High Focus States Research Articles

Heterogeneity in health funding and disparities in health outcome: a comparison between high focus and non-high focus states in India

BackgroundThe Central Government of India introduced the National Health Mission (NHM) in 2005 to improve health outcomes by enhancing publicly financed (government) health expenditure and health infrastructure at the state level. This study aims to examine the effects of the state-level heterogeneity in publicly financed spending on health services on major health outcomes such as life expectancy, infant mortality rate, child mortality rate, the incidence of malaria, and immunization coverage (i.e., BCG, Polio, Measles, and Tetanus).MethodsThis study investigates the relationships between publicly financed health expenditure and health outcomes by controlling income and infrastructure levels across 28 Indian States from 2005 to 2016. Along with all states, the empirical analysis has also been carried out for high-focus and non-high-focus states as per the NHM fund flow criteria. It has applied panel fixed-effects and random effects model wherever required based on the Hausman test.ResultsThe empirical results show that publicly financed health expenditure reduces infant mortality, child mortality, and malaria cases. At the same time, it improves life expectancy and immunization coverage in India. It also finds that the relationship between publicly financed health expenditure and health outcomes is weak, especially in the high-focus states.ConclusionsGiven the healthcare need for achieving desirable health outcomes, Indian States should enhance publicly financed expenditure on health services. This study augments essential guidance for implementing public health policies in developing countries.

Inter-state disparities in government health expenditure in India: a study of national rural health mission

PurposeThe study aims to compare India's public health expenditure at the international and state levels. The paper also empirically examines the regional disparities in NRHM spending across the 21 selected states of India.Design/methodology/approachThe tools of absolute β-and σ-convergence are used in the analysis to test the regional convergence. The average annual growth rate across the states is the dependent variable for β-convergence, and time is the second dependent variable but is used for s-convergence. In contrast, the initial value of NRHM expenditure and the coefficient of variation of NRHM expenditure are used as independent variables, respectively. Descriptive statistics are also used for the study. The data are annual and cover the panel from 2007 to 2020.FindingsThe study attests to the hypothesis of β-and σ-convergence for the selected states in the period mentioned. The observed convergence in NRHM expenditure is due to the shift in the government's attention from the non-high focus high focus states to high states through the national rural health mission policy. The coefficient of variation across the states also shows a declining trend and provides the robustness of the σ-convergence.Originality/valueAs far as the literature is concerned, none of the existing studies examines the convergence of a public health expenditure scheme like the National Rural Health Mission across the Indian states by applying the techniques of β-and σ-convergence. The novelty of the study is using the newly updated dataset and validating the convergence hypotheses in the National Rural Health Mission expenditure case.

Association between timing and type of postnatal care provided with neonatal mortality: A large scale study from India.

ObjectivesThis study examines the association between quality Postnatal Care (PNC) considering timing and providers’ type on neonatal mortality. The aim extends to account for regional disparities in service delivery and mortality including high and non-high focus states.MethodsEver-married women aged 15–49 years (1,87,702) who had delivered at least one child in five years preceding the survey date surveyed in National Family Health Survey (2015–16) were included in the study. Neonatal deaths between day two and seven and neonatal deaths between day two and twenty-eight were considered dependent variables. Descriptive statistics and multivariate regression analysis were conducted.ResultsChances of early neonatal mortality were 29% (OR = 0.71; 95%CI: 0.59–0.84) among newborns receiving PNC within a day compared to ones devoid of it while 40% (OR: 0.60; 95%CI: 0.51–0.71) likelihood for the same was noted if PNC was delivered within a week. Likelihood of neonatal mortality decreased by 24% (OR: 0.76; 95%CI: 0.65–0.88) when skilled PNC was delivered within 24 hours. Receiving quality PNC by skilled providers within a day in a non-high focus state decreased the chances of neonatal mortality by 26% (OR: 0.74; 95%CI: 0.59–0.92) compared to ones who did not receive any PNC.ConclusionsNeonatal deaths were significantly associated with socioeconomic and contextual characteristics including age, education, household wealth, social group and region. Timing of PNC delivered and by a skilled healthcare provider was found significant in reducing neonatal mortality.

Antibiotic consumption in India: geographical variations and temporal changes between 2011 and 2019.

To describe and compare private sector systemic (J01) antibiotic consumption across Indian states from 2011 to 2019. We used the nationally representative PharmaTrac dataset to describe the consumption rates in DDD across national, state and state-group [high focus (HF) and non-high focus (nHF)] levels. We used median and IQRs to describe and compare across states and state groups, and relative change and compound annual growth rate (CAGR) to examine temporal changes. The annual consumption rate decreased by 3.6% between 2011 and 2019. The share of Access antibiotics decreased (13.1%) and the Access/Watch ratio declined from 0.59 to 0.49. State consumption rates varied widely (HF states reported lower rates) and the inappropriate use increased over the years, especially among HF states. The HF and nHF states showed convergence in the share of the Access and the Access/Watch ratio, while they showed divergence in the use of Discouraged fixed-dose combinations. India's private-sector antibiotic consumption rate was lower than global rates. The rates varied across states and appropriateness of use decreased in most states over the years. States with an increase in appropriate use over time could serve as best practice examples. Studies to understand the factors affecting inappropriate use are required alongside improved data systems to monitor the public-sector provision of antibiotics to understand the total consumption.

Women autonomy and its sociodemographic correlates in high focus states of India

Background: Autonomy is a multidimensional notion that relates to the independence or freedom of will of one's activity and is defined as the ability to receive knowledge and make judgments regarding one's issues. Women's autonomy is a function of several social, cultural, and individual factors such as education, occupation, and economic condition. To determine the socio-demographic factors influencing women’s autonomy among study subjects and to find out the contribution of these significant factors.Methods: The present study is based on the data of the 4th round of the National Family Health Survey 2015-2016 (NFHS-4). This study is based on, 381927 women of reproductive age group belonging to high focus states of India. Chi-square test and binary logistic regression analysis have been used to analyze the data.Results: In nine high focus states, Jharkhand (8.6%) is the most autonomous state while Bihar (6.4%) is the least autonomous state. Age, education, wealth index, occupation are significant factors influencing autonomy.Conclusions: Women’s age, education, working status, and the number of living children is positively associated with women’s autonomy. In high focus states, women are still struggling for their independent role in decision-making.

Association of trends in child undernutrition and implementation of the National Rural Health Mission in India: A nationally representative serial cross-sectional study on data from 1992 to 2015.

BackgroundIndia launched the National Rural Health Mission (NRHM) in 2005 to strengthen its primary healthcare system in high-focus and northeast-focus states. One of the NRHM objectives was to reduce child undernutrition in India.Methods and findingsWe used data from 1992, 1998, 2005, and 2015 National Family Health Survey (NFHS) of India to evaluate trends in child undernutrition prevalence before and after NRHM and across different categories of focus states. Stunting, Wasting, and Comprehensive Index of Anthropometric Failure (CIAF) were assessed using the World Health Organization (WHO) growth curves to assess chronic, acute, and overall undernutrition. The study included 187,452 children aged 3 years or under. Survey-weighted and confounder-adjusted average annualized reduction rates (AARRs) and predicted probability ratios were used to assess trends and socioeconomic disparities for child undernutrition, respectively. Nationwide, the prevalence of all types of undernutrition decreased from 1992 to 2015. However, the trends varied before and after NRHM implementation and differentially by focus states. After NRHM, acute undernutrition declined more rapidly among high-focus states (AARR 1.0%) but increased in normal-focus states (AARR −1.9% per year; p-value for the difference <0.001). In contrast, the prevalence of chronic undernutrition declined more rapidly (AARR 1.6%) in the normal-focus states in comparison to high-focus states (0.3%; p-value for the difference = 0.01). Income and caste-based disparities in acute undernutrition decreased but did not disappear after the implementation of the NRHM. However, similar disparities in prevalence of chronic undernutrition appear to be exacerbated after the implementation of the NRHM. Major limitations of this study include the observational and cross-sectional design, which preclude our ability to draw causal inferences.ConclusionsOur results suggests that NRHM implementation might be associated with improvement in wasting (acute) rather than stunting (chronic) forms of undernutrition. Strategies to combat undernutrition equitably, especially in high-focus states, are needed.

Factors associated with minimum dietary diversity failure among Indian children

Recognising the importance of infant and young child feeding practices during the first 2 years of life, the World Health Organization's Global Nutrition Monitoring Framework developed a minimum dietary diversity (MDD) indicator for feeding children aged 6-23 months. MDD is defined as the consumption of food items from five or more groups out of a total of eight food groups. Food intake from less than five food groups is considered minimum dietary diversity failure (MDDF). Using the nationally representative National Family Health Survey (NFHS) dataset, the present study assessed the trend in MDDF between 2005-6 and 2015-16 and the factors associated with MDDF among children aged 6-23 months during 2015-16. The NFHS conducted in 2005-6 and 2015-16 covered a sample of 14 419 and 74 078 children aged 6-23 months, respectively. Overall, the MDDF reduced from 87⋅4 % (95 % confidence interval (95 % CI) 86⋅8 %, 87⋅9 %) in 2005-6 to 80⋅6 % (95 % CI 80⋅1 %, 81⋅0 %) in 2015-16. Multivariable logistic regression analysis revealed that increased child's age, second and third birth order children, higher maternal age and education, mass media exposure of mothers and more than four antenatal care visits had a negative association with the MDDF. Children living in rural areas and residing in high-focus states of India were observed with higher odds of experiencing MDDF. Exposure to community healthcare services was negatively associated with MDDF, and anaemic children were more likely to have MDDF. Socioeconomic status of mothers and children and encouragement of maternal and child healthcare use could be helpful in devising context-specific intervention to mitigate MDDF.

Did the poor gain from India\u2019s health policy interventions? Evidence from benefit-incidence analysis, 2004\u20132018

BackgroundHealth policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context.MethodsEmploying Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups.ResultsUtilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018.ConclusionsImprovement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results.

Change in full immunization inequalities in Indian children 12\u201323\u2009months: an analysis of household survey data

BackgroundIndia has made substantial progress in improving child health in recent years. However, the country continues to account for a large number of vaccine preventable child deaths. We estimated wealth-related full immunization inequalities in India. We also calculated the degree to which predisposing, reinforcing, and enabling factors contribute to these inequalities.MethodsWe used data from the two rounds of a large nationally representative survey done in all states in India in 2005–06 (n = 9582) and 2015–16 (n = 49,284). Full immunization status was defined as three doses of diphtheria-tetanus-pertussis vaccine, three doses of polio vaccine, one dose of Bacillus Calmette–Guérin vaccine, and one dose of measles vaccine in children 12–23 months. We compared full immunization coverage by wealth quintiles using descriptive statistics. We calculated concentration indices for full immunization coverage at the national and state levels. Using predisposing, reinforcing, and enabling factors associated with full immunization status identified from the literature, we applied a generalized linear model (GLM) framework with a binomial distribution and an identity link to decompose the concentration index.ResultsNational full immunization coverage increased from 43.65% in 2005–06 to 62.46% in 2015–16. Overall, full immunization coverage in both 2005–06 and 2015–16 in all states was lowest in children from poorer households and improved with increasing socioeconomic status. The national concentration index decreased from 0.36 to 0.13 between the two study periods, indicating a reduction in poor-rich inequality. Similar reductions were observed for most states, except in states where inequalities were already minimal (i.e., Tamil Nadu) and in some northeastern states (i.e., Meghalaya and Manipur). In 2005–06, the contributors to wealth-related full immunization inequality were antenatal care, maternal education, and socioeconomic status. The same factors contributed to full immunization inequality in 2015–16 in addition to difficulty reaching a health facility.ConclusionsImmunization coverage and wealth-related equality have improved nationally and in most states over the last decade in India. Targeted, context-specific interventions could help address overall wealth-related full immunization inequalities. Intensified government efforts could help in this regard, particularly in high-focus states where child mortality remains high.

Evaluating the effect of strengthening nurse midwifery pre-service education in two Indian states: A single group pre – and post – intervention study

BackgroundThe high focus states of India have higher maternal and neonatal mortality rates as compared to the national average. The quality of pre-service education (PSE) in nursing midwifery institutions in these states was found to be suboptimal. In 2013, Government of India implemented the PSE strengthening program across all public sector nursing midwifery institutions. The program focused on strengthening educational processes, training infrastructure, institutional management and clinical site practices by implementing a set of performance standards. ObjectiveTo evaluate the effect of PSE strengthening program on institutional performance and maternal neonatal health (MNH) related competences of nursing midwifery students and faculty. DesignSingle group pre-post intervention study. Settings15 sampled public sector nursing midwifery institutions in the states of Madhya Pradesh and Odisha, India. ParticipantsFinal-year students and faculty involved in teaching MNH subjects. MethodsPerformance of 15 sampled institutions was assessed at baseline, midline and endline using the performance standards. Additionally, competences of 232, 295 and 298 students and 64, 62 and 63 faculty members at baseline, midline and endline respectively were assessed on six MNH related practices using objective structured clinical examination (OSCE). ResultsNone of the institutions met 70% standards during baseline. At endline, 13 of the 15 institutions met these standards. The mean OSCE scores of students and faculty at baseline was 17.1 (SD: 8.0) and 23.5 (SD: 14.3) out of 76 respectively. It significantly increased to 66.4 (SD: 8.0) and 71.1 (SD: 5.2) during the endline. The proportion of students and faculty found competent (achieved 75% in OSCE) also significantly increased from none at baseline to 91% and 98% respectively, at endline. ConclusionThe combination of attributes included in the PSE strengthening program may have contributed to improvements in institutional performance as well as MNH related competences of nursing midwifery students and faculty.

District level inequality in reproductive, maternal, neonatal and child health coverage in India

BackgroundAs India already missed maternal and child health related millennium development goals, the maternal and child health outcomes are a matter of concern to achieve sustainable development goals (SDGs). This study is focused to assess the gap in coverage and inequality of various reproductive, maternal, neonatal and child health (RMNCH) indicators in 640 districts of India, using data from most recent round of National Family Health Survey.MethodsA composite index named Coverage Gap Index (CGI) was calculated, as the weighted average of eight preventive maternal and child care interventions at different administrative levels. Bivariate and spatial analysis were used to understand the geographical diversity and spatial clustering in districts of India. A socio-economic development index (SDI) was also derived and used to assess the interlinkages between CGI and development. The ratio method was used to assess the socio-economic inequality in CGI and its component at the national level.ResultsThe average national CGI was 26.23% with the lowest in Kerala (10.48%) and highest in Nagaland (55.07%). Almost half of the Indian districts had CGI above the national average and mainly concentrated in high focus states and north-eastern part. From the geospatial analysis of CGI, 122 districts formed hotspots and 164 districts were in cold spot. The poorest households had 2.5 times higher CGI in comparison to the richest households and rural households have 1.5 times higher CGI as compared to urban households.ConclusionEvidence from the study suggests that many districts in India are lagging in terms of CGI and prioritize to achieve the desired level of maternal and child health outcomes. Efforts are needed to reduce the CGI among the poorest and rural resident which may curtail the inequality.

Cash Incentives to Mothers or to Community Health Workers - What Contributes Better to the Health of the Mother and the Newborn? Evidence From India

This paper investigates the role of demand-side incentives to mothers and supply-side incentives to community health workers (ASHAs) in improving maternal and child health. These conditional cash benefits were part of a nationwide health intervention Janani Suraksha Yojana, introduced in India in 2005. By its unique dual focus on demand and supply, the programme entitled socio-economically backward mothers with cash assistance if they chose to give birth at public health institutions, and simultaneously employed ASHAs to act as a direct link between a pregnant woman and the public health delivery system. By using variations across eligibility of mothers, and the differential implementation of ASHAs across low-focus and high-focus states in a difference-in-difference framework, the maternal and neonatal health outcomes are evaluated. Results show causal evidence that eligible mothers who received both cash benefits and ASHA’s guidance outperformed the eligible mothers receiving only cash benefits, in outcomes such as institutional births and breastfeeding practices. To elucidate, a mother with both cash benefits and ASHA’s counsel experienced a 7.1 percentage points increase in institutional birth rate than her ineligible counterpart; whereas, the corresponding increase for a mother only eligible for cash benefits was 2.9 percentage points. A similar impact is found in the case of antenatal care check-ups of the expecting mother and BCG vaccination of the newborn.

The persistent influence of caste on under-five mortality: Factors that explain the caste-based gap in high focus Indian states.

ObjectiveAlthough under-five mortality rate (U5MR) is declining in India, it is still high in a few selected states and among the scheduled caste (SC) and scheduled tribe (ST) population of the country. This study re-examines the association between caste and under-five deaths in high focus Indian states following the implementation of the country’s National Rural Health Mission (NRHM) program. In addition, we aim to quantify the contribution of socioeconomic determinants in explaining the gap in under-five death risk between the SC/ST population and non-SC/ST population in high focus states in India.Data and methodUsing data from the National Family Health Survey (NFHS), we calculated the U5MR by applying a synthetic cohort probability approach. We applied a binary logistic regression model to examine the association of under-five deaths with the selected covariates. Further, we used Fairlie's decomposition technique to understand the relative contribution of socioeconomic variables on under-five death risk between the caste groups.FindingsIn high focus Indian states, the under-five mortality risk between well-off and deprived caste children has declined in the post-NRHM period, indicating a positive impact in terms of reducing caste-based inequalities in the high focus states. Despite the reduction in under-five death risk, children belonging to the SC population experience higher mortality rates than children belonging to the non-SC/ST population from 1992 to 2016. Both macro level (district level mortality rates) and individual (regression analysis) analyses showed that children belonging to SCs experience the highest likelihood of dying before their fifth birthday. A decomposition analysis revealed that 83% of the caste-based gap in the under-five deaths is due to the distribution of women’s level of educational attainment and household wealth between the SC/ST and non-SC/ST population. Program indicators such as place of birth and number of antenatal care (ANC) visit also contributed significantly to widening caste-based gaps in U5MR.ConclusionThe study indicates that there is still room to improve access to health facilities for mothers and children belonging to deprived caste groups in India. Continuous efforts to raise the level of maternal education and the economic status of people belonging to deprived caste groups should be pursued simultaneously.

The impact of India\u2019s accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study

BackgroundIn 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services.MethodsWe used data from Indian Human Development Surveys done in 2004–2005 and in 2011–2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the program on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled birth attendance (SBA), and giving birth at a health facility.ResultsSubstantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8–22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI − 1.6–11.1), 26% increase in SBA (95% CI 20–31.1), and 28% increase (95% CI 22.4–32.8) in facility births.ConclusionsOur results suggest that the ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize, and retain ASHAs.

The Impact of India's Accredited Social Health Activist (ASHA) Programme on the Utilization of Maternity Services: A Modelling Study

Background: In 2006, the Government of India launched a community health worker programme called the Accredited Social Health Activist (ASHA) programme, with the goal to connect marginalized communities to the healthcare system and improve maternity health outcomes. We assessed the effect of the ASHA programme on the utilization of maternity services. Methods: We used data from Indian Human Development Surveys done in 2004-2005, and in 2011-2012 to assess demographic and socio-economic factors associated with the receipt of ASHA services; and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the ASHA programme on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled attendance at birth (SBA) and delivery at a health facility. Findings: Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backwards castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8-22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI -1.6 - 11.1), 26% increase in SBA (95% CI 20-31.1), and 28% increase (95% CI 22.4-32.8) in facility births. Interpretation: Our results suggest that the ASHA programme is successfully connecting marginalized communities to maternity health services. The study highlights the need improve the coverage of four or more ANC visits, and target programmatic activities to women belonging to scheduled tribes. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize and retain ASHAs. Funding: None Declaration of Interest: The authors declare no conflicts of interest that would influence the results and recommendations of this work. Ethical Approval: Ethical approval was received from the University of North Carolina, Chapel Hill Institutional Review Board.

Decision Support System to Develop Evidence-based Policies for Inequity Reduction in Maternal and Child Health Care

To reduce inequity in maternal and child health care indicators among socio-economically different regions, strategic location-specific policies should be designed. In this research work, a knowledge-discovery-based interactive decision support system has been developed on a web platform which would assist health care policymakers to design evidence-based decisions. Two modules have been prepared under this system to find out key influential Maternal and Child Healthcare (MCH) interventions for socio-economically different regions which had high impact on health care indicators. Data of 284 districts of nine high-focus states of India have been provided into the system to find out the efficiency of the system. Those data have been collected from district- level household survey part three (DLHS-3). The first module of the system has segregated all 284 districts into three segments based on their educational, social and economic conditions, and the second module has found out key influential health care interventions for all three segments separately which had high impact on health care indicators. It has been observed that adolescent health care intervention like female sterilization and childhood health care interventions such as DPT (diphtheria, pertussis, and tetanus) vaccine and measles vaccine were key influential health care interventions. The improvement of coverage of these interventions would help to reduce inequity and improve health care indicators of regions. Further research should be done to understand how the coverage of these interventions can be improved, especially in socio-economically poor regions.

Infection control practices at facilities providing monetary incentives for facility births: An assessment at selected labour and delivery rooms in two states of India

Introduction: We report findings from an assessment of infection prevention and control (IPC) practices using a standardised assessment tool at five facilities in high maternal mortality areas of India. Methods: This study was conducted in five public facilities in the two high-focus states ‒ Odisha and Rajasthan. Both the states registered a high uptake of the Janani Suraksha Yojana programme. We surveyed facilities using the infection control assessment tool. The overall quality of those practices assessed in each section was as follows: A – excellent practices in this area (75%–100% of the possible total score); B – good practices in this area (from 50% to 75% of the possible total score) and C – poor practices needing immediate attention ( Results: The mean score for the hospital facility was 36% (27%–46%) in the C category. General ward facilities mean score was 83% (between 50% and 100%) in the A category. Biomedical waste management scored between 10% and 47% both in the C category. Adherence to policies regarding waste management scored 25%–50% in the C category. All the sites had dedicated labour rooms, and for all the modules, the mean score was Conclusions: Our study reveals that basic core components of IPC practices were not being fully implemented for safe delivery of babies. Antibiotics were being used inappropriately for normal delivery. A robust IPC programme and antimicrobial stewardship programme should be implemented in labour and delivery rooms.

One-year continuation of postpartum intrauterine contraceptive device: findings from a retrospective cohort study in India

ObjectiveTo evaluate outcomes of a national postpartum (within 48 h of delivery) copper intrauterine device placement (PPCuIUD) program in six “high-focus states” with high unmet family planning need in India. Study designWe identified high-volume district hospitals that provided PPCuIUD in six (Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh and Chhattisgarh) Indian states (two per state). Each selected hospital maintained a list of PPCuIUD acceptors with contact phone numbers. We randomly selected 100 women at each site for inclusion in a telephone survey of IUD outcomes at 1 year. Questions regarded IUD expulsion, discontinuation because of symptoms (e.g., pain, bleeding, discharge), discontinuation for other reasons and use of alternative contraception if discontinuation reported. ResultsWe could contact 844 of the 1200 randomly selected women, of whom 673 (79.7%) had postplacental insertion (within 10 min of delivery), while 171 (20.3%) had an early postpartum insertion (between 10 min to 48 h after delivery). Of those contacted, 530 women (62.8%) reported continuing with the method beyond 1 year, 63 (7.5%) reported having an expulsion, 163 (19.3%) reported having removals for associated side effects (bleeding, pain and discharge), and 88 (10.4%) reported having removals for other reasons. After removal or expulsion, almost half of the women (46.5%) did not switch to any other modern contraceptive method. ConclusionPPCuIUD continuation rate at 1 year was 62.8%. Most removals within 1 year were due to associated side effects. Almost half of the women discontinuing PPCuIUD did not switch to an alternative modern contraceptive method. ImplicationsThe 1-year continuation rate of PPCuIUD achieved through a large-scale national program in India is satisfactory. The program though needs to address the low uptake of other modern contraceptive methods after discontinuation.

Continuities and changes in spatial patterns of under-five mortality at the district level in India (1991\u20132011)

BackgroundIndia has the largest number of under-five deaths globally, and large variations in under-five mortality persist between states and districts. Relationships between under-five mortality and numerous socioeconomic, development and environmental health factors have been explored at the national and state levels, but the possible spatial heterogeneity in these relationships has seldom been investigated at the district level. This study seeks to unravel local variation in key determinants of under-five mortality based on the 1991 and 2011 censuses.MethodsUsing geocoded district-level data from the last two census rounds (1991 and 2011) and ordinary least squares and geographically weighted regressions, we identify district-specific relationships between under-five mortality rate and a series of determinants for two periods separated by 20 years (1986–1987 and 2006–2007). To identify spatial groupings of coefficients, we perform a cluster analysis based on t-values of the geographically weighted regression.ResultsThe geographically weighted regression analysis shows that relationships between the under-five mortality rate and factors for socioeconomic, development, and environmental health factors vary spatially in terms of direction, strength, and extent when considering: female literacy and labor force participation; share of scheduled castes and scheduled tribes; access to electricity; safe water and sanitation; road infrastructure; and medical facilities. This spatial heterogeneity is accompanied by significant changes over time in the roles that these factors play in under-five mortality. Important local determinants of under-five mortality in 2011 were female literacy, female labor force participation, access to sanitation facilities and electricity; while the key local determinants in 1991 were road infrastructure, safe water, and medical facilities. We identify six different clusters based on geographically weighted regression coefficients that broadly encompass the same districts in both periods; but these clusters do not follow the regional boundaries suggested by the previous studies. In particular, the high mortality states of India that are often typically classified as high focus states were classified into three different clusters based on the relationship of the factors associated with under-five mortality.ConclusionThis study demonstrates the utility of combining geographically weighted regression and cluster analyses as a methodological approach to study local-level variation in public health indicators, and it could be applied in any country using aggregate-level information from census or survey data. Identifying local predictors of under-five mortality is important for designing interventions in specific districts. Additional reduction in under-five mortality will only be possible with intervention programs designed at the local level, which take into consideration local level determinants of under-five mortality.

Factors influencing the consumption of iron and folic acid supplementations in high focus states of India

Problem consideredIron deficiency during pregnancy is identified as a serious public health problem in most developing countries including India. In India, the majority of the pregnant women are anemic due to a variety of biological and socioeconomic reasons. The purpose of this study is to assess the factors influencing the consumption of Iron and Folic Acid (IFA) supplementation in high focus states of India. Material and MethodsThe present study is based on National Family Health Survey (NFHS-3, 2005-06) data. 11085 Recently delivered women. Variables named religion, place of residence, women’s and education, birth order, wealth index, husband’s education, husband’s occupation, type of caste/tribe, and husband present during antenatal care (ANC) visit were taken as predictors. Women who received at least 90 IFA tablets were considered as outcome variable. ResultsWell educated women are four times more likely to adhere recommended dose of iron supplements (OR=4.21; 95% CI=3.30–5.36, p<0.01). Women with birth order below 2 (OR=2.33; 95% CI=1.84–2.95, p<0.01), women whose husbands are present during ANC visits (OR=2.17; CI=1.92–2.45, p<0.01) and women with high socioeconomic status (OR=2.12; 95% CI=1.70–2.65, p<0.01) are more likely to consume at least 90 days’ iron supplement. Women who had any mass media exposure had 1.34 times (OR=1.34; 95% CI=1.13–1.58, p<0.01) more chances to intake at least 90 IFA tablets. ConclusionsHigher education and lower birth order infer to more iron consumption among pregnant women.