When ownership drives change: 25 years of partnerships in India

In September, the World Diabetes Foundation Board of Directors travelled to New Delhi and Madhya Pradesh to see how 25 years of partnership in India has helped locally led ideas move from pilots into public health systems.

In many ways, India tells the story of WDF itself, and it has become one of WDF’s most important testing grounds: a place to support local partners, learn from practice, and refine approaches that would later inform programmes within and beyond the country.

Over two decades, it grew into WDF’s largest portfolio, shaped by local demand, sustained collaboration, and shared responsibility for addressing diabetes and other NCDs.

Similarly, through the Step-by-Step programme, health workers learned to recognise the early signs of foot ulcers and support people before disability became inevitable. Screening, training, and simple preventive measures showed what could change when care moved closer to people’s daily lives.

If eye care and foot care made the consequences of late diagnosis visible, hyperglycaemia in pregnancy (HIP) moved the logic further upstream. WDF Board Chair Dr Anil Kapur often returns to a key phrase: “prevention should begin where life begins”. Pregnancy offers a crucial window to reduce the risk of diabetes and other NCDs for both mother and child, making early action a natural extension of WDF’s work.

WDF’s work in this area began in 2004, in Tamil Nadu through an early partnership with the Dr V. Seshiah Diabetes Care and Research Institute. Building on that foundation, WDF and Jhpiego launched a partnership in 2018 to bring gestational diabetes care into routine public health services in Madhya Pradesh and Maharashtra, by training healthcare workers, strengthening referral pathways, equipping facilities, and making screening, treatment, and follow-up part of antenatal care.

As the partnership expanded, Dr Yashpal Jain, Associate Director at Jhpiego, saw its strength not in creating something separate, but in making HIP care part of the services women already knew.

“The WDF and Jhpiego partnership proved that HIP care does not need a parallel system,” he says. “It needs to sit inside the one a woman already uses and already trusts. For her, nothing looks different at the health centre: same ASHA (frontline community workers who serve as a critical link between communities and the public health system), same ANM, same visit. But now that visit includes a blood sugar test with 75g glucose and, if needed, support throughout her pregnancy. That is what took us from one state in 2018 to five states today, each one led by the state government, not by us.”

These examples are only part of the story. They sat alongside many other early WDF-supported initiatives across India, including successful work in school health and primary prevention, which brought prevention into classrooms, families, and communities.

These early projects helped build the foundation for later system changes, showing that diabetes care was needed, could be routinely delivered, and could grow because it responded to the realities of local services and communities.

WDF-supported programmes in India align closely with these reforms. They build the capacity of health workers, improve service delivery, support community engagement, and reinforce government-led implementation, helping shift momentum from donor-supported innovation to nationally anchored practice.

Looking back, Dr Anil Kapur, Chair of the Board, describes this evolution in terms of patience and timing. “Change takes patience,” he says. “Political will took time, but now we are seeing initiatives sprouting throughout the country.”

That momentum is now visible at national scale. In 2023, with technical support from WHO, India set out to bring 75 million people with diabetes and hypertension under care by 2025; WDF contributed to this momentum through one of its largest grants. India has already surpassed the target, reaching 94 million people, and was recognised by WHO SEARO on 8 September 2026.

As the country confronts a growing NCD burden driven by demographic and lifestyle changes, the focus is shifting from detection alone to long-term control. Stronger referral pathways, continuous follow-up, reliable supplies, treatment protocols, and digital patient tracking are becoming essential to chronic disease care. Integration also matters: diabetes prevention and care intersect with maternal health, cardiovascular disease, and other NCDs, requiring coordinated responses rather than siloed programmes.

Access where people live and work

As diabetes and NCD care became more firmly anchored in public systems, another question came into focus: who was still being missed?

For people whose working lives keep regular services out of reach, care has to move closer to the places where they spend their days. That question shapes newer partnerships such as Last Mile Care. Founded in 2021, the organisation works to make healthcare more affordable and accessible for people often left outside regular services, with a focus on India’s blue- and grey-collar workforce, where long hours, distance, and cost can push health to the margins.

As Paresh Jain, Head of Business Development and Strategic Partnerships at Last Mile Care, explains, many workers are “not in the coverage of a healthcare system or healthcare insurance and they don't have any accessible and affordable avenue to take care of their health issues”.

Preventive check-ups sit at the centre of the model, helping workers identify conditions such as diabetes, hypertension, and eye disease before complications develop. Jain describes the aim as “a transformational shift in the overall healthcare-seeking behaviour”: moving people from reactive care towards prevention and early action.

For Elin Jäger, Vice Chair of the Board, the visit showed how that shift depends on different actors carrying different parts of the work. “It is something that the private-public partnerships can do together,” she says, “where we have the government actors that can go in and do legislative change and change the policy at large scale; we have the WDF that bring in some kind of technical expertise; and then we have what partners can bring on how to actually make change in the local communities.” Partnerships allow change to happen at different levels: policy creates the conditions for scale, technical support helps strengthen the model, and local partners make change possible in the communities where care is needed most.

Communities as carriers of change

"What stood out to me the most was that the projects we visited were focused within the field of health, but they were also strengthening citizenship and strengthening people's sense of entitlement to health," shares Tine Gammeltoft, a Board member.

Across the projects the Board visited, that participation takes different forms: through schools and families, through traditional and trusted messengers, and through women’s groups and public health touchpoints. Through the involvement of communities, people are not merely recipients of care, but active participants with the confidence and capability to engage with the systems, services, and communities that shape their health.

With tribal populations across five Indian states, prevention moves through traditional and trusted messengers. School-based initiatives form part of a wider effort to reduce modifiable risk factors for diabetes, led by the Piramal Foundation, the Public Health Foundation of India, and Madras Diabetes Research Foundation, in collaboration with state Tribal Affairs Departments.

Traditional healers, often the first point of contact for health advice, use home visits, community gatherings, and cultural events to encourage healthier behaviours and referrals to public health services. By recognising their role and supporting them to refer and triage patients, projects help connect familiar community structures with the formal health system, widening both access to care and people’s ability to navigate it.

In Bhopal, women’s groups offered another pathway. The Board saw how self-help groups had become trusted spaces where conversations about diabetes, hypertension, healthy diets, and physical activity could sit alongside savings, mutual support, and regular group activities. Health awareness travelled through relationships built over years, reaching women and families through networks that already carried knowledge, trust, practical support, and a growing sense that health is something people can speak about, organise around, and expect support for.

For many women, those spaces widened confidence and opportunity. “It was very clear that the women we met had felt really empowered and strengthened through the project,” shares Tine. “Both in an economic sense, because they got access to microcredit, but also from simply getting more knowledge, getting more awareness, and being together, strengthening each other within the groups.”

Sobia Akram, a Board member, saw these examples as an ecosystem needed for change to last: trusted institutions that already sit within patient communities, and collaboration across the boundaries that often divide health programmes, social support, livelihoods, and public services.

Those community pathways also intersect with public health touchpoints. ASHA workers, nurses, community volunteers, and government officials each had a role in identifying risks early, supporting patients, keeping care connected, and making people’s entitlement to health visible in everyday practice. As Kaushik Ramaiya, a Board member, put it, “The beauty of it is that the people working at the clinics are well trained and they have a sense of responsibility and ownership.”

Digital tools are helping hold that care together. At the monthly Village Health, Sanitation and Nutrition Day in Cheerkheda, nurse Poonam Prajapati described how she screens, counsels, and follows up with pregnant women as part of routine care. The Board saw how care is organised, data recorded on the State’s digital platform, and supply logistics are managed.

Women diagnosed with gestational diabetes, diabetes, or other NCDs are registered on the state’s digital health platform, making follow-up possible even when they return to their home villages after labour to be with family and community. For Sobia, this was “the most extraordinary thing”: a sustainable digital health infrastructure that makes women visible to the system wherever they go. Elin noted the same progress on the ground, particularly the way digitalisation is connecting services across the health system.

Poonam also spoke about the practical barriers many women face. Work, childcare, and household responsibilities can make follow-up appointments difficult, so health workers involve husbands and mothers-in-law to help families support women throughout pregnancy and beyond. Even the two-hour wait during an oral glucose test becomes useful time, as health workers counsel women on healthy pregnancy, newborn health, and practical lifestyle changes.

For Poonam, the responsibility is personal as well as professional: “Now I can provide services to the women of this village and help reduce maternal and newborn mortality using my skills.”

For Bente Mikkelsen, another Board member and former WHO NCD Director, and a longtime advocate for global action on diabetes and NCDs, this was one of the most encouraging signs from the visit: local leadership in communities, supported by government policies “adapted to the context where they need to be implemented”. Seeing that vision translated into everyday work, from frontline health workers and communities to district and state authorities, was, she said, enough to give her goosebumps.

Ownership as the legacy

After more than two decades of engagement in India, WDF partnerships have helped create linkages, approaches, and practices that are now embedded within the public health system, aligned with national priorities, and led locally. Ownership can be seen in state budgets that include screening and follow-up, in health workers using new skills and tools in routine care, in communities asking for prevention and early diagnosis, and in local researchers, professional associations, and health institutions generating evidence for the next generation of solutions.

Like many countries around the globe, India continues to experience a growing diabetes burden. As awareness expands and health systems become stronger, more people are tested, diagnosed and treated than ever before. More people are receiving care earlier, allowing complications to be prevented or delayed and helping people with diabetes live longer and healthier lives. But at the same time, the number of people living with diabetes continues to rise, creating new pressures on health systems and communities alike.

For WDF, this reality reinforces the importance of the path taken in India. Long-term progress depends on sustained investment in health systems, workforce capacity, policy, financing, and community engagement, and on keeping prevention, early diagnosis, and continuous care connected as the burden grows. It also requires looking ahead while holding firm to what has made change possible: locally led partnerships, practical solutions, and shared responsibility across communities, governments, and health services. The foundations have been laid; now we get to build further on them, and perhaps, that is a reason for optimism.