Public Health Facilities In India Research Articles

Self-reported symptom burden among patients attending public health care facilities in India: Looking through ICPC-3 lens.

The objectives of this study were: 1) to describe the socio-demographics and classify the chief complaints and reasons to encounter facilities of patients presenting to public healthcare facilities; 2) to explore differences in these complaints and: International Classification of Primary Care-3 (ICPC-3) groups across socio-demographic and health system levels. This is a cross-sectional study conducted in three districts of Odisha, India. Within each district, the district hospital (DH), one Sub-district hospital (SDH) (if available), two Community health centers (CHCs), and two Primary health care centers (PHCs) were selected. Thus, a total of three DHs, three SDHs, six CHCs, and six PHCs were covered. Two tertiary healthcare facilities were also included. Patients aged 18 years and older, attending the Outpatient Departments (OPD) of sampled health facilities were chosen as study participants through systematic random sampling. A total of 3044 patients were interviewed. In general, 65% of the sample reported symptoms as their chief complaint for reason of encounter, whereas 35% reported disease and diagnosis. The most common reasons to encounter health facilities were fever, hypertension, abdominal pain, chest pain, arthritis, skin disease, cough, diabetes, and injury. Among the symptoms, the highest number of patients reported the general category (29%), followed by the digestive system (16%). In the disease category, the circulatory system has the highest proportion, followed by the musculatory system. In symptom categories, general, digestive, and musculatory systems were the key systems for the reasons of encounter in outpatient departments irrespective of different groups of the population. In terms of different tiers of health systems, the top three reasons to visit OPD were dominated by the circulatory system, respiratory system, and musculatory system. This is the first Indian study using the ICPC-3 classification for all three levels of health care. Irrespective of age, socio-economic variables, and tiers of healthcare, the top three groups to visit public health facilities according to the ICPC-3 classification were consistent i.e., general, digestive, and circulatory. Implementation of standard management and referral guidelines for common diseases under these groups will improve the quality and burden at public health facilities in India.

Determinants of public institutional births in India: An analysis using the National Family Health Survey (NFHS-5) factsheet data.

Institutional births ensure deliveries happen under the supervision of skilled healthcare personnel in an enabling environment. For countries like India, with high neonatal and maternal mortalities, achieving 100% coverage of institutional births is a top policy priority. In this respect, public health institutions have a key role, given that they remain the preferred choice by most of the population, owing to the existing barriers to healthcare access. While research in this domain has focused on private health institutions, there are limited studies, especially in the Indian context, that look at the enablers of institutional births in public health facilities. In this study, we look to identify the significant predictors of institutional birth in public health facilities in India. We rely on the National Family Health Survey (NFHS-5) factsheet data for analysis. Our dependent variable (DV) in this study is the % of institutional births in public health facilities. We first use Welch's t-test to determine if there is any significant difference between urban and rural areas in terms of the DV. We then use multiple linear regression and partial F-test to identify the best-fit model that predicts the variation in the DV. We generate two models in this study and use Akaike's Information Criterion (AIC) and adjusted R2 values to identify the best-fit model. We find no significant difference between urban and rural areas (P = 0.02, α =0.05) regarding the mean % of institutional births in public health facilities. The best-fit model is an interaction model with a moderate effect size (Adjusted2 = 0.35) and an AIC of 179.93, lower than the competitive model (AIC = 183.56). We find household health insurance (β = -0.29) and homebirth conducted under the supervision of skilled healthcare personnel (β = -0.56) to be significant predictors of institutional births in public facilities in India. Additionally, we observe low body mass index (BMI) and obesity to have a synergistic impact on the DV. Our findings show that the interaction between low BMI and obesity has a strong negative influence (β = -0.61) on institutional births in public health facilities in India. Providing households with health insurance coverage may not improve the utilisation of public health facilities for deliveries in India, where other barriers to public healthcare access exist. Therefore, it is important to look at interventions that minimise the existing barriers to access. While the ultimate objective from a policy perspective should be achieving 100% coverage of institutional births in the long run, a short-term strategy makes sense in the Indian context, especially to manage the complications arising during births outside an institutional setting.

District-Level Patterns of Health Insurance Coverage and Out-of-Pocket Expenditure on Caesarean Section Deliveries in Public Health Facilities in India

Reducing catastrophic out-of-pocket expenditure (OOPE) and increasing the rates of institutional deliveries are part of the Sustainable Development Goals (SDGs). India has made significant progress on the maternal and child health front in recent years. India’s National Health Mission (NHM) has been able to increase rates of institutional deliveries. In the present study, we aim to ascertain district-level patterns of percentage of health insurance coverage in the National Family Health Surveys NFHS 4 and NFHS 5. We also aim to ascertain district-level patterns of out-of-pocket expenditure on C-section deliveries in public health facilities in NFHS 4 and NFHS 5. The present study explores district-level data associated with health insurance coverage (%) and out-of-pocket expenditure in a public health facility (in INR) observed across NFHS 4 and NFHS 5. A spatial analysis was carried out using QGIS 3.26 (Mac version) and GeoDA 1.20.0.8. A visual assessment of the maps across NFHS 4 and NFHS 5 shows improvement in insurance coverage at the district level across the two surveys. Despite an increase in insurance coverage, North East India has experienced an increase in OOPE for C-section deliveries. Rajasthan and various parts of South India have experienced a decrease in OOPE for C-section deliveries. Kerala has experienced a rise in insurance coverage and OOPE for C-section deliveries. Univariate LISA cluster and significance maps revealed that Kerala and Tamil Nadu, the eastern coast of India and parts of Mizoram are hot spots, whereas Jammu and Kashmir and parts of Uttar Pradesh and Gujarat are cold spots. Both these findings are significant. Rajasthan emerges as a significant hot spot along with parts of Assam and a few districts on the eastern coast of India in Tamil Nadu and Andhra Pradesh. Jammu and Kashmir, Ladakh, parts of Uttar Pradesh, Maharashtra, and Karnataka have emerged as significant cold spots. The South Indian states of Kerala and Tamil Nadu are no longer hot spots indicating geospatial variations across time. An increase in the number of hot spots across NFHS 4 and NFHS 5 indicates rising out-of-pocket expenditure for C-sections despite growth in health insurance coverage. The present study does not offer any evidence to suggest that health insurance coverage decreases OOPE on C-section deliveries at government facilities. With RSBY having been launched in 2008 and Ayushman Bharat in 2018, high levels of OOPE on C-section deliveries at government facilities raise serious concerns about the efficacy of PFHIs in reducing OOPE. The government would need to plug the well-documented weaknesses of PFHIs, such as fraud, double charging, poor enrolment, and lack of awareness in addition to the unfortunate phenomena of “tips” and “tie ups” mentioned earlier that plague the public healthcare system, if we are to see any reduction in OOPE in the foreseeable future.

Subtype diversity and emergence of drug resistance in HIV-1 in solapur district of Maharashtra, India.

Even after four decades, HIV infection remains a global challenge and a leading cause of mortality in adults across the world. Anti-retroviral therapy (ART) that controls HIV viremia, is now available through public health facilities in India but drug resistance, which is likely to develop among these individuals remains poorly studied in India. The objectives of present study are to find out the HIV-1 virus subtypes, drug resistance mutations and HIV-1 drug resistance to NRTI, NNRTI and protease inhibitors in the Solapur district, India. In a cross sectional study, forty two ART-experienced HIV-1-infected patients with CD4+ count < 200 cells ml-1 and viral load (VL) > 3, 000 copies ml-1 were recruited. All patients belonged to Maharashtra State of India near Barshi Solapur and had been on ART treatment for over 5 years. EDTA whole blood from HIV-1-infected patients was centrifuged and the viral nucleic acid was purified from the plasma. Viral nucleic acid was amplified by PCR using protease and reverse transcriptase specific primers. The resulting amplicons were sequenced and studied for mutations. The tools from Stanford University website were used for subtyping of HIV-1 and identification of mutations conferring drug resistance. In present investigation, HIV-1 subtypes were subtype C in 37 (88.09%), subtype CRF01_AE in 2 (4.76%), and subtype A in 3 patients (7.14%). Drug resistance mutations of NRTI, NNRTI and protease were observed in 15 (37.71%) of 42 patients tested. Drug resistance for NRTI was observed in 12 (28.57%) and for NNRTI in 13 (30.95%) patients. No drug resistance was observed for protease inhibitors. Considerable HIV-1 drug resistance exists among patients receiving ART from a rural areas of India, suggesting more studies from rural region are required to prevent development of resistance to ART.

Maternal satisfaction among mothers delivering at public health facilities in India: a narrative review

Satisfaction is considered as a very important indicator of quality of services. Availability of patient centered services ensures optimum utilization and compliance to interventions. Maternal satisfaction with the available childbirth services has an impact on her birthing experience and ability to bond with the newborn. Multiple factors influence maternal satisfaction with childbirth services. This narrative review summates the level of maternal satisfaction with child birth services at public health facilities and its determinants. PubMed and Google Scholar data base were searched using various keywords and Mesh terminologies. Reference lists of related articles were also screened. This review concluded that the majority of the mothers were satisfied with the child birth services available at the public health facilities. All three domains of the Donabedian model of quality care including the structure, process and outcome were among the determinants of maternal satisfaction but process of care dominated the determinants of maternal satisfaction. Interpersonal behavior was a key determinant of maternal satisfaction; other determinants were provision of privacy, availability and perceived competency of human resource and cleanliness of the labor room.

Unmet need for treatment-seeking from public health facilities in India: An analysis of sociodemographic, regional and disease-wise variations.

Treatment-seeking behaviour is closely associated with the health status of individuals and countries. About 800 million people have no access to health services in the developing world. Though the situation has been improving, the inequalities across geographical regions, socioeconomic status, and disease types continued to persist. The available literature suggests research gaps in examining the unmet need for treatment-seeking from public health facilities across sociodemographic characteristics, regions, and specific diseases. Data for this study comes from the three rounds of National Sample Survey (NSS) (2004, 2014, 2018). We applied descriptive, bivariate, and multivariable analysis to investigate the unmet need for treatment-seeking for public health facilities across sociodemographic characteristics, regions, and specific diseases between 2004 and 2018. The unmet need for treatment-seeking from public health facilities remained high at 60% in 2004 to 62% in 2018. However, the proportion of respondents who did not seek treatment has reduced 12% to 3% from 2004 to 2018. In states like Andhra Pradesh, Madhya Pradesh, Maharashtra, Punjab, Telangana, Uttar Pradesh, and West Bengal, the unmet need for treatment-seeking from public health facilities was more than 60% in 2018. For 2018, the quality of services at public health facilities was the main reason for showing a higher unmet need for treatment-seeking in the richer MPCE quintiles. On the other hand, the ailment not considered serious as the main reason for the unmet need for treatment-seeking from any sources has got nearly doubled from 36% in 2004 to 71% in 2018. This study concludes that improving the availability of various kinds of services at public health facilities should be a priority under India's universal health coverage program. Education plays a vital role in treatment-seeking. Thus, there is an urgent need for increasing awareness among people for treatment-seeking. Ensuring a minimum quality of health care services and reducing long waiting timing would reduce the apathy to receive services from the public health facilities.

What is the impact of COVID-19 pandemic era 2020 on JsskJanani-Shishu Suraksha Karyakram (mother-child protection program) services utilization in India – A cross-sectional comparative research study?

In India due to the elevated fertility rate and vast population (globally next to china) mother (Janani) and child (Shishu) protection programs (Suraksha Karyakaram) are quite significant for public healthcare provision systems, especially in the ongoing COVID-19 pandemic era during which most of the necessary pregnancy and infant care protective health services utilization are disrupted. The Government of India started JSSK (Janani Shishu Suraksha Karyakaram) on 1st June 2011 for the benefit of millions of pregnant women (PW) and infants utilizing Government (public) health facilities across all the States and UTs (union territories) of India. The Government JSSK scheme provides various free entitlements and services to PW and infants. This may improve maternal and child health services utilization at public health facilities which can reduce MMR (maternal mortality rate) and IMR (infant mortality rate) in the country. The ongoing COVID 19 pandemic era has disrupted several routine health services utilization in India due to lockdowns etc particularly RCH (reproductive and child health) healthcare services which made a situation of rethinking necessary to take necessary steps in the healthcare system's current scenario to prioritize the services according to need and urgency as well as to construct a robust plan to ensure public health services utilization amidst pandemic or any disasters. This research study was done to provide reference to the scientific community and decision-makers with concrete data analysis from accredited HMIS (Health Management Information system) source (Government of India- MoHFW (Ministry of Health and Family Welfare)) to find out the COVID-19 impact on JSSK services utilization by the PW and sick infants of India attending public healthcare facilities across 36 states and UTs of India. This research study was public health facility-based, retrospective, mixed, cross-sectional study that was conducted for infants and pregnant women who utilized the available free services under JSSK in the public health facilities across 36 states and UTs of India from 1st January 2018 to 31st December 2020. The first COVID-19 patient in India was confirmed on the 27th of January 2020. Hence for this research study, the year before 2020 i.e. 2018, and 2019 were considered as the pre-pandemic period and the year 2020 was considered as the pandemic period. This research study revealed that there is an increase in almost all JSSK service utilization at public health facilities in India compared to the pre-pandemic era on a cumulative all India bases.

Cost of providing family planning services & management of pregnancy outcomes at public health facilities in India.

Background & objectives:Lack of costing data is a critical gap that exists in the field of family planning (FP) in India. The aim of this study was to estimate health system costs of FP in India for existing modern methods, and potential newer methods (etonorgestrel implant and levonorgestrel intrauterine device) and pregnancy-related services in India.Methods:A bottom-up micro-costing study was conducted in five public health facilities of an Indian State. Data of last one year were collected from existing hospital records and hospital staff was interviewed. Collected data were analyzed using standard costing methods.Results:Package costs of delivering FP services ranged from ₹ 807 (95% CI 685, 931) for condoms and ₹ 10,539 (8796, 12269) for tubal ligation. Estimates of etonorgestrel implant and levonorgestrel intrauterine system were ₹ 3,200 (2800, 3625) and 3,426 (3232, 3623). Cost of antenatal care along with vaginal delivery, caesarean and abortion were ₹ 10,916 (8744, 13078), 22,136 (17570, 26910) and 8,574 (6791, 10379), respectively. One way sensitivity analysis showed that the three most influential factors on the costs of FP services were prices of drugs and consumables, number of beneficiaries and health personnel cost.Interpretation & conclusions:The present study has generated package costs for FP and pregnancy-related services in India which could be used by publicly-funded insurance schemes, for budgeting, economic evaluations and improve resource allocation of services. The cost estimates from this study add to the limited literature in India on costs of FP.

Attributes of Standard Treatment Guidelines in Clinical Settings and Public Health Facilities in India.

Standard Treatment Guidelines (STGs) are time-tested tool to improve healthcare quality and patient safety. This study was done to review the available guidelines and assess their essential attributes using AGREE reporting checklist 2016. Publications from PubMed, World Health Organization, Global Health Regional Libraries, Index Medicus, Google, Google Scholar, and insurers, state/central government portals were searched. In total, 241 STGs met the inclusion criteria. A range of developers with a varying focus and priorities developed these guidelines (government mostly under national programs 134 (56%); professional associations 67 (28%), academic/research institutions 36 (15%); international agencies 4 [2%]). The government-led guidelines focused on program operations (mainly infections, maternal, and childcare), whereas insurers focused on surgical procedures for protection against fraudulent intentions for claims. The available STGs varied largely in terms of development process rigor, end-user involvement, updation, applicability, etc.; 12% guidelines developed documented GRADE criteria for evidence. Most guidelines focused on the primary care, and only 27 and 7% included treatment at tertiary and secondary levels, respectively, focused on general practitioners. There is a need for coordinated, and collaborative efforts to generate evidence-based guidelines, facilitate periodic revisions, standardized development process, and the standards for monitoring embedded in the guidelines. A single designated authority for the standard treatment guidelines development and a central web-based repository with free access for clinicians/users will ensure wide access to quality guidelines enhancing acceptance and stewardship.

Cost-effectiveness of uterine balloon tamponade devices in managing atonic post-partum hemorrhage at public health facilities in India.

ObjectivePost-partum hemorrhage (PPH) is the leading direct cause of maternal mortality in India. Uterine balloon tamponade (UBT) is recommended for atonic PPH cases not responding to uterotonics. This study assessed cost-effectiveness of three UBT devices used in Indian public health settings.MethodsA decision tree model was built to assess cost-effectiveness of Bakri-UBT and low-cost ESM-UBT alternatives as compared to the recommended standard of care i.e. condom-UBT intervention. A hypothetical annual cohort of women eligible for UBT intervention after experiencing atonic PPH in Indian public health facilities were evaluated for associated costs and outcomes over life-time horizon using a disaggregated societal perspective. Costs by undertaking primary costing and clinical parameters from published literature were used. Incremental cost per Disability Adjusted Life Years (DALY) averted, number of surgeries and maternal deaths with the interventions were estimated. An India specific willingness to pay threshold of INR 24,211 (USD 375) was used to evaluate cost-effectiveness. Detailed sensitivity analysis and expected value of information analysis was undertaken.ResultsESM-UBT at base-case Incremental Cost-Effectiveness Ratio (ICER) of INR -2,412 (USD 37) per DALY averted is a cost-saving intervention i.e. is less expensive and more effective as compared to condom-UBT. Probabilistic sensitivity analysis however shows an error probability of 0.36, indicating a degree of uncertainty around model results. Bakri-UBT at an ICER value of INR -126,219 (USD -1,957) per DALY averted incurs higher incremental societal costs and is less effective as compared to condom-UBT. Hence, Bakri-UBT is not cost-effective.ConclusionFor atonic PPH management in India, condom-UBT offers better value as compared to Bakri-UBT. Given the limited clinical effectiveness evidence and uncertainty in sensitivity analysis, cost-saving result for ESM-UBT must be considered with caution. Future research may focus on generating high quality comparative clinical evidence for UBT devices to facilitate policy decision making.

Text messaging improves diabetes-related knowledge of patients in India: A quasi-experimental study.

. Diabetes-related health education promotes patient efficacy for diabetes self-management. However, sub-optimal knowledge of diabetes in people with diabetes is recognized as a challenge in overcrowded public health facilities in India. We aimed to determine the effect of health education through mobile phone text messages (short messaging service [SMS]) on diabetes-related knowledge of patients with diabetes. . From February 2016 to February 2017, we recruited adult patients with diabetes for this quasi-experimental study done in the outpatient setting of a major tertiary care government hospital in Delhi, India. Participants in the intervention group received a text message on diabetes self-care practices every alternate day for 90 days. We evaluated the patients' knowledge of diabetes using the Spoken Knowledge in Low Literacy in Diabetes (SKILL-D) questionnaire and a self-designed diabetes knowledge questionnaire. . We enrolled 190 men and 160 women, of whom 52 (13.7%) were lost to follow-up. At baseline, mean diabetes knowledge scores were higher in the intervention group compared to the control group. After the intervention period of 3 months, the diabetes knowledge scores for SKILL-D and the patient diabetes knowledge questionnaire showed a statistically significant increase in the intervention group (mean difference 0.7 and 0.5, respectively; p<0.001, but there was no increase in the control group). . The use of mobile phone technology for diabetes-related health education through mobile text-message (SMS) technology is an effective method for health promotion.

Quality of care in sterilization services at the public health facilities in India: A multilevel analysis.

Female sterilization is the most popular contraceptive method among Indian couples, and the public sector is the major source of sterilization services in the country. However, concerns remain on the quality of services provided, deaths, failures, and complications following sterilization. In this paper, we study the complexities around the quality of care in female sterilization services at public health facilities and identify strategies for improving the measurement of such quality. A better understanding of these issues could inform pragmatic strategies for enhancing quality. This study uses data from the National Family Health Survey (NFHS) 2015-16 and District Level Household and Facility Survey (DLHS) 2012-13. The study is limited to only districts whose data are available in both DLHS 2012-13 and NFHS 2015-16. The methods of analysis include bivariate statistics, Pearson's chi-square test, and two-level mixed-effects logistic regression. We found that the quality of care (QoC) in sterilization service at the public health facilities in India is associated with facility readiness and the socio-economic characteristics of the clients. There is a significant association between household wealth and the QoC received. Our study provides empirical shreds of evidence on the role of structural attributes in delivering quality sterilization services. The spatial analyses revealed the geographies in the country where the QoC and facility readiness are low. Quality should be an overriding priority to establish the credibility of any health care delivery system. It is essential to provide safeguards against adverse events to develop the client's confidence in the services, which is the key to success for any voluntary family planning program like in India.

Determinants of technology use for a mobile health intervention across public health facilities in rural India: Protocol for implementation research

This paper presents a research protocol for implementation research (IR) to investigate contextual factors influencing the implementation of ASMAN mobile health intervention and their association with maternal, newborn, and child health outcomes. The IR will cover roughly 16-20 public health facilities across the states of Rajasthan and Madhya Pradesh in India. These facilities will be a sub-sample of 49 facilities covered separately under the outcome evaluation. The study employs a longitudinal mixed-methods multiple case study design with sequential data collection using constructs under the Consolidated Framework for Implementation Research (CFIR) across two phases. The first phase will be exploratory and use qualitative inquiry to contextualize the CFIR constructs. The second phase will employ a mixed-methods explanatory design with both validated and contextualized CFIR constructs and standard quantitative measures collected through outcome evaluation. Findings from this study will provide insights into factors that facilitate or impede the implementation of mobile health interventions and their association with MNCH outcomes in public health facilities in India.

Availability and use of continuous positive airway pressure (CPAP) for neonatal care in public health facilities in India: a cross-sectional cluster survey

ObjectivesTo determine the availability of continuous positive airway pressure (CPAP) and to provide an overview of its use in neonatal units in government hospitals across India.SettingCross-sectional cluster survey of a...

Strengthening the Use of Partograph in High Caseload Public Health Facilities in India through an Integrated Quality Improvement Approach.

Background:The effective implementation of evidence-based practices including the use of partograph to improve maternal and newborn outcomes is critical on account of increased institutional delivery. However, despite clear guidelines, partograph use in India is not widely practiced.Materials and Methods:Quality improvement (QI) efforts along with training and mentoring were operationalized in a total of 141 facilities across 26 high priority districts of India. Assessments were conducted across baseline, intervention period, and end line. These included reviewing the availability of partograph and staff competency in filling them at baseline and end line, as well as reviewing monthly data for use and completeness of filling. The monthly data were tabulated quarter wise to study trends. Competency scores were tabulated to show the difference across assessments.Results:An overall upward trend from 29% to 61% was seen in the practice of partograph use. Simultaneously, completeness in filling up the partograph increased from 32% to 81%. Staff competency in filling partograph improved considerably: proportion of staff scoring low decreased over the intervention period from 63% to 2.5% (P < 0.0001), and the proportion scoring high increased from 13% to 72% (P < 0.0001) from baseline to end line.Conclusion:The integrated approach of training, mentoring, and QI can be used in similar settings to strengthen partograph use.

Cross-Sectional Study of Clients’ Satisfaction With Outpatient and Inpatient Services of Public Health Facilities of a North Indian State

Satisfaction with health care services is a desired outcome of health care delivery. Nonetheless, there is scant information on client satisfaction with services provided in public health facilities in India. A cross-sectional study of persons attending public health facilities in Punjab, North India, was carried out in 2016. All district hospitals, subdistrict hospitals, 2 community health centres (CHCs), and 6 primary health centres (PHCs) were randomly selected from each of the 22 districts. A 60-item pre-tested and validated questionnaire was used to collect data. Participants (3278 outpatient department [OPD] and 1614 inpatient department [IPD]) visiting health care facilities were interviewed. Majority of OPD participants were satisfied with registration process, care providers, and personal issues like safety and security at the health facilities. Major domains of dissatisfaction were long waiting time and concern shown for patients during lab tests and x-rays. Most IPD participants were satisfied with care received from nurses and doctors, availability of medicines, and hospital environment. Domains of dissatisfaction were cleanliness of rooms and bathrooms and quietness at night. Varying levels of satisfaction were observed for experiences during stay, information about new medicine being given, pain control, and locomotion to bathroom or using bedpan. Around 71% were likely to recommend the health facility to others. Satisfaction with public health facilities is context dependent. Lack of drugs and supplies, poor information about medicines, long waiting time, poor cleanliness, lack of privacy, and peace were the major reasons for dissatisfaction in our study.

Diabetes care in public health facilities in India: a situational analysis using a mixed methods approach.

BackgroundWeak public health systems have been identified as major bottlenecks in providing good quality diabetic care in low- and middle-income countries.MethodologyThe present study assessed diabetic care services at public health facilities across six districts in three states of India using a mixed methods approach. The study described diabetes care services available at public health facilities and identified challenges and solutions needed to tackle them. The quantitative component included assessment of availability of services and resources, whilst the qualitative component was comprised of semistructured interviews with health care providers and persons with diabetes to understand the pathway of care.ResultsA total of 30 health facilities were visited: five tertiary; eight secondary and 17 primary health facilities. Patient clinical records were not maintained at the facilities; the onus was on patients to keep their own clinical records. All had the facility for blood glucose measurement, but HbA1c estimation was available only at tertiary centers. None of the primary health centers in the three states provided HbA1c estimation, lipid examination, or foot care. Lifestyle modification support was available in only a few tertiary facilities. Antidiabetic drugs (biguanides and sulphonyl ureas) were available in most facilities, and given for 14 days. Insulin and statins were available only at secondary and tertiary care centers. Forty-two physicians were interviewed and poor follow-up, patient overload, and lack of specialized training were the major barriers that emerged from the interview responses. A total of 37 patients were interviewed. Patients had to visit tertiary facilities for drugs and routine follow-up, thereby congesting the facilities. There was no formal referral or follow-up mechanism to link patients to decentralized facilities.ConclusionThere is a wide gap between effective diabetes management practices and their implementation. There should be a greater role of secondary care facilities in follow-up investigations and screening for complications. A holistic diabetic care package with a robust recording and cohort monitoring system and adequate referral mechanism is needed.

Benefit incidence analysis in public health facilities in India: utilization and benefits at the national and state levels

BackgroundBenefit Incidence Analysis (BIA) is used to understand the distribution of health care utilization and spending in comparison to income distribution. The results can illustrate how effectively governments allocate limited resources towards meeting the needs of the poor. In analyzing the distribution of public spending on inpatient, outpatient, and deliveries, this paper represents the most recent BIA completed in India.MethodsIn order to conduct the BIA statistical analysis for this project, 2014 utilization data from the most recently completed Indian National Sample Survey (NSS) was used. Unit costs were estimated for primary care, hospital inpatient, hospital outpatient, and deliveries. Concentration curves and concentration indices were estimated both at the national and state levels. Analyses were reported for overall utilization, as well as for the gross and net benefits for inpatient, outpatient, and deliveries.ResultsAccording to the results, utilization of government inpatient and delivery services is pro-poor. When gross and net benefits are included in the analysis, services become more equal and less pro-poor. Gross benefits, which are measured with state-level unit costs, are virtually equal for all services. Although there are some pro-poor gross benefits trends for national outpatient services, the results also show that the equality of national gross benefits trends hides a significant disparity across Indian States. While a number of Indian States have outpatient gross benefits that are pro-poor, few show pro-poor benefits for inpatient and delivery services. Net benefits, which considers both unit costs for each respective service, and out-of-pocket (OOP) expenditures, trend similarly to gross benefits. In addition, those who use public facilities spend considerable OOP to supplement government services.ConclusionsThis BIA reveals that government spending on public health care has not resulted in significantly pro-poor services. While some progress has been made relative to deliveries and outpatient services, inpatient stays are not pro-poor. In addition, national results mask significant disparities across Indian states.

Kayakalp – Utility of a novel Indian tool for the assessment of biomedical waste management in a district hospital of Northern India

Introduction: Kayakalp is an innovative initiative launched by the Ministry of Health and Family Welfare as a part of the Swachh Bharat Abhiyan campaign. The primary objective of this venture is the promotion of cleanliness and delivery of quality health-care services through public health facilities in India. This standardized tool was used to evaluate six key parameters of hospital management of a district hospital in northern India. In this study, we present findings of biomedical waste (BMW) management assessment, one of the six assessment domains of the tool. Methods: A cross-sectional observational study was done using Kayakalp assessment tool in a district hospital of a north Indian state in the year 2015. Methods used to assess facility were direct observation, staff interviews, and review of documents. Results were recorded as full, partial, and no compliance for the domain of waste management. Results: The total score for BMW management as per Kayakalp tool was 82 (out of a maximum of 100), with mean score of 8.2 and standard deviation ± 1.48. Overall, there were ten criteria (C1 to C10). The scores were excellent, i.e., 100% for disposal of BMW, solid general waste, and liquid waste management. Minimum score of 60% was seen in the area of sharps management. Conclusion: The standardized approach of the evaluation of public health facilities through Kayakalp tool would help in judging their performance on a uniform pedestal. Such model tools after adjustment to local needs can also be adopted by other nations for the assessment of their health services.

The Availability and Quality of Continuous Positive Airway Pressure (CPAP) for Neonatal Care in Public Health Facilities in India: A Cross- Sectional Cluster Survey

Background: Continuous Positive Airway Pressure (CPAP) is increasingly used in low- and middle-income setting to manage respiratory distress in neonates. Methods: National cross-sectional cluster survey of neonatal care units (SNCU) in 79 medical colleges (MC) and 63 district hospitals (DH) to assess availability, use, and, outcomes of CPAP. Findings: 68·3% of MC and 36·6% of DH used CPAP. Basic infrastructure was widely available. Air-oxygen blenders were available in 50·7% (95%CI 41·4,60·9) of hospitals. Equipment needed for monitoring and/or the detection and management of complications was not always in place; screening for retinopathy in 89·9%(77·2,95·9) MC and 60·3%(44·0,75·6) DH, treatment for retinopathy in 44·3%(30·9,58·5) MC and 7·9%(2·9,20·0) DH, screening for bronchopulmonary dysplasia in 62·0%(49·0,73·5) MC and 22·2%(12·5,36·3) DH, management of pneumothorax in 63·3%(49·8,74·9) of MC and 20·6%(9·8,38·3) of DH. Medical staff trained in the use of CPAP was available in 56·0%(45·8,65·8) of hospitals. The nurse:patient ratio was 7·3(95% CI 6·4-8·5) in MC and 6·6 (5·5-8·3) in DH. 72% MC and 59·3% DH used an upper oxygen saturation limit of above 94%. Respiratory circuits were reused in 52·8% of hospitals. Case Fatality Rates for neonates admitted to a SNCU were 11·5%(9·7,13·3) [13·2%(10·7,15·7) at MC and 7·4%(5·7,9·1) at DC] and 21·4%(16·6,26·2) for neonates receiving CPAP [19·8%(14·6,24·9) MC; 26·3%(15·7,37·0) DH]. Complication rates ranged from 27·9%(21·2,34·5) for rescue mechanical ventilation and 0·7%(0·2,1·2) for pneumothorax. Interpretation: Further support to infrastructure, training, and revision of current guidelines is urgently needed to improve the quality of care and ensure successful scale up of CPAP. Funding Statement: World Health Organization (Reference:2016/613341-0) Declaration of Interests: The authors have no competing interests to declare. Ethics Approval Statement: The study was approved by the Ministry of Health and Family Welfare of India (Child Health Division) and by the Liverpool School of Tropical Medicine’s Research and Ethics Committee (Research protocol 15·032).