Planning and financing of RMNCH+A under National Health Mission: A case study of the Gurugram District of Haryana State.

BACKGROUND: The Health Planning Process under National Health Mission (NHM) is participatory in nature and the State Programme Implementation Plan (PIP) is an aggregation of District PIPs which is examined and approved by the National Programme Coordination Committee (NPCC), Ministry of Health and Family Welfare, Government of India. Many times there are delays in releasing of Record of Proceedings (ROPs)/approvals. This affects utilisation of NHM funds at district level and below and desired outcomes are not achieved. The present study aims to analyse the process of fund flow, disbursement and utilisation of funds on various components under Reproductive Maternal New born Child and Adolescent Health (RMNCH+A) in the district Gurugram. METHODOLOGY: The study was conducted in the District Gurugram of Haryana State, India. One Community Health Centres (CHCs), two Primary Health Centres (PHCs) and four Sub Health Centres were randomly selected. Primary and secondary data were collected in the study. Medical Officer (I/C), Accounts Staff and Health Workers were interviewed using separate schedules regarding process of disbursement, delays in release and utilisation of funds. Separate checklists were prepared to collect data on availability and utilisation of funds at District, CHC and PHC levels under different components of programme. FINDINGS: Study found that PIP is prepared with inputs from Block level but community participation at (PHC) and below was not present. There was a delay in reaching funds to district due to delayed release of ROPs. Almost 30%-40% of the budget could not be utilised due to delay in receiving of budget. Utilisation of funds was less in some programme activities due to vacant positions project staff. Only 38% and 31% of the funds were utilised under the child health and family planning budget head for the district of Gurugram in the year 2016-17. Accounts staffs were overburdened which affected monitoring of funds utilisation. Budget release from State to District and below was through e-Banking. Auxiliary Nurse Midwives (ANMs) at Sub centre used to get Untied Funds at the end of third quarter. The Government introduced new 18 broad budget heads in NHM Budget for improving utilisation of budget. CONCLUSION: Delayed release of ROPs and erroneous estimation of budget under the programme, very rigid and large number of budget heads poses challenges of understanding and analysing expenditure and affects utilisation of funds under the NHM. Moreover, vacant positions in the programme, unrealistic planning, weak community participation in planning of expenditure and unexplained budget cut in ROPs were main challenges faced by the District.

Whole genome resequencing and comparative genome analysis of three Puccinia striiformis f. sp. tritici pathotypes prevalent in India.

Stripe rust disease of wheat, caused by Puccinia striiformis f. sp. tritici, (Pst) is one of the most serious diseases of wheat worldwide. In India, virulent stripe rust races have been constantly evolving in the North-Western Plains Zone leading to the failure of some of the most widely grown resistant varieties in the region. With the goal of studying the recent evolution of virulent races in this region, we conducted whole-genome re-sequencing of three prevalent Indian Pst pathotypes Pst46S119, Pst78S84 and Pst110S119. We assembled 58.62, 58.33 and 55.78 Mb of Pst110S119, Pst46S119 and Pst78S84 genome, respectively and found that pathotypes were highly heterozygous. Comparative phylogenetic analysis indicated the recent evolution of pathotypes Pst110S119 and Pst78S84 from Pst46S119. Pathogenicity-related genes classes (CAZyme, proteases, effectors, and secretome proteins) were identified and found to be under positive selection. Higher rate of gene families expansion were also observed in the three pathotypes. A strong association between the effector genes and transposable elements may be the source of the rapid evolution of these strains. Phylogenetic analysis differentiated the Indian races in this study from other known United States, European, African, and Asian races. Diagnostic markers developed for the identification of three Pst pathotypes will help tracking of yellow rust at farmers field and strategizing resistance gene deployment.

Cost of treatment and consequences for chronic hepatitis B and C virus infection at a tertiary care hospital in Delhi.

Patient living with chronic viral hepatitis in India faces the high cost of treatment and impoverishment. The present study is aimed to assess the cost of treatment and economic consequences among chronically infected viral hepatitis patients at a tertiary care hospital in Delhi. The descriptive cross-sectional study was undertaken during October 2016-January 2017. Three hundred and eighty-nine participants were interviewed through a schedule for variables and assessing both direct and indirect costs. Costs of hospital expenditure were extracted from records available with patients or databases of the hospital. The average outpatient expenditure and the inpatient costs were calculated. Direct nonmedical costs were also included. The analysis revealed the total cost of treatment ranged from Rs. 16,600/-to Rs. 1,709,000/-with a median of Rs. 193,500 per year. The cost of treatment increased with the severity of the disease. The cost of treatment led to impoverishment in 52.8% of families and imposed a substantial economic burden and consequences on the patients.

Evolving social health scheme for workers in unorganized sector: key evidences from study of cycle rickshaw pullers in Delhi, India.

BACKGROUND: In view of high out-of-pocket costs and low spending even for basic healthcare for the poor employed in the unorganized sector, policy makers in India have turned their attention to developing a financing mechanism for social health insurance with the desire to provide quality care to the poor and economically disadvantaged. OBJECTIVES: This study aims to assess and determine the disease profile, treatment expenditure and willingness to pay for health insurance among rickshaw pullers in Delhi. METHODS: The study was conducted among 500 rickshaw pullers from five zones of the Municipal Corporation of Delhi, taking a sample of 100 from each zone. RESULTS: The average cost of treatment was Rs.505 for outpatient and Rs. 3200 for inpatient care. To finance the treatment expenditure, 27.5% of the respondents spent from their household savings, and 43% had to borrow funds. Any "spell of sickness" and "total expenditure on acute illness" were significantly (p < 0.01) associated with the willingness to pay for health insurance. Overall, the majority (83%) of participants were willing to pay for health insurance. CONCLUSION: The study provides the evidence for the need for urgent policy development by introducing a social health insurance package including wage losses for the vulnerable groups such as rickshaw pullers in the unorganized sector in India, which significantly contribute to pollution free and cheap transportation of community, tourists and commercial goods as well.

Risk factors and costs of oral cancer in a tertiary care hospital in Delhi.

The present study conducted with 100 oral cancer patients at a private tertiary care hospital in Delhi demonstrated that stage III cancer was associated with longer use of tobacco and poor oral hygiene. There was also statistically significant association (p<.05) between consumption of tobacco and alcohol. More than 60% treatment expenditure was on surgery followed by accommodation (9%) and investigations (8%). The effect of tobacco was well known among patients as 76% of the patients knew that common cancer in tobacco chewer is 'oral cancer', 22% of the patients however responded that they did not know which cancer is common in tobacco chewers. 58% said that they learnt about ill effects of tobacco from media while 24% said they learnt from family and friends. Out of 78 tobacco users, 60 (77%) said that they never received help to quit tobacco while 18(23%) have received help to quit.

Cost of treatment for cancer: experiences of patients in public hospitals in India.

BACKGROUND: To assess the treatment pattern and expenditure incurred by cancer patients undergoing treatment at government tertiary hospitals in India. MATERIALS AND METHODS: A cross-sectional study of 508 cancer patients randomly selected from tertiary cancer hospitals funded by central/state governments located in major cities of five states in India, namely Kerala, Maharashtra, Rajasthan, West Bengal and Mizoram, during March - May 2011 was conducted. Information related to direct costs, indirect costs and opportunity costs incurred on investigations and treatment, major source of payment and difficulties faced by patients during the course of treatment was collected. RESULTS: About 45% of the patients used private health facilities as the first point of contact for cancer related diseases as against 32% in public hospitals. About 47% sought private health facilities for cancer investigations, 21% at district/sub-district hospitals, and about 4% contacted primary health care facilities. A majority of the patients (76%) faced financial problems while undergoing treatment. CONCLUSIONS: The results highlight the importance of involving the primary health care system in the cancer prevention activities.

Bioavailability of iron from wheat aegilops derivatives selected for high grain iron and protein contents.

A coupled in vitro digestion/Caco-2 model was employed to assess iron bioavailability from wheat Aegilops derivatives selected for high iron and protein contents. The iron content in wheat genotypes used in this study correlated to a great extent with both protein (r = 0.80) and phytate (r = 0.68) contents. The iron bioavailability was based on Caco-2 cell ferritin formation from cooked digests of these derivatives (relative to WL711 control) and correlated positively with dialyzable iron (r = 0.63) and total iron content (r = 0.38) but not with the phytate content. The apparently decreased phytate/iron molar ratios, however, correlated negatively (r = -0.42) with the iron bioavailability, justifying the utilization of these parameters in biofortification programs. Iron bioavailability in the derivatives increased up to 1.5-fold, corresponding to a 1.5-2.2-fold increase observed in iron content over control. These data suggest that biofortification for iron proportionately leading to higher iron bioavailability will be the most feasible and cost-effective approach to combat micronutrient deficiency.

Epigenetic regulation of TTF-I-mediated promoter-terminator interactions of rRNA genes.

Ribosomal RNA synthesis is the eukaryotic cell's main transcriptional activity, but little is known about the chromatin domain organization and epigenetics of actively transcribed rRNA genes. Here, we show epigenetic and spatial organization of mouse rRNA genes at the molecular level. TTF-I-binding sites subdivide the rRNA transcription unit into functional chromatin domains and sharply delimit transcription factor occupancy. H2A.Z-containing nucleosomes occupy the spacer promoter next to a newly characterized TTF-I-binding site. The spacer and the promoter proximal TTF-I-binding sites demarcate the enhancer. DNA from both the enhancer and the coding region is hypomethylated in actively transcribed repeats. 3C analysis revealed an interaction between promoter and terminator regions, which brings the beginning and end of active rRNA genes into close contact. Reporter assays show that TTF-I mediates this interaction, thereby linking topology and epigenetic regulation of the rRNA genes.

CTCF binding at the H19 imprinting control region mediates maternally inherited higher-order chromatin conformation to restrict enhancer access to Igf2.

It is thought that the H19 imprinting control region (ICR) directs the silencing of the maternally inherited Igf2 allele through a CTCF-dependent chromatin insulator. The ICR has been shown to interact physically with a silencer region in Igf2, differentially methylated region (DMR)1, but the role of CTCF in this chromatin loop and whether it restricts the physical access of distal enhancers to Igf2 is not known. We performed systematic chromosome conformation capture analyses in the Igf2/H19 region over >160 kb, identifying sequences that interact physically with the distal enhancers and the ICR. We found that, on the paternal chromosome, enhancers interact with the Igf2 promoters but that, on the maternal allele, this is prevented by CTCF binding within the H19 ICR. CTCF binding in the maternal ICR regulates its interaction with matrix attachment region (MAR)3 and DMR1 at Igf2, thus forming a tight loop around the maternal Igf2 locus, which may contribute to its silencing. Mutation of CTCF binding sites in the H19 ICR leads to loss of CTCF binding and de novo methylation of a CTCF target site within Igf2 DMR1, showing that CTCF can coordinate regional epigenetic marks. This systematic chromosome conformation capture analysis of an imprinting cluster reveals that CTCF has a critical role in the epigenetic regulation of higher-order chromatin structure and gene silencing over considerable distances in the genome.

Familial cases of point mutations in the XIST promoter reveal a correlation between CTCF binding and pre-emptive choices of X chromosome inactivation.

The choice mechanisms that determine the future inactive X chromosome in somatic cells of female mammals involve the regulated expression of the XIST gene. A familial C(-43)G mutation in the XIST promoter results in skewing of X chromosome inactivation (XCI) towards the inactive X chromosome of heterozygous females, whereas a C(-43)A mutation found primarily in the active X chromosome results in the opposite skewing pattern. Both mutations point to the existence of a factor that might be responsible for the skewed patterns. Here we identify this factor as CTCF, a conserved protein with a 11 Zn-finger (ZF) domain that can mediate multiple sequence-specificity and interactions between DNA-bound CTCF molecules. We show that mouse and human Xist/XIST promoters contain one homologous CTCF-binding sequence with the matching dG-contacts, which in the human XIST include the -43 position within the DNase I footprint of CTCF. While the C(-43)A mutation abrogates CTCF binding, the C(-43)G mutation results in a dramatic increase in CTCF-binding efficiency by altering ZF-usage mode required for recognition of the altered dG-contacts of the mutant site. Thus, the skewing effect of the two -43C mutations correlates with their effects on CTCF binding. Finally, CTCF interacts with the XIST/Xist promoter only in female human and mouse cells. The interpretation that this reflected a preferential interaction with the promoter of the active Xist allele was confirmed in mouse fetal placenta. These observations are in keeping with the possibility that the choice of X chromosome inactivation reflects stabilization of a higher order chromatin conformation impinging on the CTCF-XIST promoter complex.

An antisense RNA regulates the bidirectional silencing property of the Kcnq1 imprinting control region.

The Kcnq1 imprinting control region (ICR) located in intron 10 of the Kcnq1 gene is unmethylated on the paternal chromosome and methylated on the maternal chromosome and has been implicated in the manifestation of parent-of-origin-specific expression of six neighboring genes. The unmethylated Kcnq1 ICR harbors bidirectional silencer activity and drives expression of an antisense RNA, Kcnq1ot1, which overlaps the Kcnq1 coding region. To elucidate whether the Kcnq1ot1 RNA plays a role in the bidirectional silencing activity of the Kcnq1 ICR, we have characterized factor binding sites by genomic footprinting and tested the functional consequence of various deletions of these binding sites in an episome-based system. Deletion of the elements necessary for Kcnq1ot1 promoter function resulted in the loss of silencing activity. Furthermore, interruption of Kcnq1ot1 RNA production by the insertion of a polyadenylation sequence downstream of the promoter also caused a loss of both silencing activity and methylation spreading. Thus, the antisense RNA plays a key role in the silencing function of the ICR. Double-stranded RNA (dsRNA)-mediated RNA interference is unlikely to be involved, as the ICR is active irrespective of the simultaneous production of dsRNA from the genes it silences.