"My Health, My Right:" There Is More to It than Meets the Eye.

The WHO's World Health Day 2024 slogan, "My health, my right," has been unpacked through the lens of an evolving social epidemiological understanding. The operative part of the theme merely reiterates international positions that have been established for a long and is unable to adequately incorporate advances in the understanding of the central role that structural determinants play in the production of ill-health. Given the urgency of addressing Sustainable Development Goal and Universal Health Coverage goals, the reduction of health inequities through the promotion of social justice is as much a governance imperative as moral.

Adopting an intersectoral One Health approach in India: Time for One Health Committees.

Following the several episodes of zoonotic disease outbreaks and the more recent COVID-19 pandemic, the Indian policy initiatives are committed to institutionalize One Health (OH) approaches and promote intersectoral, transdisciplinary collaboration and cooperation. The OH principle needs to be visualized beyond the scope of zoonoses. While conservation, ecological and veterinary professions are getting increasingly engaged with OH, most of the medical/clinical and social sciences professions are only peripherally aware of its nuances. The OH initiatives, by their essentially multidisciplinary nature, entail working across ministries and navigating tacit institutional hierarchies and allocating leadership roles. The logical operational step will be the constitution of One Health Committees (OHC) at the State and district levels. Here, we outline the key foundational principles of OHC and hope that the framework for implementation shall be deliberated through wider consultations and piloted and adopted in a phased manner.

COVID-19 vaccination and the power of rumors: Why we must "Tune in".

Rumors have significantly affected immunization campaigns in the past. The ongoing COVID-19 vaccination program in India needs to frame public communication messages both to promote vaccine demand and update as well as counter COVID-related rumors. COVID-related rumors have had wide-ranging effects in the country, from stigmatization of health workers to a crash of prices in the poultry sector. Appropriate communication strategies are critical for tracking, negotiating, and shaping perceptions around the vaccines and the program. Issues that will shape perceptions around the vaccines include product development, prioritization strategies, program rollout activities, and adverse effects following immunization and adverse effects of special interest.

Flies Without Borders: Lessons from Chennai on improving India's municipal public health services.

India's cities face key challenges to improving public health outcomes. First, unequally distributed public resources create insanitary conditions, especially in slums - threatening everyone's health, as suggested by poor child growth even amongst the wealthiest. Second, devolving services to elected bodies works poorly for highly technical services like public health. Third, services are highly fragmented. This paper examines the differences in the organisation and management of municipal services in Chennai and Delhi, two cities with sharply contrasting health indicators. Chennai mitigates these challenges by retaining professional management of service delivery and actively serving vulnerable populations - while services in Delhi are quite constrained. Management and institutional issues have received inadequate attention in the public health literature on developing countries, and the policy lessons from Chennai have wide relevance.

Neurodevelopmental disorders in children aged 2-9 years: Population-based burden estimates across five regions in India.

BACKGROUND: Neurodevelopmental disorders (NDDs) compromise the development and attainment of full social and economic potential at individual, family, community, and country levels. Paucity of data on NDDs slows down policy and programmatic action in most developing countries despite perceived high burden. METHODS AND FINDINGS: We assessed 3,964 children (with almost equal number of boys and girls distributed in 2-<6 and 6-9 year age categories) identified from five geographically diverse populations in India using cluster sampling technique (probability proportionate to population size). These were from the North-Central, i.e., Palwal (N = 998; all rural, 16.4% non-Hindu, 25.3% from scheduled caste/tribe [SC-ST] [these are considered underserved communities who are eligible for affirmative action]); North, i.e., Kangra (N = 997; 91.6% rural, 3.7% non-Hindu, 25.3% SC-ST); East, i.e., Dhenkanal (N = 981; 89.8% rural, 1.2% non-Hindu, 38.0% SC-ST); South, i.e., Hyderabad (N = 495; all urban, 25.7% non-Hindu, 27.3% SC-ST) and West, i.e., North Goa (N = 493; 68.0% rural, 11.4% non-Hindu, 18.5% SC-ST). All children were assessed for vision impairment (VI), epilepsy (Epi), neuromotor impairments including cerebral palsy (NMI-CP), hearing impairment (HI), speech and language disorders, autism spectrum disorders (ASDs), and intellectual disability (ID). Furthermore, 6-9-year-old children were also assessed for attention deficit hyperactivity disorder (ADHD) and learning disorders (LDs). We standardized sample characteristics as per Census of India 2011 to arrive at district level and all-sites-pooled estimates. Site-specific prevalence of any of seven NDDs in 2-<6 year olds ranged from 2.9% (95% CI 1.6-5.5) to 18.7% (95% CI 14.7-23.6), and for any of nine NDDs in the 6-9-year-old children, from 6.5% (95% CI 4.6-9.1) to 18.5% (95% CI 15.3-22.3). Two or more NDDs were present in 0.4% (95% CI 0.1-1.7) to 4.3% (95% CI 2.2-8.2) in the younger age category and 0.7% (95% CI 0.2-2.0) to 5.3% (95% CI 3.3-8.2) in the older age category. All-site-pooled estimates for NDDs were 9.2% (95% CI 7.5-11.2) and 13.6% (95% CI 11.3-16.2) in children of 2-<6 and 6-9 year age categories, respectively, without significant difference according to gender, rural/urban residence, or religion; almost one-fifth of these children had more than one NDD. The pooled estimates for prevalence increased by up to three percentage points when these were adjusted for national rates of stunting or low birth weight (LBW). HI, ID, speech and language disorders, Epi, and LDs were the common NDDs across sites. Upon risk modelling, noninstitutional delivery, history of perinatal asphyxia, neonatal illness, postnatal neurological/brain infections, stunting, LBW/prematurity, and older age category (6-9 year) were significantly associated with NDDs. The study sample was underrepresentative of stunting and LBW and had a 15.6% refusal. These factors could be contributing to underestimation of the true NDD burden in our population. CONCLUSIONS: The study identifies NDDs in children aged 2-9 years as a significant public health burden for India. HI was higher than and ASD prevalence comparable to the published global literature. Most risk factors of NDDs were modifiable and amenable to public health interventions.

Governing multisectoral action for health in low- and middle-income countries.

Kumanan Rasanathan and colleagues argue that the potential of multisectoral collaboration for improving health remains untapped in many low- and middle-income countries.

Challenges of biomedical research collaboration in India: Perceptions of Indian and international researchers.

Biomedical research collaborations are to be contextualized in the larger global health agenda which also opens up new information pathways, expands research networks, and brings additional resources. A qualitative inquiry was employed to understand the perceived benefits and challenges of research collaborations by biomedical scientists from India (Global South [GS] country) and the Global North (GN). In-depth interviews were conducted with 47 biomedical scientists from India and 06 from the GN. The data was analyzed using the grounded theory approach. Complementarity of skills and resources, access to funds, improved quality of work, an opportunity to conduct multi-centric studies, development of collaborative networks, better and larger number of publications, mutual learning, opportunity to work with credible researchers, address common interests, leverage interpersonal and trusted relationships and larger societal good were some of the critical factors for eagerness of participants in joint scientific endeavors. However, the challenging aspects of dissent and disagreements were the power imbalance between the collaborators, the development of a trust deficit, and local administrative issues. The challenges reported in the current publication, also echoed in several previous publications can be surmounted and negotiated amicably when the rules of the game, law of the land, sharing of the credits, and interest of the collaborating parties are addressed and agreed up in a fair and just manner before the start of the collaboration. Overall biomedical partnerships are complex collaborations with its challenges, the processes are dynamic and outcomes are emergent. This requires constant and proactive evolution of the preparation, implementation and sustainability of the collaborative efforts be it national or international.

Turning the Gaze from Survive to Thrive for Children in India: Learnings from Two Case Studies.

Despite significant efforts and progress made in newborn care programs in India, implementation gaps persist across the continuum of care. The present case studies of two districts in Himachal Pradesh revealed that pathways of care were often fragmented with inconsistent linkages between facility and community due to poor documentation, lack of tiered referral, health system weaknesses, low utilization of primary level institutions, and inadequate post-natal home visits by Accredited Social Health Activists (ASHAs). Involvement of healthcare providers (HCPs) and frontline health workers (FHWs) was low and uneven in generating awareness across the districts with limited participation in supporting care in the community. Ensuring functionality of health centers and first-level care facilities; strengthening referral systems; adequate/trained human resources; strengthening routine health management systems, discharge processes and community-based care with adequate integration with facilities are necessary in closing access gaps.

Barriers to the Delivery and Uptake of Water Sanitation and Hygiene (WASH) Promotion and Infant Diarrhea Prevention Services: A Case Study in Rural Tribal Banswara, Rajasthan.

OBJECTIVE: We aimed to identify key barriers to Water Sanitation and Hygiene (WASH) promotion and infant diarrhea prevention services delivered by Accredited Social Health Activists (ASHAs) in rural India. METHODS: A case-study was conducted across nine tribal villages in Banswara district (Rajasthan), where in-depth observational and qualitative data was collected from frontline health workers and infant caregivers. RESULTS: ASHAs' prioritization of their incentive-based link-worker tasks over their health activist roles, limited community mobilization, and lack of monitoring of such activities hindered the delivery of WASH promotion and infant diarrhea prevention services. Caregivers' lack of trust in ASHA's health knowledge and preference for private providers and traditional healers also hindered the uptake of ASHA's health promotion services. CONCLUSIONS: Strengthening ASHAs' health activism roles and building trust on frontline health workers' knowledge among tribal communities will be the key to address the determinants of child malnutrition and stunting and accelerate progress towards the national development agenda.

Growth Faltering Among Discharged Babies from Inpatient Newborn Care Facilities: Learnings from Two Districts of Himachal Pradesh.

OBJECTIVE: To determine the burden of early growth faltering and understand the care practices for small and sick babies discharged from newborn units in the district. STUDY DESIGN: Observational and follow-up study. PARTICIPANTS: 512 babies discharged from two Special Newborn Care Units (SNCUs) and four Newborn Stabilization Units (NBSUs) in two districts of Himachal Pradesh. METHODS: Anthropometric assessments, interview of mothers and Accredited Social Health Activists (ASHAs) conducted between August, 2018 and March, 2019. Change in weight-for-age z-score (DWAZ) of <-0.67SD between birth and assessment was used to define growth faltering. OUTCOMES: Proportion of growth faltering (or catch-down growth) in small and sick babies discharged from SNCUs and NBSUs, and infant care practices. RESULTS: Growth faltering was observed in a significant proportion of both term (30%) and preterm (52.6%) babies between 1 to 4 months of age. Among babies with growth faltering (n=180), 73.9% received a home visit by ASHA, and only 36.7% received a follow-up visit at a facility. There were 71.3% mothers counselled at discharge (mostly informed about breast feeding). Most (96.7%) mothers did not perceive inadequate weight gain in their babies post-discharge. During home visits, ASHAs weighed 61.6% of the infants with growth faltering. Amongst infants who had growth faltering, only 49.6% of mothers had been provided information about their infant's growth and 57.1% mothers had received breastfeeding counselling. CONCLUSION: Small and sick newborn infants (both term and preterm babies) discharged from special care newborn units are at increased risk of early growth faltering. Follow-up care provided to these infants is inadequate. There is a need to strengthen both facility-based and home-based follow up of small and sick newborn infants discharged from newborn care facilities.

Barriers in reaching new-borns and infants through home visits: A qualitative study using nexus planning framework.

Background: Home visitation has emerged as an effective model to provide high-quality care during pregnancy, childbirth, and post-natal period and improve the health outcomes of mother- new born dyad. This 3600 assessment documented the constraints faced by the community health workers (known as the Accredited Social Health Activists, ASHAs) to accomplish home visitation and deliver quality services in a poor-performing district and co-created the strategies to overcome these using a nexus planning approach. Methods: The study was conducted in the Raisen district of Madhya Pradesh, India. The grounded theory approach was applied for data collection and analysis using in-depth interviews, and focus group discussions with stakeholders representing from health system (including the ASHAs) and the community (rural population). A key group of diverse stakeholders were convened to utilize the nexus planning five domain framework (social-cultural, educational, organizational, economic, and physical) to prioritize the challenges and co-create solutions for improving the home visitation program performance and quality. The nexus framework provides a systemic lens for evaluating the success of the ASHAs home visitation program. Results: The societal (caste and economic discrimination), and personal (domestic responsibilities and cultural constraints of working in the village milieu) issues emerged as the key constraints for completing home visits. The programmatic gaps in imparting technical knowledge and skills, mentoring system, communication abilities, and unsatisfactory remuneration system were the other barriers to the credibility of the services. The nexus planning framework emphasized that each of the above factors/domains is intertwined and affects or depends on each other for home-based maternal and newborn care services delivered with quality through the ASHAs. Conclusion: The home visitation program services, quality and impact can be enhanced by addressing the social-cultural, organizational, educational, economic, and physical nexus domains with concurrent efforts for skill and confidence enhancement of the ASHAs and their credibility.

Community engagement: The key to tackling Antimicrobial Resistance (AMR) across a One Health context?

Antimicrobial resistance (AMR) is a One Health problem underpinned by complex drivers and behaviours. This is particularly so in low - and middle-income countries (LMICs), where social and systemic factors fuel (mis)use and drive AMR. Behavioural change around antimicrobial use could safeguard both existing and future treatments. However, changing behaviour necessitates engaging with people to understand their experiences. This publication describes a knowledge-exchange cluster of six LMIC-based projects who co-designed and answered a series of research questions around the usage of Community Engagement (CE) within AMR. Findings suggest that CE can facilitate AMR behaviour change, specifically in LMICs, because it is a contextualised approach which supports communities to develop locally meaningful solutions. However, current CE interventions focus on human aspects, and demand-side drivers, of AMR. Our cluster suggests that broader attention should be paid to AMR as a One Health issue. The popularity of mixed methods approaches within existing CE for AMR interventions suggests there is interdisciplinary interest in the uptake of CE. Unfortunately, the specificity and context-dependency of CE can make it difficult to evaluate and scale. Nevertheless, we suggest that in synthesising learnings from CE, we can develop a collective understanding of its scope to tackle AMR across contexts.   .

Non-health determinants of health and healthcare in Delhi.

With only 0.05% of the total area of the country, Delhi is home to 1.34% of India's population. This creates enormous pressure on natural and man-made resources, and generates situations in which non-health determinants may take precedence over the conventional determinants directly associated with health and healthcare. With the rising advocacy on social determinants of health, several of these factors may rightly seem to be part of the broader territory of health-related variables, and in that context, they may be designated as conventional non-medical determinants. We discuss some more visible domains, such as demography, migration and floating population; the physical and biological environment; economic determinants; social determinants; legislation and enforcement, and underscore some less explored yet critical domains of the determinants related to culture, governance and politics. What emerges as a compelling reality is a wide differential in physical environment, urban planning and access to infrastructural inputs between the privileged and marginalized areas of Delhi. Inequities in physical quality of life are so gross that even a value-neutral, official narrative betrays them helplessly. We propose actionable areas to address some of the pressing non-health determinants of health and healthcare.

Determinants of utilization of services under MMJSSA scheme in Jharkhand 'Client Perspective': a qualitative study in a low performing state of India.

Preventing maternal death associated with pregnancy and child birth is one of the greatest challenges for India. Approximately 55,000 women die in India due to pregnancy- and childbirth- related conditions each year. Increasing the coverage of maternal and newborn interventions is essential if Millennium Development Goals (MDG) 4 and 5 are to be reached. With a view to accelerate the reduction in maternal and neonatal mortality through institutional deliveries, Government of India initiated a scheme in 2005 called Janani Suraksha Yojna (JSY) under its National Rural Health Mission (NRHM). In Jharkhand the scheme is called the Mukhya Mantri Janani Shishu Swasthya Abhiyan (MMJSSA). This paper focuses on community perspectives, for indentifying key areas that require improvement for proper implementation of the MMJSSA in Jharkhand. Qualitative research method was used to collect data through in-depth interviews (IDIs) and focus group discussions (FGDs) in six districts of Jharkhand- Gumla, West Singhbhum, Koderma, Deoghar, Garhwa, and Ranchi. Total 300 IDIs (24 IDIs each from mother given birth at home and institution respectively; two IDIs each with members of Village Health and Sanitation Committees (VHSC) / Rogi Kalyan Samitis (RKS) from each district) and 24 FGDs (four FGDs were conducted from pools of husbands, mothers-in-law and fathers-in-law in each district) were conducted. Although people indicated willingness for institutional deliveries (generally perceived to be safe deliveries), several barriers emerged as critical obstacles. These included poor infrastructure, lack of quality of care, difficulties while availing incentives, corruption in disbursement of incentives, behavior of the healthcare personnel and lack of information about MMJSSA. Poor (and expensive) transport facilities and difficult terrain made geographical access difficult. The level of utilization of maternal healthcare among women in Jharkhand is low. There was an overwhelming demand for energizing sub-centers (including for deliveries) in order to increase access to maternal and child health services. Having second ANMs will go a long way in achieving this end. The MMJSSA scheme will thus have to re-invent itself within the overall framework of the NRHM.

Evidence-based National Vaccine Policy.

India has over a century old tradition of development and production of vaccines. The Government rightly adopted self-sufficiency in vaccine production and self-reliance in vaccine technology as its policy objectives in 1986. However, in the absence of a full-fledged vaccine policy, there have been concerns related to demand and supply, manufacture vs. import, role of public and private sectors, choice of vaccines, new and combination vaccines, universal vs. selective vaccination, routine immunization vs. special drives, cost-benefit aspects, regulatory issues, logistics etc. The need for a comprehensive and evidence based vaccine policy that enables informed decisions on all these aspects from the public health point of view brought together doctors, scientists, policy analysts, lawyers and civil society representatives to formulate this policy paper for the consideration of the Government. This paper evolved out of the first ever ICMR-NISTADS national brainstorming workshop on vaccine policy held during 4-5 June, 2009 in New Delhi, and subsequent discussions over email for several weeks, before being adopted unanimously in the present form.

An Uphill Task for POSHAN Abhiyan: Examining the Missing Link of 'Convergence'.

The Participatory Approach for Nutrition in Children: Strengthening Health, Education, Engineering and Environment Linkages (PANChSHEEEL) project is a collaboration between University College London, Save the Children India, Jawaharlal Nehru University and Indian Institute of Technology Delhi to develop a socio-culturally appropriate, tailored, integrated and interdisciplinary intervention in rural India and test its acceptability for delivery through Anganwadi Centre (AWCs) and schools. Recognizing the socio-ecological determinants of under-nutrition, the POSHAN Abhiyan (POSHAN Mission) adopts a multi-sectoral approach to achieve five goals, of which two are directly related to children. The POSHAN Abhiyan resonates with the conceptual framework of the PANChSHEEEL study in its interdisciplinary scope and focus on local linka ges. This paper draws upon empirical evidence from the PANChSHEEEL Project in Banswara (one of the POSHAN mission districts), Rajasthan to help understand linkages between policy and practice, specifically the challenges of operationalizing 'convergence', the core strategy of the Abhiyan.

A tale of two global health programs. Smallpox eradication's lessons for the antipolio campaign in India.

India provided one of the most challenging chapters of the worldwide smallpox eradication program. The campaign was converted from a project in which a handful of officials tried to impose their ideas on a complex health bureaucracy to one in which its components were constantly adapted to the requirements of a variety of social, political, and economic contexts. This change, achieved mainly through the active participation of workers drawn from local communities in the 1970s, proved to be a momentous policy adaptation that contributed to certification of smallpox eradication in 1980. However, this lesson appears to have been largely forgotten by those currently managing the Global Polio Eradication Initiative. We hope to show ways in which contemporary efforts to eliminate polio worldwide might profitably draw on historical information, which can indicate meaningful ways in which institutional adaptability is likely to help counter the political and social challenges being encountered in India.