Geographic Inequities in Coverage of Maternal and Child health Services in Haryana State of India

Human Resources for Health in Haryana, India: What can be Done Better?

Introduction

Health systems in developing countries suffers from both input and productivity issues. We examined the status of three domains of human resources for health, i.e., availability and distribution, capacity and productivity, and motivation and job-satisfaction, of the health-care workforce employed in the public health system of Haryana, a North Indian state.

Methodology

The primary data were collected from 377 public health facilities and 1749 healthcare providers across 21 districts. The secondary data were obtained from government reports in the public domain. Bivariate and multivariate statistical techniques were used for evaluating district performances, making inter-district comparisons and identifying determinants of motivation and job-satisfaction of the clinical cadres.

Results

We found 3.6 core health-care workers (doctors, staff nurses, and auxiliary nurses-midwives) employed in the public health-care system per 10,000 population, ranging from 1.35 in Faridabad district to 6.57 in Panchkula district. Around 78% of the sanctioned positions were occupied. A number of inpatient hospitalizations per doctor/nurses per month were 17 at the community health center level and 29 at the district hospital level; however, significant differences were observed among districts. Motivation levels of community health workers (85%) were higher than clinical workforce (78%), while health system administrators had lowest motivation and job satisfaction levels. Posting at primary healthcare facility, contractual employment, and co-habitation with family at the place of posting were found to be the significant motivating factors.

Conclusions

A revamp of governance strategies is required to improve health-care worker availability and equitable distribution in the public health system to address the observed geographic variations. Efforts are also needed to improve the motivation levels of health system administrators, especially in poorly performing districts and reduce the wide gap with better-off districts.

S. Level of inequality and the role of governance indicators in the coverage of reproductive maternal and child healthcare services: Findings from India

BACKGROUND

Diligent monitoring of inequalities in the coverage of essential reproductive, maternal, new-born and child health related (RMNCH) services becomes imperative to smoothen the journey towards Sustainable Development Goals (SDGs). In this study, we aim to measure the magnitude of inequalities in the coverage of RMNCH services. We also made an attempt to divulge the relationship between the various themes of governance and RMNCH indices.

METHODS

We used National Family Health Survey dataset (2015-16) and Public Affairs Index (PAI), 2016 for the analysis. Two summative indices, namely Composite Coverage Index (CCI) and Co-Coverage (Co-Cov) indicator were constructed to measure the RMNCH coverage. Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were employed to measure inequality in the distribution of coverage of RMNCH. In addition, we have used Spearman's rank correlation matrix to glean the association between governance indicator and coverage indices.

RESULTS & CONCLUSIONS

Our study indicates an erratic distribution in the coverage of CCI and Co-Cov across wealth quintiles and state groups. We found that the distribution of RII values for Punjab, Tamil Nadu, and West Bengal hovered around 1. Whereas, RII values for Haryana was 2.01 indicating maximum inequality across wealth quintiles. Furthermore, the essential interventions like adequate antenatal care services (ANC4) and skilled birth attendants (SBA) were the most inequitable interventions, while tetanus toxoid and Bacilli Calmette- Guerin (BCG) were least inequitable. The Spearman's rank correlation matrix demonstrated a strong and positive correlation between governance indicators and coverage indices.

Cost-effectiveness of population-based screening for diabetes and hypertension in India: an economic modelling study

BACKGROUND

India faces a high burden of diabetes and hypertension. Currently, there is a dearth of economic evidence about screening programmes, affected age groups, and frequency of screening for these diseases in Indian settings. We assessed the cost effectiveness of population-based screening for diabetes and hypertension compared with current practice in India for different scenarios, according to type of screening test, population age group, and pattern of health-care use.

METHODS

We used a hybrid decision model (decision tree and Markov model) to estimate the lifetime costs and consequences from a societal perspective. A meta-analysis was done to assess the effectiveness of population-based screening. Primary data were collected from two Indian states (Haryana and Tamil Nadu) to assess the cost of screening. The data from the National Health System Cost Database and the Costing of Health Services in India study were used to determine the health system cost of diagnostic tests and cost of treating diabetes or hypertension and their complications. A total of 962 patients were recruited to assess out-of-pocket expenditure and quality of life. Parameter uncertainty was evaluated using univariate and multivariable probabilistic sensitivity analyses. Finally, we estimated the incremental cost per quality-adjusted life-year (QALY) gained with alternative scenarios of scaling up primary health care through a health and wellness centre programme for the treatment of diabetes and hypertension.

FINDINGS

The incremental cost per QALY gained across various strategies for population-based screening for diabetes and hypertension ranged from US$0·02 million to $0·03 million. At the current pattern of health services use, none of the screening strategies of annual screening, screening every 3 years, and screening every 5 years was cost-effective at a threshold of 1-time per capita gross domestic product in India. In the scenario in which health and wellness centres provided primary care to 20% of patients who were newly diagnosed with uncomplicated diabetes or hypertension, screening the group aged between 30 and 65 years every 5 years or 3 years for either diabetes, hypertension, or a comorbid state (both diabetes and hypertension) became cost-effective. If the share of treatment for patients with newly diagnosed uncomplicated diabetes or hypertension at health and wellness centres increases to 70%, from the existing 4% at subcentres and primary health centres, annual population-based screening becomes a cost saving strategy.

INTERPRETATION

Population-based screening for diabetes and hypertension in India could potentially reduce time to diagnosis and treatment and be cost-effective if it is linked to comprehensive primary health care through health and wellness centres for provision of treatment to patients who screen positive.

FUNDING

None.

Household expenditure for immunization among children in India: a two-part model approach

Background

Despite the Indian government’s Universal Immunization Program (UIP), the progress of full immunization coverage is plodding. The cost of delivering routine immunization varies widely across facilities within country and across country. However, the cost an individual bears on child immunization has not been focussed. In this context, this study tries to estimate the expenditure on immunization which an individual bears and the factors affecting immunization coverage at the regional level.

Methods

Using the 75th round of National Sample Survey Organization data, the present paper attempts to check the individual expenditure on immunization and the factors affecting immunization coverage at the regional level. Descriptive statistics and multivariate regression analysis were used to fulfil the study objectives. The two-part model has been employed to inspect the determinants of expenditure on immunization.

Results

The overall prevalence of full immunization was 59.3 % in India. Full immunization was highest in Manipur (75.2 %) and lowest in Nagaland (12.8 %). The mean expenditure incurred on immunization varies from as low as Rs. 32.7 in Tripura to as high as Rs. 1008 in Delhi. Children belonging to the urban area [OR: 1.04; CI: 1.035, 1.037] and richer wealth quintile [OR: 1.14; CI: 1.134–1.137] had higher odds of getting immunization. Moreover, expenditure on immunization was high among children from the urban area [Rs. 273], rich wealth quintile [Rs. 297] and who got immunized in a private facility [Rs. 1656].

Conclusions

There exists regional inequality in immunization coverage as well as in expenditure incurred on immunization. Based on the findings, we suggest looking for the supply through follow-up and demand through spreading awareness through mass media for immunization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07011-0.

Associated Factors for Dropout of First Vs Third Doses of Diphtheria Tetanus Pertussis (DPT) Vaccination in Nepal

Background

Immunization acts as a key intervention to reduce under-five mortality and morbidity. Despite global progress on vaccination, difficulties in the utilization of this service in developing countries have been observed. According to Nepal Demographic and Health Survey (NDHS) 2016, only 78% of children received a complete dose of vaccine among which the first-dose receiver of DPT is 98%, whereas only 83% received a third dose. This study aims to explore the influencing factors of DPT vaccination dropout in Nepal.

Methods

The explorative study was done through secondary data analysis of NDHS 2016. The KR file was used for the analysis of information for 2883 children. Factors influencing dropout of DPT vaccination were explored against the independent variables such as external environment, predisposing factors, and enabling resources. All the analyses were weighted before the analysis. The descriptive, bivariate, and multivariate analyses were performed. The variables showing collinearity have been removed in the final model.

Results

A higher dropout was reported in Terai (18.9%) and province 2 (22.0%), among uneducated mothers (18.1%) and uneducated fathers (19.4%), less than once a week internet users (22.2%), the nonradio listener (17.4%), who had <4 ANC visits (22.7%), home delivery (19.2%), no advised SBA (19.1%), long distance to health facility (17.9%), no iron supplementation in pregnancy (24.3%), and PNC by TBA/others (21.1%). All these tested relationships were found statistically significant (P value <0.05). The aOR for dropout was found to be 7.94 (4.07–15.51) for mothers with less than 4 or no ANC visit, long distance to health facility 4.68 (1.98–10.67), province 2 3.53 (1.13–11.03), and mother without formal employment 2.33 (1.52–3.55).

Conclusion

Factors related to health services, distance, provinces, and socioeconomic status of the family were influencers for vaccine dropout. Targeted intervention towards disadvantaged regions, counseling the mother during ANC, improving the education status of parents, access to the health facility, and use of mass media for advocacy are hereby recommended.

Impact of National Health Mission on infant mortality in India: An interrupted time series analysis

Government of India introduced National Rural Health Mission in 2005-now transformed into National Health Mission (NHM), to bring about architectural reforms in health sector. In this study, we evaluate the overall impact of NHM on infant mortality at national and state level. Annual data on infant mortality rate (IMR) from 1990 to 2016 were obtained from Sample Registration System bulletins. With reporting year 2009 considered as cut-off point, a two-step segmented time series regression analysis was conducted. Estimates of pre-slope, post-slope and change at the point of intervention were computed by applying auto-regressive integrated moving average (1, 0, 0) while adjusting for trend and auto correlation. We found that while IMR reduced from around 80 to 34 per 1000 live births at the national level from 1990 to 2016, the annual rate of reduction increased from 1.6 per 1000 live births before NHM to 2.2 per 1000 live births after NHM. This is estimated to have averted 248,212 infant deaths in India, between 2005 and 2017. The rate of decline in IMR accelerated in 13 out of 17 larger states, most significantly in Andhra Pradesh, Gujarat, Assam, Haryana, Punjab and Uttar Pradesh. NHM has thus been successful in accelerating the overall rate of reduction in IMR in India. There is still a need to identify the determinants of variations at state level. We recommend strengthening of NHM in terms of funding and implementation.