Family planning training needs of auxiliary nurse midwives in Jharkhand, India: Lessons from an assessment.

Background: Auxiliary nurse midwives (ANMs), who play a pivotal role in the provision of maternal health services including family planning services, must be adequately trained and skilled. Systematic assessment of their training needs helps in determining this adequacy. We did a systematic assessment of the training needs of ANMs in Jharkhand. Methods: We designed a multi-stakeholder study including (i) meeting with government officials and international development partners (n=1 5); (ii) structured observation of health facilities (n=1 7); (iii) review of health management information system data; (iv) interviews with ANMs (n=19); and (v) interviews with contraceptive users (n=31). The data were thematically analysed based on gaps in technical knowledge, skills and practices; communication and counselling; infrastructural gaps; uptake of contraceptives and emerging training needs and approaches. Results: The ANMs lacked knowledge, e.g. in natural contraceptive methods and skills, e.g. counselling and recordkeeping. Gaps in infrastructure further hampered the provision of uninterrupted service. The belief system of the community about contraception was perceived as a barrier. The lacunae in their knowledge and skills could be attributed to systemic issues such as quality of pre-service education, absence or poor implementation of in-service trainings or individual issues such as incompetence or apathy towards the provision of service. Government training to ANMs in family planning was inadequate. Conclusion: Our study found inadequacy in the training of ANMs in family planning. We suggest the need for systemic efforts with the life cycle approach to family planning, a mix of theory and practical training, appropriate duration of training, careful selection of trainers, a confidence-building approach and supportive environment to raise competencies of ANMs to help them manage their health facilities.

Utilization, preference, perception and characteristics of people adopting traditional and AYUSH systems of medicine in India: a systematic review.

Background Albeit Indian system of medicine has been practised since long however it has got recent prominence after some policy decisions made to make it more accessible to the people of India. Methods A two fold search strategy was adopted to obtain the literature; search through PUBMED and hand search through cross references. Of the 58 articles obtained through both the search approaches 13 articles were finally included in the review. Results The studies reviewed assessed the utilization, preference, perception and characteristics of people adopting traditional and AYUSH systems of medicine in India. Utilization was observed in a particular geographical area (states) and by a specific group of people such as tribal and general population, medical practitioners and religious groups. Perception about AYUSH system was mixed with different segments of the society. Preference among the general population revolved around distrust or frustration with allopathic medicine, cost effectiveness, accessibility, non-availability of other options and less side effects of AYUSH medicines. Moreover people primarily adopted AYUSH systems of medicine based on their personal experiences and recommended the same to other people as well. Conclusions A mixed response was observed through this systematic review with regard to utilization, preference, perception and characteristics of people adopting traditional and AYUSH systems of medicine in India. A higher level of awareness and governmental patronization is required to make it available to the common man at the last corner of the society for the benefit of the former and the system as well.

Can the AYUSH system be instrumental in achieving universal health coverage in India?

Universal health coverage (UHC) in the Indian context is understood as easily accessible and affordable health services for all citizens. The Planning Commission of India constituted a High Level Expert Group (HLEG) in October 2010 for the purpose of drafting the guidelines of UHC. While the primary focus of UHC is to provide financial protection to all citizens, its delivery requires an adequate health infrastructure, skilled health human resources, and access to affordable drugs and technologies so that all people receive the level and quality of care they are entitled to. This paper attempts to link the ayurveda, yoga and naturopathy, unani, siddha and homoeopathy (AYUSH) systems of medicine with UHC. Here, the AYUSH system refers to the AYUSH workforce, therapeutics and principles, and their individual role in delivering UHC to the citizens of India. In outlining the role of AYUSH, the paper lays stress on the 10 guiding principles of UHC, as proposed by the HLEG. However, as the AYUSH system is not the principal health service provider in India, the dominant system being that of allopathic medicine, a few components of UHC may not fit neatly into the AYUSH system. This paper has adopted the definition of UHC quoted by the HLEG.

Ways and Means to Utilize Private Practitioners for Tuberculosis Care in India.

The growing interest of utilizing the private practitioners in improving the outreach of public health services including Tuberculosis (TB) control programme stemmed out of people's preference for private health facilities in situations where public health facilities fail to meet the expectations. In different parts of India, many models of Public Private Partnership have been tried and tested and proved successful in providing quality TB care in the concerned community. In this paper, several ways and means have been proposed to effectively utilize private practitioners for TB care in India. These strategies are discussed under different headings: (1) identification of potential private practitioners: (2) orientation of private practitioners: (3) networking of private practitioners with patients and Directly Observed Treatment Short course (DOTS) provider: (4) follow-up and sensitization of patients by private practitioners: (5) let the word of mouth work: and (6) evaluation of the involvement of private practitioners in TB care. However the following points must be addressed before utilizing the private practitioners for TB care: time constraints in notifying the disease, adherence to DOTS regime/alternative to DOTS regime, referral of patients to public health facilities for diagnosis and treatment, follow-up and sensitization of the patients and behaviour change communication and awareness in the community by the private practitioners. Few of these are mandatory for the private practitioners; most are practicable. With the effective utilization of private practitioners many problems can be sorted out that are currently plaguing the system such as irrational and excessive use of certain drugs, over reliance on chest X-ray for diagnosis, under use of sputum microscopy, lack of knowledge regarding standard treatment protocols and varied prescription practices.

The Need and Importance of Incorporating Academic Research Results in to the Curricula of Ayurveda in India.

Every year a noticeable number of MD and PhD students pass out from various Ayurveda colleges across the country. Each of these Post Graduate (PG) and doctoral students do submit a research thesis as a part of fulfillment of their respective degrees. As on 01/04/2015 there were 98 PG Ayurveda colleges in India with an admission capacity of 2441 seats each year. Moreover many of the post graduate institutes provide doctoral level (PhD) education which is primarily involved with research thesis. Such meticulous research carried out under the supervision of an academic expert should not go in vein and hence the research findings need to be slotted in to the respective areas and disciplines of Ayurveda syllabus. This will help in bringing in the latest scientific trends of Ayurveda to graduate students. Distressingly such practices are not in vogue in Ayurveda education system and most of the colleges follow the same stereotypic pedagogy using the classical texts of Ayurveda or their respective commentaries written decades back. Use of classical treatises and their respective commentaries offers very limited access to the recent scientific developments of Ayurveda as these commentaries are mostly one time efforts and do not undergo repeated revisions thus limiting the inclusion of present day innovations. In this commentary an effort has been made to understand the source, output, need and importance of such academic research finding with reference to their incorporation in to curricula of Ayurveda.

Impact of a Structured Tuberculosis Awareness Strategy on the Knowledge and Behaviour of the Families in a Slum Area in Chhattisgarh, India.

INTRODUCTION: Of different methods of disease prevention, health education and awareness programmes can empower people regarding several aspects of disease management and thereby enabling them in accessing the right treatment, in right time, at right place. AIM: The aim of this study was to assess the impact of a structured Tuberculosis (TB) awareness strategy on the knowledge and behaviour of slum dwellers of Durg, Chhattisgarh, India. MATERIALS AND METHODS: A TB awareness intervention was implemented in terms of informing the houses of marginalized and vulnerable communities about TB, its symptoms, diagnosis, treatment and Revised National TB Control Program (RNTCP) services and the impact of the same was assessed through a survey questionnaire before and after the implementation of the intervention. RESULTS: Of the knowledge components the improvement was incurred above 90% among the study participants in all components except in two components such as; modes of TB transmission and availability of free treatment facilities. In the behavioural segment, after the implementation of the awareness strategy, 53% and 92% of the respondents reported to visit government health facility for seeking help for their general and TB related problems respectively. Similarly the responses regarding not approaching the government health facility for TB care were changed after the implementation of the awareness strategy and 36% of the respondents said they would prefer to visit government health facility for TB care. CONCLUSION: Health education activities should be directed to improve the knowledge of slum dwellers regarding the modes of TB transmission and availability of free treatment at public health facilities.

Salient Features of a Proposed Adolescent Health Policy Draft for India.

India is one of the most populous countries in the world. The adolescent population in India constitutes about one fifth of the total Indian population. Adolescent phase is a transitional phase in life and the adolescents are neither child nor adult at this stage and are full of energy, have significant drive and new ideas. The relatively lower death rate and relatively good health status of the adolescents has always been a misleading measure to adolescent health and thus given lesser priorities. In order to respond effectively to the needs of adolescent health and development, it is important to place adolescence in a life-span perspective within dynamic sociological, cultural and economic realities. For this, government of India has started a national programme known as "Rashtriya Kishor Swathya Karyakram" in 2014. However, India as a country does not have an adolescent health policy till date and hence the country requires a national adolescent health policy. The key priorities should include sexual and reproductive health, nutritional problems (both under and over nutrition), substance abuse, mental health, road traffic accidents, intentional violence and non-communicable diseases. In addition to key priorities, the policy draft should include pertinent components such as a preamble, guiding principles, coordinating agencies, monitoring and evaluation, research and documentation components.

"Exit exams" for medical graduates: a guarantee of quality?

Despite a great deal of opposition from many segments of the medical community, the Medical Council of India (MCI) has proposed to the Ministry of Health and Family Welfare, Government of India that a pan-India exit examination be introduced for graduating MBBS doctors. Whether the proposal should be put forward was considered twice, once in 2010 and again in 2013, and finally the plan was ready to be taken forward seriously in 2015. The proposal has elicited appreciation and criticism from different segments of the medical community. It aims to improve the quality of medical professionals and create an all-India chapter of doctors. People are ready to welcome the move if it is integrated with the final year MBBS examination and licentiate examination and serves as an entrance examination for medical graduates. Further, the Supreme Court's order that the National Eligibility and Entrance Test (NEET) be made compulsory aims to create a fair, transparent and non-exploitative system. This move has the potential to reduce corruption and foster a merit-based system of medical education. However, making NEET compulsory would have an impact on the proposed exit examination. Given this background, we analyse the pros and cons of the new initiative on the basis of articles published in newspapers and journals, with a special focus on its impact on improving the standards of quality in the medical profession.

Ayurvedic management of pulmonary tuberculosis: A systematic review.

BACKGROUND: Tuberculosis (TB) is a global public health crisis. 25% of world's TB cases are found in India. Ayurveda, an ancient medical science may offer some solution to this problem. Hence, a systematic review was carried out to assess the role of Ayurveda for the management of TB. METHODOLOGY: A systematic review was carried out using published literature obtained through "PubMed" until April 2015. The key words used for literature search include "Ayurveda, role and TB." RESULTS AND DISCUSSION: It was observed that a couple of single and compound drugs have been used for the management of TB. However, none of the studies could reflect the true anti-TB activities of any drug, both single and compound. Two of the studies revealed in vitro anti-TB properties of some herbs which can potentially be brought into the realm of a clinical trial to test their efficacy in a human subject. Most of these Ayurvedic therapeutic preparations studied in different clinical settings primarily reflected their adjunct properties for the management of TB. These studies revealed that Ayurvedic therapeutics was able to reduce associated symptoms and the adverse drug effects of ATDs (anti-TB drugs). Furthermore, some of the preparations showed potential hepato-protective properties that can be simultaneously administered with ATDs. CONCLUSION: Distressingly research on the role of Ayurveda in the management of TB is very scanty and mostly limited to adjunct or supportive therapy. Being a global public health crisis, it is highly recommended to carry out clinical trials on TB patients using Ayurvedic drugs and therapeutic regimens.

Ayurvedic preparations for the management of Iron Deficiency Anemia: A systematic review.

Iron deficiency anemia (IDA) is a global public health crisis, so also in India. As per the World Health Organization's report, half of the total anemia is IDA. Ayurveda offers several formulations for the management of IDA. Given in this context, a systematic review was carried out to understand the role of Ayurvedic formulations for the management of IDA. For this purpose, articles were obtained from PubMed and through hand search process. Of the 37 articles identified, 10 articles were finally selected for the review. Of the 10 studies identified, 3 studies were (n = 10) exclusively focused on pregnant women, 2 studies (n = 10) were exclusively focused on pediatric age group, 1 study (n = 10) was exclusively focused on geriatric anemia and 4 studies (n = 10) were focused on general population. The response of most of the Ayurvedic formulations was better than Allopathic formulations and there was no untoward effect as observed with iron salts. Statistically significant results were obtained in favor of most of the Ayurvedic formulations in subjective and hematological parameters. Among six different formulations, Sarva-Jvara-Hara Lauha is suggested as the drug of choice for IDA as the Hb regeneration with this drug is highest- 0.16 g/dl/day, as reported by one of the studies. In addition, Punarnavadi Mandura is currently used as an anemia correcting agent at the community level promoted by the National Rural Health Mission and is included in the Accredited Social Health Activist's drugs kit. As most of these Ayurvedic formulations are found effective against IDA, their usage should be fostered at all level in addition to modern allopathic medicines.

Health Seeking Behaviour among Tuberculosis Patients in India: A Systematic Review.

INTRODUCTION: The Revised National Tuberculosis Control Programme's (RNTCP) passive case finding approach strongly influence the health seeking behaviour of patients and the timing of health seeking as well. AIM: A systematic review was carried out to understand the health seeking behaviour, related delays and the knowledge and attitude regarding Tuberculosis (TB) and the health services linked with it. MATERIALS AND METHODS: A manual search strategy was adopted using PUBMED and Google Scholar search engines to obtain research papers in the said subject. Of 113 articles obtained by the end of this search process 10 full text articles were finally selected for the purpose of this review. RESULTS: Of the 10 studies identified, the results were delineated in 7 thematic areas such as: (1) Knowledge and perception of TB patients regarding TB and health services for TB; (2) Delays in seeking help; (3) Facility based health seeking behaviour; (4) Reasons for not seeking care/Delay in seeking care; (5) Geographical pattern (Rural-Urban) of health seeking; (6) Socio-cultural factors associated with health seeking; and (7) Gender based health seeking behaviour. CONCLUSION: Health seeking behaviour and related delays are of utmost importance in TB care from two important perspectives; firstly TB requires timely treatment and secondly it requires protracted treatment. Required level of knowledge and positive health behaviour helps the patients in taking timely help from appropriate health facility.

An Evaluation on Medical Education, Research and Development of AYUSH Systems of Medicine through Five Year Plans of India.

INTRODUCTION: Indian system of medicine has its origin in India. The system is currently renamed as AYUSH, an acronym for Ayurveda, Yoga & Naturopathy, Unani, Sidha and Homeopathy. These are the six Indian systems of medicine prevalent and practiced in India and in few neighboring Asian countries. OBJECTIVE: The primary objective of this review was to gain insight in to the prior and existing initiatives which would enable reflection and assist in the identification of future change. MATERIALS AND METHODS: A review was carried out based on the five year plan documents, obtained from the planning commission web portal of Govt. of India, on medical education, research and development of AYUSH systems of medicine. RESULTS: Post independence, the process of five year planning took its birth with the initiation of long term planning in India. The planning process embraced all the social and technology sectors in it. Since the beginning of five year planning, health and family welfare planning became imperative as a social sector planning. Planning regarding Indian Systems of Medicine became a part of health and family welfare planning since then. During the entire planning process a progressive path of development could be observed as per this evaluation. A relatively sluggish process of development was observed up to seventh plan however post eighth plan the growth took its pace. Eighth plan onwards several innovative development processes could be noticed. Despite the relative developments and growth of Indian systems of medicine these systems have to face lot of criticism and appraisal owing to their various characteristic features. In the beginning the system thrived with great degree of uncertainty, as described in 1(st) five year plan, however progressed ahead with a vision to be a globally accepted system, as envisaged in 11(th) five year plan. CONCLUSION: A very strong optimistic approach in spreading India's own medical heritage is the need of the hour. The efforts are neither completely insufficient nor sufficient enough; hence a continuous endeavor for the revival and dissemination of India's own medical inheritance for the welfare of the society at large is highly desirable.

Maternal Health Situation in Bihar and Madhya Pradesh: A Comparative Analysis of State Fact Sheets of National Family Health Survey (NFHS)-3 and 4.

INTRODUCTION: Maternal health constitutes the health of women during pregnancy, childbirth and the postpartum period. Bihar and Madhya Pradesh (MP) constitute the Empowered Action Group (EAG) states under National Rural Health Mission (NRHM) and are consistently having poor maternal health indicators. AIM: The main objective of this study was to assess the maternal health situation of Bihar and MP based on National Family Health Survey (NFHS-3) and 4 fact sheets. MATERIALS AND METHODS: The study adopted a narrative description in which the NFHS fact sheets (NFHS-3 & 4) of both these states were obtained from appropriate sources and compared for various maternal health indicators. RESULTS AND DISCUSSION: Albeit progress has been observed from NFHS-3 to NFHS-4 however, the progress is very dismal compared with the progress of other similar Indian states. Relatively MP has shown better progress compared to Bihar. Poor performance is being observed in all the three levels of maternal health; pregnancy {Ante-Natal Care (ANC), Tetanus toxoid (TT) and Iron and Folic Acid (IFA)}, child birth (Institutional delivery by Skilled Birth Attendant (SBA), Caesarean Section (CS) and post partum care (hospital stay and Janani Suraksha Yojna (JSY). The poor performance of both these states in all these indicators requires multipronged approach strong political will, health system strengthening, community mobilization and awareness. CONCLUSION: Given the status of maternal health in India and more especially in states BIMARU (Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh) and EAG states (Empowered action group), improvement in the performance of maternal health related activities is highly necessary.

Perspectives and Challenges of HMIS Officials in the Implementation of Health Management Information System (HMIS) with Reference to Maternal Health Services in Assam.

INTRODUCTION: Health Management Information System (HMIS) is one of the important components of National Rural Health Mission (NRHM). The web portal of HMIS was launched by the Ministry of Health and Family Welfare (MOHFW), Govt. of India (GOI) in 21(st) Oct. 2008 to enable capturing of public health data from both public and private institutions in rural and urban areas across the country. AIM: The aim of the study was to assess the quality perspectives and challenges among HMIS officials in implementing HMIS at their respective levels, i.e. district and block level. MATERIALS AND METHODS: We conducted a pilot qualitative study in two districts of Assam. HMIS officials working at district and block level were interviewed in-depth with the help of a semi-structured interview schedule which lasted from May to July 2014. RESULTS: Both HMIS and MCTS (Mother and Child Tracking System) formats were considered useful, by the HMIS officials, for data collection, planning at various levels, tracking maternal and neonatal deaths, institutional deliveries. HMIS officials reported that MCTS is useful for monitoring individual health status especially the status of the mother and child and HMIS being helpful as a health facility monitoring tool. CONCLUSION: The study used a small sample size, hence similar type of studies are required with large sample size to understand the perspectives and challenges of HMIS officials in the implementation of HMIS.

Health System Competency for Maternal Health Services in Balasore District and Jaleswar Block, Balasore, Odisha, India: An Assessment.

INTRODUCTION: A competent health system is of paramount importance in delivering the desired health services in a particular community. AIM: The broad objective of this study was to assess the health system competency for the maternal health services in Balasore District and Jaleswar block of Balasore district, Odisha, India. MATERIALS AND METHODS: A mixed method approach was adopted in order to understand the health system competency for maternal health services in the study area. RESULTS: There was poor accessibility through road, poor electricity connection and piped water for the health care centers in the district. Even, existing Primary Health Centres (PHCs) lack ECG and X-Ray machines for proper diagnostic services which jeopardize the catering of health services. Community Health Centres (CHC) lack basic diagnostic and ambulance services making the tribal pockets inaccessible. The tribal dominated Jaleswar block shows poor performance in terms of total registered Antenatal Checkups (ANC) (only 77%). A gradual decrease in the rate of ANC, from first to fourthcheckup, was observed in the district. CONCLUSION: Lack of public health infrastructure in general and non-compliance to Indian Public Health Standards (IPHS) in particular, affect the health of tribal women resulting in lack of interest in availing the institutional delivery services and other pertinent maternal health services.

Situational analysis and future directions of AYUSH: An assessment through 5-year plans of India.

AYUSH is an acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy. These are the six indigenous systems of medicine practiced in India. A department called Department of Indian System of medicine was created in March 1995 and renamed to AYUSH in November 2003 with a focus to provide increased attention for the development of these systems. Very recently, in 2014, a separate ministry was created under the union Government of India, which is headed by a minister of state. Planning regarding these systems of medicine was a part of 5-year planning process since 1951. Since then many developments have happened in this sector albeit the system was struggling with a great degree of uncertainty at the time of 1(st)5-year plan. A progressive path of development could be observed since the first to the 12(th)5-year plan. It was up to the 7(th)plan the growth was little sluggish and from 8(th)plan onward the growth took its pace and several innovative development processes could be observed thereafter. The system is gradually progressing ahead with a vision to be a globally accepted system, as envisaged in 11(th)5-year plan. Currently, AYUSH system is a part of mainstream health system implemented under National Rural Health Mission (NRHM). NRHM came into play in 2005 but implemented at ground level in 2006 and introduced the scheme of "Mainstreaming of AYUSH and revitalization of local health traditions" to strengthen public health services. This scheme is currently in operation in its second phase, since 1(st)April 2012, with the 12(th)5-year plan. The scheme was primarily brought in to operation with three important objectives; choice of treatment system to the patients, strengthen facility functionally and strengthen the implementation of national health programmes, however, in some places it seems to be a forced medical pluralism owing to a top-down approach by the union government without considerable involvement of the concerned community. In this study, the 5-year planning documents have been reviewed, from the 1(st)plan to 12(th)plan, to enable reflection and throw some light into the future directions of AYUSH system.

Role of AYUSH workforce, therapeutics, and principles in health care delivery with special reference to National Rural Health Mission.

Decades back AYUSH systems of medicine were limited to their own field with few exceptions in some states as health in India is a state issue. This took a reverse turn after the initiation of National Rural Health Mission (NRHM) in 2005 which brought the concept of "Mainstreaming of AYUSH and Revitalization of Local Health Traditions" utilizing the untapped AYUSH workforces, therapeutics and principles for the management of community health problems. As on 31/03/2012 AYUSH facilities were co-located in 468 District Hospitals, 2483 Community Health Centers and 8520 Primary Health Centers in the country. Several therapeutics are currently in use and few drugs have been included in the ASHA drug kit to treat common ailments in the community. At the same time Government of India has recognized few principles and therapeutics of Ayurveda as modalities of intervention to some of the community health problems. These include Ksharasutra (medicine coated thread) therapy for ano-rectal surgeries and Rasayana Chikitsa (rejuvenative therapy) for senile degenerative disorders etc. Similarly respective principles and therapeutics can also be utilized from other systems of AYUSH such as Yoga and Naturopathy, Unani, Siddha and Homoeopathy. Akin to Ayurveda these principles and therapeutics can also help in managing community health problems if appropriately implemented. This paper is a review on the role of AYUSH, as a system, in the delivery of health care in India with special reference to National Rural Health Mission.

Family Planning Practices, Programmes and Policies in India Including Implants and Injectables with a Special Focus on Jharkhand, India: A Brief Review.

The National Family Health Survey (NFHS)-3 clearly delineates that the usage of contraceptive practices has increased considerably but is more inclined toward terminal methods of contraception especially the female sterilization. The fact is also evident from various studies carried out from time to time in different Indian states. Given the context we carried out a short review to understand the family planning practices, programs and policies in India including implants and injectable contraceptives with a special focus on the state of Jharkhand. We found that among the reversible methods IUCD (intra uterine contraceptive devices), OC (oral contraceptive) pills and condoms are the most commonly used methods. In this review, in addition to national picture, we specially focused on the state of Jharkhand owing to its very gloomy picture of family planning practices as per NFHS -3 reports. The current usage of any methods of contraception in Jharkhand is only 35.7% out of which terminal methods especially female sterilization accounts to 23.4% and male sterilization being only 0.4%. Similar picture is also reflected in the conventional methods such as; IUCD-0.6%, oral pill -3.8% and condom-2.7%. Compared to the national figure the unmet need for family planning in Jharkhand is also relatively high for the conventional reversible methods than that of terminal methods which is 11.9 and 11.3 respectively. Injectable contraceptives are available only through private or social marketing channels, because of which their use is limited. The studies carried out in different Indian states show improvement in contraceptive prevalence but the same needs further improvement.