of Non-Governmental Health Care: A Study of its Scope and Potential With a Focus on Policies to Promote its Contribution to Improved Health (China, India, Laos, Uganda, Zambia, Vietnam)
Principal Investigator: Peter Berman, Professor of the Practice of Global Health Systems and Economics
Department: Department of Global Health and Population
Sponsor(s): Swedish International Development Cooperation Agency

Dates of Research:
July 1, 2004 — December 31, 2007

The program analyzes the organization of health services and health care delivery for a set of important population health needs and outcomes. Targeted health problems are leading causes of illness and deaths, e.g. TB STI, ARI, diarrhea, malaria. The program assesses the role of private providers and public-private linkages in relation to these health needs. The program has two main phases. The first includes development of methodology and implementation of descriptive and analytical studies in the six participating countries. The second involves the design, implementation and evaluation of policy interventions to improve health systems’ outcomes. The overall objective of the research program is to strengthen health systems’ performance and their outcome in terms of improved health. A second overall objective is to seek ways through which the non-government sector can be involved in providing health care to the public, and in particular to those in most need, while ensuring financial protection of those seeking this care. For more information, see link.


Strengthening Child Protection Initiatives (India)
Principal Investigator: Theresa Betancourt
Department: Department of Global Health and Population
Sponsor: The Oak Foundation
Dates of Research: June 1, 2012-August 31, 2013

In 2009, the Indian government rolled out the Integrated Child Protection Scheme to strengthen the prevention of child rights violations, enhance infrastructure of prevention services, increase investment in child protection, and raise awareness of child rights and violation of child rights in India.   The Ministry of Women and Child Development has indicated that a core component of such changes is the creation of rigorous and valid tools of monitoring and assessment to improve reporting mechanisms, accountability, and generate a body of reliable data which can inform evidence based child protection interventions at the state and national level.

Children at the Mobile Creche

Children at Mobile Crèche

In response to this need, the SAFE Child Protection Initiative worked in collaboration with Mobile Crèches, FXB Suraksha, and the Public Health Foundation of India to develop and pilot the SAFE Toolkit – a comprehensive assessment of child protection within a specific environment for the purpose of fostering and improvement children’s development and spreading awareness of the needs and rights of children. The SAFE Toolkit was piloted in two primary areas where there were considerable problems relating to child labor, trafficking, sexual exploitation, and discrimination: the Indian railways and construction sites.  In the short run, findings from these pilots were used to inform the development of standards for protection and care for street children living in and around railway stations in India, and children of migrant laborers.  Further, as the SAFE Toolkit continues to be refined and developed to better address the nuanced protection needs within the Indian context, we hope to work with the Ministry of Women and Child Development to improve the development of systems governing accountability, monitoring, and evaluation within the child protection arena.


The Shanu Project Adolescent Agency Initiative
Principal Investigator: Dr. Jacqueline Bhabha
Department: Francois-Xavier Bagnoud Center for Health and Human Rights

Girl in Gujarat

Girl in Gujarat

The Shanu Project Adolescent Agency Initiative aimed to better understand the educational opportunities for adolescents, particularly girls, in rural Gujarat. Researchers mapped the educational attainment status of a sample of boys and girls aged 10-13 and 14-17 in the villages and identifying key trends. Future phases of the project will involve the monitoring and evaluation of education interventions to be implemented by local partner NGOs. This project was in collaboration with the Self Employed Women’s Association (SEWA), a 1.2-million member women’s union in India. Please click here for a report.

A system for household enumeration and re-identification in densely populated slums to facilitate community research, education, and advocacy

Principal Investigators: Dana Thomson, Research Associate in the Department of Global Health and Social Medicine at Harvard Medical School, Anita Patil-Deshmukh, an HSPH alumnus and Executive Director of PUKAR (Partners for Urban Knowledge, Action and Research in Mumbai; David Bloom, Clarence James Gamble Professor of Economics and Demography
The team devised and implemented an innovative Location-Based Household Coding System (LBHCS) appropriate to a densely populated informal settlement in Mumbai, India. LBHCS codes were designed to double as unique household identifiers and as walking directions; when an entire community is enumerated, LBHCS codes can be used to identify the number of households located per road (or lane) segment. LBHCS was used in community-wide biometric, mental health, diarrheal disease, and water poverty studies. It also facilitated targeted health interventions by a research team of youth from Mumbai, including intensive door-to-door education of residents, targeted follow-up meetings, and a full census. In addition, LBHCS permitted rapid and low-cost preparation of GIS mapping of all households in the slum, and spatial summation and spatial analysis of survey data.


Exploring the Social and Physical Determinants of Urban Health 
Principal Investigator: David Bloom, Clarence James Gamble Professor of Economics and Demography
Sponsor(s): Rockefeller Foundation

Dates of Research:
January 1, 2009 — December 31, 2011

The Harvard School of Public Health (HSPH) worked in close collaboration with Partners for Urban Knowledge, Action, and Research (PUKAR), based in Mumbai, India, to carry out a multifaceted study of urban health. The project examined the physical and social determinants of health in a disadvantaged urban setting in Mumbai, focusing on water- and immunization-related challenges in particular. All aspect of the project involved collaboration among HSPH students, PUKAR members, and “barefoot researchers”, young members of the community under study who were integral members of the ground team.


Health and Retirement Survey for India
Principal Investigator: David Bloom, Clarence James Gamble Professor of Economics and Demography
Department: Department of Global Health and Population
Sponsor(s): NIH/NIA

Dates of research: 09/15/2008 – 08/31/2010

This study prepared the way for increased scientific investigation of the economic, social, and biological determinants and consequences of population aging in India. Internationally harmonized data was disseminated over the Internet to the global research community enabling further coordinated research on the health and well-being of the elderly in India in comparative perspective. This research had the potential to inform policy in India and other Asian Countries, including China, Japan, and South Korea. The long-term goals of this research were to develop a nationally representative survey of aging, health and retirement in India; to provide the foundation for new, rigorous, multidisciplinary studies of aging that will inform policy making and advance scientific knowledge; and to provide internationally harmonized data for cross-national comparative studies on aging to advance understanding of how different institutions, cultures, and policies influence aging. The survey instrument included areas of health such as disease, mental health, and diet, as well as other social indicators including family structure, health care utilization, housing, and employment retirement.


Center for Global Demography of Aging 
Principal Investigator: David Bloom, Clarence James Gamble Professor of Economics and Demography
Department: Department of Global Health and Population
Sponsor(s): NIH/NIA

The Health and Retirement Study (HRS) was initiated in the U.S. nearly two decades ago to provide longitudinal data for researchers, policy analysts, and program planners making policy decisions related to labor supply and savings behavior, the demand for health and life insurance, and social and economic wellbeing of the elderly and their families. The HRS were collectively designed to facilitate direct and close comparisons related to the health and retirement behavior of relatively old populations in different countries. The proposed project aimed to take steps to add India to the growing list of countries who conduct HRS. We recognize that there are many important scientific questions related to health, retirement, and population aging in all countries, but we believe India’s socio and economic characteristics merit special attention. An Indian HRS would be of unusual scientific interest as India’s population is relatively impoverished, primarily rural, substantially illiterate, predominantly informally employed, and is privately responsible for a high share of national health expenditures (75%). For more information, please see this site.


Andhra Pradesh Health Sector Reforms Programme
Principal Investigator: Thomas Bossert, Senior Lecturer on Global Health Policy
Department: Department of Global Health and Population
Sponsor(s): FHI360

The Government of Andhra Pradesh has embarked upon significant reforms of the health sector, and they have developed a health reform strategy that sets out its vision for the sector, and its commitment to ensure better services for the poor. An emphasis of the Health Strategy is to reduce infant and maternal mortality, communicable disease burden, under-nutrition and regional and social inequalities in health outcomes. Thomas Bossert on behalf of the International Health Systems Program within the Department of Population and International Health helped the program to improve the health status of the people, especially the poorest, of Andhra Pradesh and increase the quality of their health services.


Develop Training Curriculum Project (Human Resources Course in India)
Principal Investigator: Thomas Bossert, Senior Lecturer on Global Health Policy
Department: Department of Global Health and Population
Sponsor(s): World Bank

Thomas Bossert works in conjunction with the National Institute of Health and Family Welfare (NIHFW) for the World Bank Institute (WBI) which acts as a global catalyst for creating, sharing, and applying the cutting edge knowledge necessary for poverty reduction and economic and social development, and by stimulating the conditions for client countries to be able to utilize knowledge to achieve development goals particularly a development program on health systems policy and management in India. To achieve this goal they designed a 5-6 day health training course with a focus on human resource management. They helped to create the concept, find local Indian resources and staff, and make recommendations for suitable case studies. The team also made recommendations for long-term sustainability of the course.


India HNP (Health, Nutrition & Population) Sector: Decentralization and Public Health Management (Archived)
Principal Investigator: Thomas Bossert, Senior Lecturer on Global Health Policy
Department: Department of Global Health and Population
Sponsor(s): World Bank

The central government of India and various state governments have made an active commitment towards decentralizing “funds, functions, and functionaries” to local governments and to support local planning. At the same time, management of services and many public health functions need strengthening at state and lower levels of government. In response this project provides technical support on multiple health, nutrition and population projects. The project assists India’s Ministry of Health and Family Welfare to: respond appropriately to the current changes in health systems governance; ensure that its operations are consistent with the development of decentralized government at the different levels; help design innovative mechanisms of decentralization at different authorities; and design and implement effective strategies for better management of public health programs, especially as they relate to the essential public health functions discussed above.


SEARCH–Systematic Explanatory Analyses of Risk Factors Affecting Cardiovascular Health in Brazil, China, India and Mexico
Principal Investigator: Joseph Brain, Cecil K. and Philip Drinker Professor of Environmental Physiology at Harvard School of Public Health

Dr. Joseph Brain presented the results of his study at “The Future of Human Longevity” conference” at the Swiss Re Center for Global Dialogue on November 11, 2013. The conference was sponsored by: Swiss Re Centre for Global Dialogue and Harvard School of Public Health. See more on this groundbreaking study at this website. In addition, Dr. Brain was instrumental in organizing a symposium on October 15 and 16, 2013 at the American Academy of Arts and Sciences on the impact of cardiovascular diseases risk factors on health conditions in emerging markets. The symposium was sponsored by Swiss Re, in collaboration with HSPH and swissnex Boston. See more at the swissnex Boston website.


Decentralization Course in India

Principal Investigator: Paul Campbell, Lecturer on Global Health Department: Department of Global Health and Population Department of Health Policy and Management

Sponsor(s): Constella Futures International, LLC

Dr. Campbell, as well as other HSPH faculty members, has been holding international courses on “Decentralizing Health Systems” in Boston for a number of years and faculty have also been working in India on related issues. This project supported the development and provision of a course on decentralization offered during the week of July 30, 2007 in India. The purpose of this course was to deepen understanding of political and managerial decentralization internationally, and in India especially related to NRHM (National Rural Health Mission), and to develop written draft plans for implementing decentralization in the participating states. Dr. Thomas Bossert was co-director and taught many of the sessions and engaged Indian faculty as well.


Randomized trial of vitamin B12 in pregnant Indian women

Principal Investigator: Christopher Duggan, Associate Professor in the Department of Nutrition

Department: Department of Nutrition

Sponsor(s): NIH/NICHD

Study started December 2008. Estimated study completion date April 2014

The incidence of poor fetal growth and adverse maternal and infant birth outcomes is quite high in India, and several lines of evidence suggest that maternal nutritional status may be an important factor. In a prospective cohort study of 410 pregnant Indian women, these researchers recently found a strong relationship between maternal serum vitamin B12 concentration and the risk of infant intrauterine growth retardation. We have recently completed a randomized, double-blind trial among 300 pregnant Indian women in order to determine the effectiveness of vitamin B12 supplementation in improving child and maternal B12 status. Follow-up of these mother-infant dyads through 36 months post-partum is underway. See the study record detail.


Bangalore Boston Nutrition Collaborative
Principal Investigator: Christopher Duggan, Associate Professor in the Department of Nutrition
Department: Department of Nutrition
Sponsor(s): Anonymous

Emerging demographic, economic and dietary factors suggest that a large burden of preventable illness is poised to develop in India. In order to document these developments and to design feasible and valid public health interventions designed to reduce these health outcomes, a new generation of Indian nutrition scientists need to be trained. Since 2009, we have undertaken a collaborative educational effort with faculty at St. John’s Research Institute that includes: 1. An annual two week course in Nutrition Research Methods in Bangalore, co-taught by HSPH, Tufts and St. John’s faculty; 2. Distance learning with an interactive website; and 3. Student and faculty exchange visits for research collaboration. See Bangalore Boston Nutrition Collaborative.

See the January 2014 research article published by Biomed Central detailing the collaborative.


Dose Response Modeling in Epidemiologic Cohort Studies 
Principal Investigator: Ellen Eisen, Adjunct Professor of Environmental Health
Department: Department of Environmental Health
Sponsor(s): NIH/NCI

This proposal builds on current work applying semiparametric statistical methods to model nonlinear exposure-response curves with smooth functions of exposure in occupational cohort studies (R01CA81345). In the course of adapting penalized splines for survival analysis, there have been two issues identified that need further development: 1) criteria for choosing the optimal amount of smoothness; and 2) diagnostic statistics to identify influential observations and measure their influence on the fitted values of the curve. These issues are examined in the presence of the right skewed distributions typical of workplace exposures. Comparisons are made of the goodness of fit and resistance of penalized splines to that of two other common smoothers: restricted cubic spines, and a locally weighted regression smoother called “loess.” They will re-analyze two cancer mortality studies: larynx, lung, prostate and rectal cancer in autoworkers exposed to metalworking fluids (MWF) and lung cancer in California’s diatomaceous earth industry exposed to crystalline silica.


Global Maternal Morbidity and Mortality Policy Model
Principal Investigator: Susanne Goldie, Roger Irving Lee Professor of Public Health
Sponsor(s): John D. and Catherine T. MacArthur Foundation

This project focused on the development and refinement of a Global Maternal Morbidity and Mortality Policy Model. The project adapted this model to permit evaluation of strategies for the reduction of maternal death and disability in India. Specific activities included: modification of the natural history to reflect the epidemiologic pattern of maternal health in India, and modification of the intervention module to reflect India-specific utilization patterns of interventions and intervention effectiveness; expansion of the model to allow for Monte Carlo simulation to evaluate targeted strategies (i.e., increased risk for complications due to age and parity); and increasing the model’s capacity to consider additional health and economic measures of maternal morbidity or co-morbidity. Using the model, our analyses will focused primarily on maternal outcomes but secondary analyses were expected to encompass the broader societal viewpoint, such as the positive effects of maternal health interventions on neonatal health, survival, and the welfare of the family.


Optimizing HIV Care in Less Developed Countries
Principal Investigator: Susanne Goldie, Roger Irving Lee Professor of Public Health
Department: Department of Health Policy and Management Center for Health Decision Science
Sponsor(s): Massachusetts General Hospital

Advances in the treatment of HIV disease have produced dramatic reductions in AIDS-related morbidity and mortality in the United States and Europe. However, because of severe resource constraints in Africa, Asia and less developed countries throughout the world, neither prevention of opportunistic infections nor HAART have been widely available. This project utilizes the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) model to focus efforts in three less developed countries, with the following specific aims: 1) to develop a comprehensive state-transition model of the natural history and treatment of HIV disease in less developed countries; 2) to analyze data on HIV natural history, treatment efficacy, treatment cost, and quality of life in Ivory Coast, India, and South Africa; and 3) to utilize the model with country-specific data to determine the clinical impact, cost, and cost-effectiveness of different strategies for opportunistic infection prophylaxis, tuberculosis preventive therapy, and antiretroviral use in each of these countries, and to disseminate these analyses to help inform and develop country specific guidelines for HIV care.


Gender-Based Violence and HIV/AIDS (China, India, Thailand, Vietnam)
Principal Investigator: Sofia Gruskin, Adjunct Professor of Global Health
Department: Department of Global Health and Population
Sponsor(s): Ford Foundation

Dates of Research: August 1, 2004 — May 31, 2007

In 2004, the Program on International Health and Human Rights (PIHHR) developed a pilot project with the aim of using a human rights framework to facilitate programming, advocacy efforts and research amongst those working on issues of HIV, GBV, and sexuality. The program supports translation of the growing theoretical and policy discussion about the links between HIV and GBV into enhanced programming. In its initial stage, the project collaborated with partners in China, India, Thailand, and Vietnam to bring together two organizations in each country, one working primarily on HIV and one working primarily on GBV, to collaborate and work together. In India the program collaborates with Swasthya and Action India.


Study of Lead Exposure and Outcomes Amongst Children in Chennai, India
Principal Investigator: Howard Hu, Adjunct Professor of Occupational and Environmental Medicine
Department: Department of Environmental Health
Sponsor(s): NIH/FIC

This project studied 750 children aged 4-6 years attending specific public schools in Chennai, India. These schools were chosen to represent areas of the city that are high-high, high-low, low-high, and low-low with respect to traffic and industry. The study measured levels of lead in blood and shed primary teeth, assess IQ, visuospatial function, visuomotor function, and behavior for each child. With this information, the study explored lead exposure and exposure dose relationships, tested specific hypotheses on the relationship of lead dose to neurobehavioral outcomes, and explored other relationships of interest.

Howard Hu is now heading the Dalla Lana School of Public Health at University of Toronto


Assessing the Public Health Consequences of Sex Trafficking in India, Nepal and Bangladesh
Principal Investigator: Jay Silverman, Adjunct Associate Professor of Society, Human Development, and Health
Department: Department of Society, Human Development, and Health
Sponsor(s): Department of State-BINL

Dates of Research:
November 30, 2006 — November 30, 2008

Trafficking in persons for prostitution (TIP/P) is a significant global public health issue. An estimated 600,000-800,000 people are trafficked globally each year, approximately 80% of whom are women and children trafficked for prostitution. A significant percentage of these victims are trafficked for prostitution across India, Nepal and Bangladesh. To date, there is no adequate estimate of the global or South Asian regional public health impact of TIP/P. This project assesses and documents the public Health impact of TIP/P across India, Nepal and Bangladesh.


Promoting Tobacco Cessation among School Teachers (2008-2012). Conducted with the full support of the Bihar Department of Education, Drs. Sorensen, Viswanath and Nagler collaborated with the Healis-Sekhsaria Institute for Public Health on a five-year research study funded by the U.S. National Institutes of Health to promote tobacco use cessation among teachers in 72 schools in the state of Bihar. Teachers are the focus of the study because as role models for youth and key opinion leaders in society, they represent an important group for tobacco control. Using a randomized controlled design, this study assessed the effectiveness of a school-based tobacco use cessation program, the Tobacco-Free Teachers, Tobacco-Free Society program, which combined school policy initiatives and tobacco use cessation assistance for teachers through discussion groups, cessation support, and educational materials.

The program was found to be effective at increasing tobacco use quit rates in school personnel. Immediately after the program was completed, the percentage of school personnel reporting they quit tobacco within the last 30 days was 50% in intervention schools compared to 15% in control schools. Nine months after the program ended, 19% of school personnel in intervention schools reported quitting tobacco within the past 6 months, compared to 7% in the control schools. When compared only among school personnel employed in the school for the entire time the intervention was implemented, the number of teachers quitting within the past 6 months was 20% in intervention schools and 5% in control schools.

For more information on these results, please refer to this publication:

Sorensen G, Pednekar M, Sinha DN, Stoddard AM, Nagler EM, Aghi M, Lando HA, Viswanath K, Pawar P, Gupta PC. Effects of a tobacco control intervention for teachers in India: Results of the Bihar School Teachers Study. Am J Public Health. 2013 Nov;103(11):2035-40. doi: 10.2105/AJPH.2013.301303. Epub 2013 Sep 12. PMCID 3828698.


The psychological toll of slum living in Mumbai, India: A mixed methods study

Principal Investigators: Drs. Ramnath Subbaraman, David E. Bloom, and Anita Patil-Deshmukh. Dr. Patil-Deshmukh is an HSPH alumnus and Executive Director of PUKAR in Mumbai.

In India, “non-notified” slums are not officially recognized by city governments; they suffer from insecure tenure and poorer access to basic services than “notified” (government-recognized) slums. Subbaraman et al. conducted a study in a non-notified slum of about 12,000 people in Mumbai to determine the prevalence of individuals at high risk for having a common mental disorder (i.e., depression and anxiety), to ascertain the impact of mental health on the burden of functional impairment, and to assess the influence of the slum environment on mental health.

The PUKAR team lobbied the Mumbai government to start health camps and bring water into the community. Kaula Bandar residents trained by the PUKAR team through these programs are using their compensation from the research work for school bills, and may themselves pursue careers in public health.


 The social ecology of water in a Mumbai slum: failures in water quality, quantity, and reliability

Principal Investigators: Drs. Ramnath Subbaraman, David E. Bloom, and Anita Patil-Deshmukh.

The findings revealed severe deficiencies in water-related health and social equity indicators. All bacterial contamination of drinking water occurred due to post-source contamination during storage in the household, except during the monsoon season, when there was some point-of-source water contamination. This suggests that safe storage and household water treatment interventions may improve water quality in slums. Problems of exorbitant expense, inadequate quantity, and poor point-of-source quality can only be remedied by providing unrecognized slums with equitable access to municipal water supplies.

Off the map: the health and social implications of being a non-notified slum in India

Principal Investigators: Drs. Ramnath Subbaraman, David E. Bloom, and Anita Patil-Deshmukh.

Approximately half of all slums in India are not recognized by the government. Lack of government recognition, also referred to as “non-notified status” in the Indian context, may create entrenched barriers to legal rights and basic services such as water, sanitation, and security of tenure. This paper shows the relationship between non-notified status and health outcomes in Kaula Bandar (KB), a slum in Mumbai, India. This relationship is illuminated using the findings of a four-year series of studies in the community.