Informal Providers-Ground Realities in South Asian Association for Regional Cooperation Nations: Toward Better Cancer Primary Care: A Narrative Review.

PURPOSE: South Asian Association for Regional Cooperation (SAARC) nations are a group of eight countries with low to medium Human Development Index values. They lack trained human resources in primary health care to achieve the WHO-stated goal of Universal Health Coverage. An unregulated service sector of informal health care providers (IPs) has been serving these underserved communities. The aim is to summarize the role of IPs in primary cancer care, compare quality with formal providers, quantify distribution in urban and rural settings, and present the socioeconomic milieu that sustains their existence. METHODS: A narrative review of the published literature in English from January 2000 to December 2021 was performed using MeSH Terms Informal Health Care Provider/Informal Provider and Primary Health Care across databases such as Medline (PubMed), Google Scholar, and Cochrane database of systematic reviews, as well as World Bank, Center for Global Development, American Economic Review, Journal Storage, and Web of Science. In addition, citation lists from the primary articles, gray literature in English, and policy blogs were included. We present a descriptive overview of our findings as applicable to SAARC. RESULTS: IPs across the rural landscape often comprise more than 75% of primary caregivers. They provide accessible and affordable, but often substandard quality of care. However, their network would be suitable for prompt cancer referrals. Care delivery and accountability correlate with prevalent standards of formal health care. CONCLUSION: Acknowledgment and upskilling of IPs could be a cost-effective bridge toward universal health coverage and early cancer diagnosis in SAARC nations, whereas state capacity for training formal health care providers is ramped up simultaneously. This must be achieved without compromising investment in the critical resource of qualified doctors and allied health professionals who form the core of the rural public primary health care system.

Healthcare in post-COVID India: A call for a decentralized healthcare system.

Over the years, healthcare system in India has been largely centralized, expensive and impersonal. In a country where expenditure on healthcare is low, most healthcare expenditure is out-of-pocket and where most of the population continue to live in rural areas or in urban fringes, such a care is inaccessible, unresponsive and unaffordable. COVID pandemic exposed these realities further. Based on experiences of directly managing health services during COVID-19 pandemic in different settings and across different levels, authors of this paper argue for a decentralized, distributed and responsive health systems for India, that is likely to be more effective and sustainable in normal times, and in times of crisis.

Pathways to Enable Primary Healthcare Nurses in Providing Comprehensive Primary Healthcare to Rural, Tribal Communities in Rajasthan, India.

Background: Emerging health needs and uneven distribution of human resources of health have led to poor access to quality healthcare in rural areas. Rural pathways provide an approach to plan and evaluate strategies for ensuring availability, retention, motivation, and performance of human resources for health in rural areas. While effectiveness of primary healthcare (PHC) nurses to deliver primary health care is established, there is not enough evidence on ways to ensure their availability, retention, motivation, and performance. The paper draws on the program experience and evidence from a primary healthcare network (AMRIT Clinics), in which nurses play a central role in delivering primary healthcare in rural tribal areas of Rajasthan, India, to bridge this gap. Methods: Rural, tribal areas of Rajasthan have limited access to functional healthcare facilities, despite having a high burden of diseases. We used the rural pathway approach to describe factors that contributed to the performance of the nurses in AMRIT Clinics. We analyzed information from the human resource information system and health management information system; and supplemented it with semi-structured interviews with nurses, conducted by an independent organization. Results: Most nurses were sourced from rural and tribal communities that the clinics serve; nurses from these communities were likely to have a higher retention than those from urban areas. Sourcing from rural and tribal communities, on-going training in clinical and social skills, a non-hierarchical work environment, and individualized mentoring appear to be responsible for high motivation of the primary healthcare nurses in AMRIT Clinics. Task redistribution with due credentialing, intensive and on-going training, and access to tele-consultation helped in sustaining high performance. However, family expectations to perform gendered roles and pull of government jobs affect their retention. Conclusion: Rural and remote areas with healthcare needs and scarcity of health provisions need to optimize the health workforce by adopting a multi-pronged pathway in its design and implementation. At the same time, there is a need to focus on structural factors that affect retention of workforce within the pathway. Our experience highlights a pathway of up-skilling PHC nurses in providing comprehensive primary healthcare in rural and remote communities in Low and Middle-Income Countries (LMICs).

Food Insecurity in Tribal High Migration Communities in Rajasthan, India.

BACKGROUND: The COVID pandemic and subsequent lockdown has disrupted food supplies across large parts of India, where even prior to the pandemic, food insecurity and malnutrition were widely prevalent. Tribal populations in southern Rajasthan, India, live in extreme scarcity, rely mainly on outward migration for sustenance, and have been significantly affected by the pandemic. In this study, we assess the availability of foodstuffs at the household level and community experiences about satiety and hunger during lockdown. METHODOLOGY: We conducted a rapid assessment of food security in rural southern Rajasthan, India, using a structured questionnaire. Trained interviewers conducted telephonic interviews using KoBoToolbox, an open-source tool. A total of 211 respondents including community volunteers, family members of tuberculosis patients and malnourished children, pregnant women, and influential members in the villages participated in the study. RESULTS: A cereal was reported to be present by 97% of the respondents, two-thirds had pulses, and nearly half had milk. The amount of cereals available was adequate for about 5 months and that of pulses, oil/ ghee, and sugar for about 1 to 2 weeks. Two-thirds of the respondents reported that food in their households was sometimes not sufficient for the amount they wanted to eat, and 97% of these mentioned not having money to buy food as the reason for not having sufficient food. CONCLUSION: This study highlights widespread food insecurity among tribal communities in southern Rajasthan, and the scenario is likely to be similar in other tribal migration dependent areas of the country.

Financing primary healthcare for rural areas.

CONTEXT: Primary healthcare in India is provided by both public and private providers. However, access to good quality primary healthcare is lacking in underserved populations such as communities in rural and remote areas and families in low income quartiles. While there are government programs on comprehensive primary healthcare, stagnant investments restrict their reach and quality. At the same time, there are several for-profit and not-for-profit primary healthcare providers that fill the gap, but are limited in scale and geographical reach. They also often find it challenging to provide affordable comprehensive primary healthcare. AIMS: The Consultation on Financing Primary Healthcare was organized to draw lessons for financial sustenance of comprehensive and equitable primary healthcare initiatives. Eighteen academicians and practitioners, representing different institutions from across India, presented and engaged in discussions around the theme of financing primary healthcare. METHODS AND MATERIAL: The Consultation proceedings were recorded, transcribed, analyzed, and synthesized to bring out the key insights. RESULTS: The Consultation drew insights from the experiences and evidence shared by the participants on the ways to finance primary healthcare services sustainably, especially for underserved populations. The financing models discussed include public-private partnership, user fees, community financing, subscription and cross-subsidy. Cost-reduction strategies such as task-shifting and use of appropriate technology were also identified as key to improving efficiency in service delivery.

Strengthening primary care in rural India: Lessons from Indian and global evidence and experience.

India has made significant advances in health of its populations over more than a decade, reducing the gap between rural and urban areas and between the rich and the poor. Huge disparities, however, still remain, and access to healthcare in rural areas remains a huge challenge. A one-day National Consultation, nested within the World Rural Health Conference, was held to share learnings from experiences and evidence of rural primary healthcare within India and from across the world, to identify elements that may guide improvements in healthcare in rural India. From discussions, this article summarizes the evidence on what works for rural primary care, and then provides recommendations for strengthening healthcare in rural India.

Designing primary healthcare systems for future in India.

Changing epidemiology, rapid urbanization, and rising expectations of populations are creating new challenges and opportunities for India's primary healthcare system. A group of primary care experts, practitioners, and researchers got together to design key elements of primary healthcare models for the future that would address these challenges and make use of emergent opportunities in rural and urban India. Based on experiences and evidence from India and across the globe shared in the consultation, the article lays out a vision and components of India's primary healthcare for future. It provides answers to questions such as how will healthcare be financed and organized, what mechanisms will assure quality of services, who will provide primary healthcare, and what role will technology have. Finally, it provides an agenda for primary healthcare practitioners and researchers to translate this vision into action.

Communicable or noncommunicable diseases? Building strong primary health care systems to address double burden of disease in India.

Between 1990 and 2016, India has seen an epidemiological transition in disease burden and deaths, with a steady rise in noncommunicable disease (NCD) burden. This has led to a tussle for policy attention and resources between proponents of communicable diseases such as tuberculosis, and of NCDs, such as cardiovascular diseases and diabetes. Review of evidence from global burden of diseases studies and from our own field data from rural south Rajasthan reveals that communicable-malnutrition- maternal-newborn diseases (CMNND), injuries, and NCDs are major causes of disease burden and deaths in childhood, youth and older age group, respectively. Risk factors related to diet, nutrition, and air pollution contribute significantly to communicable as well as NCDs. Many NCDs in adults have origins in malnutrition during pregnancy and early childhood; similarly, certain NCDs are caused by a communicable disease. We argue that the binary of communicable and NCD is incorrect, and that resources and policy attention be focused on strengthening primary health care systems that address CMMNDs as well as NCDs; and reduce the underlying risk factors.

Cost Effectiveness of Implementing Integrated Management of Neonatal and Childhood Illnesses Program in District Faridabad, India.

INTRODUCTION: Despite the evidence for preventing childhood morbidity and mortality, financial resources are cited as a constraint for Governments to scale up the key health interventions in some countries. We evaluate the cost effectiveness of implementing IMNCI program in India from a health system and societal perspective. METHODS: We parameterized a decision analytic model to assess incremental cost effectiveness of IMNCI program as against routine child health services for infant population at district level in India. Using a 15-years time horizon from 2007 to 2022, we populated the model using data on costs and effects as found from a cluster-randomized trial to assess effectiveness of IMNCI program in Haryana state. Effectiveness was estimated as reduction in infant illness episodes, deaths and disability adjusted life years (DALY). Incremental cost per DALY averted was used to estimate cost effectiveness of IMNCI. Future costs and effects were discounted at a rate of 3%. Probabilistic sensitivity analysis was undertaken to estimate the probability of IMNCI to be cost effective at varying willingness to pay thresholds. RESULTS: Implementation of IMNCI results in a cumulative reduction of 57,384 illness episodes, 2369 deaths and 76,158 DALYs among infants at district level from 2007 to 2022. Overall, from a health system perspective, IMNCI program incurs an incremental cost of USD 34.5 (INR 1554) per DALY averted, USD 34.5 (INR 1554) per life year gained, USD 1110 (INR 49,963) per infant death averted. There is 90% probability for ICER to be cost effective at INR 2300 willingness to pay, which is 5.5% of India's GDP per capita. From a societal perspective, IMNCI program incurs an additional cost of USD 24.1 (INR 1082) per DALY averted, USD 773 (INR 34799) per infant death averted and USD 26.3 (INR 1183) per illness averted in during infancy. CONCLUSION: IMNCI program in Indian context is very cost effective and should be scaled-up as a major child survival strategy.

Effect of implementation of integrated management of neonatal and childhood illness programme on treatment seeking practices for morbidities in infants: cluster randomised trial.

OBJECTIVE: To determine the effect of implementation of the Integrated Management of Neonatal and Childhood Illness strategy on treatment seeking practices and on neonatal and infant morbidity. DESIGN: Cluster randomised trial. SETTING: Haryana, India. PARTICIPANTS: 29,667 births in nine intervention clusters and 30,813 births in nine control clusters. MAIN OUTCOME MEASURES: The pre-specified outcome was the effect on treatment seeking practices. Post hoc exploratory analyses assessed morbidity, hospital admission, post-neonatal infant care, and nutritional status outcomes. INTERVENTIONS: The Integrated Management of Neonatal and Childhood Illness intervention included home visits by community health workers, improved case management of sick children, and strengthening of health systems. Outcomes were ascertained through interviews with randomly selected caregivers: 6204, 3073, and 2045 in intervention clusters and 6163, 3048, and 2017 in control clusters at ages 29 days, 6 months, and 12 months, respectively. RESULTS: In the intervention cluster, treatment was sought more often from an appropriate provider for severe neonatal illness (risk ratio 1.76, 95% confidence interval 1.38 to 2.24), for local neonatal infection (4.86, 3.80 to 6.21), and for diarrhoea at 6 months (1.96, 1.38 to 2.79) and 12 months (1.22, 1.06 to 1.42) and pneumonia at 6 months (2.09, 1.31 to 3.33) and 12 months (1.44, 1.00 to 2.08). Intervention mothers reported fewer episodes of severe neonatal illness (risk ratio 0.82, 0.67 to 0.99) and lower prevalence of diarrhoea (0.71, 0.60 to 0.83) and pneumonia (0.73, 0.52 to 1.04) in the two weeks preceding the 6 month interview and of diarrhoea (0.63, 0.49 to 0.80) and pneumonia (0.60, 0.46 to 0.78) in the two weeks preceding the 12 month interview. Infants in the intervention clusters were more likely to still be exclusively breast fed in the sixth month of life (risk ratio 3.19, 2.67 to 3.81). CONCLUSION: Implementation of the Integrated Management of Neonatal and Childhood Illness programme was associated with timely treatment seeking from appropriate providers and reduced morbidity, a likely explanation for the reduction in mortality observed following implementation of the programme in this study.Trial registration Clinical trials NCT00474981; ICMR Clinical Trial Registry CTRI/2009/091/000715.

Cost of delivering child health care through community level health workers: how much extra does IMNCI program cost?

BACKGROUND AND METHODS: In the setting of a cluster randomized study to assess impact of the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) program in the district of Faridabad in India, we randomly selected auxiliary nurse midwives (ANM), anganwadi workers (AWW) and accredited social health activists (ASHA) from intervention and control areas to collect cost data using an economic perspective. Bootstrap method was used to estimate 95% confidence interval. RESULTS: The annual per-child cost of providing health services through an ANM, AWW and ASHA is INR 348 (USD 7.7), INR 588 (USD 13.1) and INR 87 (USD 1.9), respectively. The annual per-child incremental cost of delivering IMNCI is INR 124.8 (USD 2.77), INR 26 (USD 0.6) and INR 31 (USD 0.7) at the ANM, AWW and ASHA level, respectively. CONCLUSION: Implementation of IMNCI imposes additional costs to the health system. A comprehensive economic evaluation of the IMNCI is imperative to estimate the net cost implications in India.

Cost of neonatal intensive care delivered through district level public hospitals in India.

OBJECTIVE: To assess the unit cost of level II neonatal intensive care treatment delivered through public hospitals and its fiscal implications in India. DESIGN: Cost analysis study. SETTINGS: Four Special Care Newborn Units (SCNUs) in public sector district hospitals in three Indian states, i.e. Bihar, Madhya Pradesh and Orissa, for the period 2010. METHODS: Bottom-up economic costing methodology was adopted. Health system resources, i.e. capital, equipment, drugs and consumables, non-consumables, referral and overheads, utilized to treat all neonates during 2010 were elicited. Additionally, 360 randomly selected treatment files of neonates were screened to estimate direct out-of-pocket (OOP) expenditure borne by the patients. In order to account for variability in prices and other parameters, we undertook a univariate sensitivity analysis. MAIN OUTCOME MEASURES: Unit cost was computed as INR (Indian national rupees) per neonate treated and INR per bed-day treatment in SCNU. Standardized costs per neonate treatment and per bed day were estimated to incorporate the variation in bed occupancy rates across the sites. RESULTS: Overall, SCNU neonatal treatment costs the Government INR 4581 (USD 101.8) and INR 818 (USD 18.2) per neonate treatment and per bed-day treatment, respectively. Standardized treatment costs were estimated to be INR 5090 (USD 113.1) per neonate and INR 909 (USD 20.2) per bed-day treatment. In the event of entire direct medical expenditure being borne by the health system, we found cost of SCNU treatment as INR 4976 (USD 110.6) per neonate and INR 889 (USD 19.8) per bed-day. CONCLUSION: Level II neonatal intensive care at SCNUs is cost intensive. Rational use of SCNU services by targeting its utilization for the very low birth weight neonates and maintenance of community based home-based newborn care is required. Further research is required on cost-effectiveness of level II neonatal intensive care against routine pediatric ward care.

Promoting appropriate management of diarrhea: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health, India.

BACKGROUND: Scaling up of evidence-based management and prevention of childhood diarrhea is a public health priority in India, and necessitates robust literature review, for advocacy and action. OBJECTIVE: To identify, synthesize and summarize current evidence to guide scaling up of management of diarrhea among under-five children in India, and identify existing knowledge gaps. METHODS: A set of questions pertaining to the management (prevention, treatment, and control) of childhood diarrhea was identified through a consultative process. A modified systematic review process developed a priori was used to identify, synthesize and summarize, research evidence and operational information, pertaining to the problem in India. Areas with limited or no evidence were identified as knowledge gaps. RESULTS: Childhood diarrhea is a significant public health problem in India; the point (two weeks) prevalence is 9 to 20%. Diarrhea accounts for 14% of the total deaths in under-five children in India. Infants aged 6 to 24 months are at the highest risk of diarrhea. There is a lack of robust nation-wide data on etiology; rotavirus and diarrheogenic E.coli are the most common organisms identified. The current National Guidelines are sufficient for case-management of childhood diarrhea. Exclusive breastfeeding, handwashing and point of use water treatment are effective strategies for prevention of all-cause diarrhea; rotavirus vaccines are efficacious to prevent rotavirus specific diarrhea. ORS and zinc are the mainstay of management during an episode of childhood diarrhea but have low coverage in India due to policy and programmatic barriers, whereas indiscriminate use of antibiotics and other drugs is common. Zinc therapy given during diarrhea can be upscaled through existing infrastructure is introducing the training component and information, education and communication activities. CONCLUSION: This systematic review summarizes current evidence on childhood diarrhea and provides evidence to inform child health programs in India.

Does facility based newborn care improve neonatal outcomes? A review of evidence.

CONTEXT: Facility based newborn care is gaining importance as an intervention aiming at reduction of neonatal mortality. OBJECTIVE: To assess different factors that affect effectiveness of facility based newborn care on neonatal outcomes. EVIDENCE ACQUISITION: Electronic search using key search engines along with search of grey literature manually. Observational and interventional studies published between 1966-Aug 2010 in English having a change in neonatal mortality as an outcome measure were considered. RESULTS: A total of 40 articles were fully reviewed for generating synthesized evidence. All were observational studies. The exposure variables that affected neonatal outcomes were grouped into three categories- regionalization of perinatal care (17 articles), strengthening of lower level neonatal facilities (12), and other miscellaneous factors (11). Regionalization played a key role in advancing newborn care practices. It increased in-utero transfer of high risk newborns and improved survival outcomes especially for very low birth weight neonates at level III facilities. It led to reduction in neonatal mortality owing primarily to enhanced survival of low birth weight infants. Strengthening of lower level units contributed significantly in reducing neonatal mortality. High patient volume (>2,000 deliveries/year), inborn status, availability of referral system and inter-facility transfers, and adequate nursing care staff in neonatal units also demonstrated protective effect in averting neonatal deaths. CONCLUSIONS: Countries investing in facility based newborn care should give impetus to establishing regionalized systems of perinatal care. Strengthening of lower level units with high case loads, can yield optimal reduction in NMR.