Developing a roadmap to reach and sustain 90% full immunization coverage through a cross-sectoral system strengthening strategy in Bihar, India.

INTRODUCTION: Reducing childhood mortality by curtailing the incidence of vaccine preventable diseases is contingent upon a robust and high-performing routine immunization system. According to the available data, the full immunization coverage (FIC) in the state of Bihar (India) has reached ~ 71%. While the government aspires to reach 90% FIC, a systematic evidence-based investigation of the reasons behind underimmunization as well as the identification of drivers and enablers to reach and sustain 90% FIC is critical. This study aimed to review the factors leading to underimmunized children in the state of Bihar and develop a forward-looking roadmap to reach and sustain 90% FIC by adopting a system strengthening approach. METHOD: We conducted a desk review, followed by extensive stakeholder interviews and field visits to document and analyze the data and evidence relevant to routine immunization system performance in the state of Bihar. The stakeholders included the State Immunization Officer, District Immunization Officers, Block-level health officials, representatives from development agencies, healthcare workers, and caregivers. A total of eighty-six structured interviews were conducted, which included qualitative and quantitative parameters. RESULT: While positive results were observed from the assessment of Bihar's immunization system, the implementation of targeted strategies for supply, service delivery and demand can provide a means to achieve FIC of 90%. The roadmap developed by the Government of Bihar enlists 40 + interventions across key thematic areas and has been prioritized over a 5-year time horizon as short, medium, and long-term milestones to achieve 90% FIC. These interventions include strengthening the data availability and quality, improving the governance and review mechanism, augmenting the capacity of health workers involve with immunization programme, and initiatives to increase demand for immunization services. CONCLUSION: The Bihar's Immunization Roadmap development project work follows a methodical approach to assess and identify intervention to improve immunization coverage and can provide information and reference to other states and countries that are aiming to formulate similar action plans.

Impact Evaluation of Technology Driven Mental Health Capacity Building in Bihar, India.

Task-shifting is an important means to address the barrier of inadequate specialist human resources for mental health in countries such as India. This paper aims to report the impact of one such task-shifting initiative. Twenty-two non-specialist Medical Officers of Bihar, an eastern Indian state were engaged in a ten-month long hybrid (a 15-days onsite orientation to psychiatry and periodic online mentoring in primary care psychiatry) training program to enable them to identify commonly presenting psychiatric disorders in their respective clinics. 20 online sessions (hub and spoke ECHO model) occurred over the next 10 months. Apart from didactic topics, 75 cases covering severe mental disorders, common mental disorders and substance use disorders were discussed (case presentations by the primary care doctors (PCDs)) and moderated by a specialist psychiatrist and clinical psychologist). 12 successive self-reported monthly reports (comprising of the number and nature of psychiatric cases seen by the trainee PCDs) were analyzed. The mean (SD) number of sessions attended was 9 (8.0) and median was 13 (Range: 0-20). Mean number of cases (per PCD) discussed was 3.4 (3.4) (Median: 4; Range: 0-10). Total 20,909 patients were cared for in the 12 months after initiation of the training program. Increasingly, a greater number of patients were cared for as the training progressed. This pattern was mainly driven by more identifications of severe mental disorders (SMDs), common mental disorders (CMDs), dementias and substance use disorders. Mean (SD) number of patients seen per month before and after training was 1340.33 (86.73) and 1876.44 (236.51) (t = - 3.5, p < 0.05) respectively. A hybrid model of training PCDs is feasible and can be effective in identification of persons with psychiatric disorders in the community. Prospective, well designed studies are essential to demonstrate the effectiveness of this model.

Capacity Building in Mental Health for Bihar: Overview of the 1-Year Blended Training Program for Nonspecialist Medical Officers.

Objective The aim of this study is to give an experiential overview of a 1-year blended training program for nonspecialist medical officers (primary care doctors; PCDs) of Bihar State of India. The training program was aimed to enable PCDs identify, diagnose, and treat commonly presenting psychiatric disorders in primary care Methods PCDs had a brief onsite orientation program to psychiatric practice at National Institute of Mental Health and Neuro-Sciences (NIMHANS), followed by 10 months of online blended training. The online program followed the NIMHANS Virtual Knowledge- Extension for Community Healthcare Outcomes (ECHO) model, that is, a hub and spokes model of training Results Twenty-two PCDs participated in this program. Eleven of them got accredited at the end. The onsite orientation consisted of exposure to various psychiatry facilities at NIMHANS, in addition to learning psychiatric history taking and mental status examination. The ECHO model of online learning consisted of fortnightly sessions, lasting 2 hours each. There were 20 such sessions. Each session consisted of a didactic lecture by the psychiatrist followed by a case discussion. The cases were presented by PCDs, moderated by the hub specialists (NIMHANS). At the end of the training, participants rated an average of 4.5/5 on the mode, content and relevance of training and increase in knowledge due to the training. Around 23,000 patients were cared for during the said 1 year by the trained PCDs. Conclusion Training PCDs in a manner that enables retaining the learnt skills is feasible. However, rigorous evaluation protocols are needed in order to test this in a systematic fashion.