Assessing the impact of COVID-19 management on the workload of human resources working in India's National Tuberculosis Elimination Program.

BACKGROUND: In 1993, WHO declared tuberculosis (TB) as a global health emergency considering 10 million people are battling TB, of which 30% are undiagnosed annually. In 2020 the COVID-19 pandemic took an unprecedented toll on health systems in every country. Public health staff already engaged in TB control and numerous other departments were additionally tasked with managing COVID-19, stretching human resource (HR) capacity beyond its limits. As part of an assessment of HR involved in TB control in India, The World Bank Group and partners conducted an analysis of the impact of COVID-19 on TB human resources for health (HRH) workloads, with the objective of describing the extent to which TB-related activities could be fulfilled and hypothesizing on future HR requirements to meet those needs. METHODS: The study team conducted a Workload Indicators and Staffing Needs (WISN) analysis according to standard WHO methodology to classify the workloads of priority cadres directly or indirectly involved in TB control activities as over-, adequately or under-worked, in 18 districts across seven states in India. Data collection was done via telephone interviews, and questions were added regarding the proportion of time dedicated to COVID-19 related tasks. We carried out quantitative analysis to describe the time allocated to COVID-19 which otherwise would have been spent on TB activities. We also conducted key informant interviews (KII) with key TB program staff about HRH planning and task-shifting from TB to COVID-19. RESULTS: Workload data were collected from 377 respondents working in or together with India's Central TB Division (CTD). 73% of all respondents (n = 270) reported carrying out COVID-19 tasks. The average time spent on COVID-19 tasks was 4 h / day (n = 72 respondents). Multiple cadres highly instrumental in TB screening and diagnosis, in particular community outreach (ASHA) workers and CBNAAT/TrueNAAT laboratory technicians working at peripheral, block and district levels, were overworked, and spending more than 50% of their time on COVID-19 tasks, reducing time for TB case-finding. Qualitative interviews with laboratory technicians revealed that PCR machines previously used for TB testing were repurposed for COVID-19 testing. CONCLUSIONS: The devastating impact of COVID-19 on HR capacity to conduct TB case-finding in India, as in other settings, cannot be overstated. Our findings provide clear evidence that NTEP human resources did not have time or essential material resources to carry out TB tasks during the COVID pandemic without doing substantial overtime and/or compromising on TB service delivery. To minimize disruptions to routine health services such as TB amidst future emerging infectious diseases, we would do well, during periods of relative calm and stability, to strategically map out how HRH lab staff, public health resources, such as India's Health and Wellness Centers and public health cadre, and public-private sector collaboration can most optimally absorb shocks to the health system.

SMS feedback system as a quality assurance mechanism: experience from a household survey in rural India.

The increasing use of digital health solutions to support data capture both as part of routine delivery of health services and through special surveys presents unique opportunities to enhance quality assurance measures. This study aims to demonstrate the feasibility and acceptability of using back-end data analytics and machine learning to identify impediments in data quality and feedback issues requiring follow-up to field teams using automated short messaging service (SMS) text messages. Data were collected as part of a postpartum women's survey (n=5095) in four districts of Madhya Pradesh, India, from October 2019 to February 2020. SMSs on common errors found in the data were sent to supervisors and coordinators. Before/after differences in time to correction of errors were examined, and qualitative interviews conducted with supervisors, coordinators, and enumerators. Study activities resulted in declines in the average number of errors per week after the implementation of automated feedback loops. Supervisors and coordinators found the direct format, complete information, and automated nature of feedback convenient to work with and valued the more rapid notification of errors. However, coordinators and supervisors reported preferring group WhatsApp messages as compared with individual SMSs to each supervisor/coordinator. In contrast, enumerators preferred the SMS system over in-person group meetings where data quality impediments were discussed. This study demonstrates that automated SMS feedback loops can be used to enhance survey data quality at minimal cost. Testing is needed among data capture applications in use by frontline health workers in India and elsewhere globally.

Does exposure to health information through mobile phones increase immunisation knowledge, completeness and timeliness in rural India?

INTRODUCTION: Immunisation plays a vital role in reducing child mortality and morbidity against preventable diseases. As part of a randomised controlled trial in rural Madhya Pradesh, India to assess the impact of Kilkari, a maternal messaging programme, we explored determinants of parental immunisation knowledge and immunisation practice (completeness and timeliness) for children 0-12 months of age from four districts in Madhya Pradesh. METHODS: Data were drawn from a cross-sectional survey of women (n=4423) with access to a mobile phone and their spouses (n=3781). Parental knowledge about immunisation and their child's receipt of vaccines, including timeliness and completeness, was assessed using self-reports and vaccination cards. Ordered logistic regressions were used to analyse the factors associated with parental immunisation knowledge. A Heckman two-stage probit model was used to analyse completeness and timeliness of immunisation after correcting for selection bias from being able to produce the immunisation card. RESULTS: One-third (33%) of women and men knew the timing for the start of vaccinations, diseases linked to immunisations and the benefits of Vitamin-A. Less than half of children had received the basic package of 8 vaccines (47%) and the comprehensive package of 19 vaccines (44%). Wealth was the most significant determinant of men's knowledge and of the child receiving complete and timely immunisation for both basic and comprehensive packages. Exposure to Kilkari content on immunisation was significantly associated with an increase in men's knowledge (but not women's) about child immunisation (OR: 1.23, 95% CI 1.02 to1.48) and an increase in the timeliness of the child receiving vaccination at birth (Probit coefficient: 0.08, 95% CI 0.08 to 0.24). CONCLUSION: Gaps in complete and timely immunisation for infants persist in rural India. Mobile messaging programmes, supported by mass media messages, may provide one important source for bolstering awareness, uptake and timeliness of immunisation services. TRIAL REGISTRATION NUMBER: NCT03576157.