Why are they "unreached"? Macro and Meso determinants of health care access in hard to reach areas of Odisha, India.

BACKGROUND: Reaching hard to reach populations is key to reduce health inequities. Despite targeted interventions, status of crucial public health indicators like neonatal and maternal mortality is still far from optimal. Complex interplay of social determinants can influence both communities and health care workers to effectively access each other. We argue that culturally sensitive and contextually relevant healthcare provision has potential to increase health care utilization by the vulnerable communities living in remote areas. METHODS: The study is an exploratory case study using rapid ethnographic techniques to understand the interplay of social determinants in hard to reach areas of Odisha state, India. We used in-depth interviews, focus group discussion, participatory action research and key informant interviews as tools for data collection. The analysis of data has been guided by thematic analysis approach. RESULTS: We found that there are further layers within the designated hard to reach areas and those can be designated as-i) extremely remote ii) remote and iii) reachable areas. Degree of geographic difficulties and cultural dynamics are deciding the 'perceived' isolation and interaction with health care providers in hard to reach areas. This ultimately leads to impacting the utilization of the facilities. At extremely remote areas, felt health needs are mainly fulfilled by traditional healers and ethno-medical practices. In reachable areas, people are more prone to seek care from the public health facilities because of easy accessibility and outreach. Being in middle people in remote areas, diversify health care seeking depending upon social (e.g. patient's gender) economic (e.g. avoid catastrophic expenditure) and health system (timely availability of health human resources, language barriers) factors. CONCLUSION: Our research highlights the need to value and appreciate different worldviews, beliefs and practices, and their understanding of and engagement with the pluralistic health care system around them. Other than pursuing the 'mainstreaming' of a standardized health system model across hard to reach areas, strategies need to be adaptive as per local factors. To handle that existing policies need revision with a focus on culturally sensitive and contextual care provision.

Resource flow and fund management at district level in Odisha: Evidence for improving district health systems in developing countries.

Planning, budgeting and utilisation of resources at the district level are critical issues for strengthening district health systems. The objectives of this study are to examine budget making, budget execution and budget monitoring processes at the district level; analyse the trend and pattern of public health expenditure at district level. Two districts based on district development index were selected. A mixed-method study design, both quantitative and qualitative, was used. Quantitative data on resource allocations and utilisation by the government for health were collected and analysed. Qualitative interviews were conducted with government officials to examine budget making, execution and monitoring processes. Resources are transferred through treasury and state health society (SHS) to public health institutions at the district level. Bottom-up planning process is mainly followed for money routed through SHS constituting 36%-40% of total district spending. It takes around 21 days to transfer funds from the treasury to the SHS and the district gets a major proportion of total funds within 10-15 days. Overall, utilisation of resources is around 80%-85% under treasury and 71%-85% under National Health Mission. However, utilisation for specific programmes, non-communicable diseases, is extremely low. Multiple bank accounts, number of rules and regulations at each layer of administration make the system complex. There is a lack of integration of different programmes at the district and below. This study suggests to get rid of input-based budgeting gradually and introduce outcome-based budgeting to increase efficiency.

Effect of caste on health, independent of economic disparity: evidence from school children of two rural districts of India.

Caste, a stratifying axis of the Indian society, is associated with wealth and health. However, to what extent caste-based health inequality is explained by wealth disparities, is not clear. Therefore, we aimed to examine the caste-based differences in anaemia (haemoglobin < 11 gm/dl) and self-reported sickness absenteeism in schoolchildren and the mediating role of economic disparity. Students (n = 1764) were surveyed from 54 government schools of Dhenkanal and Angul, Odisha state. Socioeconomic data, anaemia and absenteeism were recorded. The relative risks of anaemia among Scheduled Tribe (least advantaged) and Scheduled Caste (second least advantaged) students were 1.19 (95% CI: 1.08, 1.26) and 1.13 (1.03, 1.20), respectively, as compared to students of the most advantaged caste and that for sickness absenteeism were 2.78 (2.03, 3.82) and 2.84 (2.13, 3.78); p < 0.05, with marginal attenuation when controlled for inter-caste economic disparities. Caste had an independent effect on anaemia and sickness absenteeism in school children, unexplained by inter-caste economic disparities.

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.

Prevalence, correlates, and outcomes of multimorbidity among patients attending primary care in Odisha, India.

PURPOSE: Little information is available on multimorbidity in primary care in India. Because primary care is the first contact of health care for most of the population and important for coordinating chronic care, we wanted to examine the prevalence and correlates of multimorbidity in India and its association with health care utilization. METHODS: Using a structured multimorbidity assessment protocol, we conducted a cross-sectional study, collecting information on 22 self-reported chronic conditions in a representative sample of 1,649 adult primary care patients in Odisha, India. RESULTS: The overall age- and sex-adjusted prevalence of multimorbidity was 28.3% (95% CI, 24.3-28.6) ranging from 5.8% in patients aged 18 to 29 years to 45% in those aged older than 70 years. Older age, female sex, higher education, and high income were associated with significantly higher odds of multimorbidity. After adjusting for age, sex, socioeconomic status (SES), education, and ethnicity, the addition of each chronic condition, as well as consultation at private hospitals, was associated with significant increase in the number of medicines intake per person per day. Increasing age and higher education status significantly raised the number of hospital visits per person per year for patients with multiple chronic conditions. CONCLUSION: Our findings of higher prevalence of multimorbidity and hospitalizations in higher SES individuals contrast with findings in Western countries, where lower SES is associated with a greater morbidity burden.

How a low income state of India managed the unemployment situation during COVID-19? Lessons for future pandemic management.

Background: The partial and complete lockdown to curb the spread of COVID-19 caused enormous economic and social disruptions throughout the world. India witnessed the sharpest decline in its Gross Domestic Product (GDP), and the unemployment rate rose sharply in the first quarter of 2020-21. Odisha, one of the low income states of India, has faced a steep rise in unemployment, with lakhs of migrant workers returning to the state. This article attempts to examine Odisha's unemployment situation compared to the low-income states of India as well as with the national average during COVID-19. This also investigates to what extent the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) provided relief to the people by providing short-term employment opportunities. Design: This is a descriptive study and is based upon repetitive cross sectional secondary data on unemployment rate and labour force participation rate across the low-income states of India. Method: The study used descriptive statistics to analyze the secondary data from the Center for Monitoring Indian Economy (CMIE) and MGNREGA report. The labour force participation rate (LFPR) and unemployment rate (UER) data were collected from the CMIE trimester reports. The information related to number days of employment demanded and employment provided were collected from the MGNREGA reports. Total time period was divided in to two parts - 2017-19 pre pandemic period and 2020-2021 pandemic period. Results: The analysis of UER revealed that the unemployment situation in Odisha was better than the low-income states and overall India. The UER during COVID-19 (Sep-Dec 2020 to Sep-Dec 2021) was lower than the pre COVID-19 level in Odisha (1.6% in Sep-Dec 2020), compared to all India, where this was more than the pre-COVID-19 level (7.4% in Sep-Dec 2020). Odisha government had nearly doubled the employment generation through MGNREGA during 2020-21.The state government undertook a number of proactive measures - increasing wage rate, providing extra days of work in vulnerable districts to address the unemployment situation during the pandemic. Conclusion: The state government's effort to manage the livelihood crisis was notable during the pandemic.. Proper implementation of the wage employment programmes led to higher decline in the UER in Odisha compared to other states These experiences can be emulated by other states or countries.

Motivation and job satisfaction among multipurpose health workers in hilly and non-hilly areas of Jashpur District, Chhattisgarh: an exploratory study.

It is essential to have a capable and motivated health workforce for building an effective, responsive health system and in turn achieve national health goals. The present cross sectional study was conducted in Chhattisgarh, India to assess the level of motivation and job satisfaction among multipurpose health workers (MPWs) and to study factors influencing them. A pre-tested semistructured questionnaire was used to obtain information about the respondents' perceived importance of various job characteristics and perceived job satisfaction. The majority of MPWs were not satisfied with their existing job conditions. Motivators or satisfiers like career advancement and achievement had low scores for all the participants. Working conditions and salary were found to be the dissatisfiers with low scores. The present study suggests that, although financial incentives are important, they are not sufficient to motivate personnel to perform better.

Prevalence of afebrile malaria and development of risk-scores for gradation of villages: A study from a hot-spot in Odisha.

INTRODUCTION: Malaria is a public health emergency in India and Odisha. The national malaria elimination programme aims to expedite early identification, treatment and follow-up of malaria cases in hot-spots through a robust health system, besides focusing on efficient vector control. This study, a result of mass screening conducted in a hot-spot in Odisha, aimed to assess prevalence, identify and estimate the risks and develop a management tool for malaria elimination. METHODS: Through a cross-sectional study and using WHO recommended Rapid Diagnostic Test (RDT), 13221 individuals were screened. Information about age, gender, education and health practices were collected along with blood sample (5 µl) for malaria testing. Altitude, forestation, availability of a village health worker and distance from secondary health center were captured using panel technique. A multi-level poisson regression model was used to analyze association between risk factors and prevalence of malaria, and to estimate risk scores. RESULTS: The prevalence of malaria was 5.8% and afebrile malaria accounted for 79 percent of all confirmed cases. Higher proportion of Pv infections were afebrile (81%). We found the prevalence to be 1.38 (1.1664-1.6457) times higher in villages where the Accredited Social Health Activist (ASHA) didn't stay; the risk increased by 1.38 (1.0428-1.8272) and 1.92 (1.4428-2.5764) times in mid- and high-altitude tertiles. With regard to forest coverage, villages falling under mid- and highest-tertiles were 2.01 times (1.6194-2.5129) and 2.03 times (1.5477-2.6809), respectively, more likely affected by malaria. Similarly, villages of mid tertile and lowest tertile of education had 1.73 times (1.3392-2.2586) and 2.50 times (2.009-3.1244) higher prevalence of malaria. CONCLUSION: Presence of ASHA worker in villages, altitude, forestation, and education emerged as principal predictors of malaria infection in the study area. An easy-to-use risk-scoring system for ranking villages based on these risk factors could facilitate resource prioritization for malaria elimination.

Mass drug administration for lymphatic filariasis elimination in a coastal state of India: a study on barriers to coverage and compliance.

BACKGROUND: Lymphatic filariasis is targeted for elimination in India through mass drug administration (MDA) with diethylcarbamazine (DEC) combined with albendazole (ABZ). For the strategy to be effective, >65% of those living in endemic areas must be covered by and compliant to MDA. Post the MDA 2011 campaign in the endemic district of Odisha, we conducted a survey to assess: (i) the filariasis knowledge in the community, (ii) the coverage and compliance of MDA from the community perspective, and (iii) factors affecting compliance, as well as the operational issues involved in carrying out MDA activities from the drug distributor's perspective. METHODS: A sample of 691 participants - both male and female, aged two years or above - were selected through multistage stratified sampling and interviewed using a semi-structured questionnaire. Additionally, drug distributors and the medical officers in charge of the MDA were also interviewed to understand some of the operational issues encountered during MDA. RESULTS: Ninety-nine percent of the study participants received DEC and ABZ tablets during MDA, of which only just above a quarter actually consumed the drugs. The cause of non-compliance was mostly due to fear of side effects, lack of awareness of the benefits of MDA, and non-attendance of health staff in the villages. Lack of adequate training of drug distributors and poor health communication activities before the MDA campaign commenced and the absence of follow-up by health workers following MDA were a few of the operational difficulties encountered during the MDA campaign. CONCLUSION: Currently MDA is restricted to the distribution of drugs only and the key issues of implementation in compliance, health education, managing side effects, and logistics are not given enough attention. It is therefore essential to address the issues linked to low compliance to make the program more efficient and achieve the goal of filariasis elimination.