Assuring health coverage for all in India.

Successive Governments of India have promised to transform India's unsatisfactory health-care system, culminating in the present government's promise to expand health assurance for all. Despite substantial improvements in some health indicators in the past decade, India contributes disproportionately to the global burden of disease, with health indicators that compare unfavourably with other middle-income countries and India's regional neighbours. Large health disparities between states, between rural and urban populations, and across social classes persist. A large proportion of the population is impoverished because of high out-of-pocket health-care expenditures and suffers the adverse consequences of poor quality of care. Here we make the case not only for more resources but for a radically new architecture for India's health-care system. India needs to adopt an integrated national health-care system built around a strong public primary care system with a clearly articulated supportive role for the private and indigenous sectors. This system must address acute as well as chronic health-care needs, offer choice of care that is rational, accessible, and of good quality, support cashless service at point of delivery, and ensure accountability through governance by a robust regulatory framework. In the process, several major challenges will need to be confronted, most notably the very low levels of public expenditure; the poor regulation, rapid commercialisation of and corruption in health care; and the fragmentation of governance of health care. Most importantly, assuring universal health coverage will require the explicit acknowledgment, by government and civil society, of health care as a public good on par with education. Only a radical restructuring of the health-care system that promotes health equity and eliminates impoverishment due to out-of-pocket expenditures will assure health for all Indians by 2022--a fitting way to mark the 75th year of India's independence.

Challenges of Implementing Universal Newborn Hearing Screening at a Tertiary Care Centre from India.

OBJECTIVES: To report experience of implementing universal newborn hearing screening (UNHS) in a tertiary care neonatal unit, identify risk factors associated with failed two-step automated acoustic brainstem response (AABR) screen and evaluate cost of AABR. METHODS: This was a prospective study of UNHS outcomes of all live births with two step AABR using BERAphone MB11®. Outcome measures were screening coverage, refer, pass and lost to follow up rates and cost of AABR using micro-costing method. To identify risk factors for failed screening, authors performed multivariate logistic regression with failed two-step AABR screen as dependent variable and baseline risk factors significant on univariate analysis as predictors. RESULTS: Screening coverage was moderate (84 %), with 2265 of total 2700 eligible infants screened with initial AABR (mean gestation 37.2 ± 2.3 wk; birth weight 2694 ± 588 g; 305 received nursery care). A total of 273 of 2265 infants were "refer" on first screen. Second screen was done on 233, of which 58 were "refer". Of these, 35 underwent conventional ABR, of which 5 were diagnosed to have hearing impairment. Only 2 could get hearing aid. Overall, a total of 2197 (81.4 %) infants passed, 496 (18.4 %; excluding 2 deaths) were lost to follow up at various stages, and 5 (0.2 %) were diagnosed with hearing impairment, all of whom were high risk. Average cost of AABR was INR 276 per test. No factor emerged as significant on multivariate analysis. CONCLUSIONS: UNHS is feasible to implement, but significant lost to follow up and non-linkage with appropriate rehabilitation services limit its utility. Cost effectiveness of UNHS compared to high risk based screening needs to be determined.

Who has been caring for the baby?

Nearly a decade ago, The Lancet published the Neonatal Survival Series, with an ambitious call for integration of newborn care across the continuum of reproductive, maternal, newborn, and child health and nutrition (RMNCH). In this first of five papers in the Every Newborn Series, we consider what has changed during this decade, assessing progress on the basis of a systematic policy heuristic including agenda-setting, policy formulation and adoption, leadership and partnership, implementation, and evaluation of effect. Substantial progress has been made in agenda setting and policy formulation for newborn health, as witnessed by the shift from maternal and child health to maternal, newborn, and child health as a standard. However, investment and large-scale implementation have been disappointingly small, especially in view of the size of the burden and potential for rapid change and synergies throughout the RMNCH continuum. Moreover, stillbirths remain invisible on the global health agenda. Hence that progress in improvement of newborn survival and reduction of stillbirths lags behind that of maternal mortality and deaths for children aged 1-59 months is not surprising. Faster progress is possible, but with several requirements: clear communication of the interventions with the greatest effect and how to overcome bottlenecks for scale-up; national leadership, and technical capacity to integrate and implement these interventions; global coordination of partners, especially within countries, in provision of technical assistance and increased funding; increased domestic investment in newborn health, and access to specific commodities and equipment where needed; better data to monitor progress, with local data used for programme improvement; and accountability for results at all levels, including demand from communities and mortality targets in the post-2015 framework. Who will step up during the next decade to ensure decision making in countries leads to implementation of stillbirth and newborn health interventions within RMNCH programmes?

Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?

Progress in newborn survival has been slow, and even more so for reductions in stillbirths. To meet Every Newborn targets of ten or fewer neonatal deaths and ten or fewer stillbirths per 1000 births in every country by 2035 will necessitate accelerated scale-up of the most effective care targeting major causes of newborn deaths. We have systematically reviewed interventions across the continuum of care and various delivery platforms, and then modelled the effect and cost of scale-up in the 75 high-burden Countdown countries. Closure of the quality gap through the provision of effective care for all women and newborn babies delivering in facilities could prevent an estimated 113,000 maternal deaths, 531,000 stillbirths, and 1·325 million neonatal deaths annually by 2020 at an estimated running cost of US$4·5 billion per year (US$0·9 per person). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1·9 million [range 1·6-2·1 million]), 33% of stillbirths (0·82 million [0·60-0·93 million]), and 54% of maternal deaths (0·16 million [0·14-0·17 million]) per year. These reductions can be achieved at an annual incremental running cost of US$5·65 billion (US$1·15 per person), which amounts to US$1928 for each life saved, including stillbirths, neonatal, and maternal deaths. Most (82%) of this effect is attributable to facility-based care which, although more expensive than community-based strategies, improves the likelihood of survival. Most of the running costs are also for facility-based care (US$3·66 billion or 64%), even without the cost of new hospitals and country-specific capital inputs being factored in. The maximum effect on neonatal deaths is through interventions delivered during labour and birth, including for obstetric complications (41%), followed by care of small and ill newborn babies (30%). To meet the unmet need for family planning with modern contraceptives would be synergistic, and would contribute to around a halving of births and therefore deaths. Our analysis also indicates that available interventions can reduce the three most common cause of neonatal mortality--preterm, intrapartum, and infection-related deaths--by 58%, 79%, and 84%, respectively.

A micro-costing model of neonatal intensive care from a tertiary Indian unit: feasibility and implications for insurance.

OBJECTIVE: To calculate and compare costs of neonatal intensive care by micro-costing and gross-costing methods. METHODS: The costs of resources of a tertiary care neonatal intensive care unit were estimated by the two methods to arrive at specific costs per diagnosis related categories for 33 neonates followed-up prospectively. RESULTS: Gross-costing as compared to micro-costing resulted in higher cost per bed (Rs 6315 vs. Rs 4969) and wide variations of costs (-34.8% to +13.4%). Intensity of interventions, relative stay in neonatal intensive care unit compared to the step-down nursery, and total length of hospital admission accounted for these variations. CONCLUSION: Estimates based on micro-costing arrived in this study may be used as a starting point in developing assumptions for insurance models covering neonatal intensive care.

Trek to MDG 4: state of Indian States.

OBJECTIVES: To provide projections of progress towards the national and state specific MDG 4 using infant mortality rates (IMR) as the indicator. METHODS: Infant mortality rates (IMR) of major Indian states for year 1990 were used as the base for evaluating their progress in child health. In the absence of any specific guidelines, the state specific target IMR was derived from the IMR:U5MR (under 5 mortality rate) of the countries whose current U5MR is between 11 and 47 per 1,000 live-births (range of target U5MR for Indian states). The projected IMR for year 2015 was then estimated by the average annual rate of reduction (AARR) from 2005 to 2012. RESULTS: Only a few major states-Karnataka, Maharashtra, Odisha, Punjab, and Tamil Nadu are likely to achieve their respective target IMR within the stipulated time (2015). The other major states, and India as a whole, are likely to miss the MDG 4. The two worst performers, Assam and West Bengal, are likely to achieve their respective targets by 2032 and 2022 respectively. Almost all the states have witnessed a significant progress since the advent of National Rural Health Mission (NRHM) in mid-2005-the AARR has almost doubled in the post-NRHM epoch for most states and India as a whole. CONCLUSIONS: The overall progress of most Indian states towards achieving MDG 4 is presently unsatisfactory. However, given the momentum gained since the commencement of NRHM, acceleration in child survival is quite possible in these states.

Towards achievement of universal health care in India by 2020: a call to action.

To sustain the positive economic trajectory that India has had during the past decade, and to honour the fundamental right of all citizens to adequate health care, the health of all Indian people has to be given the highest priority in public policy. We propose the creation of the Integrated National Health System in India through provision of universal health insurance, establishment of autonomous organisations to enable accountable and evidence-based good-quality health-care practices and development of appropriately trained human resources, the restructuring of health governance to make it coordinated and decentralised, and legislation of health entitlement for all Indian people. The key characteristics of our proposal are to strengthen the public health system as the primary provider of promotive, preventive, and curative health services in India, to improve quality and reduce the out-of-pocket expenditure on health care through a well regulated integration of the private sector within the national health-care system. Dialogue and consensus building among the stakeholders in the government, civil society, and private sector are the next steps to formalise the actions needed and to monitor their achievement. In our call to action, we propose that India must achieve health care for all by 2020.

Reducing intrapartum-related deaths and disability: can the health system deliver?

BACKGROUND: Each year 1.02 million intrapartum stillbirths and 904,000 intrapartum-related neonatal deaths (formerly called "birth asphyxia") occur, closely linked to 536,000 maternal deaths, an estimated 42% of which are intrapartum-related. OBJECTIVE: To summarize the results of a systematic evidence review, and synthesize actions required to strengthen healthcare delivery systems and home care to reduce intrapartum-related deaths. METHODS: For this series, systematic searches were undertaken, data synthesized, and meta-analyses carried out for various aspects of intrapartum care, including: obstetric care, neonatal resuscitation, strategies to link communities with facility-based care, care within communities for 60 million non-facility births, and perinatal audit. We used the Lives Saved Tool (LiST) to estimate neonatal deaths prevented with relevant interventions under 2 scenarios: (1) to address missed opportunities for facility and home births; and (2) assuming full coverage of comprehensive emergency obstetric care and emergency newborn care. Countries were first grouped into 5 Categories according to level of neonatal mortality rate and examined, and then priorities were suggested to reduce intrapartum-related deaths for each Category based on health performance and possible lives saved. RESULTS: There is moderate GRADE evidence of effectiveness for the reduction of intrapartum-related mortality through facility-based neonatal resuscitation, perinatal audit, integrated community health worker packages, and community mobilization. The quality of evidence for obstetric care is low, requiring further evaluation for effect on perinatal outcomes, but is expected to be high impact. Over three-quarters of intrapartum-related deaths occur in settings with weak health systems marked by low coverage of skilled birth attendance (<50%), low density of skilled human resources (<0.9 per 1000 population) and low per capita spending on health (

Alma-Ata 30 years on: revolutionary, relevant, and time to revitalise.

In this paper, we revisit the revolutionary principles-equity, social justice, and health for all; community participation; health promotion; appropriate use of resources; and intersectoral action-raised by the 1978 Alma-Ata Declaration, a historic event for health and primary health care. Old health challenges remain and new priorities have emerged (eg, HIV/AIDS, chronic diseases, and mental health), ensuring that the tenets of Alma-Ata remain relevant. We examine 30 years of changes in global policy to identify the lessons learned that are of relevance today, particularly for accelerated scale-up of primary health-care services necessary to achieve the Millennium Development Goals, the modern iteration of the "health for all" goals. Health has moved from under-investment, to single disease focus, and now to increased funding and multiple new initiatives. For primary health care, the debate of the past two decades focused on selective (or vertical) versus comprehensive (horizontal) delivery, but is now shifting towards combining the strengths of both approaches in health systems. Debates of community versus facility-based health care are starting to shift towards building integrated health systems. Achievement of high and equitable coverage of integrated primary health-care services requires consistent political and financial commitment, incremental implementation based on local epidemiology, use of data to direct priorities and assess progress, especially at district level, and effective linkages with communities and non-health sectors. Community participation and intersectoral engagement seem to be the weakest strands in primary health care. Burgeoning task lists for primary health-care workers require long-term human resource planning and better training and supportive supervision. Essential drugs policies have made an important contribution to primary health care, but other appropriate technology lags behind. Revitalisng Alma-Ata and learning from three decades of experience is crucial to reach the ambitious goal of health for all in all countries, both rich and poor.

The current state of newborn health in low income countries and the way forward.

Of the 4 million neonatal deaths that occur worldwide each year 99% of these occur in developing countries. South Asia and sub-Saharan Africa regions account for two thirds of the global burden. Skilled professionals attend only 35% deliveries in South Asia and 41% in sub-Saharan Africa. Known, affordable interventions delivered through a rational mix of outreach, family/community and clinical services can reduce over 70% of all neonatal deaths. The Millennium Development Goal of reducing the mortality of children under 5 years by two thirds by the year 2015 from the 1990 baseline would require a substantial reduction in neonatal mortality in the next decade. For this, the low and middle-income countries must urgently review their existing programs, and design and implement improved, integrated action plans for maternal, newborn and child health. International community, including the academics, institutions and professional bodies in developed countries can play a crucial role to make this mission a success.

Simple clinical criteria to identify sepsis or pneumonia in neonates in the community needing treatment or referral.

BACKGROUND: Sepsis, meningitis and pneumonia annually kill 1.1 million neonates in developing countries; most deaths occur at home. OBJECTIVES: To develop simple clinical criteria, enabling health workers in communities to identify neonates with potentially fatal sepsis; and to identify the danger signs alerting mothers to seek care. METHODS: In a field trial in 39 villages in Gadchiroli, India, trained health workers visited all neonates at home 8 times during the first 28 days of life, recording signs and outcome without interventions during 1995-1996 and with home-based management of sick neonates during 1996-1999. An independent neonatologist assigned the cause of death. We use the term "sepsis" to include sepsis, meningitis and pneumonia. We evaluated 31 signs as predictors of 43 sepsis deaths among 3567 neonates. We also evaluated mothers' observations as the danger signs to seek care. RESULTS: Simultaneous presence of any 2 of 7 signs (reduced or stopped sucking; weak or no cry; limbs becoming limp; vomiting or abdominal distension; baby cold to touch; severe chest indrawing; umbilical infection) predicted sepsis death with sensitivity 100%, specificity 92%, positive predictive value 27.2% and negative predictive value 100% in the nonintervention period. The criteria identified 10.6% of the neonates in the community as suspected sepsis, at a mean of 5.4 days before death. The criteria remained valid in the postintervention period. Any 1 of the 5 maternally observed danger signs (reduced sucking, drowsy or unconscious, baby cold to touch, fast breathing and chest indrawing) gave 100% sensitivity and identified 23.9% neonates for seeking care. CONCLUSION: These criteria identify neonates in the community who are at risk for dying of infection with excellent sensitivity, specificity and negative predictive value but a moderate positive predictive value. They can be used by health workers to select sick neonates for treatment or referral. One potentially fatal case would be treated per 4 presumptive cases treated.

Neonatal survival: a call for action.

To achieve the Millennium Development Goal for child survival (MDG-4), neonatal deaths need to be prevented. Previous papers in this series have presented the size of the problem, discussed cost-effective interventions, and outlined a systematic approach to overcoming health-system constraints to scaling up. We address issues related to improving neonatal survival. Countries should not wait to initiate action. Success is possible in low-income countries and without highly developed technology. Effective, low-cost interventions exist, but are not present in programmes. Specific efforts are needed by safe motherhood and child survival programmes. Improved availability of skilled care during childbirth and family/community-based care through postnatal home visits will benefit mothers and their newborn babies. Incorporation of management of neonatal illness into the integrated management of childhood illness initiative (IMCI) will improve child survival. Engagement of the community and promotion of demand for care are crucial. To halve neonatal mortality between 2000 and 2015 should be one of the targets of MDG-4. Development, implementation, and monitoring of national action plans for neonatal survival is a priority. We estimate the running costs of the selected packages at 90% coverage in the 75 countries with the highest mortality rates to be US4.1 billion dollars a year, in addition to current expenditures of 2.0 billion dollars. About 30% of this money would be for interventions that have specific benefit for the newborn child; the remaining 70% will also benefit mothers and older children, and substantially reduce rates of stillbirths. The cost per neonatal death averted is estimated at 2100 dollars (range 1700-3100 dollars). Maternal, neonatal, and child health receive little funding relative to the large numbers of deaths. International donors and leaders of developing countries should be held accountable for meeting their commitments and increasing resources.

Systematic scaling up of neonatal care in countries.

Every year about 70% of neonatal deaths (almost 3 million) happen because effective yet simple interventions do not reach those most in need. Coverage of interventions is low, progress in scaling up is slow, and inequity is high, especially for skilled clinical interventions. Situations vary between and within countries, and there is no single solution to saving lives of newborn babies. To scale up neonatal care, two interlinked processes are required: a systematic, data-driven decision-making process, and a participatory, rights-based policy process. The first step is to assess the situation and create a policy environment conducive to neonatal health. The next step is to achieve optimum care of newborn infants within health system constraints; in the absence of strong clinical services, programmes can start with family and community care and outreach services. Addressing missed opportunities within the limitations of health systems, and integrating care of newborn children into existing programmes--eg, safe motherhood and integrated management of child survival initiatives--reduces deaths at a low marginal cost. Scaling up of clinical care is a challenge but necessary if maximum effect and equity are to be achieved in neonatal health, and maternal deaths are to be reduced. This step involves systematically strengthening supply of, and demand for, services. Such a phased programmatic implementation builds momentum by reaching achievable targets early on, while building stronger health systems over the longer term. Purposeful orientation towards the poor is vital. Monitoring progress and effect is essential to refining strategies. National aims to reduce neonatal deaths should be set, and interventions incorporated into national plans and existing programmes.