Strengthening of District/Taluk Level Hospitals Through Implementation of Post-graduate Medical Courses in Karnataka, India.

The World Health Organization (WHO) recommends the requirement of human resource for health (HRH) stands at 44.5 skilled health workers per 10,000 population. WHO recognizes India as one of the countries which has HRH crisis. Karnataka, a southern state in India, has the highest number of medical colleges yet faces the shortage of specialists in the public hospitals. We conducted desk review to understand the HRH crisis, particularly the medical specialists in India. Simultaneously, we conducted secondary research to explore the initiatives taken by the Government of Karnataka (GoK) to mitigate the shortage of medical specialists in the rural areas. GoK scaled up the National Board of Examination in Medical Sciences (NBEMS) postgraduate and super-speciality courses such as Diplomate of National Board (DNB), Diploma, and Doctorate of National Board (DrNB) in district hospitals (minimum 250-500 bedded) and taluk hospitals (minimum 100 bedded) by utilizing the existing resources. Karnataka is the first state in India to expand the NBEMS (DNB and Diploma) courses in taluk hospitals and to begin DrNB courses in district hospitals. The paper documents the process of implementation of the NBEMS courses at district and taluk hospitals of Karnataka, which has supported in strengthening these hospitals in the state.

Determinants of severity among hospitalised COVID-19 patients: Hospital-based case-control study, India, 2020.

BACKGROUND: Risk factors for the development of severe COVID-19 disease and death have been widely reported across several studies. Knowledge about the determinants of severe disease and mortality in the Indian context can guide early clinical management. METHODS: We conducted a hospital-based case control study across nine sites in India to identify the determinants of severe and critical COVID-19 disease. FINDINGS: We identified age above 60 years, duration before admission >5 days, chronic kidney disease, leucocytosis, prothrombin time > 14 sec, serum ferritin >250 ng/mL, d-dimer >0.5 ng/mL, pro-calcitonin >0.15 µg/L, fibrin degradation products >5 µg/mL, C-reactive protein >5 mg/L, lactate dehydrogenase >150 U/L, interleukin-6 >25 pg/mL, NLR ≥3, and deranged liver function, renal function and serum electrolytes as significant factors associated with severe COVID-19 disease. INTERPRETATION: We have identified a set of parameters that can help in characterising severe COVID-19 cases in India. These parameters are part of routinely available investigations within Indian hospital settings, both public and private. Study findings have the potential to inform clinical management protocols and identify patients at high risk of severe outcomes at an early stage.

Indian Public Health Students' Perspectives on Global Health Education.

Global health discipline is of increasing interest for educators and students in public health across the world. Public health education is recently gaining momentum in India, but global health is still at an embryonic stage. Value of students as stakeholders in curriculum development is increasingly recognized but literature about perspectives of public health students regarding global health education is limited. This study aimed to explore Indian public health students' perspectives about global health education and to provide platform for the development of global health education framework for future public health professionals. This study involved a series of focus groups with students and sought to understand perceptions about global health and global health education framework. We recruited public health students at three institutes across India for focus group discussions. Focus groups questions covered current understanding of global health, opinions regarding global health education for public health curriculum and the relevance of global health competency domains for future employment. Recordings were transcribed verbatim and the transcripts were read along with field notes and then analyzed thematically. A total of 36 students participated in four focus groups. There was a general recognition that global health is transnational and that a global outlook is now essential. But there were concerns regarding local and global priorities in public health. Global health was regarded as being wider than public health by some, but others viewed public health being the umbrella term with global health as a specialization. Global health competencies were viewed as a "step up" from the public health competencies but core public health competencies were considered essential. International experiences and use of technology were key themes for delivery of global health education. Employability and career progression for global health graduates were of concern for many participants. This study provides insight into the student perspectives regarding global health education for public health programs in India. Clear direction in terms of curriculum and its utility for career growth and employability as a global health professional needs to be established for global health education in India and other similar settings.

Socio-demographic and socioeconomic differences in tobacco use prevalence among Indian youth.

The study aims to assess the association between socio-demographic factors such as age, gender, area of residence, father's education, and standard of living and the likelihood of tobacco use in adolescence. We conducted secondary data analysis on a large scale cross-sectional study comprising of 1386 adolescents, living in regions representative of three different socioeconomic positions in New Delhi. Data was collected through clinical oral examination and interviewer-administered questionnaire. Multiple logistic regression analysis with an unadjusted model for assessing the association between the respective explanatory variable and ever tobacco use. Sequential models were adjusted for confounders as well as the other explanatory variables. The number of tobacco users was 185 (13%). Gender wise tobacco use shows significant (P = 0.001) difference between girls vs. boys; the girls are about 40% less likely to use tobacco than boys (OR = 0.58, 95% CI = 0.42-0.80). Among socio-economic classes, residents of resettlement colonies were twice as likely to use tobacco as middle/upper middle class residents (OR = 2.26, 95% CI = 1.45-3.53). Adolescents with fathers educated up to the primary or secondary levels were almost twice likely to have used tobacco than those with fathers educated till graduation or above (OR = 2.08 95% CI = 1.30-3.34 vs. OR = 2.24, 95% CI = 1.43-3.51, respectively). Significant (P = 0.001) difference in tobacco use among adolescents was also observed based on their standard of living. A significant association exists in terms of area of residence, father's education, and standard of living.

Surgical conditions - A neglected aspect of public health: Call to action.

The burden of surgical conditions is large, though unrecognized. Surgical interventions are cost - effective, but thought to be otherwise. Investments aimed at including surgery at primary care level are affordable. Globally, a momentum is being created to strengthen surgery infrastructure especially for the poor in the low and middle income countries - who bear the burden most. In India, the Association of Rural Surgeons of India, and a body for implementing Lancet Commission of Global Surgery, India are taking lead. A blue print of activities needed to bring surgery on the centre stage of public health in India has been developed. The IPHA can play a catalytic role and use its convening power in getting various associations of public health professionals in India to partner surgeons in this effort. Integration of surgery in public health has the potential to improve equity, access, and universal health coverage.

Health Management Workforce for India in 2030.

Introduction: Since its launch in the year 2005, National Rural Health Mission (NHM) has exhibited a felt need for health management training in India against the background of a shortfall of trained public health managers in the country. In India's context, health (hospital) management professionals are those, who are working in the health sector, belonging to medical and non-medical backgrounds and are trained in health (hospital) management/administration programs or other public health programs (for e.g., Master of Public Health) wherein health (hospital) management/administration is significant part of the curriculum. The presence of trained management professionals in the health sector has grown over the years. Objectives: To estimate the supply, need and requirement for health management professionals for India in the year 2030. Materials and methods: The supply data for health management professionals was calculated based on the output from various academic programs related to health management/administration and other public health programs. Need was calculated using "service target approach" and benchmark analysis with 2.97 health managers per 100,000 population (NACCHO 2011). Supply-need gap was estimated using normative need as base number for projections whereas for rest of the years (2018-2030) projections were done at a constant growth rate as per India's population projections. Results: The overall supply capacity of trained health management professionals was 3,463 for 2017. However, based upon a service target approach India requires 11,304 health management professionals in 2017. If India is to reach the normative standards of 2.97 health managers per 100,000 population, the country would need 39,774 health management professionals in 2017. This need would increase to approximately 44,936 health management professionals by the year 2030 to maintain the normative standard of 2.97 health managers per 100,000 population. Conclusions: The supply side will match the requirement of HMPs earliest by the year 2026 in a high seat occupancy scenario.Moreover, there is a need to improve the quality of the output in terms of an explicitly stated and standardized competency framework that is tailored to the Indian context.

The need to focus on medical education in rural districts of India.

Background: . Globally, India has the highest number of medical colleges followed by Brazil and China. The density of physicians in rural India was 3 per 10 000 population against 13 per 10 000 in urban areas. Worldwide, studies show that medical schools play an important role in overcoming the shortage of physicians locally. Hence, we studied the distribution of medical colleges in India and reviewed the shortage of established and new medical colleges in rural districts with the year 2000 as baseline. Methods: . We used the database of the Medical Council of India as on 27 April 2017; and Census 2011 data, based on the percentage of rural/urban population, for the classification of districts (rural/urban). All the 640 districts were included with 1210.9 million population. Results: . Of the 480 rural districts in India, only 132 (27.5%) had a medical college. Jharkhand, Jammu and Kashmir and Arunachal Pradesh had no medical colleges in rural districts. Madhya Pradesh, Uttar Pradesh, Bihar, Assam, Punjab, Uttarakhand, Haryana and Rajasthan had <30% of rural districts with a medical college. Of the 286 new medical colleges established since 2000 in India, 130 (45.5%) were in rural districts with uneven distribution with lower percentage of new medical colleges in states with predominance of rural population. Conclusion: . There is an overall shortage of medical colleges in rural districts of India. Paradoxically, the trend of uneven rural-urban distribution continues among the newly opened medical colleges as well.

How Do Masters of Public Health Programs Teach Monitoring and Evaluation?

INTRODUCTION: The health systems in developing countries face challenges because of deficient monitoring and evaluation (M&E) capacity with respect to their knowledge, skills, and practices. Strengthening M&E training in public health education can help overcome the gaps in M&E capacity. There is a need to advance the teaching of M&E as a core element of public health education. OBJECTIVES: To review M&E teaching across Masters of Public Health programs and to identify core competencies for M&E teaching in South Asian context. MATERIALS AND METHODS: We undertook two activities to understand the M&E teaching across masters level programs: (1) desk review of M&E curriculum and teaching in masters programs globally and (2) review of M&E teaching across 10 institutions representing 4 South Asian countries. Subsequently, we used the findings of these two activities as inputs to identify core competencies for an M&E module through a consultative meeting with the 10 South Asian universities. RESULTS: Masters programs are being offered globally in 321 universities of which 88 offered a Masters in Public Health, and M&E was taught in 95 universities. M&E was taught as a part of another module in 49 institutions. The most common duration of M&E teaching was 4-5 weeks. From the 70 institutes where information on electives was available, M&E was a core module/part of a core module at 42 universities and an elective at 28 universities. The consultative meeting identified 10 core competencies and draft learning objectives for M&E teaching in masters programs in South Asia. CONCLUSION: The desk review showed similarities in M&E course content but variations in course structure and delivery. The core competencies identified during the consultation included basic M&E concepts. The results of the review and the core competencies identified at the consultation are useful resources for institutions interested in refining/updating M&E curricula in their postgraduate degree programs. Our approach for curriculum development as well as the consensus building experience could also be adapted for use in other situations.

Motivating and demotivating factors for community health workers: A qualitative study in urban slums of Delhi, India.

Background Community health workers play an important role in delivering health-care services, especially to underserved populations in low- and middle-income countries. They have been shown to be successful in providing a range of preventive, promotive and curative services. This qualitative study investigated the factors motivating or demotivating community health workers in urban settings in Delhi, India. Methods In this sub-study of the ANCHUL (Ante Natal and Child Healthcare in Urban Slums) implementation research project, four focus-group discussions and nine in-depth interviews were conducted with community health workers and medical officers. Utilizing a reflexive and inductive qualitative methodology, the data set was coded, to allow categories of motivating and demotivating factors to emerge. Results Motivating factors identified were: support from family members for their work, improved self-identity, job satisfaction and a sense of social responsibility, prior experiences of ill health, the opportunity to acquire new skills and knowledge, social recognition and status conferred by the community, and flexible work and timings. Negative experiences in the community and at health centres, constraints in the local health system in response to the demand generated by the community health workers, and poor pay demotivated community health workers in this study, even causing some to quit their jobs. Conclusion Community-health-worker programmes that focus on ensuring the technical capacity of their staff may not give adequate attention to the factors that motivate or discourage these workers. As efforts get under way to ensure universal access to health care, it is important that these issues are recognized and addressed, to ensure that community health worker programmes are effective and sustainable.

Sputum smear grading and treatment outcome among directly observed treatment-short course patients of tuberculosis unit, Jagdalpur, Bastar.

INTRODUCTION: Tuberculosis (TB) is a major global health problem. In 2014, worldwide, 1.5 million deaths were reported from TB. The study was planned to assess sputum smear grading and treatment outcome among TB patients attending tuberculosis unit (TU), Jagdalpur of Bastar district in Chhattisgarh. MATERIALS AND METHODS: It was a record-based analysis for the year 2014 data from TU, Jagdalpur, Bastar of Chhattisgarh. STATISTICAL ANALYSIS USED: Data entry and analysis were done using STATA/SE 14.1 software. RESULTS: Out of total registered 496 TB patients in 2014, 207 were sputum smear positive with 83 (40.1%) having 3 + and 14 (6.8%) having scanty sputum grading. The percentage of successfully treated was lowest, 71.4% in scanty followed by 1+ (80.2%), compared to 84.1% in sputum smear negative (P = 0.02335). Overall rate of unfavorable outcome was 16.9%. Factors associated with unfavorable outcome were age more than 40 years (P = 0.01894), male gender (P = 0.06722), and retreatment cases (P = 0.0001136). Death rate was higher (6.6%) among patients of Category II. Higher default rate in new smear positive (8.3%), new smear negative (7.8%), and retreatment (16.7%) was noted. CONCLUSIONS: Overall rate of unfavorable outcome was higher in patients with scanty and 1+sputum grading. Age more than 40 years, male sex, and retreatment category were factors associated with unfavorable outcome.

Occupational health training in India: Need for a competency-driven approach.

BACKGROUND: In order to cater to the changing business scenario, employment and education profiles of labor, newer occupations, and emerging occupational health challenges, it is time to improve the performance of occupational health professionals by adapting core professional competencies while drawing on global knowledge. OBJECTIVE: To delineate the competencies required for medical graduates, medical postgraduates, and Masters in Public Health (MPH) graduates practicing occupational health in India. MATERIALS AND METHODS: First, offline and online literature searches were carried out to enlist the core competencies for occupational health. A draft template was prepared for the identified competencies and stakeholders were asked to rank the listed competencies on a three-point scale stating must, desirable, and not required for each of the three categories of professionals, i.e., medical graduates, medical postgraduates, and MPH graduates. RESULTS: Through the extensive literature search, 23 competencies were identified for occupational health practitioners. According to stakeholders, five competencies were a must, nine were desirable, and nine were not required by a medical graduate. Similarly for a medical postgraduate, except the ability to judge the ergonomic design of the workplace and working tools, which is considered desirable, all other competencies were considered a must while for an MPH graduate all the enlisted 23 competencies were considered a must by the stakeholders. CONCLUSION: The framework of occupational health competencies developed through this research can be used to strengthen the training of occupational health professionals in India.

Role of the private sector in vaccination service delivery in India: evidence from private-sector vaccine sales data, 2009-12.

BACKGROUND: India's Universal Immunization Programme (UIP) provides basic vaccines free-of-cost in the public sector, yet national vaccination coverage is poor. The Government of India has urged an expanded role for the private sector to help achieve universal immunization coverage. We conducted a state-by-state analysis of the role of the private sector in vaccinating Indian children against each of the six primary childhood diseases covered under India's UIP. METHODS: We analyzed IMS Health data on Indian private-sector vaccine sales, 2011 Indian Census data and national household surveys (DHS/NFHS 2005-06 and UNICEF CES 2009) to estimate the percentage of vaccinated children among the 2009-12 birth cohort who received a given vaccine in the private sector in 16 Indian states. We also analyzed the estimated private-sector vaccine shares as function of state-specific socio-economic status. RESULTS: Overall in 16 states, the private sector contributed 4.7% towards tuberculosis (Bacillus Calmette-Guérin (BCG)), 3.5% towards measles, 2.3% towards diphtheria-pertussis-tetanus (DPT3) and 7.6% towards polio (OPV3) overall (both public and private sectors) vaccination coverage. Certain low income states (Uttar Pradesh, Rajasthan, Madhya Pradesh, Orissa, Assam and Bihar) have low private as well as public sector vaccination coverage. The private sector's role has been limited primarily to the high income states as opposed to these low income states where the majority of Indian children live. Urban areas with good access to the private sector and the ability to pay increases the Indian population's willingness to access private-sector vaccination services. CONCLUSION: In India, the public sector offers vaccination services to the majority of the population but the private sector should not be neglected as it could potentially improve overall vaccination coverage. The government could train and incentivize a wider range of private-sector health professionals to help deliver the vaccines, especially in the low income states with the largest birth cohorts. We recommend future studies to identify strengths and limitations of the public and private health sectors in each Indian state.

Does decentralization influence efficiency of health units? A study of opinion and perception of health workers in Odisha.

BACKGROUND: Health systems in low and middle income countries are struggling to improve efficiency in the functioning of health units of which workforce is one of the most critical building blocks. In India, Rogi Kalyan Samiti (RKS) was established at every health unit as institutions of local decision making in order to improve productive efficiency and quality. Measuring efficiency of health units is a complex task. This study aimed at assessing the perception (opinion and satisfaction) of health workers about influence of RKS on improving efficiency of peripheral decision making health units (DMHU); examining differences between priority and non-priority set-ups; identifying predictors of satisfaction at work; and discussing suggestions to improve performance. METHODS: Following a cross-sectional, comparative study design, 130 health workers from 30 institutions were selected through a multi-stage stratified random sampling. A semi-structured questionnaire was administered to assess perception and opinion of health workers about influence of RKS on efficiency of decision making at local level, motivation and performance of staff, and availability of funds; improvement of quality of services, and coordination among co-workers; and participation of community in local decision making. Three districts with highest infant mortality rate (IMR), one each, from 3 zones of Odisha and 3 with lowest IMR were selected on the basis of IMR estimates of 2011. The former constituted priority districts (PD) and the latter, non-priority districts (NPD). Composite scores were developed and compared between PD and NPD. Adjusted linear regression was conducted to identify predictors of satisfaction at work. RESULTS: A majority of respondents felt that RKS was efficient in decision making that resulted in improvement of all critical parameters of health service delivery, including quality; this was significantly higher in PD. Further, higher proportion of respondents from PD was highly satisfied with the current set of provisions and manners of functioning of the sample health units. Active community engagement, participation of elected representatives, selection of a pro-active Chairman, and training to RKS members were suggested as the immediate priority action points for the state government. Mean scores differed significantly between PD and NPD with regard to: influence of RKS on individual-centric, organizational-centric and patient-centric performance, and the responsibilities to be entrusted with RKS. Absenteeism was strongly associated with satisfaction and local self-governance. Work-related factors, systemic factors, local accountability and patients' involvement were found to be the key predictors of satisfaction of health workforce. CONCLUSION: The understanding on quality improvement strategies was found to be very poor among the health workers. Tailor-made capacity building measures at district and sub-district levels could be critical to equip the peripheral health units to achieve the universal health coverage goals. Work environment, systemic factors and accountability need to be addressed on priority for retention of health workforce. The hypothesized link between efficient local decision making, perception of health workers about efficiency of health units and the health status of population needs further investigation.

Local self governance in health - a study of it's functioning in Odisha, India.

BACKGROUND: Local decision making is linked to several service quality improvement parameters. Rogi Kalyan Samitis (RKS) at peripheral decision making health units (DMHU) are composite bodies that are mandated to ensure accountability and transparency in governance, improve quality of services, and facilitate local responsiveness. There is scant literature on the nature of functioning of these institutions in Odisha. This study aimed to assess the perception of RKS members about their roles, involvement and practices with respect to local decision making and management of DMHUs; it further examined perceptual and functional differences between priority and non-priority district set-ups; and identified predictors of involvement of RKS members in local governance of health units. METHODS: As members of RKS, health service providers, officials in administrative/managerial role, elected representatives, and officials from other departments (including independent members) constituted our study sample. A total of 112 respondents were interviewed across 6 districts, through a multi-stage stratified random sampling; we used a semi-structured interview schedule that comprised mainly of close-ended and some open-ended questions. Descriptive and inferential statistics were used to compare 3 priority (PD) and 3 non-priority districts (NPD), categorized on the basis of Infant Mortality Rate (IMR) estimates of 2011 as proxy of population health. Governance, human resource management, financial management and quality improvement functions were studied in detail. Opinion about various individual and organizational factors in local self-governance and predictors of involvement were identified. RESULTS: The socio-demographic profile and composition of respondents were comparable between PD and NPD. Majority of respondents were 'satisfied' with their current roles in the governance of local health institutions. About one-fourth opined that the amount of funds allocated to RKS under National Health Mission (NHM) was 'grossly insufficient'. Fifty percent of respondents said they requested for additional funds, last year, and 38.8 % informed that they requested additional funds for purchase of drugs. About 87 % respondents were satisfied with their role in the local governance of the health units (PD = 94.3 % vs. NPD = 80.7 %). Almost all (PD = 98 % vs. NPD = 80.7 %) opined that local decision making helped in improving the performance of health units. For most of the open-ended questions the responses were non-specific. Staggering differences were found between PD and NPD with respect to their involvement in district plan preparation (NPD = 78.9 % vs. PD = 58.5 %), training in plan preparation (NPD = 47.4 % vs. PD = 27.5 %), participation of officials from other departments (PD = 96.9 % vs. NPD = 45.5 %), and inclusion of activities of other sectors (PD = 70.8 % vs. NPD = 41.8 %). Whereas, no significant PD-NPD difference was found about their perceived 'involvement' in undertaking the 12 designated responsibilities. Composite scores on various individual and organizational factors were compared and found to be varying significantly. Through regression, we inferred work experience, qualification and non-monetary incentives as strong determinants of current level of involvement of RKS members in governance and management of health units. CONCLUSION: Poor knowledge/expectation of RKS members was diluting the decision making process at DMHUs. There is an urgent need to improve their knowledge, understanding and expertise in areas of governance and management practices. A locally-monitored and time-bound capacity building plan could achieve this. Yearly resource allocation for drug procurement needs revision. Specific eligibility criteria based on work experience and qualification may be fixed for RKS membership. Further research may focus on identifying the underlying individual and systemic factors behind such large PD-NPD differences.

Situational analysis of industrial hygienists in India.

BACKGROUND: Industrial growth in India has resulted in increased employment opportunities thereby inflating the size of the workforce engaged in both organized and unorganized sectors. This workforce is exposed to various occupational factors at workplace and hence is susceptible to occupational diseases, the control of which requires trained occupational health manpower. METHODS: The present study was undertaken to map the institutions offering courses to develop industrial hygienist in India, estimate the requirement of such occupational health manpower and to design competencies and curriculum for such a course. RESULTS: Though there are no norms for the industrial hygienist in the Indian Factories Act, on assumption on the basis of norms provided for Safety Officer, it is estimated that for 26.92 million workforce engaged in organized sector, a total of 5407 Industrial hygienists will be required. Thus there is an estimated deficit of 51% for Industrial hygienist based on current ratio of employment. However on supply side there are only three institutes offering specialized courses on industrial hygiene out of which only one is full time residential course while rest two are offered through distance learning mode. CONCLUSIONS: Therefore, there is a vital need for the development of industrial hygienist not only in quantity but also in quality so that the workers in industries and communities lead socially and environmentally productive lives.

Building Interdisciplinary Leadership Skills among Health Practitioners in the Twenty-First Century: An Innovative Training Model.

Transformational learning is the focus of twenty-first century global educational reforms. In India, there is a need to amalgamate the skills and knowledge of medical, nursing, and public health practitioners and to develop robust leadership competencies among them. This initiative proposed to identify interdisciplinary leadership competencies among Indian health practitioners and to develop a training program for interdisciplinary leadership skills through an Innovation Collaborative. Medical, nursing, and public health institutions partnered in this endeavor. An exhaustive literature search was undertaken to identify leadership competencies in these three professions. Published evidence was utilized in searching for the need for interdisciplinary training of health practitioners, including current scenarios in interprofessional health education and the key competencies required. The interdisciplinary leadership competencies identified were self-awareness, vision, self-regulation, motivation, decisiveness, integrity, interpersonal communication skills, strategic planning, team building, innovation, and being an effective change agent. Subsequently, a training program was developed, and three training sessions were piloted with 66 participants. Each cohort comprised a mix of participants from different disciplines. The pilot training guided the development of a training model for building interdisciplinary leadership skills and organizing interdisciplinary leadership workshops. The need for interdisciplinary leadership competencies is recognized. The long-term objective of the training model is integration into the regular medical, nursing, and public health curricula, with the aim of developing interdisciplinary leadership skills among them. Although challenging, formal incorporation of leadership skills into health professional education is possible within the interdisciplinary classroom setting using principles of transformative learning.