How do diverse low-income and middle-income countries implement primary healthcare team integration to support the delivery of comprehensive primary health care? A mixed-methods study protocol from India, Mexico and Uganda.

INTRODUCTION: Attainment of universal health coverage is feasible via strengthened primary health systems that are comprehensive, accessible, people-centred, continuous and coordinated. Having an adequately trained, motivated and equipped primary healthcare workforce is central to the provision of comprehensive primary healthcare (CPHC). This study aims to understand PHC team integration, composition and organisation in the delivery of CPHC in India, Mexico and Uganda. METHODS AND ANALYSIS: A parallel, mixed-methods study (integration of quantitative and qualitative results) will be conducted to gain an understanding of PHC teams. Methods include: (1) Policy review on PHC team composition, organisation and expected comprehensiveness of PHC services, (2) PHC facility review using the WHO Service Availability and Readiness Assessment, and (3) PHC key informant interviews. Data will be collected from 20, 10 and 10 PHCs in India, Mexico and Uganda, respectively, and analysed using descriptive methods and thematic analysis approach. Outcomes will include an in-depth understanding of the health policies for PHC as well as understanding PHC team composition, organisation and the delivery of comprehensive PHC. ETHICS AND DISSEMINATION: Approvals have been sought from the Institutional Ethics Committee of The George Institute for Global Health, India for the Indian sites, School of Medicine Research Ethics Committee at Makerere University for the sites in Uganda and the Research, Ethics and Biosecurity Committees of the Mexican National Institute of Public Health for the sites in Mexico. Results will be shared through presentations with governments, publications in peer-reviewed journals and presentations at conferences.

Supporting Immunization Uptake during a Pandemic, Using Remote Phone Call Intervention among Babies Discharged from a Special Neonatal Care Unit (SNCU) in South India.

COVID-19 has impacted children's immunization rates, putting the lives of children at risk. The present study assesses the impact of phone-call counseling, on immunization uptake during the pandemic. Families of babies discharged from the SNCUs in six government centers in three South Indian states were recruited. Calls were made 10 days after the immunization due date. Missed vaccinees were counseled and followed up on 7 and 15 days. Of 2313 contacted, 2097 completed the survey. Respondents were mostly mothers (88.2%), poor (67.5%), and had secondary level education (37.4%). Vaccinations were missed due to the baby's poor health (64.1%), COVID-19 related concerns (32.6%), and lack of awareness (16.8%). At the end of the intervention, the immunization uptake increased from 65.2% to 88.2%. Phone-call intervention can safely support immunization and lower the burden on health workers.

Functioning and time utilisation by female multi-purpose health workers in South India: a time and motion study.

BACKGROUND: Auxillary nurse midwives (ANMs) are the most important frontline multi-purpose workers in rural India. This study was conducted to assess the spectrum of service delivery, time utilisation, work planning, and factors affecting functioning of ANMs in South India. METHODS: We conducted a time and motion study in three districts across two states in South India. The districts selected in such a manner that they had a considerable tribal population. We conducted multi-stage sampling to select ANMs. We directly observed 43 ANMs consecutively for six working days and in-depth interviewed all selected ANMs, their supervisors, medical officers, and district health officials. We conducted an FGD to substantiate the findings from observations and interviews. Observation findings were analysed under three broad domains: (i) programme activities, (ii) programme support activities, and (iii) other work. Time spent was calculated in median (interquartile range, IQR) minutes/ANM per week or day. Qualitative data were coded and analysed using grounded theory, and appropriate themes and sub-themes were identified. RESULTS: ANMs worked for median 7 h a day (7:10 h, non-tribal; 6:20 h, tribal). There is variation in the hours of work, the pattern of service provided and time utilisation across days of a week. ANMs spent 60% of their on-job time on programmatic activities (median 22:38 h; IQR, 20:48-27:01 h) in a week. Emphasis is more on home visits, universal immunisation, antenatal care, school health, and seasonal diseases. ANMs spent negligible time on non-communicable diseases, adolescent health, nutrition, etc. ANMs spent the remaining time in program support activities, such as meetings with seniors, community meetings, and other non-health related work. There are no renewed job description, work plans, and supervision guidelines, even with newly added programs and tasks. ANMs prioritised work as per the priorities set by the supervisors and leaders. Health administration often disrupts the regular functioning of ANMs for training, meetings and other ad hoc work. CONCLUSION: ANMs are overworked; they often multi-task and fail to deliver efficiently. The administration needs to re-assess the workload. The administration may reduce expected work, provide strong supervisory support, and make conscious efforts to pose fewer disruptions in regular working of ANMs.

Time motion study using mixed methods to assess service delivery by frontline health workers from South India: methods.

BACKGROUND: In India, amidst the increasing number of health programmes, there are concerns about the performance of frontline health workers (FLHW). We assessed the time utilisation and factors affecting the work of frontline health workers from South India. METHODS: This is a mixed methods study using time and motion (TAM) direct observations and qualitative enquiry among frontline/community health workers. These included 43 female and 6 male multipurpose health workers (namely, auxiliary nurse midwives (ANMs) and male-MPHWs), 12 nutrition and health workers (Anganwadi workers, AWWs) and 53 incentive-based community health workers (accredited social health activists, ASHAs). We conducted the study in two phases. In the formative phase, we conducted an in-depth inductive investigation to develop observation checklists and qualitative tools. The main study involved deductive approach for TAM observations. This enabled us to observe a larger sample to capture variations across non-tribal and tribal regions and different health cadres. For the main study, we developed GPRS-enabled android-based application to precisely record time, multi-tasking and field movement. We conducted non-participatory direct observations (home to home) for consecutively 6 days for each participant. We conducted in-depth interviews with all the participants and 33 of their supervisors and relevant officials. We conducted six focus group discussions (FGDs) with ASHAs and one FGD with ANMs to validate preliminary findings. We established a mechanism for quality assurance of data collection and analysis. We analysed the data separately for each cadre and stratified for non-tribal and tribal regions. RESULTS: On any working day, the ANMs spent median 7:04 h, male-MPHWs spent median 5:44 h and AWWs spent median 6:50 h on the job. The time spent on the job was less among the FLHWs from tribal areas as compared to those from non-tribal areas. ANMs and AWWs prioritised maternal and child health, while male-MPHWs were involved in seasonal diseases and school health. ASHAs visited homes to provide maternal health, basic curative care, and follow-up of tuberculosis patients. The results describe issues related with work planning, time management and several systemic, community-based and personnel factors affecting work of FLHWs. CONCLUSION: TAM study with mixed methods can help researchers as well as managers to periodically review work patterns, devise appropriate job responsibilities and improve the efficiency of health workers.

Primary or specialist medical care: Which is more equitable? A policy brief.

BACKGROUND: Equity in health and equitable access to healthcare has been at the core of health policy in India. The key policy challenge has been how to make that possible? Various health insurance schemes such as the Rashtriya Swasthya Bima Yojana and Arogyasri seek to improve poor people's access to specialist medical care in the public and private sectors. On the other hand, access to primary medical care has been left to the supply side interventions. METHODS: We did a focused review of evidence on equity aspects of primary medical care versus specialist medical care. We selected relevant publications from the Cochrane Library, PubMed and Google Scholar searches and articles snowballing out of them. RESULTS: Higher primary care physician-to-population ratio is invariably associated with better health outcomes. Primary care may partly protect the poor from adverse effects of income inequality on health status. On the other hand, populations do not necessarily benefit from an overabundance of specialists in a geographical area. CONCLUSIONS: Three key policy lessons emerge from this review. First, states should strengthen primary medical care by upgrading health centres. Second, a family health protection plan should be introduced as a demand side intervention to deliver primary care through health centres, non-profit and for-profit clinics. Third, postgraduate courses in family medicine should be introduced for a balanced development of the specialty of primary care pari passu other specialties.

Community based maternal death review: lessons learned from ten districts in Andhra Pradesh, India.

Maternal death is as much a social phenomenon as a medical event. Maternal death review (MDR), a strategy for monitoring maternal deaths, provides information on medical, social and health system factors that should be addressed to redress gaps in service provision or utilisation. To strengthen MDR implementation in the state of Andhra Pradesh, India. The project involved development of state specific guidelines, technical assistance in operationalization and analysing processes and findings of MDR in ten districts. 284 deaths were recorded over 6 months (April-September 2012) of which 193 (75.4 %) could be reviewed. Post-partum haemorrhage (24 %) and hypertensive disorders (27.4 %) followed by puerperal sepsis in the post-partum period (16.8 %) were the leading causes of maternal deaths. 68.3 % deaths occurred at health facilities. 67 % of mothers dying during the natal or post-natal period, delivered at home, though the death occurred in a health facility. Type 1 delay (58.9 %) was the most common underlying cause of death, followed by type 3 delay (33.3 %). Under or nil reporting from the facilities was observed. Program staff could identify broad areas of intervention but lacked capacity to monitor, analyse, interpret and utilize the generated information to develop feasible actionable plans. Information gathered was incomplete and inaccurate in many cases. Challenges observed showed that it will require more time and continuous committed efforts of health staff for implementation of high quality MDR. Successful implementation will improve the response of the health system and contribute to improved maternal health.

Institutionalizing district level infant death review: an experience from southern India.

BACKGROUND: An Infant Death Review (IDR) programme was developed and implemented in two districts of Karnataka. OBJECTIVE: We explored the processes that led to the development of the IDR programme with a view to improving the existing pilot programme and to ensuring its sustainability. METHODS: A sequential mixed-methods design was followed in which quantitative data collection (secondary data) was followed by qualitative data collection (in-depth interviews). Quantitative data were entered using EpiInfo (version 3.5.1) software and qualitative data were analysed manually. RESULTS: Apart from ascertaining the cause of infant deaths, the IDR Committee discusses social, economic, behavioural and health system issues that potentially contribute to the deaths. As a result of the IDR programme, key actors perceived an improvement in infant death reporting at district level, the development of a rapport with the local community, and elaboration of a feedback system for corrective actions. This has led to improved health care during pregnancy. CONCLUSIONS: We found that involvement of the different stakeholders in planning and implementing the IDR programme offered a platform for collective learning and action. Impediments to the success of the programme need to be addressed by corrective actions at all levels for its future sustainability.