Decentralisation, health and Sustainable Development Goal 3.

SETTING: Kerala State, India, implemented decentralising reforms of healthcare institutions 25 years ago through transfer of administrative control and a sizeable share of the financial allocation. OBJECTIVE: To describe the main impacts of decentralisation in Kerala on local policy formulation, programme implementation and service delivery for sustainable health systems. DESIGN: This was part of a broader qualitative study on decentralisation and health in Kerala. We conducted 25 in-depth interviews and reviewed 31 government orders or policy documents, five related transcripts and five thematic reports from the main study. RESULTS: Liaising between health system and local governments has improved over time. A shift from welfare-centric projects to infrastructure, human resources and services was evident. Considerable heterogeneity existed due to varying degrees of involvement, capacity, resources and needs of the community. State-level discourse and recent augmentation efforts for moving towards the UN Sustainable Development Goals (SDGs) strongly uphold the role of local governments in planning, financing and implementation. CONCLUSION: The 25-year history of decentralised healthcare administration in Kerala indicates both successes and failures. Central support without disempowering the local governments can be a viable option to allow flexible decision-making consistent with broader system goals.

CONTEXTE: L'État du Kerala, en Inde, a mis en œuvre des réformes de décentralisation des établissements de santé il y a 25 ans, en transférant le contrôle administratif et une part importante de l'allocation financière. OBJECTIF: Décrire les principaux impacts de la décentralisation au Kerala sur la formulation de politiques locales, la mise en œuvre de programmes et la prestation de services pour des systèmes de santé durables. MÉTHODE: Cette étude faisait partie d'une étude qualitative plus vaste sur la décentralisation et la santé au Kerala. Nous avons mené 25 entretiens approfondis et examiné 31 décrets ou documents de politique du gouvernement, cinq transcriptions connexes et cinq rapports thématiques de l'étude principale. RÉSULTATS: La liaison entre le système de santé et les gouvernements locaux s'est améliorée au fil du temps. Une réorientation des projets centrés sur le bien-être vers les infrastructures, les ressources humaines et les services était évidente. Une hétérogénéité considérable existe en raison des différents degrés d'implication, de capacité, de ressources et de besoins de la communauté. Le discours au niveau de l'État et les récents efforts d'augmentation en vue d'atteindre les objectifs de développement durable (SDG) de l'ONU soutiennent fortement le rôle des gouvernements locaux dans la planification, le financement et la mise en œuvre. CONCLUSION: Les 25 ans d'histoire de l'administration décentralisée des soins de santé au Kerala révèlent à la fois des réussites et des échecs. Un soutien central sans déresponsabiliser les gouvernements locaux peut être une option viable pour permettre une prise de décision flexible et cohérente avec les objectifs plus larges du système.

Facilitators and barriers to medication adherence among stroke survivors in India.

Strict compliance with medication and life style modification are integral to secondary stroke prevention. This study was undertaken to find out medication adherence among stroke survivors and factors associated with it. Cross sectional survey among stroke survivors was conducted. Interview based self-reported medication adherence was defined as consumption at least >80% of their medications for last two weeks, based on last prescription. Structured interview using pretested interview schedule was done to collect other data. Sequential step wise logistic regression analysis was done to find out the facilitators and barriers to medication adherence. Two hundred and forty stroke survivors (mean age 58.64 ± 10.96 years; 25.4% females) with a mean post-stroke period of 6.65 ± 3.36 months were participated. Overall medication adherence was 43.8% (n = 105). Medication adherence was 34.3% (n = 134), 52.6% (n = 190) and 56.7% (n = 224) for antidiabetics, antihypertensives and statins respectively and was associated with risk factor control (Diabetes: Odds Ratio (OR) = 4.85; 95% Confidence Interval (CI) 2.12-11.08, Hypertension: OR = 3.42; 95% CI 1.83-6.4, Dyslipidaemia: OR = 3.88; 95% CI 1.96-4.04). Having daily routine (OR = 2.82; 95% CI 1.52-5.25), perceived need of medication (OR = 2.33; 95% CI 1.04-5.2) and perceived poor state of health (OR = 2.65; 95% CI 1.30-5.40) were facilitators. Memory issues (OR = 0.34; 95% CI 0.16-0.71), side effects (OR = 0.24; 95% CI 0.11-0.42) and financial constraints (OR = 0.46; 95% CI 0.24-0.91) were barriers to medication adherence. Establishing daily routines, periodic reminders, financial supports to buy medicines and patient education can enhance medication adherence to prevent future strokes.

Lack of association of mirSNP rs11174811 in AVPR1A gene with arterial blood pressure and hypertension in South Indian population.

Epigenetic regulation of arterial blood pressure mediated through mirSNPs in renin-angiotensin aldosterone system (RAAS) genes is a less explored hypothesis. Recently, the mirSNP rs11174811 in the 3'UTR of the AVPR1A gene was associated with higher arterial blood pressure in a large study population from the Study of Myocardial Infarctions Leiden (SMILE). The aim of the present study was to replicate the association of mirSNP rs11174811 with blood pressure outcomes and hypertension in a south Indian population. Four hundred and fifteen hypertensive cases and 416 normotensive controls were genotyped using a 5' nuclease allelic discrimination assay. Logistic regression was used to test the association of mirSNP rs11174811 with the hypertension phenotype. Censored normal regression was used to test the association of the polymorphism with continuous blood pressure outcomes such as systolic and diastolic blood pressure. The mirSNP rs11174811 did not show any significant association with hypertension. The adjusted odds ratio was 1.02, with 95% CI of 0.72 to 1.45 (p = 0.909). The mean systolic and diastolic blood pressure values were not significantly different across the three genotypic groups, between hypertensives and normotensives, or when stratified by gender. Despite having a similar minor allele frequency (MAF) of 14.5% compared with the SMILE cohort, our results did not support an association of the mirSNP rs11174811 with the hypertension phenotype or with continuous blood pressure outcomes in the south Indian population.

The interactions of ethical notions and moral values of immediate stakeholders of immunisation services in two Indian states: a qualitative study.

OBJECTIVES: This study examines the existing norms regarding immunisation within the communities and the ethical notions that govern the actions of different health professionals and their collective synergistic or conflicting effects on the governance of the programme. DESIGN: We used descriptive and analytical qualitative methods as it suited the research question. SETTING: The data were collected from areas under 16 primary health centres in Kerala and Tamil Nadu identified through a three-step sampling process. PARTICIPANTS: This involved in-depth interviews with stakeholders including providers, beneficiaries and other stakeholders, focus group discussions with mothers of under-five children and participant and non-participant observations of vaccination-related activities. RESULTS: Unlike most other ethical analyses that look at the ethics of vaccination policies, the interactions of normative principles and notions are analysed in this article. Moral obligation of parents towards their children, beneficence of healthcare providers and the utilitarian aspirations of the state are the key normative principles involved. Our analysis points to the interplay of both synergy and conflict in ethical notions and moral values in the context of immunisation services. Paternalistic interventions like special immunisation campaigns against polio and Japanese encephalitis are a case in point: they generate conflict at the normative level and create mistrust. CONCLUSIONS: Analysis of vaccination policies and programmes needs to go beyond factors that assess monetary benefits or herd immunity. Understanding the interactions of normative notions that shape the social organisation of the providers and the users of vaccination is important in creating a sustainable environment for the programme.

Impact of vitamin A supplementation through different dosages of red palm oil and retinol palmitate on preschool children.

Red palm oil (5 ml and 10 ml), ground nut oil fortified with 400 and 800 retinol equivalent retinol palmitate, and ground nut oil (5 and 10 ml), were administered to six groups of preschool children (four experimental and two control groups) in randomly assigned balwadis of Ramanathapuram District of Tamil Nadu for a period of 7 months, to monitor the difference in the efficacy of the mode of supplementation and the optimum dose for improving vitamin A status. Results show that red palm oil groups recorded more gain in retinol and beta-carotene levels compared to other dosage groups, and that administration of 10 ml did not offer any substantial improvement over the 5-ml daily dose.

Impact of beta-carotene supplementation through red palm.

A 10-month long feeding trial was conducted to assess the impact of beta-carotene supplementation through red palm oil (RPO) with the focus on vitamin A status, morbidity status and acceptability of an RPO-incorporated noon-meal as a dietary supplement among two cohorts of 409 (experimental) and 346 (control) preschool children in two southern districts of rural Tamil Nadu, selected by stratified random sampling. Information was gathered on ocular symptoms of vitamin A deficiency and anthropometry, and blood samples were drawn at baseline and final rounds for estimation of serum beta-carotene, retinol and tocopherol. Data about Socioeconomic Status (SES) were collected once during the study period, while information on attendance, consumption and morbidity was recorded by preschool teachers. The results showed the following. 1. Significant improvement in the vitamin A status of children in terms of disappearance of Bitot's spots (50.0 per cent) in the experimental group vs. 28.0 per cent in the control group. 2. After feeding of RPO, incidence rate of new Bitot's spots cases was low at 2.13 in the experimental children vs. 4.78 in control children. 3. Marked improvement in the serum beta-carotene levels after 10 months of feeding. 4. RPO is acceptable to children as an edible grade oil as there is no perceptible difference in the consumption pattern between experimental and control children.

High prevalence of type 2 diabetes in an urban settlement in Kerala, India.

BACKGROUND: Prevalence of type 2 or non insulin dependent diabetes mellitus is high among Indians living in India as well as abroad. Prevalence among persons of Indian origin in many countries is greater than that of people of other ethnic extraction. The Indian state of Kerala is distinguished by a high level of achievement in the health sector, characterised by both lower mortality rates and greater density of health care institutions that ensure access to most people. These attributes make the prevalence of diabetes and the pattern of its management in Kerala worth studying. OBJECTIVE: To estimate the prevalence of diabetes among persons 20 years or older in an urban housing settlement in Trivandrum city, the capital of Kerala, as well as study the management of the disease in subjects affected. DESIGN: Cross sectional survey for detecting diabetes and other chronic diseases in all willing residents of an urban housing settlement in Trivandrum, the capital city of Kerala, as part of a preventive campaign against lifestyle diseases. Fasting plasma glucose, serum triglycerides, cholesterol, height, weight and blood pressure were measured, and a detailed questionnaire administered to ascertain previous diabetic status and management. RESULTS: Overall prevalence of type 2 diabetes is 16.3%. In the 30-64 age group, age standardised prevalence is 13.7%. Gender differences in prevalence are negligible. Greater prevalence is associated with advancing age, body mass index above 24.99, sedentary habits, serum total cholesterol > 239, serum triglycerides > 149, hypertension and smoking. Compared to non-diabetics, diabetics have greater mean and range of fasting plasma glucose values (8.87 +/- 3.6 mM/l as against 4.34 +/- 0.53 mM/l). 32 out of 38 diabetics among the subjects (82.4%) were already diagnosed even before the survey; of them, 89% were on medication. 3% of subjects had impaired fasting glucose, or FPG level between 110-125 mg/dl. CONCLUSION: Prevalence of type 2 diabetes among a group of urban residents in Trivandrum city in Kerala is very high. This is associated also with a high detection rate and compliance to treatment.