Effect of a Quality Improvement Package on Reducing Newborn Mortality from 26 to 14 in a Himalayan North Indian State

Background: In India, newborn mortality remains high due to a number of factors, including poor quality of care at health facilities. The experience of executing complete neonatal care quality improvement (QI) package at selected hospitals in Himachal Pradesh and reduction in newborn mortality rate (NMR) is described in this study. Objective: The short-term objective was the participants’ retention of knowledge and skills, and the achievement of uniform QI objectives following training and after a minimum of 6 months. Overall reduction in NMR was long-term objective. Methods: Newborn care QI package was implemented according to India Newborn Action Plan over a period of 48 months from 2013 to 2016, through infrastructure, trainings, and supportive supervision. Results: Total 13 health facilities were upgraded; 350 staff nurses and medical officers were trained. The mean posttraining knowledge score was 75% compared to 29% in the pretraining test, and 63% 1 year later. The competencies of health workers in the care of high?risk babies and 12 QI targets had improved, resulting in a 46% reduction in neonatal mortality in the state across all gestations and weights based on sample registration survey. Conclusion: Implementation of a bundle of evidence-based practices in low-resource setting for health system strengthening for intrapartum and neonatal care was linked to changed care behaviors among health-care providers, and reduction in NMR.

Contextualizing Indian Masters of Public Health (MPH) programs – challenges and the way forward.

Introduction: Traditionally, public health education in India is offered through Departments of Community Medicine in medical colleges open only for medical graduates. Against the background of manpower shortages in public health professions, several programs aimed at increasing numbers in specific areas of public health have been initiated recently for medical and non-medical graduates. MPH programs have been introduced for over two decades in the country, however, to date no systematic effort has been undertaken to synthesize all the information related to these courses. Objective: To critically examine and understand the evolution and current status of MPH programs in India and to undertake a curriculum scan of the existing programs. Methods: Information on Indian institutes offering MPH programs was collected using multiple approaches. The list was prepared by collating information from various sources. The institutes were contacted for procuring information related to MPH programs using a detailed structured questionnaire and the data was assembled in a matrix for further analysis. Results: Twenty three institutes offering two year MPH programs were identified. Most offer a general MPH with a focus on core areas of public health. However, some of the institutions offer MPH with specialization (social epidemiology, health services management, environmental health, field epidemiology etc.) The course curriculum, eligibility criteria, structure of the program and evaluation system varies across the 23 institutes. A total of 16 batches (including 2010) have produced 1544 MPH graduates till 2010. Conclusion: The absence of competency frameworks for the MPH courses in India and absence of a central accrediting body need to be urgently addressed. These will lead towards the gradual establishment of career pathways for these graduates in the public health system. The MPH programs also need to be standardized across the country with a uniform curriculum.

Assessment of Essential Newborn Care Services in Secondary-level Facilities from Two Districts of India.

India faces a formidable burden of neonatal deaths, and quality newborn care is essential for reducing the high neonatal mortality rate. We examined newborn care services, with a focus on essential newborn care (ENC) in two districts, one each from two states in India. Nagaur district in Rajasthan and Chhatarpur district in Madhya Pradesh were included. Six secondary-level facilities from the districts─two district hospitals (DHs) and four community health centres (CHCs) were evaluated, where maximum institutional births within districts were taking place. The assessment included record review, facility observation, and competency assessment of service providers, using structured checklists and sets of questionnaire. The domains assessed for competency were: resuscitation, provision of warmth, breastfeeding, kangaroo mother care, and infection prevention. Our assessments showed that no inpatient care was being rendered at the CHCs while, at DHs, neonates with sepsis, asphyxia, and prematurity/low birthweight were managed. Newborn care corners existed within or adjacent to the labour room in all the facilities and were largely unutilized spaces in most of the facilities. Resuscitation bags and masks were available in four out of six facilities, with a predominant lack of masks of both sizes. Two CHCs in Chhatarpur did not have suction device. The average knowledge score amongst service providers in resuscitation was 76% and, in the remaining ENC domains, was 78%. The corresponding average skill scores were 24% and 34%, highlighting a huge contrast in knowledge and skill scores. This disparity was observed for all levels of providers assessed. While knowledge domain scores were largely satisfactory (>75%) for the majority of providers in domains of kangaroo mother care and breastfeeding, the scores were only moderately satisfactory (50-75%) for all other knowledge domains. The skill scores for all domains were predominantly non-satisfactory (<50%). The findings underpin the need for improving the existing ENC services by making newborn care corners functional and enhancing skills of service providers to reduce neonatal mortality rate in India.

Social and Behavioural Science Teaching in Medicine and Public Health in India.

The importance of social determinants on health has been consistently highlighted in public health debates. However, this has not been the case in the sphere of medical or public health education. This review paper aims to discuss the status and problems associated with teaching social and behavioural sciences in medicine and public health programs in India. A country like India requires a medical / public health manpower that is responsive to social reality and sensitive to the role of social determinants in shaping health and health-inequity. Although social and behavioural sciences form a part of the curriculum in undergraduate and postgraduate medical, public health and health management programs, the space made available for such are limited. The problem rests on the institutional structures through which these programs are offered and on issues such as the way medicine is practiced vis-à-vis the patient and overriding emphasis on doctors in professional hierarchy in public health practice and research. In most medical institutions social and behavioural sciences (SBSs) are taught by people with no formal training in these disciplines. Correspondingly, the priority given to students is too low. Absence of efforts to make a tangible connection between social science learning and medical / public health practice, lack of well-defined career opportunities and professional dominance of mainstream medical disciplines over others are some of the reasons for this low priority. Problems also reside in the degree of heterogeneity in content, vastness of scope, diversity in perspectives within each discipline, and a lack of standardized curriculum and reading materials.

Accreditation of public health education in India: Enhancing quality, competence and trust.

With an increase in the number of institutes offering public health education, there is a need for discussion on future directions and challenges. The World Health Report 2006 identified the need to improve the quality of public health education. There are various mechanisms and bodies that look after accreditation issues in several countries. The Council on Education for Public Health in the USA assists in the accreditation of schools of public health, as well as public health programmes. The Australian Network of Academic Public Health Institutions is actively engaged in discussions to improve the quality of its programme and institutions. In Europe, the European Agency for Accreditation in Public Health Education is responsible for accreditation. The South-East Asia Public Health Education Institutes Network facilitates accreditation of public health education in the region. In India, public health education varies across institutes. India needs an accreditation system to ensure that public health education is of the desired quality. Certain initiatives, such as conferences, consultation and the Calcutta Declaration, have been taken in the past two decades. However, the ideas mooted have yet to be translated into reality. The broad framework for accreditation may entail an institutional self-assessment against set standards, preparation of a database, cataloguing, and site visits by a peer team. There is a need for an apical body with all stakeholders participating in the process. Accreditation has specific benefits, but there are critical challenges as well. For example, the autonomy of the institutions needs to be protected, the accreditation bodies should exhibit professionalism and substantial financial resources are required. Before tackling specific criteria for accreditation, it is necessary to define a collective vision for schools of public health in India.

Veterinary public health capacitybuilding in India: a grim reflection of the developing world’s underpreparedness to address zoonotic risks.

Veterinary public health (VPH) is ideally suited to promote convergence between human, animal and environmental sectors. Recent zoonotic and emerging infectious disease events have given rise to increasing calls for efforts to build global VPH capacities. However, even with their greater vulnerability to such events, including their economic and livelihood impacts, the response from lowand middle-income countries such as India has been suboptimal, thereby elevating global health risks. Addressing risks effectively at the human–animal interface in these countries will require a clear vision, consistent policies, strategic approach and sustained political commitment to reform and refine the current VPH capacitybuilding efforts. Only then can the discipline serve its goal of disease prevention, poverty alleviation and support for sustainable livelihoods through improvements in human and animal health.

Landscaping biostatistics education in India.

Biostatistics plays an important role in measuring, understanding, and describing the overall health and well-being of a population. Biostatistics as a subject evolved from the application of statistics in various research aspects of biology, biomedical care, and public health. However, with a recent increase in number of health and pharmacy related research, the demand for trained biostatisticians is also increasing. The present paper is an attempt to undertake a situational analysis of biostatistics education in India. A systematic, predefined approach, with three parallel strategies was used to collect and assemble the data regarding training in biostatistics in India. Our study results show that there is paucity of programs providing specialized training in biostatistics in India. Only about 19 institutions in India are offering various courses in biostatistics/medical statistics/health statistics/biometry. It is important to look into the current capacity building initiatives in this domain. Some other means for giving importance to biostatistics could be by making it a separate branch/specialization in a majority of the institutions, particularly in medical colleges.

Emerging need for health policy teaching in India.

The core functions of public health agencies at all levels of government are identified as assessment, policy development, and assurance. However, the public health agencies in India are struggling with issues of access, inefficiency, and inequity. There has been failure in terms of health service delivery by public sector. Health Policy is being increasingly recognized as a discipline that has much to offer developing countries in addressing the problems related to policy, governance, and regulatory failure. However, the information about skill-oriented courses on health policy especially from the context of translating public health science into policy action is incomplete and limited. This paper attempts to address this knowledge gap and stimulate discussion in this direction.

Tracking Survival of Institutional Births for Neonatal Period- Feasibility at District Hospitals.

We assessed the feasibility of involving routine district health system personnel in tracking survival of institutional births for neonatal period in two district hospitals (Nagaur in Rajasthan and Chhatarpur in Madhya Pradesh) for the month of March 2010. A centralized district level tracking system was used in Nagaur, whereas in Chattarpur, block-wise tracking of births was performed. A total of 607 live births were tracked with 17 identified neonatal deaths. Prematurity and infections were commonest causes of deaths with majority occurring within first week of life. The block-wise approach resulted in identifying extra neonatal deaths.

An innovative National Rural Health Mission capacity development initiative for improving public health practice in India.

National Rural Health Mission (NRHM) foresaw improved health management in India through sustained capacity development of in-service health personnel and their post-training duties in the public health system. Acknowledging the urgency of addressing this issue, the Indian Government, under the NRHM, launched a 1-year Post Graduate Diploma in Public Health Management (PGDPHM) to impart public health management knowledge and skills to these professionals in the state health services. Four institutes partnered this program in 2008, its first year. Between 2008 and 2011, this expanded to 10 institutes and 386 students have graduated the program. The program offered across all these institutes is uniquely identified as against other Health Management courses being offered across the country. The NRHM context in its content and pedagogy is its prime feature. The program offers multiple opportunities to encourage states and the central government to clearly delineate a much needed specialized public health cadre in India. The efforts of this program emphasize on improved public health practice and are a unique pathway to a better health system. Its multidisciplinary facets are aimed at addressing the mismatch of demand and supply of health professionals who could contribute effectively to strengthening the public health system in India through proficient public health practice.

History and evolution of public health education in India.

In order to respond to the changing paradigm of public health challenges, India needs adequately trained public health professionals. Public health education is a tool to create public health professionals. Public health education in India is at cross-roads on several fronts. Traditionally, public health education in India was offered through medical schools and was open for medical graduates only. However, recently the country has witnessed an emergence of institutions offering public health programs to nonmedical background graduates. An examination of the history and current status of public health education can provide us with an insight into the evolution of the discipline in the country. This is important as in order to respond to the public health education challenges in the present time, we need to understand the historical directions taken by the discipline in the past. This review captures how the public health education efforts in the country have been aided by concerted actions within the discipline and by an enabling environment and a positive intent at the national level, whereby we can better understand the context for the recent developments in Indian public health.

Public health engineering education in India: Current scenario, opportunities and challenges.

Public health engineering can play an important and significant role in solving environmental health issues. In order to confront public health challenges emerging out of environmental problems we need adequately trained public health engineers / environmental engineers. Considering the current burden of disease attributable to environmental factors and expansion in scope of applications of public health / environmental engineering science, it is essential to understand the present scenario of teaching, training and capacity building programs in these areas. Against this background the present research was carried out to know the current teaching and training programs in public health engineering and related disciplines in India and to understand the potential opportunities and challenges availables. A systematic, predefined approach was used to collect and assemble the data related to various teaching and training programs in public health engineering / environmental engineering in India. Public health engineering / environmental engineering education and training in the country is mainly offered through engineering institutions, as pre-service and in-service training. Pre-service programs include diploma, degree (graduate) and post-graduate courses affiliated to various state technical boards, institutes and universities, whereas in-service training is mainly provided by Government of India recognized engineering and public health training institutes. Though trainees of these programs acquire skills related to engineering sciences, they significantly lack in public health skills. The teaching and training of public health engineering / environmental engineering is limited as a part of public health programs (MD Community Medicine, MPH, DPH) in India. There is need for developing teaching and training of public health engineering or environmental engineering as an interdisciplinary subject. Public health institutes can play an important and significant role in this regard by engaging themselves in initiating specialized programs in this domain.

Understanding the current status and exploring the potential for distance education in public health in India.

Continuing education of health care providers plays an important role in producing a health work force that is efficient and effective. In India public health education has primarily relied on conventional methods of training. However, such methods have limitations in equipping the health workforce of a vast and varied country like India. This paper analyzes the current status of distance education in public health and lists the various courses that are presently available in India through the distance education mode. Presently 25 institutions in India are offering 69 courses in various domains of public health through distance education. The providers of these programs comprised both government and private educational institutions. This paper also points out the role and importance of various stakeholders in the design and delivery of distance education programs in public health and raises key areas that need attention in the governance of such programs. It urges the use of digital technology in the delivery of distance education programs and points out how distance education that is designed and delivered using the latest technology could address the current gap in training human resources for health in India.

How can departments of community medicine shape the future of Public Health Education in India.

In order to effectively respond to a changing public health paradigm, it is imperative that the medical education and overall public health education (PHE) parallel the public health challenges faced by countries. Community medicine departments play a crucial role in PHE. This review analyzes the current situation of community medicine departments in the context of PHE, using a framework that outlines academic activities undertaken by these departments. This framework includes the syllabus of academic programs, internship, and infrastructure and faculty strength in the community medicine departments. The review also discusses how skill building of existing faculty members can help us in addressing emerging public health issues, and the role of partnerships and collaborative activities in advancing the PHE agenda, thereby continuing to shape the role played by these departments toward shaping the future of PHE in India.

Need and opportunities for health management education in India.

Public Health Management has taken a momentous leap and seeks to provide a plausible answer to many issues related to public health. A key area identified to aid the public health objectives in the country is human resource management. The country faces a dire crunch in the available work force in almost all the healthcare network. Countering the current health situation in the country, various institutes have come up offering specialized courses in public health management. The wide gap between supply and demand for trained health care managers/ administrators to work for hospitals, pharmaceutical companies, health insurance and third party administration and other health care provider organizations needs attention. The paper is a situational analysis of all such courses offered pan India. A systematic, predefined approach was used to collect and assemble the data. All the institutes offering such courses were contacted for detailed information. Fifty one institutes have been identified which annually produce around 2122 qualified professional to work in the domain of public health management. The paper also discusses the demand analysis where these prospective students can be placed. An estimated 19,930 professionals would be required based upon the country's present status, which reflects the dearth in their workforce capacity. The paper also enlightens the scope of strengthening the existing system, by effectively training the existing workforce for their capacity building, and highlights training opportunities for working professional to pursue a related academic program.