Public health activism: success story of overcoming barriers to health care faced by a migrant family.

This is a case study from a village in Haryana. A migrant family from another state was working in poultry farm. Family had six children. Youngest was girl infant with grade IV malnutrition and unimmunised. This family was denied immunisation, registration to Anganwari centre, and there were issues of child labour. With public health activism, all these problems were solved. This case study demonstrates that if there is strong commitment and confidence among public health practitioners, they can overcome most of the barriers. Such Public Health Activism should be promoted.

Inequity in dental care utilisation: what gets delivered gets known - evidence from Chandigarh and Haryana.

Background: Studies till date have focussed on the prevalence of dental disorders and the related health seeking behaviour. Inequity in seeking dental health care is debated based on age, wealth and education. This study focussed on geographical inequity in awareness and treatment seeking for dental health care. Methods: Paper compares awareness for dental problems and related treatment practices of rural population of a district in Haryana with rural area of adjoining union territory Chandigarh. Results: In rural Chandigarh, more than 90% knew about dental caries and dentures, whereas, in rural Haryana only 50% knew about dental caries and 70% about dentures. Knowledge about gum problems, mal-alignment, and growth of plaque was low. Knowledge about scaling, and root canal treatment was low in both rural areas. Majority of subjects (66.7%) attending health camp in rural Haryana never underwent a dental check-up, compared to 41% in rural Chandigarh. In rural Haryana, commonly available dental services are extractions and filling, whereas, Chandigarh has wider spectrum of services available. Conclusions: Poor awareness of dental morbidity, treatment practices and treatment seeking is possibly linked to the availability of the services. Overall, penetration of newer treatments for dental health care in the community has been slower and more so in the rural areas.

Impact of referral transport system on institutional deliveries in Haryana, India.

Background & objectives: Creation of a strong referral transport network across the country is necessary for improving physical access to public sector health facilities. In this study we evaluated the referral transport services in Haryana, i.e. Haryana Swasthya Vaahan Sewa (HSVS), now known as National Ambulance Service (NAS), to assess the extent and pattern of utilization, and to ascertain its effect on public sector institutional deliveries. Methods: Secondary data on 116,562 patients transported during April to July 2011 in Haryana state were analysed to assess extent and pattern of NAS utilization. Exit interviews were conducted with 270 consecutively selected users and non- users of referral services respectively in Ambala (High NAS utilization), Hisar (medium utilization) and Narnaul (low utilization) districts. Month-wise data on institutional deliveries in public facilities during 2005-2012 were collected in these three districts, and analysed using interrupted time series analysis to assess the impact of NAS on institutional deliveries. Results: Female gender (OR = 77.7), rural place of residence (OR = 5.96) and poor socio-economic status (poorest wealth quintile OR = 2.64) were significantly associated with NAS ambulance service usage. Institutional deliveries in Haryana rose significantly after the introduction of NAS service in Ambala (OR=137.4, 95% CI=22.4-252.4) and Hisar (OR=215, 95% CI=88.5-341.3) districts. No significant increase was observed in Narnaul (OR=4.5, 95% CI= -137.4 to 146.4) district. Interpretation & conclusions: The findings of the present study showed a positive effect of referral transport service on increasing institutional deliveries. However, this needs to be backed up with adequate supply of basic and emergency obstetric care at hospitals and health centres.

Cost & efficiency evaluation of a publicly financed & publicly delivered referral transport service model in three districts of Haryana State, India.

Background & objectives: Various models of referral transport services have been introduced in different States in India with an aim to reduce maternal and infant mortality. Most of the research on referral transport has focussed on coverage, quality and timeliness of the service with not much information on cost and efficiency. This study was undertaken to analyze the cost of a publicly financed and managed referral transport service model in three districts of Haryana State, and to assess its cost and technical efficiency. Methods: Data on all resources spent for delivering referral transport service, during 2010, were collected from three districts of Haryana State. Costs incurred at State level were apportioned using appropriate methods. Data Envelopment Analysis (DEA) technique was used to assess the technical efficiency of ambulances. To estimate the efficient scale of operation for ambulance service, the average cost was regressed on kilometres travelled for each ambulance station using a quadratic regression equation. Results: The cost of referral transport per year varied from `5.2 million in Narnaul to `9.8 million in Ambala. Salaries (36-50%) constituted the major cost. Referral transport was found to be operating at an average efficiency level of 76.8 per cent. Operating an ambulance with a patient load of 137 per month was found to reduce unit costs from an average ` 15.5 per km to ` 9.57 per km. Interpretation & conclusions: Our results showed that the publicly delivered referral transport services in Haryana were operating at an efficient level. Increasing the demand for referral transport services among the target population represents an opportunity for further improving the efficiency of the underutilized ambulances.

User charges in health care: Evidence of effect on service utilization & equity from north India.

Background & objectives: User charges have been advocated on efficiency grounds despite the widespread criticism about their adverse effect on equity. We assessed the effect of user charges on inpatient hospitalizations rate and equity in Haryana State. Methods: The inpatient department (IPD) statistics of the public sector facilities in Yamuna Nagar district where user charges had been introduced were analysed and compared with Rohtak district which did not have user charge between 2000 and 2006. National Sample Survey data of Haryana for the 2004-2005 period were analyzed to compare utilization of public sector facilities for hospitalization, cost of hospitalization, and prevalence of catastrophic out-of-pocket (OOP) expenditure by income quintiles in three districts which had user charges and 17 districts of Haryana which did not levy user charges. Results: During 2000 and 2006, hospital admissions declined by 23.8 per cent in Yamuna Nagar district where user charges had been introduced compared to an almost static hospitalization rate in Rohtak district which did not have user charges (P<0.01). Public sector hospital utilization for inpatient services had a pro-rich (concentration index 0.144) distribution in the three districts with user charges and pro-poor (concentration index -0.047) in the 17 districts without user charges. Significantly higher prevalence of catastrophic health expenditure was observed in public sector institutions with user charges (48%) compared to those without user charges (35.4%) (P<0.001). Interpretation & conclusions: The findings of our study showed that user charges had a negative influence on hospitalizations in Haryana especially among the poor. Public policies for revenue generation should avoid user charges.

Knowledge and skills of primary health care workers trained on integrated management of neonatal and childhood illness: Follow-up assessment 3 years after the training.

Background: The primary health care workers of a district in northern India were trained in the year 2006 for Integrated Management of Neonatal and Childhood Illness (IMNCI) using two different training methods: conventional 8-day training and new interrupted 5-day training. Knowledge and skills may decline over a period of time. Rate of decline may be associated with the type of training. A study was thus conducted to see the retention of knowledge and skills in the two training groups, 3 years after the initial training. Materials and Methods: This study was done in the Panchkula district of Haryana state in northern India. In the year 2006, 50 primary health care workers were given new interrupted 5-day training and another 35 workers were given conventional 8-day training on IMNCI. Knowledge and skills of the same workers were evaluated in the year 2009, using the same methodology and tools as were used in the year 2006. Data analysis was done to see the extent of decline in knowledge and skills in these 3 years and whether decline was more in any particular training group. Results: Compared to post-training score in the year 2006, composite knowledge and skill scores for Auxilliary Nurse Midwives (ANMs) and Anganwari workers (AWWs) together declined significantly in the year 2009 from 74.6 to 58.0 in 8-day training group and from 73.2 to 57.0 in 5-day training group (P < 0.001). Follow-up composite scores in the two training groups were similar. Whereas the decline was more for knowledge scores in 8-day training group and for skill score in 5-day training group, the pattern of decline was inconsistent for different health conditions and among ANMs and AWWs. Conclusion: Long-term retention of knowledge and skills in 5-day group was equivalent to that in 8-day training group. Refresher trainings may boost up the decline in the knowledge and skills.

Knowledge of men and women about reproductive tract infections and AIDS in a rural area of north India: impact of a community-based intervention.

This study of a community-level health-education intervention on reproductive tract infections/sexually transmitted diseases (RTIs/STDs) was conducted in three villages of Haryana in north India. The study was aimed at increasing awareness among men and women of reproductive age about the prevention and treatment of RTIs, modes of HIV/AIDS transmission, and methods of prevention. Health education was imparted through one-to-one interactions with men and women during home visits, at village-based clinics and health camps, and through health-education talks with men and women. Cumulative effects of the intervention were examined at the end of the survey by comparing the change in knowledge from the baseline. Records of clinic attendance were examined to assess the probable impact of the intervention on clinic attendance. Baseline and follow-up evaluations revealed that there was an improvement in the median total knowledge score of women from 0 to 6, whereas it remained at 5 for men both at baseline and follow-up. Knowledge about RTI/STIs increased among both men and women from the median score of 0 to 2 and from 0 to 3 respectively. The median knowledge score on HIV/AIDS declined among men from 4 to 2 but increased from 0 to 3 among women. Clinic attendance for RTI/STI cases, referred to the Naraingarh hospital, showed an eight-fold rise from an average of four cases per month in 1998-1999 to an average of 35 cases per month in 1999-2000. The findings of the study suggest that health-education strategy through home visits, RTI case management and counselling, and organizing a weekly clinic and occasional camps and health-education talks can increase the level of awareness about RTIs/STIs among both men and women and improve clinic attendance.

Syndromic management of vaginal discharge and pelvic inflammatory disease among women in a rural community of Haryana, India: agreement of symptoms enquiry with clinical diagnosis.

World Health Organisation (1984) advocated syndromic approach for management of reproductive tract infections/sexually transmitted diseases. Some investigators have cautioned against using this approach to diagnose and treat vaginal discharge and pelvic inflammatory disease. The prevalence of RTIs in rural areas of Haryana is high and availability of per-speculum examination facility is scarce. The scope for laboratory diagnosis of RTI in rural areas is remote in near future. A community-based study was conducted to assess the agreement of symptoms enquiry with the syndromic diagnosis of RTIs/STDs (based upon per speculum examination). A total of 812 women were interviewed by ANMs and were examined by a lady doctor. History based ANM's diagnosis was found to be having high sensitivity (80.5%) and high positive predictive value (81.3%). However it had low specificity (48.6%) and low negative predictive value (47.5%) compared to clinical diagnosis. Level of agreement was found to be fair (Kappa = 0.28, 95% CI = 0.20-0.36). The chances of over treatment for vaginal discharge and pelvic inflammatory disease were only 16% and 15% respectively. However, history based syndromic protocols need revision. Proposed protocol is discussed in this paper.