Public Health System In India Research Articles

Morbidity pattern of communicable diseases in a tertiary care hospital in metropolitan city of western Maharashtra

Background: In India, infectious diseases continue to be predominant with emerging non-communicable diseases, imposing a double burden of diseases on health care system. Hence, the tertiary health care hospital-based study was done to compare the morbidity pattern of communicable diseases with respect to non-communicable diseases. Methods: A 2 years’ record-based data of admitted patients was collected in a tertiary health care hospital. The data was analysed using Microsoft Excel version 365. Significance of association and difference in proportions has been checked with chi-square test and Z test for SEDP respectively at significance level of 0.05. Results: During the study period of two years, 6818 patients were admitted in the hospital, of which 74.51% suffered from communicable diseases while 25.49% suffered from other types of disease including non-communicable diseases. Of the 5080, patients with communicable diseases, 57.74% were males and 42.26% were females. Communicable diseases and non-communicable diseases had male predominance (p<0.05) and was higher amongst age group 0-15 years (p<0.05). Hospital stay was prolonged in patients suffering from communicable disease (p<0.05). Significant increased difference was found in AFI, Malaria, Dengue and in Leptospirosis prevalence and significant decreased difference was found in acute gastroenteritis, IV, Covid-19, Respiratory infections and enteric fever (p<0.05). Conclusions: Communicable diseases continue to be a major threat to public health system in India. Through effective surveillance programmes, any change in trends of disease can be identified and suitable measures can be adapted to control and prevent it.

Budget impact and cost-utility analysis of prophylactic emicizumab versus on-demand bypassing agents for adolescent severe haemophilia A patients with inhibitors in India

IntroductionSevere Haemophilia A patients with inhibitors are currently being treated with bypassing agents like activated prothrombin complex concentrates (aPCC) and recombinant factor VIIa. Emicizumab is a recombinant humanized monoclonal antibody, introduced to reduce the bleeding events, improve treatment adherence, and quality of life. However, cost-effectiveness and long-term sustainability of the intervention is not studied in a low middle income setting like India. AimThe primary objective of this study was to evaluate the cost-utility of Emicizumab compared to traditional bypassing agents in the treatment of severe haemophilia A patients with inhibitors in India. Secondary objective was to analyze the budgetary impact of introducing Emicizumab for this patient population from the perspective of public health system in India. MethodsMarkov model was created to compare the prophylactic emicizumab therapy against bypassing agents for a hypothetical cohort of 10-year-old adolescents in India. The time horizon was 10 years and model built based on health system perspective. Cost utility was expressed as costs per quality-adjusted life-years (QALYs) gained. All costs were expressed as 2021 US dollars. Probabilistic sensitivity analysis was performed to check the robustness of the estimates. ResultsProphylactic emicizumab was a cost saving intervention with negative Incremental Cost Utility Ratio (ICUR) against recombinant factor VIIa of −853,573 USD (INR -63,109,773), and negative ICUR of −211,675 USD (INR -15,650,403) against APCC. The estimated total budget for treating all the severe Haemophilia A patients with inhibitors in India was USD 59,042,000 (INR 4,365,329,312) for 10 years’ time horizon (per patient cost of USD 295,210 [INR 21,826,646.56]). ConclusionProphylactic emicizumab therapy is a cost saving intervention when compared to both the bypassing agents as it is less costly and more effective for severe Haemophilia A patients with inhibitors in India.

Effectiveness of Continued Nursing Education programme on Knowledge regarding concept of Middle Level Health Provider (MLHP) in bridging Health Gap at Peripheral level among Undergraduate Nursing Students of selected Nursing College at Bangalore South, Karnataka, India

The public health system in India was designed with an architectural correction in mind to deliver Primary Health Care. The Indian government has introduced a new position under mid-level healthcare providers: the community health officer. When patients are seeking treatment at HWCs, MLHPs also serve as the primary healthcare providers. Aim: The aim of this study was to determine the effectiveness of Continued Nursing Education Programme on enhancing the Knowledge of Undergraduate Nursing Students on concept of MLHP. Methodology: Quantitative approach with one group Pre-test and Post-test Research Design was used for the study. The Sample Consist of Undergraduate Nursing Students and Non probability purposive sampling technique was used for this study. Study conducted in selected Nursing College of Bangalore. The sample size was 60 Undergraduate Nursing students. Data was gathered through Structured Knowledge Questionnaire on various Concept of MLHP. Result: Post-test Mean percentage knowledge score (Mean percentage =74.28 and SE = 0.341) was found higher than Pre-test Mean percentage knowledge score (Mean percentage = 49.48 and SE = 0.348). Enhancement of Mean Percentage was 24.80%. Conclusion: The study found that Continued Nursing Education Programme was effective in improving the knowledge of undergraduate nursing students on Concept of MLHP. For MLHPs to perform better, they must have access to ongoing training materials.

Access to medicines in the Indian Public Health System – what works and what does not? A review of the National Health Mission Common Review Mission Reports (2007-2021)

Since the inception of India’s flagship “National Health Mission” (formerly known as the National Rural Health Mission), considerable efforts have been made to ensure access to quality and affordable healthcare, including medicines. Over time, there has been a differential, yet noticeable improvement in the availability and access to medicines across states. This underscores the need to review and analyse various state-specific practices in India supported or recommended by the NHM, to identify key enablers and barriers. Consequently, a review of NHM’s Common Review Mission (CRM) reports between 2007 and 2021 was undertaken. All findings relevant to medicines were identified, retrieved and analysed. Core themes pertaining to medicines included: mechanisms adopted by states for procurement and supply chain management, health system factors influencing the supply chain, the convergence of national health programs, the rollout of the Free Drugs Service Initiative and Comprehensive Primary Health Care, and awareness among the healthcare providers and community. The article further expounds on these themes in the Indian context, highlighting the determinants of access to medicines as well as their interlinkages. In conclusion, it underscores the need to strengthen the overall health system to accelerate universal access to free essential medicines at public health facilities.

Strength, weaknesses, opportunities, and threats analysis on the current scenario of primary health care in India

The Indian public health system is organized as a three-tiered pyramid, with primary, secondary, and tertiary healthcare facilities. The cornerstone of healthcare delivery anywhere in the world is primary care. Even after primary healthcare reform, problems with poor infrastructure and a serious lack of medical staff and resources continued throughout time. The whole foundation of this study is secondary data acquired from various government publications, journals, and press releases retrieved from databases like google scholar, PubMed, science direct, and search engines like Google. An analysis of strengths, weaknesses, opportunities, and threats (SWOT) was carried out using the structure and dynamics of primary healthcare systems as well as literature searches. Upgrades should be made to PHC delivery service facilities, newer housing should be built to meet population expansion demands, and a bottom-up strategy should be employed with a focus on community empowerment, illness prevention, and health promotion.

Understanding what really helps to ensure access to diagnostic services in the Indian Public Health System: a realist synthesis of the Common Review Mission reports (2007-2021)

Background In India, the National Health Mission (NHM) has been supporting the states in building an integrated public healthcare network across the levels of care. This effort has improved access to, and utilization of, diagnostic services at public healthcare facilities. To continually enhance citizens’ ability to seek and avail quality and affordable services, it is imperative to take stock of various components of the diagnostic ecosystem that may be common or unique to states and understand their influence on equipping the health system. The objective of the study was to understand key health system factors augmenting or limiting access to diagnostic services and outcomes. Methods Common Review Mission (CRM) reports between 2007 and 2021 were selected for the study. Data relevant to diagnostic services were retrieved using defined search terms. The data were segregated for each Indian state and categorized under the pre-determined themes: state-specific practices, key findings, and challenges. Analysis of the data was done iteratively to identify the themes emerging from the reports over the years. Each theme was analysed further to deduce context-specific enablers and barriers influencing access to diagnostic service delivery. Results The major themes that emerged include (i) the approach to health systems strengthening, (ii) efficiency of procurement and distribution systems, (iii) infrastructure, (iv) modes of service delivery, (v) implementation of Free Diagnostic Service Initiative, Comprehensive Primary Health Care and Biomedical Equipment Management and Maintenance Program, and (vi) quality of care , and (vii) diagnostic service outcomes. Conclusions In a complex adaptive system, access to diagnostic services depends on the concurrent strengthening of various health system components across the levels of care. The nation has strategized accessible, affordable and acceptable diagnostic services to achieve universal health coverage and care-continuum pathways. States need to leverage the existing mechanisms, assess their implementation, and arrive at feasible and sustainable solutions to strengthen access to diagnostic services.

Economic evaluation of participatory women's groups scaled up by the public health system to improve birth outcomes in Jharkhand, eastern India.

An estimated 2.4 million newborn infants died in 2020, 80% of them in sub-Saharan Africa and South Asia. To achieve the Sustainable Development Target for neonatal mortality reduction, countries with high mortality need to implement evidence-based, cost-effective interventions at scale. Our study aimed to estimate the cost, cost-effectiveness, and benefit-cost ratio of a participatory women's groups intervention scaled up by the public health system in Jharkhand, eastern India. The intervention was evaluated through a pragmatic cluster non-randomised controlled trial in six districts. We estimated the cost of the intervention at scale from a provider perspective, with a 42-month time horizon for 20 districts. We estimated costs using a combination of top-down and bottom-up approaches. All costs were adjusted for inflation, discounted at 3% per year, and converted to 2020 International Dollars (INT$). Incremental cost-effectiveness ratios (ICERs) were estimated using extrapolated effect sizes for the impact of the intervention in 20 districts, in terms of cost per neonatal deaths averted and cost per life year saved. We assessed the impact of uncertainty on results through one-way and probabilistic sensitivity analyses. We also estimated benefit-cost ratio using a benefit transfer approach. Total intervention costs for 20 districts were INT$ 15,017,396. The intervention covered an estimated 1.6 million livebirths across 20 districts, translating to INT$ 9.4 per livebirth covered. ICERs were estimated at INT$ 1,272 per neonatal death averted or INT$ 41 per life year saved. Net benefit estimates ranged from INT$ 1,046 million to INT$ 3,254 million, and benefit-cost ratios from 71 to 218. Our study suggests that participatory women's groups scaled up by the Indian public health system were highly cost-effective in improving neonatal survival and had a very favourable return on investment. The intervention can be scaled up in similar settings within India and other countries.

Geographic information systems applications in India's public health are we moving towards the right direction?

Governments worldwide focus particularly on digital healthcare sensors for leveraging data and technology like Geographic Information Systems (GIS) to improve governance and service delivery. Geoinformatics technology can help with epidemiological research and outbreak response, minimizing the health consequences in communities beforehand, during, and then after epidemic episodes. We can all agree that location and time play a crucial role in carrying out an efficient public health response. Since location information is essential for every stage of planning, response, and recovery, GIS helps the location-based support of public health preparedness programmes like support for decisions, resource allocation, communication and collaboration, and civic participation. GIS scales to situations ranging from adverse weather to pandemics. Public health professionals can coordinate their efforts with those of other organizations and external stakeholders due to maps and apps. The public health preparedness community may achieve significant strides by incorporating GIS data, models, communication and engagement centres, and location-centric apps. GIS technology can help with this efficient method for gathering data, performing analysis, where they are most needed, interacting with decision-makers, and finally achieving health equity can be created with the aid of a location-based strategy. During COVID-19, this reality was disseminated more extensively through the news media and the national, state, and local governments. This paper evaluates the application of GIS in the Indian public health system and the various aspects of public health where GIS may emerge as a game-changer for future policy decisions.

Cost-effectiveness and budget impact of adding tranexamic acid for management of post-partum hemorrhage in the Indian public health system

BackgroundPostpartum hemorrhage (PPH) is the global leading cause of maternal mortality, affecting nearly 3 to 6 percent of all women giving birth in India. The World Health Organization (WHO) has updated its guidelines to recommend the early use of intravenous (IV) tranexamic acid (TXA) in addition to standard care for all diagnosed PPH cases. This study aimed to assess the cost-effectiveness of introducing TXA for PPH management in the Indian public health system.MethodsA decision analytic model was built using a decision tree to determine the cost-effectiveness of administering IV TXA to women experiencing PPH within 3 h of birth to existing management with uterotonics and supportive care. Using a disaggregated societal perspective, the costs and consequences for a hypothetical cohort of women experiencing PPH in public health facilities was estimated. The model was populated using probabilities, clinical parameters, and utilities from published literature, while cost parameters were largely derived from a primary economic costing study. The primary outcome of interest was the incremental cost-utility ratio (ICUR). Associated clinical events and net benefits were estimated. One-way and probabilistic sensitivity analysis (PSA) was undertaken. The budget impact was estimated for a national-level introduction.ResultsFor an estimated annual cohort of 510,915 PPH cases in India, the addition of IV TXA would result in a per-patient disaggregated societal cost of INR 6607 (USD 95.15) with a discounted gain of 20.25 QALYs, as compared to a cost of INR 6486 (USD 93.41) with a discounted gain of 20.17 QALYs with standard care PPH management. At an ICUR value of INR 1470 per QALY gained (USD 21), the addition of IV TXA is cost-effective in Indian public health settings. The intervention is likely to prevent 389 maternal deaths, 177 surgeries, and 128 ICU admissions per 100,000 PPH cases. The findings are robust under uncertainty, with 94.5% of PSA simulations remaining cost-effective. A cumulative increase of 2.3% financial allocation for PPH management over five years will be incurred for TXA introduction.ConclusionsAddition of tranexamic acid for primary PPH management, as recommended by WHO, is cost-effective in Indian public health settings. Policy guidelines, training manuals, and facility checklists should be updated to reflect this recommendation.

Hypertension treatment capacity in India by increased workforce, greater task-sharing, and extended prescription period: a modelling study

The worldwide control rate for hypertension is dismal. An inadequate number of physicians to treat patients with hypertension is one key obstacle. Innovative health system approaches such as delegation of basic tasks to non-physician health workers (task-sharing) might alleviate this problem. Massive scale up of population-wide hypertension management is especially important for low- and middle-income countries such as India. Using constrained optimization models, we estimated the hypertension treatment capacity and salary costs of staff involved in hypertension care within the public health system of India and simulated the potential effects of (1) an increased workforce, (2) greater task-sharing among health workers, and (3) extended average prescription periods that reduce treatment visit frequency (e.g., quarterly instead of monthly). Currently, only an estimated 8% (95% uncertainty interval 7%-10%) of ∼245 million adults with hypertension can be treated by physician-led services in the Indian public health system (assuming the current number of health workers, no greater task-sharing, and monthly visits for prescriptions). Without task-sharing and with continued monthly visits for prescriptions, the least costly workforce expansion to treat 70% of adults with hypertension would require ∼1.6 (1.0-2.5) million additional staff (all non-physicians), with ∼INR 200 billion (≈USD 2.7 billion) in additional annual salary costs. Implementing task-sharing among health workers (without increasing the overall time on hypertension care) or allowing a 3-month prescription period was estimated to allow the current workforce to treat ∼25% of patients. Joint implementation of task-sharing and a longer prescription period could treat ∼70% of patients with hypertension in India. The combination of greater task-sharing and extended prescription periods could substantially increase the hypertension treatment capacity in India without any expansion of the current workforce in the public health system. By contrast, workforce expansion alone would require considerable, additional human and financial resources. Resolve to Save Lives, an initiative of Vital Strategies, was funded by grants from Bloomberg Philanthropies; the Bill and Melinda Gates Foundation; and Gates Philanthropy Partners (funded with support from the Chan Zuckerberg Foundation).

Challenges in the execution of public health research: Reflections from Public Health Research Initiative (PHRI) grant management in India.

Well-planned health research is fundamental to the success of any public health system in leading to better population health outcomes. Although the Indian public health system is unique, it lacks strong linkages between research and practice. There is a pressing need to address the gap in the research to reduce the disease burden in the country. Although various efforts are made to enhance public health research, such research is rarely documented as a process. The objective of the present paper is to document issues and challenges in managing public health research grants awarded to the PHRI fellows from 2013-to 2021 under the PHRI project. A mixed-method approach, including qualitative (in-depth) interviews and secondary review, was adopted to collect the challenges in executing PHRI grants (during 2013-2021). The in-depth interviews were conducted among the PHRI execution team, whereas the secondary document review was conducted among the PHRI fellows, and the findings are documented under major themes like administrative, technical, and financial issues and/or challenges. A total of 35 candidates 16 intramural (IM) candidates affiliated with PHFI or IIPH institutes and 19 extramural (EM) candidates affiliated to other academic institutes were selected for the fellowship, The common challenges identified amongst intra & extramural fellows were inability to disseminate the study findings, challenges in communication and getting audited statements, changes in study methods without prior permission, mid study attrition of CO-PIs and high budget utilization. The specific difficulties identified from extramural fellows were change in institute affiliation, lack of support to fund utilization from the parent institute and difficulties in field validation. The present perspective emphasizes that the management and implementation of a research grant is the crucial part of achieving a project's desired outcome. The learnings of PHRI grant execution allows the researchers to understand the issues in terms of methodological rigour and financial guidelines, rigorous tracking of the project activities, and complying with the terms of funding agreement are crucial. The challenges explored in this grant execution recommend developing a structured public health grant management leadership program for researchers and executors.

Characteristics and contributing factors of adverse drug reactions: an analytical study of patients with tuberculosis receiving treatment under the National TB Program of India

Background Tuberculosis (TB) continues to pose a serious threat to the public health system in India. Although the National Tuberculosis Elimination Program (NTEP) is providing a wide range of interventions from early diagnosis to complete treatment to reduce morbidity and mortality from TB, adverse drug reactions (ADR) remain a challenge in treatment adherence and completion. Methods An observational cross-sectional study was conducted in selected districts of Gujarat state. A total of 593 reported TB patients were recruited with an adjusted unified distribution based on the type of cases, site of diseases, and service facility through a simple random sampling method. A semi-structured questionnaire tool was used to collect socio-demographic, clinical, and ADR-related data from the TB patients. Data was analyzed for the frequency, percentage, chi-squared, and adjusted odds ratio to find the association between the variables. Results The majority of the study participants were male (87.2%), aged 15 to 60 (57.8%), daily laborers (22.4%), and married (64.2%). Over 75% of individuals had pulmonary TB, with 87% having experienced their first episode, 83% being new cases, and 44.7% having a history of addiction. ADR with mild symptoms was reported by more than a quarter (29%) of TB patients during the intensive phase (77%). The association between ADR experience and drug susceptibility was significant (p<0.005) and drug-resistant TB patients experience two times more ADRs than drug-sensitive TB patients (OR 2.04). Binomial logistic regression was carried out to describe the association between various variables and occurrence of ADRs. Conclusion The study highlighted a need to enhance health care providers’ capacity and program structure for managing ADRs among TB patients. In order to completely eliminate TB across the country, it also emphasized the attention for a holistic and all-encompassing strategy for managing TB patients at the field level.

Unequal lives: a sociodemographic analysis of COVID-19 transmission and mortality in India

ObjectivesExisting socio-economic inequalities shape, in very particular and measurable ways, the differential impact that a disease has on different sections of the same society. This is particularly true of COVID-19, which has rapidly exhausted the public health system in India, and magnified the gradient of vulnerability in an underserved populace. Using publicly available data, we have aimed to deconstruct this gradient into individual variables of inequality and quantify their impact on the transmission and mortality outcomes of COVID-19 in India. Study designSociodemographic analysis. MethodsWe quantify doubling times and case fatality ratios for all districts in India, then correlate them to 20 variables of socio-economic vulnerability and demographic structure. Variables that exhibit persistent correlation are then analysed using multivariate beta regression models to validate their impact on COVID-19 outcomes in India. ResultsThe transmission of COVID-19 in India is enhanced by the lack of access to indoor latrines, drainage facilities, electricity, and proximate sources of drinking water. Transmission is slowed by the presence of an elderly population. Fatality rates relate negatively to an area's medical infrastructure and the presence of a college-educated populace. ConclusionsAn interactive matrix of social inequalities, cultural practices, and behavioural patterns determines the path of COVID-19 through a community. Specific variables exhibit patterns of persistent vulnerability; others indicate a resistance to infection and mortality. This body of evidence, when incorporated into policy design, may lead to localised, need-sensitive models of intervention, both for preventive measures and medical care.

Engagement of health workers and peer educators from the National Adolescent Health Programme-Rashtriya Kishor Swasthya Karyakram during the COVID-19 pandemic: Findings from a situational analysis.

BackgroundTo understand the impact of COVID-19 on implementation of the peer education programme of the National Adolescent Health Programme-Rashtriya Kishor Swasthya Karyakram (RKSK); repurposing of the RKSK health workers and Peer Educators (PEs) in COVID-19 response activities and effect on adolescents´ health and development issues.MethodsVirtual in-depth interviews were conducted with stakeholders (n = 31) (aged 15 to 54 years) engaged in the implementation of the RKSK and peer education programme at state, district, block, and village levels in Madhya Pradesh and Maharashtra (India). These interviews were thematically coded and analysed to address the research objectives.ResultsDespite most peer education programme activities being stopped, delayed, or disrupted during the pandemic and subsequent lockdown, some communication networks previously established, helped facilitate public health communication regarding COVID-19 and RKSK, between health workers, PEs, and adolescents. There was repurposing of RKSK health workers and PEs’ role towards COVID-19 response-related activities. PEs, with support from health workers, were involved in disseminating COVID-19 information, maintaining migrant and quarantine records, conducting household surveys for recording COVID-19 active cases and providing essential items (grocery, sanitary napkins, etc.) to communities and adolescents.ConclusionPEs with support from community health workers are able to play a crucial role in meeting the needs of the communities during a pandemic. There is a need to further engage, involve and build the skills of PEs to support the health system. PEs can be encouraged by granting more visibility and incorporating their role more formally by paying them within the public health system in India.

Using machine learning to understand determinants of IUD use in India: Analyses of the National Family Health Surveys (NFHS-4)

Intra-uterine devices (IUDs) are a safe and effective method to delay or space pregnancies and are available for free or at low cost in the Indian public health system; yet, IUD uptake in India remains low. Limited quantitative research using national data has explored factors that may affect IUD use. Machine Learning (ML) techniques allow us to explore determinants of low prevalence behaviors in survey research, such as IUD use. We applied ML to explore the determinants of IUD use in India among married women in the 4th National Family Health Survey (NFHS-4; N = 499,627), which collects data on demographic and health indicators among women of childbearing age. We conducted ML logistic regression (lasso and ridge) and neural network approaches to assess significant determinants and used iterative thematic analysis (ITA) to offer insight into related variable constructs generated from a series of regularized models. We found that couples’ shared family planning (FP) goals were the strongest determinants of IUD use, followed by receipt of FP services and desire for no more children, higher wealth and education, and receipt of maternal and child health services. Findings highlight the importance of male engagement and family planning services for IUD uptake and the need for more targeted efforts to support awareness of IUD as an option for spacing, especially for those of lower SES and with lower access to care.

Protocol for developing telephone-based brief psychosocial intervention for COVID-19 patients in India.

The ongoing Coronavirus disease 2019 (COVID-19) pandemic has had a huge mental health impact on people, especially the infected population. They are at greater risk of developing psychological symptoms due to the fear of death and developing severe disability, lack of proper treatment and social restrictions, stigma, and discrimination. The early psychological symptoms, if ignored, may have long-term consequences on the health and well-being of COVID patients. Due to the COVID-19 pandemic, the mental health services have been impacted negatively, and the need for technology-based psychological interventions has been identified as an alternative treatment method. Hence, the Telephone-Based Brief Psycho-Social interventions (TBPSI) will be developed for COVID-19 patients. A five-session tele psychosocial intervention including rapport establishment and assessment, supportive counselling, activity scheduling, relaxation technique, and post-assessment will be developed based on the extensive review of the literature. Face and content validation of the intervention package will be done by the mental health experts. Further, the feasibility of the intervention program will be tested on COVID-19 patients in the Dharwad district, and later, the same will be implemented across the COVID hospitals of Karnataka state. The study results may bring new insights into the culturally sensitive technology-oriented interventions during this pandemic in the country. The paradigm may be shifted from routine treatment to cost-effective and time-based intervention in the public health system in India. The telephonic brief psychosocial interventions can be utilised as a mainstream treatment during non-emergency situations as well.

Post-COVID-19 pandemic public health: Issues and challenges in India.

COVID-19 was an unexpected public health emergency. The key positive features of the Indian health system were demonstrated during the pandemic. Postpandemic is the time to introspect. Various issues and challenges facing the Indian Public Health System require due attention.

Effectiveness of participatory women’s groups scaled up by the public health system to improve birth outcomes in Jharkhand, eastern India: a pragmatic cluster non-randomised controlled trial

IntroductionThe WHO recommends community mobilisation with women’s groups practising participatory learning and action (PLA) to improve neonatal survival in high-mortality settings. This intervention has not been evaluated at scale with...

Abstract MP64: Estimated Impact Of Public Health System Reforms To Increase Hypertension Treatment Coverage In India

Background: Approaches to scale up hypertension (HTN) treatment are needed in India, where only ~10% of individuals with HTN have controlled blood pressure. Objective: Estimate the current HTN treatment capacity of the public health system in India and model the effects of selected health system reform options. Methods: Using constrained optimization models, we estimated the HTN treatment capacity and salary costs of HTN-treating staff within the public health system; and simulated the potential effects of 1) increased workforce, 2) greater task sharing, and/or 3) reduced visit frequency (quarterly) vs the common practice of monthly visits for prescription refills. Results: An estimated 8% of all adults with HTN could be treated in the status quo (current number of health workers, no further task sharing, and monthly visits) (Figure). Treating 70% of adults with HTN with monthly visits without greater task sharing could require an additional 1.6 million staff, with ~200 billion ₹ (≈US$2.7 billion)) in additional annual salaries. Greater task sharing was estimated to allow the current workforce to treat ~25% of individuals with HTN with monthly visits. Quarterly visits (i.e., longer prescription periods) together with greater task sharing could allow the current workforce to treat ~70% of patients with HTN in India. Conclusion: Expanding HTN treatment coverage through workforce expansion alone will require substantial human and financial resources. The combination of greater task sharing and quarterly visits could increase the coverage of HTN treatment to ~70% of adults with HTN in India, without any expansion of the current workforce of the public health system.

The architecture of the primary mental healthcare system for older people in India: what public policies tell us

BackgroundOld age mental healthcare is an issue that cuts across old age, general health, and mental healthcare policies. While strengthening the primary mental healthcare system in India is a common strategy across policy fields to improve the mental health of older persons, very little is known about the system’s planned architecture. This study explores public policy strategies for and approaches to the mental health of older persons, focusing on the primary healthcare (PHC) level and the role of the family.MethodsA document analysis of 39 key public national policy documents (2007 – 2019) from three thematically grouped policy fields (mental health, old age, and general health) was conducted.ResultsComprehensive community-based primary mental healthcare – focusing on vulnerable population groups including older persons – has been strengthened significantly since 2007. The promulgated approaches and strategies build on traditional community-based approaches to mental healthcare in India. They focus on (a) integrating community health workers into primary mental healthcare, (b) empowering the community to participate in healthcare planning, implementation, and monitoring, (c) supporting the family through a family-led approach to mental healthcare, and (d) integrating traditional Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa and Homeopathy (AYUSH) services into primary mental healthcare.ConclusionsWhile all policy fields address mental PHC, they do so in different ways, and approaches and strategies that promote an integrated perspective across policy fields are lacking. To realize the policies vision, strengthening PHC will be essential. Further research should evaluate strategies and approaches in light of social developments, such as eroding family norms and the poor state of the public health system in India, in order to assess their opportunities, challenges, and overall feasibility, with the benefits older people would experience taking centre stage in these inquiries.