Indian Public Health Research Articles

How Energy Access Impacts Primary Healthcare: Evidence from India

Background: Basic primary healthcare provides a critical safety net for the poor, but it is not always accessible. Unfortunately, primary health systems worldwide suffer from major gaps in infrastructure and human resources. One key infrastructure gap is access to reliable electricity, absence of which can significantly affect the quantity and quality of healthcare services being delivered at rural primary health facilities. However, absence of granular empirical evidence is a barrier for quantitatively understanding the significance of energy access as one of the determinants of access to reliable primary healthcare. Methods: We study the linkages between energy access and primary health services in extra-urban parts of India by focusing on the Primary Health Centers (PHCs), which are the main points of comprehensive primary care in the Indian public health system. Using data from District Level Household and Facility Survey, we develop zero-inflated negative binomial models with state-level fixed effects to estimate the relationship between levels of electricity access and the quantity of basic health services delivered at the PHCs. Findings: We find that lack of electricity access is associated with a significant and large decrease in the number of deliveries (64 percent), number of in-patients (43 percent), and number of out-patients (40 percent). We further find that lower level of energy access at primary health centers disproportionately affects women’s access to safe and quality healthcare. Interpretation: The evidence presented makes a strong case for rural health system policies to pay much more attention to understanding and integrating reliable energy access as an enabler of more equitable access to primary healthcare.

\u201cPublic health is global\u201d: examining Indian stakeholders\u2019 perspectives on Global Health education

BackgroundGlobal health education has attracted significant attention in recent years from academic institutions in developed countries. In India however, a recent analysis found that delivery of global health education is fragmented and called for academic institutions to work towards closing the developing country/developed country dichotomy. Our study explored the understanding of global health in the Indian setting and opportunities for development of a global health education framework in Indian public health institutions.MethodsThe study involved semi-structured interviews with staff of Indian public health institutes and other key stakeholders in global health in India. The interview questions covered participants’ interpretation of global health and their opinion about global health education in India. Thematic analysis was conducted. A theoretical framework developed by Smith and Shiffman to explain political priority for global health initiatives was adapted to guide our analysis to explore development of global health education in Indian public health institutions.ResultsA total of 17 semi-structured interviews were completed which involved 12 faculty members from five public health institutes and five stakeholders from national and multilateral organisations. Global health was viewed as the application of public health in real-world setting and at a broader, deeper and transnational scale. The understanding of global health was informed by participants’ exposure to work experiences and interaction with overseas faculty. Most common view about the relationship between global health and public health was that public health has become more global and both are interconnected. Integration of global health education into public health curriculum was supported but there were concerns given public health was still a new discipline in India. Most participants felt that global health competencies are complementary to public health competencies and build on core public health skills. Employability, faculty exposure to global health and ‘sensitisation’ of all stakeholders were key barriers to offering global health education programs.ConclusionGlobal health as a concept and educational practice is embryonic in India but there is considerable potential to grow in order to ensure that education meets the needs of future practitioners of global health in the context of sustainable development.

Cost Effectiveness of Introducing Etonorgestrel Contraceptive Implant into India’s Current Family Welfare Programme

The aim of this study was to provide evidence to policy makers on cost effectiveness and budget impact for the introduction of the etonorgestrel implant into the Indian public health system. An economic evaluation was conducted to ascertain the potential costs and outcomes of adding the etonorgestrel implant to the public health system of India as compared to the current scenario. A decision analytical model (Markov cohort) was conceptualized from a societal perspective, where a hypothetical population of 15-year-old females was followed until menopause. The primary outcome was incremental cost-utility ratio (ICUR). Sources for model inputs included country-level secondary data analysis, government reports, an observational primary costing study, a systematic review of etonorgestrel implant and targeted literature reviews. One-way and probabilistic sensitivity analyses (OWSA and PSA) were performed to account for uncertainty. The impact of etonorgestrel implant introduction on the annual Indian health budget was also analysed. The base-case ICUR was 16,475 Indian rupees (INR) (USD 232) per quality-adjusted life-year gained, which showed the etonorgestrel implant to be very cost effective (ICUR below willingness-to-pay threshold of INR 137,945 [USD 1943]). OWSA showed that discount rate, percentage of people who do not use contraceptives and costs of managing side effects were the important parameters that affected ICUR. PSA showed that ICUR values of all 1000 Monte Carlo simulations were cost effective. Budget impact analysis showed that introduction of the implant would account for < 1% of the total annual health budget of India, even if acceptance of the implant varied between 0.2 and 4%. Adding the etonorgestrel implant to the public health system would be cost effective for India, with a feasible budgetary allocation.

Longevity and Economic Growth in China and India Using a Newly Developed Bootstrap ARDL Model.

In this study, we use a recently developed Bootstrap ARDL model to examine the influence of longevity (life expectancy after giving birth) and alcohol consumption on economic progression (GDP) in both China and India during the years between 1992 and 2015. Empirical results have shown an extended link across economic development, longevity, and alcohol use in both China and India. The Granger causality test, derived from the Bootstrap ARDL model, demonstrates a unidirectional relationship between economic growth and longevity in China. However, a bidirectional causality exists between longevity and alcohol use in India. Results have important implications for Indian and Chinese governments' public health policies, focused on alcohol consumption reduction specifically, and population health generally.

Indian agriculture, air pollution, and public health in the age of COVID.

Emerging evidence supports the intuitive link between chronic health conditions associated with air pollution and the vulnerability of individuals and communities to COVID-19. Poor air quality already imposes a highly significant public health burden in Northwest India, with pollution levels spiking to hazardous levels in November and early December when rice crop residues are burned. The urgency of curtailing the COVID-19 pandemic and mitigating a potential resurgence later in the year provides even more justification for accelerating efforts to dramatically reduce open agricultural burning in India.

Should We Judge PHCs by Only IPHS Guidelines or Probe Further?

Background: Indian Public Health Standards (IPHS) evaluates supply side compliance of Primary Health Centers (PHCs). Patient Satisfaction (PS) on the other hand, assesses the demand side. Objective: Examining the supply side compliance and relating it to PS in the domain of Reproductive Health (RH). Methods: Using multistage stratified sampling, six rural and three urban PHCs in sub-districts, Ramanagara and Channapatna, in District Ramanagara, state of Karnataka, India, were chosen. Information collected using IPHS proforma for PHCs was compared with PS questionnaire (PSQ 18) data, collected from 398 patients visiting these facilities. Results: Using descriptive and inferential analysis, sub-optimal compliance levels in ease of access, physical &amp; human infrastructure, patient data and usage of untied funds was found. Existing behavioral compliance was found to be optimal. These findings were in alignment with PS findings. Conclusion: Results call for PHC capacity building, incentivization and a crucial need to look into PS side, before passing judgement about performance standard.

Assessment of risk of intussusception after pilot rollout of rotavirus vaccine in the Indian public health system

BackgroundPre-licensure trials of ROTAVAC® were not adequately powered to assess risk of intussusception, a rare adverse event associated with other rotavirus vaccines in some settings. We examined the risk of intussusception after ROTAVAC® vaccination among Indian infants during pilot rollout of the vaccine in the public health system in three states - Himachal Pradesh, Maharashtra and Tamil Nadu. MethodsPassive surveillance for intussusception was set up in 35 sentinel health facilities covering 26.3 million population in the three states under monitoring of an Interministerial-Interagency Steering Committee. Clinical and immunization data were collected by independent teams. An expert committee blinded to vaccination status, classified intussusception cases using Brighton criteria. The self-controlled case-series method was used to estimate risk of intussusception (Brighton Level 1) after ROTAVAC® vaccination. Results151 intussusception cases were included in the analysis. The relative incidence (incidence during the risk period compared to the control period) 1–21 days after doses 1 and 2 combined was 1.56 (95% CI, 0.0–5.28) and that for three doses combined was 1.88 (95% CI, 0.76–4.30). Attributable risk 1–21 days after doses 1 and 2 combined was 0.11 (95% CI, 0.0–0.25) and that for 3 doses combined was 0.42 (95% CI, 0.0–0.70) per 100,000 doses. ConclusionsNo increased risk of intussusception within 21 days of receipt of the first two doses combined or all 3 doses combined of ROTAVAC® was detected.

Measuring accuracy of plethysmography based respiratory rate measurement using pulse oximeter at a tertiary hospital in India

BackgroundChildhood pneumonia continues to be a major infectious killer in India. WHO recommended respiratory rate and oxygen saturation (SpO2) measurements are not well implemented in Indian public health outpatient facilities with the result that treatment decision-making rely on subjective assessments from variably trained and supervised healthcare providers. The introduction of a multi-modal pulse oximeter (POx) that gives reliable measurements would mitigate incorrect diagnosis. In light of future potential use of pulse oximeter in peripheral health centres, it becomes important to measure accuracy of respiratory rate and oxygen saturation of such an instrument. The current study measures accuracy of plethysmography based respiratory rate (RR) using a pulse oximeter (Masimo Rad-G) by comparing it with a gold standard (pediatrician) measurement.Study designA cross sectional study was conducted in the OPD and emergency ward of Kalawati Saran Children’s Hospital over a 2 week period wherein a convenience sample of 97 children (2 to 59 months) were assessed by a pediatrician as part of routine assessment alongside independent measure by a consultant using pulse oximeter. The level of agreement between plethymography based RR and pediatrician measure was analyzed along with sensitivity and specificity of fast breathing of plethymography based RR measure.ResultsBoth methods of measurement show strong association (97%, p < 0.001) and observed values, falling on line of unity, obtained either from pulse oximeter or by pediatrician are very close to each other. Fast breathing measured by POx has a sensitivity of 95% and specificity of nearly 94%.ConclusionThe current study provides evidence of the accuracy of a plethysmography based RR using a pulse oximeter which can potentially be of use in planning of pneumonia management in public health facilities.

PIH14 COST-EFFECTIVENESS AND BUDGET IMPACT OF ADDING ETONORGESTREL CONTRACEPTIVE IMPLANT TO INDIA'S CURRENT FAMILY WELFARE PROGRAM

To provide evidence of cost effectiveness and budget impact for introduction of Etonorgestrel contraceptive implant into the Indian public health system to policy makers. An economic evaluation and a budget impact analysis were conducted.The potential costs and effects of the current contraceptive scenario in the public health system in India was compared with a hypothetical Etonorgestrel implant scenario using a decision analytical model (Markov cohort) from a dis aggregated societal perspective. A hypothetical cohort of 15-year old females were followed till menopause, with primary outcome of Incremental Cost-Utility Ratio (ICUR). Sources for model inputs included country-level secondary data analysis, a multi-center Indian Randomized Control Trial, a primary costing study, systematic review of Etonorgestrel implant and targeted literature reviews. One-way and Probabilistic Sensitivity Analyses (OWSA and PSA) were done to account for uncertainty due to existing diversity in Indian context. The base-case ICUR of USD 232.55 showed that Etonorgestrel implant was very cost effective in Indian context (ICUR was below the willingness to pay threshold of USD 2041.1) OWSA showed that percentage of people who use contraceptives, costs of managing side-effects of contraception and utility-score of Etonorgestrel implant use were the top parameters that affected ICUR. PSA showed that ICUR values of all the 1000 Monte Carlo simulations were cost-effective, making the results of the model robust. Budget impact analysis showed that introduction of the implant into the public health system of India would account for less than 0.5% of the total Indian annual health budget. Adding Etonorgestrel implant to the current contraceptive basket in the public health system would be cost-effective for India, with a feasible budgetary allocation. However acceptability and feasibility studies need to be conducted before its introduction.

Turning gold into platinum: a supplement to guest editorial on “Ministry of Public Health”

Dr. Ravinder Singh indeed articulated an urgent need for a new, robust Indian public health law based on principles of prevention and promotion by empowering communities. He avers that the current framework of laws is inadequate to deal with new and emerging healthcare emergencies and indeed, even basic healthcare needs. He calls for a comprehensive public health law. He proposes that a new Ministry be formed by integrating modern principles of public health with the ancient Indian indigenous systems of medicine which are currently housed under the AYUSH ministry, which will be the implementation agency for this law. This change, he states, will include expanding the basic medical degree to combine all aspects of medical health, encompassing social, spiritual, mental and medical components of healthcare system (integration at ministry level and college level).

Audio-visual training intervention improves knowledge, skill, confidence, and performance of barefoot nurses for screening noncommunicable disease

CONTEXT: In India, the primary health system is inadequate to screen noncommunicable diseases (NCDs) at a population level due to sub-centers being short-staffed and underequipped. Training barefoot nurses (BFNs) to screen NCD is an important strategy of task shifting. Again, there is paucity of studies exploring the effectiveness of training program using technology for training BFNs in the screening of NCDs.AIMS: The aim of the study was to assess the effectiveness of audio-visual-based training to improve knowledge, skill, confidence, and performance (number screened and completeness of data entry) of BFNs to strengthen NCD screening.SETTINGS AND DESIGN: This study was conducted at Doddaballapura taluk of Bengaluru rural district, India. A mixed-method research design was employed to assess the effectiveness of an audio-visual module for training BFNs.SUBJECTS AND METHODS: Descriptive analysis was conducted to test the effectiveness of intervention in pre- and post-intervention period. A focus group discussion was conducted to explore the facilitators and barriers to the intervention.STATISTICAL ANALYSIS USED: Statistical analysis was performed using mean knowledge score (MKS) and two-tailed t-test. Descriptive analysis was done using simple percentages.RESULTS: The MKS of BFN improved across all the six components by 15% after the introduction of the video intervention. This improvement in MKS was statistically significant. The qualitative analysis testifies the improvement in skillsets, namely, finger pricking, swab placement, blood specimen collection, and waste disposal. In addition, the BFNs experience heightened confidence in conducting these procedures. The performance of BFNs has improved the number of screening and data entry into mobile apps.CONCLUSIONS: The findings from this study suggest that audio-visual-based training of BFNs improves their knowledge, skill, confidence, and performance during the screening of NCDs. This evidence has relevance for the Indian public health system, which is struggling due to short-staffing, and is a value addition for training BFNs.

The Effect of Early Childhood Undernutrition on Pre-Adolescent Physical Growth and Cognitive Achievement: Results from India's First Nationally Representative Panel Dataset

Background: There is a lack of nationally representative estimates for the consequences of early child undernutrition on pre-adolescent outcomes in India. Understanding this relationship is helpful to develop interventions that not only prevent child undernutrition but also mitigate its consequences. Methods: Data from two waves of India Human Development, a nationally representative panel survey dataset was used to identify 7,868 children who were assessed for undernutrition during early childhood (0-5 years) in 2004-05 and later re-interviewed during their pre-adolescent (8-11 years) years in 2011-12. Early childhood undernutrition was assessed using the Composite Index of Anthropometric Failure (CIAF). Short stature (height-for-age z <-2), thinness (BMI <18·5 kg/m2), reading, and arithmetic skills during pre-adolescence were considered as outcomes. We used survey-weighted generalized linear models to determine the association between child undernutrition and pre-adolescent outcomes. We assessed differences in this association based on child sex and sociodemographic variables using three-way interaction terms. Results: CIAF increased the odds of short stature and thinness in the pre-adolescent period by 73% and 52%, respectively, while it decreased the odds of achieving a higher reading and arithmetic score by 20%. The disparity in outcomes based on CIAF increased with age, especially for girls. Increased level of female education within the household reduced the disadvantages of undernutrition among female children. Discussion: Early child undernutrition is associated with several adverse pre-adolescent physical and cognitive outcomes, especially among female children. Improved female education can mitigate these consequences. Female education promotion should assume a central role in Indian public health policy-making. Funding Statement: AS received support from the National Institute of General Medical Science (T32GM107000), National Center for Advancing Translational Sciences (TL1-TR001454) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (1F30HD091975-03). TMS received support from the National Center for Chronic Disease Prevention and Health Promotion (5U01DP006093-04). JA received support from the National Institute on Minority Health and Health Disparities (P60-MD006912-05). JAF received support from the National Institute of Health (R01 HD092374-03), and the National Institute of Child Health and Human Development (UH3OD023348-03). Declaration of Interests: The authors have indicated they have no potential conflicts of interest to disclose. Dr. Frazier has had research support from F. Hoffmann-La Roche Ltd., Fulcrum Therapeutics, Janssen Research & Development, LLC, and has served as a consultant for Takeda Pharmaceuticals. However, these activities were not related to the research contained in this manuscript. Ethics Approval Statement: The IRB at the University of Massachusetts Medical School reviewed the protocol and exempted it from full committee review because the publicly available data contained no personal identifiable information on survey participants.

Strategic mental health psychosocial responses in times of COVID-19 in India

The magnitude of the mental health problems and the treatment gap has been an unaddressed concern in the Indian public health system. With the arrival of the COVID-19 pandemic, India is at the brink of a mental health crisis. An overburdened health system will have to cater not just to the existing mental health needs, but also to the added psychosocial adversities arising due to the COVID-19 pandemic. The following article aims to describe the mental health needs of the nation at a time of an infectious epidemic. It further outlines the modalities and the process of service delivery using cross-sectoral, multi-tiered, transdisciplinary human resources, and technological interventions.

Situation Analysis of Implementation of National Health Programmes in Primary Health Centres (Phcs) At Uttarakhand

Context: The Bhore Committee in 1946 gave the concept of PHC as comprehensive primary health care to the community and maintain an acceptable standard of quality of care. The study was conducted to assess the implementation of National Health Programmes at PHCs in Uttarakhand.&#x0D; Methodology: An observational cross-sectional study was conducted at two PHCs (Thano and Raiwala) from March 2019 to April 2019. Interviews of health functionaries and beneficiaries of national health programmes were done based on standard Indian Public Health Standards (IPHS) guidelines and check list, for both PHCs. Beneficiaries under each programme were also observed.&#x0D; Result: Various programmes such as Universal Immunization Programme, School Health Programme, and Pulse Polio Programme, National nutrition Programme, National family welfare Programme, NPCDCS and Jansankhya Niyantran Yojna were implemented successfully at both PHCs. Although knowledge among peripheral health workers was found to be little inadequate.&#x0D; Conclusion: The functioning and execution of some of the National Health Programs at PHCs Thano and Raiwala were found to be inclined with IPHS guidelines.

Gaps in facilities available at Community Health Centers/Rural Hospitals as per Indian public health standards - Study from Western Maharashtra.

Background:The launch of the National Rural Health Mission (NRHM) gives us the opportunity to review the functioning and bring up the Community Health Centers (CHC) services to the level of Indian Public Health Standards and thus improve the lives of citizens.Objectives:Assessment of the gaps in the facilities available at Community health centers/Rural hospitals as per Indian Public health standards.Methods:Facility based cross-sectional study was conducted in the Satara district of Maharashtra.Results:This study in the majority showed that the gap in the delivery of healthcare according to IPHS. It was observed that the Funded CHCs had a better quality of services than the non-funded CHCs. The non-funded CHCs lacked essential emergency services. Along with ANC care, newborn care in the first few minutes of life is very crucial, but very little priority was given to the newborn care as those services were not as per norms. Specialists as well as paramedical and other support staff are deficient in both funded and non funded CHCs/rural hospitals (RHs).Conclusion:Standards were greatly influenced by funds delivered by IPHS itself. A staffing pattern is one of the important pillars in delivering various health services. A better salary, working place with continuous water supply, electricity, and cleanliness will improve the staffing pattern. Therefore, competent manpower and well-built infrastructure will help in the standard delivery of healthcare at CHC/RH and will thus serve the purpose of dispensing basic health services to every individual in the remotest areas.

‘Ayushman Bharat is a Boon for the Country’: Against the Motion

Background: Ayushman Bharat, came into existence in 2018, was based on recommendations of National Health Policy 2017 with an aim to provide Universal Health Coverage to citizens of India. Under this, two inter-connected components were envisaged namely, Health and Wellness Centres and National health protection scheme. But since its inception, there has been concerns with its implementation throughout the country. Objectives: This article primarily identifies the lacunaes in framework and implementation of Ayushman Bharat across the nation. The secondary objective was to study the potential consequences of this scheme on health care infrastructure of country. Result: There is a shortfall of about 20% Sub centres and an equal number of Primary health centres in India and almost 90% of existing ones do not meet Indian Public health standards. This coupled with shortage of manpower is a crucial barrier in concept of HWCs. Inadequate and incomplete coverage of health services with exclusion of outpatient services, ambiguity in beneficiary definitions and concerns related to reports of frauds might affect NHPS implementation. Insufficient financial allocation is a key obstacle for successful implementation of AB. This scheme might lead to compromise in other health related programmes. Conclusion: Without addressing existing deficiencies in health care system, mere introduction of a new comprehensive scheme might fail to achieve its objectives. There is a need to address these gaps first to get the expected results and improve health outcomes in country.

Assessment of primary health centres of a district in North Karnataka according to Indian Public Health Standards 2012 guidelines: a cross sectional study

Background: Primary health centre (PHC) is a basic health unit to provide an integrated curative and preventive health care to the rural population as close to the people as possible, with emphasis on preventive and promotive aspects of health care.Methods: A facility based cross-sectional study was conducted in Belagavi district of Karnataka in India. Twenty PHCs, two PHCs from each of the 10 talukas of Belagavi district were selected by simple random sampling. The study period was from 1st January 2014 to 31st December 2014. Data was collected using a predesigned and structured questionnaire for IPHS facility survey.Results: In this study, only 60% of primary health centres covered the population as per the IPHS norms. All the PHCs were providing the regular outpatient department (OPD) services, referral services, antenatal care, family planning and in-patient services. Bed occupancy rate was less than 40% in 55% of PHCs. Building area in 75% of PHCs were inadequate according to IPHS norms. Residential facility for staff was available only in half of the studied PHCs.Conclusions: IPHS guidelines were not fully being followed at PHC level in the district. Though the requirement of medical officers and pharmacists was fulfilled in almost all the PHCs, deficiency was seen in the appointing of Ayush doctors and staff nurses at PHCs. There is an urgent need of recruiting the deficient staff for efficient functioning of the PHCs.

Comparison of pre training and post training knowledge of hypertension among medical officers of Narmada district of Gujarat, India

Background: Hypertension is a major risk factor contributing to cardiovascular and cerebrovascular diseases and death. Medical officers play an important role in Indian public health care system. The objective of this study was to evaluate the impact of training program on knowledge about hypertension among medical officers working in government health centres in Gujarat, India.Methods: A one day training program was conducted for medical officers of various Primary Health Centres (PHCs) and Community Health Centres (CHCs) in Narmada district of Gujarat. This training focussed on screening, diagnosis and management of hypertension, essential and secondary hypertension, lifestyle modifications, various anti-hypertensive drugs and practical aspects of examining a patient with hypertension. Impact of the training program was evaluated by a questionnaire consisting of 10 questions which was used as a pre-test and a post-test.Results: A total of 30 medical officers (18 male and 12 female) attended the training. The mean age of participants was 37.4 years and average clinical experience was 11 years. The pre-test mean score of participants was 4.52 and post-test mean score was 8.44. This improvement in the post-test mean score was found to be statistically significant. On comparison of questions answered incorrectly in pre-test and post-test, we found that there was a significant reduction in the number of questions answered incorrectly in the post-test.Conclusion: There was a significant improvement in the knowledge of medical officers regarding screening, diagnosis and management of hypertension as a result of their training.

Levels of Health Care and Health Outcomes in Northeast India

This article investigates basic parameters of health, namely health profile, health infrastructure, health expenditure and health care utilization in Northeast India and provides an analysis of regional disparities in health care sector. Health profile is represented through different health indicators like crude birth rate, infant mortality rate, total fertility rate and so on in the region. The status of Sub Centres, Primary Health Centres and Community Health Centres with their various facilities and manpower resources indicates better performance of most Northeastern states compared to the rest of India. However, in practice, the health centres in Northeast India do not fulfil some of the objectives and norms of Indian Public Health Standards. Further, the coefficient of variation shows the regional disparities is widening and worsening for health workforce in Northeast India. The geographic condition and inaccessible terrain of Northeast India seems to be a constraint, among others, in providing health infrastructure in the region.

Readiness of public health facilities to provide quality maternal and newborn care across the state of Bihar, India: a cross-sectional study of district hospitals and primary health centres

IntroductionPoor access to quality healthcare is one of the most important reasons of high maternal and neonatal mortality in India, particularly in poorer states like Bihar. India has implemented initiatives...