Indian Health System Research Articles

Epidemiology of Delayed Union of Long Bones

Aim: To study the epidemiology of delayed union of long bones. Introduction: In India, the availability of fracture healing therapies to the general public is limited. The infrastructure of the health system in India, involving both public and private sector does not provide adequate opportunity for rural and low-income inhabitants to access the needed care. Due to these reasons, majority of the global burden of injuries are borne by low and middle-income countries. Material and methods: Patients getting admitted in AVBRH hospital above the age of 18 years of either sex with radiological features of delayed union. Study was a prospective, case control observational type carried out in a rural health setup at AVBRH. It comprised of 153 patients out of which 43 patients had delayed union of a long bone, 53 patients had non-union. These patients were compared with 57 patients that had postoperative fracture union which were included as a control group who had the same risk factors for delayed union. Results: Aging, female gender, comminuted and segmental fractures, higher grades of soft tissue injury, smoking, and infection were found to be independent risk factors for delayed union in long bone fractures. Among the risk factors, smoking and infection can be controlled to decrease the prevalence of delayed union. Conclusion: It is necessary that we create awareness about the importance of primary treatment like immobilization and wound debridement, as patients should reach as early as possible. Patient’s relative’s moral support is necessary in order to get early hospitalization so as to reduce the risk of delayed union among patients and so that appropriate modality of treatment (surgical and conservative) with use of bone regeneration substitutes such as bone grafting and PRP can be done to promote faster healing keeping infection in control.

Prediabetes and Undiagnosed Diabetes Mellitus: The Hidden Danger

ABSTRACT Introduction Diabetes is considered as a major challenge to the public health system in India. Recent articles clearly mention that the hidden danger in the form of prediabetes and undiagnosed diabetes is greatly adding to the burden silently. Awareness regarding the same, particularly among youth, can help diagnose the condition very early and thus, initiate early management. Objectives With an aim to estimate the frequency of prediabetes and undiagnosed diabetes in the adult population, a camp was organized in our institute to screen the adults in our locality by estimating fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c). Materials and methods A total of 246 individuals were selected for analysis after excluding the known diabetic cases. Height, weight, pulse, blood pressure (BP), waist circumference, and body mass index (BMI) were measured. Plasma fasting sugar and fasting serum lipid profile were analyzed. The HbA1c was estimated in hyperglycemic subjects. Results The frequency of hyperglycemia in the study population was found to be 28%. The total frequency of prediabetes was 18.3% and that of undiagnosed diabetes was 9.75%. The raised sugar could be significantly associated with age, waist circumference, BMI, hypertriglyceridemia, and cholesterol-to-high-density lipoprotein (Chol:HDL) ratio. Aging, greater BMI, hypertriglyceridemia, and raised low-density lipoprotein (LDL) depicted significant odds ratio (OR) to predict the risk factor for diabetes. Conclusion The hidden burden of diabetes in our locality is quite high, which, if not taken care, would result in a public health catastrophe. How to cite this article Patel S, Nanda R, Abraham J, Sahoo S, Ganguly A, Mohapatra E. Prediabetes and Undiagnosed Diabetes Mellitus: The Hidden Danger. Indian J Med Biochem 2017;21(2):91-95.

Tribal health care: The unaddressed aspect in Indian health system

Tribal health care: The unaddressed aspect in Indian health system

Health systems in India.

Health systems and polices have a critical role in determining the manner in which health services are delivered, utilized and affect health outcomes. ‘Health' being a state subject, despite the issuance of the guidelines by the central government, the final prerogative on implementation of the initiatives on newborn care lies with the states. This article briefly describes the public health structure in the country and traces the evolution of the major health programs and initiatives with a particular focus on newborn health.

Distribution of ophthalmologists and optometrists in Islamic Republic of Iran and their associated factors.

We aimed to determine the distribution of ophthalmic care providers and its correlation with health and socioeconomic status and health system indicators. Data were gathered from the Iran Medical Council and the Iranian Societies of Ophthalmology and Optometry. Concurrent indicators were collected from the Statistical Center of Iran and national studies. A population-adjusted number of combined ophthalmologists and optometrists was used as the main dependent variable. Optometrist/ophthalmologist ratio was 0.9. We had 1 ophthalmologist and 1 optometrist for every 40 000 and 45 000 individuals, respectively. We observed a direct correlation between the number of ophthalmologists, optometrists and life expectancy at the provincial level. Gross provincial income and expenditure and provincial literacy were correlated as well. Provincial unemployment had a negative correlation. Provincial hospital statistics and population density were also significantly correlated. The Islamic Republic of Iran has met the World Health Organization's desired per capita number of ophthalmologists and optometrists, but there is wide variation in their density.

Rising Health Expenditure Due to Non-Communicable Diseases in India: An Outlook.

With ongoing demographic transition, epidemiological transition has been emerged as a growing concern in India. The share of non-communicable disease in total disease burden has increased from 31% in 1990 to 45% in 2010. This paper seeks to explore the health scenario of India in the wake of the growing pace of non-communicable diseases such as diabetes and hypertension among Indian population using data from health and morbidity survey of the National Sample Survey Organisation (2004) and notifies about the resource needed to tackle this growing health risk. Given the share of private players (70%) in Indian health system, results indicate a higher private expenditure, mostly out-of-pocket expense, on account of non-communicable diseases. A timely look into the matter may tackle a more dreadful situation in near future.

Essential Health Package for India: Approach and Costing

This work analyses the disease burden and health systems indicators for states, and for the country as a whole, to understand how India might implement an Essential Health Package (EHP) under the Universal Health Coverage (UHC) programme. The analysis indicates much disparity among states, and suggests that they will need flexibility in terms of contents and mix of services as well as operational design in their EHP; one standard, countrywide EHP will not help. The operational part will depend on the availability of health infrastructure and personnel on the one hand and on the ability to raise resources for health on the other.

Inpatient and outpatient health care utilization and expenditures among older adults aged 50 years and above in India

Background: Social and economic inequality in utilization of health care services, as well as high out of pocket expenditures are prevalent in overall Indian population. The situation among older adults will be much more critical as they require long-term health care services. The objective of this study is to assess the utilization of outpatient and inpatient care among older adults and incurred out of pocket health expenditure. It also tried to explore the association between socioeconomic factors on receiving health care services and out of pocket health expenditure among older adults in India.Data source: The data from the Study on Global Ageing and Adult Health (SAGE) Wave 1 was used, which was conducted in 2007-08 in India. Respondents aged 50 and above are taken as older adult population. The final sample size was 7150 respondents aged 50 years and above.Results: The percentage of older adults aged 50 years and above receiving outpatient and inpatient health care service were 87.5% and 14.6% respectively. The use of private health facilities was high compared to government health facility. High utilization of outpatient among women and high use of inpatient care among men were found, which was insignificant after adjusting for other variables. Socioeconomic characteristics also play an important role in access to health care among older adults. Place of residence, marital status, caste, education and presence of morbidity were related to the utilization of health care services. Place of residence, education and wealth quintile were also significantly associated with health expenditures.Conclusion: Requirement of long-term health care among older adult population may result in increasing burden of health care expenditures. Socioeconomic characteristics also play an important role in access to health care among older adults. Developing quality and affordable health care services for older adults to ensure equity in accessibility and affordablility will be a major task for the public health system in India.

Operational Pathways for Integrating National Disease Control Programmes for Universal Health Coverage

A mix-methods study was conducted to identify operational pathways for integration of national vertical programs under the UHC mandate in 7 Indian states. Background:Universal Health Coverage (UHC) is a widely shared global health agenda. WHO estimates that 20-40% of health budgets globally are wasted on system inefficiencies that range from de-motivated health workers, fragmentation, duplication of services, and inappropriate use of medicines and technologies. India currently has 13 national disease control and 2 health promotion programs to address primary healthcare delivery.From a practitioners perspective this report examines within the context of the Indian health system: 1) The role of Centre-State dynamics in program integration and design 2) Is integration desirable (will it add value) and opportune to strengthening weak health systems? 3) Indicate under what circumstances vertical and horizontal programs have a role in health systems and factors policy-makers must take into account when implementing vertical programs and managing integrated servicesObjectives: 1) To assess perceived levels of integration among disease control programs currently under the NRHM in India. 2) To identify operational pathways of integration of various disease control programs within a framework of UHC.Methods: The study incorporates mixed qualitative and quantitative methods with purposive sampling of 125 key informants with equal representation from the government, professionals and civil society. Phase 1 of the study involved desk review to document the history, architecture, and networks among preventive and promotive programs, both at the central and the state levels.Phase 2 resulted in development of a scale to identify and measure the level of integration of national disease control programs. To better clarify the depth of integration within programs five distinct levels demonstrating degrees (or extent) of integration were synthesized and measured according to the number of program components involved. In this scale, various program components correlate with increased levels of integration. A tool was developed to measure the informant’s perception on the level of integration of the disease control programs under the NRHM. Responses were analysed and scored to identify the level of integration among and within programmes and the number of components involved.Results: Our study indicates that the word ‘integration’ has varied interpretations at different levels. Discordance in definitions of integration has led to the concept being used loosely with the terms coordination, collaboration, convergence and cooperation used inter-changeably. Evidence through key informants identified several advantages as well as some drawbacks of programme integration in creating people-centered health systems; and recognized current barriers to integration while providing measures to overcoming them. State-centric models were exemplified in determining various operational pathways to effective integration. Review of integrated programmes shows that their effectiveness, and the factors that facilitate or impede success, depend substantially on the context in which the intervention takes place. Attempts to integrate programmes cannot therefore be seen as separate from their service delivery, geographic, financial and policy contexts. Although the autonomy of individual jurisdictions have been sacrosanct in public health, extending this principle to the design and implementation of the country’s disease control programmes has created challenges in conceiving a workable national health system. On the ground, a programme’s context, organizational capability of a health system and political clout of policy makers eventually influenced the extent of horizontal and vertical integration within and between programmes and ultimately determined solutions for efficient programme design. Integrating programmes will involve using alternative design elements through joint planning and capacity building before they are eventually rolled out at the national and state level. The one-size-fits-all norms and design of many national programmes impose inefficient restrictions on states and annual state plans for programmes are made in a routine manner without consideration for the widely varying requirements of states. Though programme stakeholders from different professional affiliations had different interpretations of the term ‘integration’, overall, the perceived benefits of integrating programmes at Central and State levels to form coordinated networks that contributed to better quality of care for individual patients, improved population health outcomes and reduced costs was unanimously recognized.Both vertical and horizontal approaches to program integration can be beneficial in different contexts and can coexist in health systems. In the long term, the limited evidence base, highly varied contexts and differences in health system capacity call for a pragmatic approach to programme integration rather than reactionary approaches driven by vested interests.

Eradication of Polio in the World; Iran is at Risk for Reemerging of Polio: A Review of the Literature

Context: The wild polio virus is disrupted in all countries in the world, except Afghanistan and Pakistan, the two neighboring countries of Iran. Because of illegal migrations and some geographical, socioeconomic and managerial problems, Iran is exposed to reemerging of the disease. The current study aimed to assess the condition of the disease in Iran and propose preventive measures. Evidence Acquisition: Authors extracted and evaluated 33 relevant articlesamong189 polio related abstracts. The key words were: polio, poliomyelitis, polio eradication, oral polio vaccine (OPV), inactivated polio vaccine (IPV), acute flaccid paralysis (AFP), vaccination derived paralysis (VDP) and Iran. PubMed was used as an international site and IranMedex as a national motor search to assess the subject. Results: Since 2001, Iran is recognized as a polio free country by world health organization (WHO). Afghanistan and Pakistan, the two neighboring countries of Iran, are still infected with wild poliovirus. About 2.5 million Afghan refugees live in Iran and they communicate with their compatriots. Iran and its neighbors are different regarding vaccination coverage rates, rate of access to safe drinking water, political, security and cultural issues, health system and managerial indicators. Conclusions: Health managers in Iran should continuously monitor the coverage of vaccination with at least three doses of OPV in the level of over 95%, monitor the health of the Helmand River water which comes from Afghanistan to Iran, vaccinate the immigrants and replace bivalent vaccine (bOPV) with trivalent (tOPV) vaccine.

Service user involvement for mental health system strengthening in India: a qualitative study.

BackgroundThere is a wide recognition that involvement of service users and their caregivers in health system policy and planning processes can strengthen health systems; however, most evidence and experience has come from high-income countries. This study aimed to explore baseline experiences, barriers and facilitators to service user-caregiver involvement in the emerging mental health system in India, and stakeholders’ perspectives on how greater involvement could be achieved.MethodsA qualitative study was conducted in Sehore district of Madhya Pradesh, India. In-depth interviews (n = 27) and a focus group discussion were conducted among service users, caregivers and their representatives at district, state and national levels and policy makers, service providers and mental health researchers. The topic guide explored the baseline situation in India, barriers and facilitators to service user and caregiver involvement in the following aspects of mental health systems: policy-making and planning, service development, monitoring and quality control, as well as research. Framework analysis was employed.ResultsRespondents spoke of the limited involvement of service users and caregivers in the current Indian mental health system. The major reported barriers to this involvement were (1) unmet treatment and economic needs arising from low access to mental health services coupled with the high burden of illness, (2) pervasive stigmatising attitudes operating at the level of service user, caregiver, community, healthcare provider and healthcare administrators, and (3) entrenched power differentials between service providers and service users.Respondents prioritised greater involvement of service users in the planning of their own individual-level mental health care before considering involvement at the mental health system level. A stepwise progression was endorsed, starting from needs assessment, through empowerment and organization of service users and caregivers, leading finally to meaningful involvement.ConclusionsSocietal and system level barriers need to be addressed in order to facilitate the involvement of service users and caregivers to strengthen the Indian mental health system. Shifting from a largely ‘provider-centric’ to a more ‘user-centric’ model of mental health care may be a fundamental first step to sustainable user involvement at the system level.

Development of a Screening and Brief Intervention Process for Symptoms of Psychological Trauma Among Primary Care Patients of Two American Indian and Alaska Native Health Systems.

American Indian and Alaska Native (AI/AN) people experience high rates of acute, chronic, and intergenerational trauma. Traumatic experiences often increase the risk of both medical and behavioral health problems making primary care settings opportune places to screen for trauma exposure or symptomology. The objective of this study was to determine considerations and recommendations provided by patients, health care providers, health care administrators, and tribal leaders in the development of an adult trauma screening, brief intervention, and referral for treatment process to pilot at two large AI/AN primary care systems. A qualitative and iterative data collection and analysis process was undertaken using a community-based participatory research approach guided by a cross-site steering committee. Twenty-four leaders and providers participated in individual interviews, and 13 patients participated in four focus groups. Data were thematically analyzed to select a trauma screening instrument, develop a screening process, and develop brief intervention materials. The nature of traumas experienced in the AI/AN community, the need to develop trusting patient-provider relationships, and the human resources available at each site drove the screening, brief intervention, and referral process decisions for a future trauma screening pilot in these health systems.

Expectant Mother’s Preferences for Services in Public Hospitals of Tamil Nadu, India

Substantial programmatic efforts have been undertaken to improve the access to maternal care services in the public health system of India, yet the service users are often regarded as passive recipients. Limited research is available on the preferences of service users on what they regard the greatest issues in service delivery. A hospital-based discrete choice experiment (DCE) has been conducted in the public health facilities of Tamil Nadu, a southern state of India. This study uses a sample of 261 women who came for antenatal check-ups across six different public hospitals in Tamil Nadu. The DCE technique, which is rooted in random utility theory (RUT), and conditional logit model have been used to analyze the relative importance of health service attributes. The result showed that regular ward visits by specialist doctors like obstetricians and gynaecologists (O&G) and paediatricians were the most preferred attribute of the maternal care service. Expectant mothers are willing to wait the maximum and are prepared to tolerate health service characteristics in public hospitals, such as poor patient amenities, poor staff attitude and lack of privacy maintained during physical examination, provided specialist doctors are available in the hospitals.

Healthcare under the Panchayati Raj Institutions (PRIs) in a decentralised health system.

Purpose This paper aims to explore the challenges and benefits arising from the involvement of Panchayati Raj Institutions (PRIs) in the provisioning of primary healthcare in a decentralised health system of India. Design/methodology/approach A qualitative study design was used in this study. Data were collected through semi-structured interviews from 89 respondents selected from nine primary health centres across the district. A thematic analytical framework approach was used to analyse the data. Findings The research results indicate that there are several challenges resulting from PRIs involvement, including prioritisation of service providers and users, coercive unethical work and lack of communication. However, there are some benefits associated with the involvement of the PRIs in service provisioning, including improved availability and regularity of healthcare providers at the health centres. Research limitations/implications The implications of the findings suggest that the PRIs play an important role in healthcare provisioning; however, their involvement is ineffective due to their partial capabilities and approach, which creates a non-conducive environment. Practical implications Health issues are among the most important human concerns, and recognising and addressing the grassroot challenges help to locate, and overcome the challenges that hinder the smooth healthcare provisioning process. Originality/value National Rural Health Mission has recognised the PRIs as a platform to promote decentralised health planning and for achieving its goals in India. The PRIs are significantly involved in planning, monitoring and provisioning of primary healthcare services at grassroot level. This paper addresses the challenges and benefits that emerged due to their involvement.

Can draft national health policy-2015 revamp mental health system in India?

Mental Health is an indispensable dimension for human development. It deals with human thoughts and emotions, and provides a pathway for healthy minds and contributes to a healthy living. Absence of healthy mind poses a great burden to the economic, political, and social functioning of human beings, society and nation. Mental health in India is a neglected paradigm with the shortage of trained staff and inadequate infrastructure. Mental illness has been veiled in stigma, ignorance and superstition since a long time in India. Lack of political and administrative leadership, financial commitments and human resources, are missing in the national and expanded district programmes. Efforts have been put in recent times by the government to oversee the disease burden and provide remedial measures. Draft national health policy formulated in 2015 had thrown a light of hope in this scenario. The gap in the provision of efficient health care to the needy was the building block of this draft formulation.The hassles in the existing system should be identified and efforts to cut down the over-burdened system should be made to cater to the actual needs of the community.

Behavior of health workers toward the implementation of clinical guidelines

Background: The maternal health situation in the country always presents challenges before the overall health system in India. Implementation of clinical guidelines can bring uniformity and standards of treatment protocol, leading to better maternal health outcome. Objectives: To understand the attitude, behavior, and challenges faced by health workers with regard to the implementation of clinical guidelines and protocols in the domain of maternal health. Setting and Design: Different cadres of health care providers working at the district and block levels were selected conveniently with the permission of the State health administration. In addition, nursing and medical academicians were also included in the study. Materials and Methods: A pilot qualitative study in two districts of Assam was carried out. Different cadres of health workers such as Medical Officers (MO), Rural Health Practitioners (RHP), and Nurses working at the district and block levels were interviewed in-depth with the help of a semistructured interview schedule, which lasted for 26 days during May-July 2014. Results: The study elicited several pertinent issues related to the implementation of clinical guidelines, which include the introduction of clinical guidelines as a part of academic training, awareness about clinical guidelines, the commonest conditions for which clinical guidelines are used, challenges faced in accessing and implementing guidelines, and specific areas where clinical guidelines should be developed. Poor penetration of clinical guideline implementation was observed in the domain of maternal health care in the study area. Conclusion: Given the situation of maternal morbidity and mortality, the implementation of clinical guidelines appears rational.

Screening of tuberculosis patients for diabetes mellitus is feasible with the existing health system in India.

Screening of tuberculosis patients for diabetes mellitus is feasible with the existing health system in India.

An epidemiological study of prevalence of hypertension and its risk factors in a rural community of Nellore, Andhra Pradesh, India

Background: Hypertension [HTN] is responsible for 57% of stroke deaths and 24% of coronary heart disease [CHD] deaths in India. As per the statistics of Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, the overall prevalence of hypertension in India by 2020 will be 159.46/1000 population. Hypertension will be the major cause of death and disability by the end of 2020. The prevalence of hypertension is increasing in both rural and urban communities. The objectives of the study were to assess the prevalence of hypertension and its associate risk factors in a rural population. Methods: A cross sectional study was conducted by the Department of community medicine in the rural field practice area of a Medical college of Nellore from October 2013 to September 2015. The socio demographic variables and risk factors were obtained by interviewing the subjects in the study and collected in a predesigned questionnaire sheet. The sample size was calculated by prevalence of HTN in previous studies and 1025 subjects were included. The blood pressure was assessed and classified using recent JNC 7 and WHO criteria to grade hypertension. Results: In the study the prevalence of pre-hypertension was 42.63% (437 subjects), stage-I hypertension was 26.15% (268 subjects) and stage-II hypertension was 10.34%. The peak age of prevalence of HTN in both males and females was 60-69 years. Significant association was observed between age, low socio economic index, high salt intake (>10gms/day)) with hypertension. A linear trend of association was seen with tobacco and alcohol use, obesity (BMI>25) and waist-hip ratio more than the cut-off value (p value<0.005). Conclusions: Indian health system is challenged with increasing prevalence of non-communicable diseases and HTN being one of the major. Prioritization of population based prevention approaches requiring multi sectoral actions and evidence based clinical approaches focusing on early detection and treatment can provide benefit to population health. To increase the awareness on hypertension, information about prevention and control of hypertension can be incorporated in the information education and communication (IEC) components of all national programmes. This can complement overall efforts to increase societal awareness through other approaches.

Maternal Health in India: An Overview

Health promotion of the poor is an emerging concern for policy research and action worldwide. In India, most of the population is rural and they live under poor health conditions, especially women who are the poorest of the poor. Early marriage is a common cultural practice and a woman is pressurized to undergo several pregnancies, starting from adolescence. This results in maternal deaths and women's poor reproductive health status. Gender has been ignored as a critical dimension of reproductive health, and in health and family planning programmes. This paper highlights the importance of maternal health in India by stressing on factors such as socio-cultural aspects, maternal mortality, quality of health services, unmet need for family planning and the neglected health needs of adolescents. Reduction of maternal mortality rates by three quarters is one of the Millennium Health Development Goals that India is committed to achieve by 2015. The recently launched National Rural Health Mission is making commendable efforts in strengthening the public health system in India. Implementation of all the existing health programmes has to be strengthened with an increased spending on the health. The paper further suggests the need to bring together holistic concerns for linking health to family and gender by addressing adolescents' health needs, expanding health infrastructure and empowering women. Civil society and other stakeholders could contribute towards maternal health in order to make human development sustainable.

Cultivation Prospective of Some Commercially Important Medicinal Plants for Indian Health System

Attempts have been made to provides comprehensive information on the distribution pattern, nativity, classification, cultivation practices and uses of some important medicinal plants of India. The distribution pattern of the species plays an important role for prioritization of the species for cultivation and conservation. It has been noted that cultivation of medicinal plants within the distribution range has received greater success than the cultivation of species outside the distribution range. India has rich diversity in medicinal plants, which needs to be exploited judiciously without disturbing its ecological balance. Undoubtedly, resources need to be harnessed for economic development but simultaneously we have to be concerned about their regeneration, preservation and propagation, so what these are available to us for use on a sustainable basis.