Interventions for Tobacco Prevention and Control in Humanitarian Settings: A Scoping Review.

INTRODUCTION: Tobacco usage is an epidemic as statistics point towards smoking as the second leading cause of death. Populations experiencing humanitarian emergencies may experience a higher propensity for tobacco, alcohol, and other substance abuse disorders. This review aimed to map tobacco prevention and control interventions in humanitarian settings. METHODS: The search for this scoping review was conducted in six databases and supplemented with a gray literature search. Articles were screened at title-abstract and full-text by two pairs of authors, and data was abstracted by three individuals independently. An adapted diffusion of governance framework is used to discuss the findings. RESULTS: A total of 26 articles were included from the searches conducted in the databases and grey literature. The interventions targeted all age groups. The documents retrieved from the grey literature search were classified as population-based interventions, as they were not restricted to a particular group of individuals. Interventions were delivered at various locations, using different methods and engaging multiple stakeholders. Interventions assessed were grouped into packaging, labeling, and other policy interventions (pricing and taxes). CONCLUSION: There are few tobacco prevention and control interventions in the humanitarian context. The diffusion of governance perspective in implementing these interventions in humanitarian settings provides a cue for inter-sectoral cooperation among different stakeholders and disciplines beyond the health sector. Our review recommends exploring complementarity between the demand and supply side interventions for tobacco control. IMPLICATIONS: The scoping review has highlighted various tobacco prevention and control efforts in humanitarian settings. The interventions were delivered using various modes, and yet the burden of smoking is higher among the humanitarian population. Further research may use impact evaluation techniques to assess the impact of these interventions to facilitate the re-design of the implementation approach and policy priorities.

Non-communicable diseases, digital education and considerations for the Indian context - a scoping review.

INTRODUCTION: The increasing ageing of the population with growth in NCD burden in India has put unprecedented pressure on India's health care systems. Shortage of skilled human resources in health, particularly of specialists equipped to treat NCDs, is one of the major challenges faced in India. Keeping in view the shortage of healthcare professionals and the guidelines in NEP 2020, there is an urgent need for more health professionals who have received training in the diagnosis, prevention, and treatment of NCDs. This paper conducts a scoping review and aims to collate the existing evidence on the use of digital education of health professionals within NCD topics. METHODS: We searched four databases (Web of Science, PubMed, EBSCO Education Research Complete, and PsycINFO) using a three-element search string with terms related to digital education, health professions, and terms related to NCD. The inclusion criteria covered the studies to be empirical and NCD-related with the target population as health professionals rather than patients. Data was extracted from 28 included studies that reported on empirical research into digital education related to non-communicable diseases in health professionals in India. Data were analysed thematically. RESULTS: The target groups were mostly in-service health professionals, but a considerable number of studies also included pre-service students of medicine (n = 6) and nursing (n = 6). The majority of the studies included imparted online learning as self-study, while some imparted blended learning and online learning with the instructor. While a majority of the studies included were experimental or observational, randomized control trials and evaluations were also part of our study. DISCUSSION: Digital HPE related to NCDs has proven to be beneficial for learners, and simultaneously, offers an effective way to bypass geographical barriers. Despite these positive attributes, digital HPE faces many challenges for its successful implementation in the Indian context. Owing to the multi-lingual and diverse health professional ecosystem in India, there is a need for strong evidence and guidelines based on prior research in the Indian context.

Achieving universal health coverage and sustainable development goals by 2030: investment estimates to increase production of health professionals in India.

BACKGROUND: COVID-19 has reinforced the importance of having a sufficient, well-distributed and competent health workforce. In addition to improving health outcomes, increased investment in health has the potential to generate employment, increase labour productivity and foster economic growth. We estimate the required investment for increasing the production of the health workforce in India for achieving the UHC/SDGs. METHODS: We used data from National Health Workforce Account 2018, Periodic Labour Force Survey 2018-19, population projection of Census of India, and government documents and reports. We distinguish between total stock of health professionals and active health workforce. We estimated current shortages in the health workforce using WHO and ILO recommended health worker:population ratio thresholds and extrapolated the supply of health workforce till 2030, using a range of scenarios of production of doctors and nurses/midwives. Using unit costs of opening a new medical college/nursing institute, we estimated the required levels of investment to bridge the potential gap in the health workforce. RESULTS: To meet the threshold of 34.5 skilled health workers per 10 000 population, there will be a shortfall of 0.16 million doctors and 0.65 million nurses/midwives in the total stock and 0.57 million doctors and 1.98 million nurses/midwives in active health workforce by the year 2030. The shortages are higher when compared with a higher threshold of 44.5 health workers per 10 000 population. The estimated investment for the required increase in the production of health workforce ranges from INR 523 billion to 2 580 billion for doctors and INR 1 096 billion for nurses/midwives. Such investment during 2021-2025 has the potential of an additional employment generation within the health sector to the tune of 5.4 million and to contribute to national income to the extent of INR 3 429 billion annually. CONCLUSION: India needs to significantly increase the production of doctors and nurses/midwives through investing in opening up new medical colleges. Nursing sector should be prioritized to encourage talents to join nursing profession and provide quality education. India needs to set up a benchmark for skill-mix ratio and provide attractive employment opportunities in the health sector to increase the demand and absorb the new graduates.

Strengthening institutions for public health education: results of an SWOT analysis from India to inform global best practices.

BACKGROUND: Developing public health educational programs that provide workers prepared to adequately respond to health system challenges is an historical dilemma. In India, the focus on public health education has been mounting in recent years. The COVID-19 pandemic is a harbinger of the increasing complexities surrounding public health challenges and the overdue need to progress public health education around the world. This paper aims to explore strengths and challenges of public health educational institutions in India, and elucidate unique opportunities to emerge as a global leader in reform. METHODS: To capture the landscape of public health training in India, we initiated a web-based desk review of available offerings and categorized by key descriptors and program qualities. We then undertook a series of in-depth interviews with representatives from a purposively sample of institutions and performed a qualitative SWOT analysis. RESULTS: We found that public health education exists in many formats in India. Although Master of Public Health (MPH) and similar programs are still the most common type of public health training outside of community medicine programs, other postgraduate pathways exist including diplomas, PhDs, certificates and executive trainings. The strengths of public health education institutions include research capacities, financial accessibility, and innovation, yet there is a need to improve collaborations and harmonize training with well-defined career pathways. Growing attention to the sector, improved technologies and community engagement all hold exciting potential for public health education, while externally held misconceptions can threaten institutional efficacy and potential. CONCLUSIONS: The timely need for and attention to public health education in India present a critical juncture for meaningful reform. India may also be well-situated to contextualize and scale the types of trainings needed to address complex challenges and serve as a model for other countries and the world.

Size, composition and distribution of health workforce in India: why, and where to invest?

BACKGROUND: Investment in human resources for health not only strengthens the health system, but also generates employment and contributes to economic growth. India can gain from enhanced investment in health workforce in multiple ways. This study in addition to presenting updated estimates on size and composition of health workforce, identifies areas of investment in health workforce in India. METHODS: We analyzed two sources of data: (i) National Health Workforce Account (NHWA) 2018 and (ii) Periodic Labour Force Survey 2017-2018 of the National Sample Survey Office (NSSO). Using the two sources, we collated comparable estimates of different categories of health workers in India, density of health workforce and skill-mix at the all India and state levels. RESULTS: The study estimated (from NHWA 2018) a total stock of 5.76 million health workers which included allopathic doctors (1.16 million), nurses/midwives (2.34 million), pharmacist (1.20 million), dentists (0.27 million), and traditional medical practitioner (AYUSH 0.79 million). However, the active health workforce size estimated (NSSO 2017-2018) is much lower (3.12 million) with allopathic doctors and nurses/midwives estimated as 0.80 million and 1.40 million, respectively. Stock density of doctor and nurses/midwives are 8.8 and 17.7, respectively, per 10,000 persons as per NHWA. However, active health workers' density (estimated from NSSO) of doctor and nurses/midwives are estimated to be 6.1 and 10.6, respectively. The numbers further drop to 5.0 and 6.0, respectively, after accounting for the adequate qualifications. All these estimates are well below the WHO threshold of 44.5 doctor, nurses and midwives per 10,000 population. The results reflected highly skewed distribution of health workforce across states, rural-urban and public-private sectors. A substantial proportion of active health worker were found not adequately qualified on the one hand and on the other more than 20% of qualified health professionals are not active in labor markets. CONCLUSION: India needs to invest in HRH for increasing the number of active health workers and also improve the skill-mix which requires investment in professional colleges and technical education. India also needs encouraging qualified health professionals to join the labor markets and additional trainings and skill building for already working but inadequately qualified health workers.

National sero-surveillance to monitor the trend of SARS-CoV-2 infection transmission in India: Protocol for community-based surveillance.

Conducting population-based serosurveillance for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) will estimate and monitor the trend of infection in the adult general population, determine the socio-demographic risk factors and delineate the geographical spread of the infection. For this purpose, a serial cross-sectional survey would be conducted with a sample size of 24,000 distributed equally across four strata of districts categorized on the basis of the incidence of reported cases of COVID-19. Sixty districts will be included in the survey. Simultaneously, the survey will be done in 10 high-burden hotspot cities. ELISA-based antibody tests would be used. Data collection will be done using a mobile-based application. Prevalence from the group of districts in each of the four strata will be pooled to estimate the population prevalence of COVID-19 infection, and similarly for the hotspot cities, after adjusting for demographic characteristics and antibody test performance. The total number of reported cases in the districts and hotspot cities will be adjusted using this seroprevalence to estimate the expected number of infected individuals in the area. Such serosurveys repeated at regular intervals can also guide containment measures in respective areas. State-specific context of disease burden, priorities and resources should guide the use of multifarious surveillance options for the current COVID-19 epidemic.

"Public health is global": examining Indian stakeholders' perspectives on Global Health education.

BACKGROUND: Global health education has attracted significant attention in recent years from academic institutions in developed countries. In India however, a recent analysis found that delivery of global health education is fragmented and called for academic institutions to work towards closing the developing country/developed country dichotomy. Our study explored the understanding of global health in the Indian setting and opportunities for development of a global health education framework in Indian public health institutions. METHODS: The study involved semi-structured interviews with staff of Indian public health institutes and other key stakeholders in global health in India. The interview questions covered participants' interpretation of global health and their opinion about global health education in India. Thematic analysis was conducted. A theoretical framework developed by Smith and Shiffman to explain political priority for global health initiatives was adapted to guide our analysis to explore development of global health education in Indian public health institutions. RESULTS: A total of 17 semi-structured interviews were completed which involved 12 faculty members from five public health institutes and five stakeholders from national and multilateral organisations. Global health was viewed as the application of public health in real-world setting and at a broader, deeper and transnational scale. The understanding of global health was informed by participants' exposure to work experiences and interaction with overseas faculty. Most common view about the relationship between global health and public health was that public health has become more global and both are interconnected. Integration of global health education into public health curriculum was supported but there were concerns given public health was still a new discipline in India. Most participants felt that global health competencies are complementary to public health competencies and build on core public health skills. Employability, faculty exposure to global health and 'sensitisation' of all stakeholders were key barriers to offering global health education programs. CONCLUSION: Global health as a concept and educational practice is embryonic in India but there is considerable potential to grow in order to ensure that education meets the needs of future practitioners of global health in the context of sustainable development.

Medical schools in India: pattern of establishment and impact on public health - a Geographic Information System (GIS) based exploratory study.

BACKGROUND: Indian medical education system is on the brink of a massive reform. The government of India has recently passed the National Medical Commission Bill (NMC Bill). It seeks to eliminate the existing shortage and maldistribution of health professionals in India. It also encourages establishment of medical schools in underserved areas. Hence this study explores the geographic distribution of medical schools in India to identify such under and over served areas. Special emphasis has been given to the mapping of new medical schools opened in the last decade to identify the ongoing pattern of expansion of medical education sector in India. METHODS: All medical schools retrieved from the online database of Medical Council of India were plotted on the map of India using geographic information system. Their pattern of establishment was identified. Medical school density was calculated to analyse the effect of medical school distribution on health care indicators. RESULTS: Presence of medical schools had a positive influence on the public health profile. But medical schools were not evenly distributed in the country. The national average medical school density in India amounted to 4.08 per 10 million population. Medical school density of provinces revealed a wide range from 0 (Nagaland, Dadra and Nagar Haveli, Daman and Diu and Lakshadweep) to 72.12 (Puducherry). Medical schools were seen to be clustered in the vicinity of major cities as well as provincial capitals. Distance matrix revealed that the median distance of a new medical school from its nearest old medical school was just 22.81 Km with an IQR of 6.29 to 56.86 Km. CONCLUSIONS: This study revealed the mal-distribution of medical schools in India. The problem is further compounded by selective opening of new medical schools within the catchment area of already established medical schools. Considering that medical schools showed a positive influence on public health, further research is needed to guide formulation of rules for medical school establishment in India.

Private sector vaccine share in overall immunization coverage in India: Evidence from private sector vaccine utilization data (2012-2015).

The objective of this research was to generate the evidence on the private sector's contribution to overall immunization coverage for selected pediatric vaccines in India. Using IMS Health's (now IQVIA) vaccine sales audit data and innovative methodological approach we estimated private-sector vaccine share in the total immunization coverage across selected pediatric vaccines in India. Our estimates suggest that private sector remains an important contributor to immunization services in India not only for Universal Immunization Program vaccines (Bacillus Calmette-Guérin [19.23%], HiB pentavalent [11.09%], hepatitis B [5.75%], oral poliovirus vaccine [5.48%], Diphtheria-Pertussis-Tetanus [2.66%], and measles [2.17%]) but also for newer vaccines (hepatitis A [4.2%], rotavirus [3.4%], typhoid [3.3%], and pneumococcal conjugate vaccine [2.5%]). As the private sector continues to remain an important access point for immunization services in the country, avenues for potential synergy between public and private sectors should be explored to improve the coverage and quality of immunization services.

Burden and management of obstetric fistula in South-East Asian region countries: A systematic review and meta-analysis.

BACKGROUND: Each year, between 50,000 and 100,000 women worldwide develop obstetric fistulae. Approximately 2 million girls across Asia and Africa are estimated to be affected by this condition. However, there is no reliable data on its prevalence in South-East Asia region (SEAR). OBJECTIVES: The objective of this study is to systematically review and synthesize the data on the prevalence and management of obstetric fistula in SEAR. METHODS: We searched for the literature that described the prevalence and management practices of obstetric fistula in SEAR. We followed the PRISMA guidelines to select the articles for the review. The quality and relevance were assessed by two reviewers independently using the SIGN checklist. A total of five articles and reports were selected for the review. To review the management practices, we found 63 original studies that were included in the review. RESULTS: We found five community-based studies estimating the prevalence of obstetric fistula in SEAR; 3 studies were from India, one from Bangladesh and one from Nepal. The pooled prevalence according to self-reports was 1.11 (3 studies including 671,133 participants, 95% confidence interval [CI] 1.09, 1.14) per 100 women. The pooled prevalence of obstetric fistula based on the clinical examination was 0.10 (3 studies involving 4547 participants, 95% CI 0.01, 0.20) per 100 women. The value was close to the pooled estimate based on the smaller studies. CONCLUSION: More studies are needed to estimate reliable community-based prevalence data and also need to develop evidence-based management guidelines.

Assessment of health professional education across five Asian countries-a protocol.

BACKGROUND: There is an increasing consensus globally that the education of health professionals is failing to keep pace with scientific, social, and economic changes transforming the healthcare environment. This catalyzed a movement in reforming education of health professionals across Bangladesh, China, India, Thailand, and Vietnam who jointly volunteered to implement and conduct cooperative, comparative, and suitable health professional education assessments with respect to the nation's socio-economic and cultural status, as well as domestic health service system. METHODS: The 5C network undertook a multi-country health professional educational study to provide its countries with evidence for HRH policymaking. Its scope was limited to the assessment of medical, nursing, and public health education at three levels within each country: national, institutional, and graduate level (including about to graduate students and alumni). RESULTS: This paper describes the general issues related to health professional education and the protocols used in a five-country assessment of medical, nursing, and public health education. A common protocol for the situation analysis survey was developed that included tools to undertake a national and institutional assessment, and graduate surveys among about-to-graduate and graduates for medical, nursing, and public health professions. Data collection was conducted through a mixture of literature reviews and qualitative research. CONCLUSIONS: The national assessment would serve as a resource for countries to plan HRH-related future actions.

The need to focus on medical education in rural districts of India.

Background: . Globally, India has the highest number of medical colleges followed by Brazil and China. The density of physicians in rural India was 3 per 10 000 population against 13 per 10 000 in urban areas. Worldwide, studies show that medical schools play an important role in overcoming the shortage of physicians locally. Hence, we studied the distribution of medical colleges in India and reviewed the shortage of established and new medical colleges in rural districts with the year 2000 as baseline. Methods: . We used the database of the Medical Council of India as on 27 April 2017; and Census 2011 data, based on the percentage of rural/urban population, for the classification of districts (rural/urban). All the 640 districts were included with 1210.9 million population. Results: . Of the 480 rural districts in India, only 132 (27.5%) had a medical college. Jharkhand, Jammu and Kashmir and Arunachal Pradesh had no medical colleges in rural districts. Madhya Pradesh, Uttar Pradesh, Bihar, Assam, Punjab, Uttarakhand, Haryana and Rajasthan had <30% of rural districts with a medical college. Of the 286 new medical colleges established since 2000 in India, 130 (45.5%) were in rural districts with uneven distribution with lower percentage of new medical colleges in states with predominance of rural population. Conclusion: . There is an overall shortage of medical colleges in rural districts of India. Paradoxically, the trend of uneven rural-urban distribution continues among the newly opened medical colleges as well.

Surgical conditions - A neglected aspect of public health: Call to action.

The burden of surgical conditions is large, though unrecognized. Surgical interventions are cost - effective, but thought to be otherwise. Investments aimed at including surgery at primary care level are affordable. Globally, a momentum is being created to strengthen surgery infrastructure especially for the poor in the low and middle income countries - who bear the burden most. In India, the Association of Rural Surgeons of India, and a body for implementing Lancet Commission of Global Surgery, India are taking lead. A blue print of activities needed to bring surgery on the centre stage of public health in India has been developed. The IPHA can play a catalytic role and use its convening power in getting various associations of public health professionals in India to partner surgeons in this effort. Integration of surgery in public health has the potential to improve equity, access, and universal health coverage.

Teaching of geriatric health in India: Mapping the terrain.

India is currently undergoing a rapid demographic transition along with a dramatic upsurge in the number of elderly adults. Creating a cadre of specialized health care professionals in geriatric medicine is clearly vital to address the health care needs of this growing population. The authors undertook a mapping of the available academic programs in geriatric health in India and examined their content, duration, architecture, and student intake. A total of 20 programs were identified in geriatric health, thus highlighting a paucity of training options in this field. Compared to Western countries, relatively few programs are offered in clinical and public health geriatrics in India. This is further compounded by an insignificant thrust of geriatrics in undergraduate health professional curricula. Our results underscore the need for a national-level curricular initiative to strengthen and mainstream the teaching of geriatric health in the country. Alternative educational strategies such as blended learning and interprofessional education should be explored to enhance geriatric health workforce competence.

Improving reporting of infant deaths, maternal deaths and stillbirths in Haryana, India.

Underreporting hampers the accurate estimation of the numbers of infant and maternal deaths and stillbirths in India. In Haryana state, a surveillance-based model - the Maternal Infant Death Review System - was launched in 2013 to try to resolve this issue. The system is a mixture of routine passive data collection and active surveillance by specially recruited and trained field volunteers. The volunteers gather the relevant data from child day-care centres, community health centres, cremation grounds, hospitals, the municipal corporation's offices and primary health centres and regularly visit health subcentres. The collected data are triangulated against the standard death registers and discussions with relevant community members. The details of any unregistered death are rapidly uploaded on the system's web-based platform. In April 2014, we made field observations, reviewed records and conducted in-depth interviews with the key stakeholders to see if the system's performance matched the state government's planned objectives. The data collected indicate that implementation of the system has led to quantitative and qualitative improvements in reporting of infant and maternal deaths and stillbirths. Completeness and consistency in the reporting of deaths are essential for focused policy and programmatic interventions and there remains scope for improvement in Haryana via further reform and changes in policy. The model in its current form is potentially sustainable and scalable in similar settings elsewhere.

En Inde, le sous-signalement empêche d'estimer correctement le nombre de décès infantiles et maternels et de mortinaissances. Dans l'État d'Haryana, un modèle basé sur la surveillance ­ le Maternal Infant Death Review System ­ a été lancé en 2013 afin de tenter de résoudre ce problème. Ce système mélange recueil passif de données de routine et surveillance active par des bénévoles de terrain spécialement recrutés et formés à cet effet. Ces derniers recueillent des données auprès de garderies, de centres de santé communautaires, de crématoriums, d'hôpitaux, de centres de soins primaires et des bureaux des municipalités et se rendent régulièrement dans des centres de soins secondaires. Les données ainsi recueillies sont triangulées par rapport aux registres standards des décès et aux discussions avec des membres de la communauté. Les détails de tout décès non enregistré sont rapidement chargés sur la plate-forme Internet du système. En avril 2014, nous avons effectué des observations de terrain, examiné des registres et mené des entretiens approfondis avec les principales parties prenantes afin de voir si les performances du système répondaient aux objectifs du gouvernement de l'État. Les données recueillies indiquent que la mise en œuvre de ce système a entraîné une amélioration quantitative et qualitative du signalement des décès infantiles et maternels ainsi que des mortinaissances. L'exhaustivité et la cohérence du signalement des décès sont essentielles pour avoir des politiques ciblées et des interventions programmatiques, et l'État d'Haryana présente d'autres possibilités d'amélioration, via d'autres réformes et des changements stratégiques. Le modèle, dans sa forme actuelle, est potentiellement utilisable à long terme et transposable dans des lieux similaires.

La escasez de informes obstaculiza una estimación exacta de las cifras de muertes maternas e infantiles y mortinatos en India. En 2013, en el estado de Haryana, se lanzó un modelo basado en el seguimiento (el Sistema de Análisis de la Mortalidad Infantil y Materna) para tratar de resolver este problema. El sistema combina una recopilación de datos rutinarios pasivos y un seguimiento activo realizados por voluntarios contratados capacitados en este campo. Los voluntarios reúnen información relevante de guarderías, centros de salud, terrenos destinados a incineraciones, hospitales, oficinas de la corporación municipal y centros de atención primaria, y visitan con asiduidad subcentros de salud. Los datos recopilados se triangulan según los registros normalizados de fallecimientos y análisis con miembros relevantes de la comunidad. Los detalles sobre todas las muertes no registradas se introducen con rapidez en la plataforma en línea del sistema. En abril de 2014, se realizaron observaciones de campo, se analizaron los registros y se llevaron a cabo entrevistas en profundidad con las partes interesadas fundamentales para comprobar que el rendimiento del sistema se equiparaba con los objetivos planificados por el gobierno estatal. Los datos recopilados indican que la implementación del sistema logró mejoras cuantitativas y cualitativas a la hora de redactar informes sobre la mortalidad infantil y materna y los mortinatos. Es fundamental que los informes sobre los fallecimientos sean minuciosos y coherentes para poder realizar intervenciones políticas y programáticas, y sigue existiendo margen para implementar mejoras en Haryana mediante más reformas y cambios de las políticas. El modelo actual puede mantenerse y ampliarse en otras ubicaciones similares.

Risk Factors for Stillbirth: Findings from a Population-Based Case-Control Study, Haryana, India.

BACKGROUND: Stillbirth is a prevalent adverse outcome of pregnancy in India despite efforts to improve care of women during pregnancy. Risk factors for stillbirths include sociodemographic factors, medical complications during pregnancy, intake of harmful drugs, and complications during delivery. The objective of the study was to examine the risk factors for stillbirth with a focus on sex selection drugs (SSDs). METHODS: A population-based case-control study was undertaken in Haryana. Cases of stillbirths were identified from the Maternal Infant Death Review System portal of Haryana state for the months of August-September 2014. A consecutive birth from the same geographical area as the case was selected as the control. The sample size was 325 per group. Mothers were interviewed using a validated tool. Bivariate analyses and logistic regression were conducted to examine the association between risk factors and stillbirth. Attributable risk proportions (ARP) and population attributable risk proportions (PARP) were estimated. RESULTS: The sociodemographic profiles of the cases and controls were similar. History of intake of SSDs [adjusted odds ratio (OR) 2.6, 95% confidence interval (CI) 1.5, 4.5] emerged as a risk factor. Other significant factors were preterm <37 weeks (OR 3.5, 95% CI 2.1, 6.0), history of previous stillbirths (OR 4.0, 95% CI 2.1, 7.8), and complications during labour (OR 3.3, 95% CI 2.1, 5.3). Estimates of the ARP and PARP for intake of SSDs were 0.60 (95% CI 0.32, 0.77) and 0.1 (95% CI -0.13, 0.28), respectively. CONCLUSIONS: SSDs could be attributed as a risk factor in a fifth of the cases of stillbirths. The number needed to harm for the use of SSDs in causing adverse effect of stillbirths was 5, suggesting thereby that for every five mothers exposed to SSDs, one would have stillbirth. Greater efforts are required to inform people about the harmful effects of SSD consumption during pregnancy.

A study of organizational versus individual needs related to recruitment, deployment and promotion of doctors working in the government health system in Odisha state, India.

BACKGROUND: An effective health workforce is essential for achieving health-related new Sustainable Development Goals. Odisha, one of the states in India with low health indicators, faces challenges in recruiting and retaining health staff in the public sector, especially doctors. Recruitment, deployment and career progression play an important role in attracting and retaining doctors. We examined the policies on recruitment, deployment and promotion for doctors in the state and how these policies were perceived to be implemented. METHODS: We undertook document review and four key informant interviews with senior state-level officials to delineate the policies for recruitment, deployment and promotion. We conducted 90 in-depth interviews, 86 with doctors from six districts and four at the state level to explore the perceptions of doctors about these policies. RESULTS: Despite the efforts by the Government of Odisha through regular recruitments, a quarter of the posts of doctors was vacant across all institutional levels in the state. The majority of doctors interviewed were unaware of existing government rules for placement, transfer and promotion. In addition, there were no explicit rules followed in placement and transfer. More than half (57%) of the doctors interviewed from well-accessible areas had never worked in the identified hard-to-reach areas in spite of having regulatory and incentive mechanisms. The average length of service before the first promotion was 26 (±3.5) years. The doctors expressed satisfaction with the recruitment process. They stated concerns over delayed first promotion, non-transparent deployment policies and ineffective incentive system. Almost all doctors suggested having time-bound and transparent policies. CONCLUSIONS: Adequate and appropriate deployment of doctors is a challenge for the government as it has to align the individual aspirations of employees with organizational needs. Explicit rules for human resource management coupled with transparency in implementation can improve governance and build trust among doctors which would encourage them to work in the public sector.

Does decentralization influence efficiency of health units? A study of opinion and perception of health workers in Odisha.

BACKGROUND: Health systems in low and middle income countries are struggling to improve efficiency in the functioning of health units of which workforce is one of the most critical building blocks. In India, Rogi Kalyan Samiti (RKS) was established at every health unit as institutions of local decision making in order to improve productive efficiency and quality. Measuring efficiency of health units is a complex task. This study aimed at assessing the perception (opinion and satisfaction) of health workers about influence of RKS on improving efficiency of peripheral decision making health units (DMHU); examining differences between priority and non-priority set-ups; identifying predictors of satisfaction at work; and discussing suggestions to improve performance. METHODS: Following a cross-sectional, comparative study design, 130 health workers from 30 institutions were selected through a multi-stage stratified random sampling. A semi-structured questionnaire was administered to assess perception and opinion of health workers about influence of RKS on efficiency of decision making at local level, motivation and performance of staff, and availability of funds; improvement of quality of services, and coordination among co-workers; and participation of community in local decision making. Three districts with highest infant mortality rate (IMR), one each, from 3 zones of Odisha and 3 with lowest IMR were selected on the basis of IMR estimates of 2011. The former constituted priority districts (PD) and the latter, non-priority districts (NPD). Composite scores were developed and compared between PD and NPD. Adjusted linear regression was conducted to identify predictors of satisfaction at work. RESULTS: A majority of respondents felt that RKS was efficient in decision making that resulted in improvement of all critical parameters of health service delivery, including quality; this was significantly higher in PD. Further, higher proportion of respondents from PD was highly satisfied with the current set of provisions and manners of functioning of the sample health units. Active community engagement, participation of elected representatives, selection of a pro-active Chairman, and training to RKS members were suggested as the immediate priority action points for the state government. Mean scores differed significantly between PD and NPD with regard to: influence of RKS on individual-centric, organizational-centric and patient-centric performance, and the responsibilities to be entrusted with RKS. Absenteeism was strongly associated with satisfaction and local self-governance. Work-related factors, systemic factors, local accountability and patients' involvement were found to be the key predictors of satisfaction of health workforce. CONCLUSION: The understanding on quality improvement strategies was found to be very poor among the health workers. Tailor-made capacity building measures at district and sub-district levels could be critical to equip the peripheral health units to achieve the universal health coverage goals. Work environment, systemic factors and accountability need to be addressed on priority for retention of health workforce. The hypothesized link between efficient local decision making, perception of health workers about efficiency of health units and the health status of population needs further investigation.

Local self governance in health - a study of it's functioning in Odisha, India.

BACKGROUND: Local decision making is linked to several service quality improvement parameters. Rogi Kalyan Samitis (RKS) at peripheral decision making health units (DMHU) are composite bodies that are mandated to ensure accountability and transparency in governance, improve quality of services, and facilitate local responsiveness. There is scant literature on the nature of functioning of these institutions in Odisha. This study aimed to assess the perception of RKS members about their roles, involvement and practices with respect to local decision making and management of DMHUs; it further examined perceptual and functional differences between priority and non-priority district set-ups; and identified predictors of involvement of RKS members in local governance of health units. METHODS: As members of RKS, health service providers, officials in administrative/managerial role, elected representatives, and officials from other departments (including independent members) constituted our study sample. A total of 112 respondents were interviewed across 6 districts, through a multi-stage stratified random sampling; we used a semi-structured interview schedule that comprised mainly of close-ended and some open-ended questions. Descriptive and inferential statistics were used to compare 3 priority (PD) and 3 non-priority districts (NPD), categorized on the basis of Infant Mortality Rate (IMR) estimates of 2011 as proxy of population health. Governance, human resource management, financial management and quality improvement functions were studied in detail. Opinion about various individual and organizational factors in local self-governance and predictors of involvement were identified. RESULTS: The socio-demographic profile and composition of respondents were comparable between PD and NPD. Majority of respondents were 'satisfied' with their current roles in the governance of local health institutions. About one-fourth opined that the amount of funds allocated to RKS under National Health Mission (NHM) was 'grossly insufficient'. Fifty percent of respondents said they requested for additional funds, last year, and 38.8 % informed that they requested additional funds for purchase of drugs. About 87 % respondents were satisfied with their role in the local governance of the health units (PD = 94.3 % vs. NPD = 80.7 %). Almost all (PD = 98 % vs. NPD = 80.7 %) opined that local decision making helped in improving the performance of health units. For most of the open-ended questions the responses were non-specific. Staggering differences were found between PD and NPD with respect to their involvement in district plan preparation (NPD = 78.9 % vs. PD = 58.5 %), training in plan preparation (NPD = 47.4 % vs. PD = 27.5 %), participation of officials from other departments (PD = 96.9 % vs. NPD = 45.5 %), and inclusion of activities of other sectors (PD = 70.8 % vs. NPD = 41.8 %). Whereas, no significant PD-NPD difference was found about their perceived 'involvement' in undertaking the 12 designated responsibilities. Composite scores on various individual and organizational factors were compared and found to be varying significantly. Through regression, we inferred work experience, qualification and non-monetary incentives as strong determinants of current level of involvement of RKS members in governance and management of health units. CONCLUSION: Poor knowledge/expectation of RKS members was diluting the decision making process at DMHUs. There is an urgent need to improve their knowledge, understanding and expertise in areas of governance and management practices. A locally-monitored and time-bound capacity building plan could achieve this. Yearly resource allocation for drug procurement needs revision. Specific eligibility criteria based on work experience and qualification may be fixed for RKS membership. Further research may focus on identifying the underlying individual and systemic factors behind such large PD-NPD differences.

Estimates on state-specific Pneumococcal Conjugate Vaccines (PCV) coverage in the private sector in the year 2012: Evidence from PCV utilization data.

The pneumococcal conjugate vaccine (PCV) is not available through universal immunization programs but is available through private healthcare providers. Because the PCV coverage rates are unknown, we developed a Microsoft Excel-based coverage assessment model to estimate state-specific PCV coverage for the year 2012. Our findings suggest that in the private sector, the "overall PCV coverage" was around 0.33% that ranged between a minimum of 0.07% for Assam, India and a maximum of 2.38% for Delhi, India. Further, in major metropolitan areas, overall PCV coverage rates were: 2.28% for Delhi, India, 13.31% for Mumbai (Maharashtra), India 0.76% for Lucknow (Uttar Pradesh), India, 1.93% for Kolkata (West Bengal), India, and 4.92% for Chennai (Tamil Nadu), India highlighting that urban centers are major drivers for PCV utilization driver in the states with high PCV consumption. Hence, to improve PCV coverage, both demand side (increasing consumer awareness about pneumonia prevention) and supply side (controlling vaccine prices and indigenous vaccine production) interventions are required.