Estimates on state-specific Pneumococcal Conjugate Vaccines (PCV) coverage in the private sector in the year 2012: Evidence from PCV utilization data.

The pneumococcal conjugate vaccine (PCV) is not available through universal immunization programs but is available through private healthcare providers. Because the PCV coverage rates are unknown, we developed a Microsoft Excel-based coverage assessment model to estimate state-specific PCV coverage for the year 2012. Our findings suggest that in the private sector, the "overall PCV coverage" was around 0.33% that ranged between a minimum of 0.07% for Assam, India and a maximum of 2.38% for Delhi, India. Further, in major metropolitan areas, overall PCV coverage rates were: 2.28% for Delhi, India, 13.31% for Mumbai (Maharashtra), India 0.76% for Lucknow (Uttar Pradesh), India, 1.93% for Kolkata (West Bengal), India, and 4.92% for Chennai (Tamil Nadu), India highlighting that urban centers are major drivers for PCV utilization driver in the states with high PCV consumption. Hence, to improve PCV coverage, both demand side (increasing consumer awareness about pneumonia prevention) and supply side (controlling vaccine prices and indigenous vaccine production) interventions are required.

Pediatricians' perspectives on pneumococcal conjugate vaccines: An exploratory study in the private sector.

There is a lack of information on supply-side determinants, their utilization, and the access to pneumococcal vaccination in India. The objective of this exploratory study was to document the perceptions and perspectives of practicing pediatricians with regard to pneumococcal conjugate vaccines (PCVs) in selected metropolitan areas of India. A qualitative study was conducted to generate evidence on the perspective of pediatricians practicing in the private sector regarding pneumococcal vaccination. The pediatricians were identified from 11 metropolitan areas on the basis of PCV vaccine sales in India through multilevel stratified sampling method. Relevant information was collected through in-depth personal interviews. Finally, qualitative data analysis was carried out through standard techniques such as the identification of key domains, words, phrases, and concepts from the respondents. We observed that the majority (67.7%) of the pediatricians recommended pneumococcal vaccination to their clients, whereas 32.2% recommended it to only those who could afford it. More than half (62.9%) of the pediatricians had no preference for any brand and recommended both a 10-valent pneumococcal conjugate vaccine (PCV10) and a 13-valent PCV (PCV13), whereas 8.0% recommended none. An overwhelming majority (97.3%) of the pediatricians reported that the main reason for a patient not following the pediatrician's advice for pneumococcal vaccination was the price of PCV. To reduce childhood pneumonia-related burden and mortality, pediatricians should use every opportunity to increase awareness about vaccine-preventable diseases, especially vaccine-preventable childhood pneumonia among their patients.

Landscaping academic programs offered in demography and population studies in India.

As per the United Nations 2013 report, India’s population is expected to reach 1.2 billion by 2015. Thus, there is a need for professionals trained in demography and population studies to carry out research regarding population aspects and project population growth/trends. This study landscapes the academic courses being offered in demography and population studies in India (in regular and distance learning modes). It outlines the details of these courses with respect to available courses, fee structure, number of seats, eligibility criteria, duration, nature of the program, etc. The details of the institutes offering demography and population studies courses were collected and compiled. A systematic and predefined approach including Internet search, search in the leading newspapers and discussions with students, academicians, and faculties were used to collect information for different courses provided by institutes all over India. There are around 22 institutions currently offering certificate, diploma, Masters, Master of Philosophy (M.Phil), and doctoral courses in demography and population studies in India (through regular and distance learning modes). Based on the annual intake capacity of these academic institutions, around 1,052 qualified professionals are available to work in the field of demography and population studies in India. This work has helped us to identify and track various academic courses being offered in demography and population studies in India. However, the courses that are being offered are relatively small in number when compared with the number of demographers/population scientists required. A need was also felt to include demography at the Bachelor’s degree level.

Landscaping capacity-building initiatives in epidemiology in India: bridging the demand–supply gap.

India, the second most populous country in the world, has 17% of the world’s population but its total share of global disease burden is 21%. With epidemiological transition, the challenge of the public health system is to deal with a high burden of noncommunicable diseases, while still continuing the battle against communicable diseases. To combat this progression, public health capacity-building initiatives for the health workforce are necessary to develop essential skills in epidemiology and competencies in other related fields of public health. This study is an effort to systematically explore the training programmes in epidemiology in India and to understand the demand–supply dynamics of epidemiologists in the country. A systematic, predefined approach, with three parallel strategies, was used to collect and assemble the data regarding epidemiology training in India and assess the demand–supply of epidemiologists in the country. The programmes offering training in epidemiology included degree and diploma courses offered by departments of preventive and social medicine/community medicine in medical colleges and 19 long-term academic programmes in epidemiology, with an estimated annual output of 1172 per year. The demand analysis for epidemiologists estimated that there is need for at least 3289 epidemiologists to cater for the demand of various institutions in the country. There is a wide gap in demand–supply of epidemiologists in the country and an urgent need for further strengthening of epidemiology training in India. More capacity-building and training initiatives in epidemiology are therefore urgently required to promote research and address the public health challenges confronting the country.

Demand–supply gaps in human resources to combat vector-borne disease in India: capacity-building measures in medical entomology.

Vector-borne diseases account for a significant proportion of the global burden of infectious disease. They are one of the greatest contributors to human mortality and morbidity in tropical settings, including India. The World Health Organization declared vector-borne diseases as theme for the year 2014, and thus called for renewed commitment to their prevention and control. Human resources are critical to support public health systems, and medical entomologists play a crucial role in public health efforts to combat vector-borne diseases. This paper aims to review the capacity-building initiatives in medical entomology in India, to understand the demand and supply of medical entomologists, and to give future direction for the initiation of need-based training in the country. A systematic, predefined approach, with three parallel strategies, was used to collect and assemble the data regarding medical entomology training in India and assess the demand-supply gap in medical entomologists in the country. The findings suggest that, considering the high burden of vector-borne diseases in the country and the growing need of health manpower specialized in medical entomology, the availability of specialized training in medical entomology is insufficient in terms of number and intake capacity. The demand analysis of medical entomologists in India suggests a wide gap in demand and supply, which needs to be addressed to cater for the burden of vector-borne diseases in the country.

Association between household air pollution and neonatal mortality: an analysis of Annual Health Survey results, India.

Background: In India, household air pollution (HAP) is one of the leading risk factors contributing to the national burden of disease. Estimates indicate that 7.6% of all deaths in children aged under 5 years in the country can be attributed to HAP. This analysis attempts to establish the association between HAP and neonatal mortality rate (NMR). Methods: Secondary data from the Annual Health Survey, conducted in 284 districts of nine large states covering 1 404 337 live births, were analysed. The survey was carried out from July 2010 to March 2011 (reference period: January 2007 to December 2009). The primary outcome was NMR. The key exposure was the use of firewood/crop residues/cow dung as fuel. The covariates were: sociodemographic factors (place of residence, literacy status of mothers, proportion of women aged less than 18 years who were married, wealth index); health-system factors (three or more antenatal care visits made during pregnancy; institutional deliveries; proportion of neonates with a stay in the institution for less than 24 h; percentage of neonates who received a check-up within 24 h of birth); and behavioural factors (initiation of breast feeding within 1 h). Descriptive analysis, with district as the unit of analysis, was performed for rural and urban areas. Bivariate and multivariable linear regression analysis was carried out to investigate the association between HAP and NMR. Results: The mean rural NMR was 42.4/1000 live births (standard deviation [SD] = 11.4/1000) and urban NMR was 33.1/1000 live births (SD=12.6/1000). The proportion of households with HAP was 92.2% in rural areas, compared to 40.8% in urban areas, and the difference was statistically significant (P < 0.001). HAP was found to be strongly associated with NMR after adjustment (β = 0.22; 95% confidence interval [CI] = 0.09 to 0.35) for urban and rural areas combined. For rural areas separately, the association was significant (β = 0.30; 95% CI = 0.13 to 0.45) after adjustment. In univariable analysis, the analysis showed a significant association in urban areas (β = 0.23; 95% CI = 0.12 to 2.34) but failed to demonstrate an association in multivariable analysis (β = 0.001; 95% CI = –0.15 to 0.15). Conclusion: Secondary data from district level indicate that HAP is associated with NMR in rural areas, but not in urban areas in India.

Human Resource Capacity Building Initiatives for Public Health Laboratories in India.

Public health laboratories play a critical role in disease surveillance and response. With changes in disease dynamics and transmission, their role has evolved over time, and they serve a range of important public health functions. For their effective functioning, it is important to have specialized manpower in these laboratories, which can contribute to their maximum utilization. The present manuscript is an attempt to explore the human resource capacity building initiatives for public health laboratories in India. Using three parallel methods we have attempted to gather information regarding various human resource capacity building initiatives for public health laboratories in India. Our study results show that there is a paucity of programs providing specialized training for human resources in public health laboratories in India. It highlights the urgent need to address this scarcity and introduce capacity building measures to generate human resources for public health laboratories to strengthen their role in public health action.

Teaching of public health ethics in India: a mapping exercise.

Public health ethics has been receiving increasing attention in recent years. Frequently, public health practitioners have to confront complex decisions, with numerous and often conflicting ethical implications. The objective of this study was to obtain information on the teaching of public health ethics in India by making a detailed examination of the public health and community medicine curricula. The specific areas of interest included the content and structure of the courses and electives available to students. The results of this study indicate that ethics courses are yet to find their rightful place in the teaching of public health in India. The curricula vary across institutes in terms of the time and content devoted to the teaching of public health ethics. It is suggested that public health programmes in India develop and incorporate ethics courses so as to keep pace with the emerging challenges in the field. An interdisciplinary consortium should preferably be formed at the national level to take up this academic endeavour.

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.

A Case-control Study Examining Association between Infectious Agents and Acute Myocardial Infarction.

Background: Coronary heart disease is multi-factorial in origin and its burden is expected to rise in developing countries, including India. Evidence suggests that the inflammation caused by infection is associated with the development of atherosclerosis and heart disease. An increasing number of clinical and experimental studies point to a contribution of various infectious organisms to the development of atherosclerosis in humans. Acute myocardial infarction (AMI) is associated with atherosclerosis. Objectives: The objective of the following study is to study the association between Helicobacter pylori, Chlamydia pneumoniae and C-reactive protein (CRP) with AMI. Materials and Methods: This group-matched case-control study was carried out in Government Medical College, Nagpur, Maharashtra, India. The study compared the risk of occurrence of AMI (outcome) if subjects were ever-infected with H. pylori or C. pneumoniae; and their CRP positivity (exposure). Incident cases of myocardial infarctions in a tertiary care hospital were included as cases. Results: The study recruited 265 cases and 265 controls and detected an odds ratio (OR) of 2.50 (95% confidence interval [CI]: 1.69-3.70) and an OR of 2.50 (95% CI: 1.71-3.65) for C. pneumoniae and H. pylori, respectively. Raised CRP levels had an OR of 3.85 (95% CI: 2.54-5.87). Conclusion: Although our study indicates the role of infections in the etiology of AMI in study population, the relative public health impact of these agents in the overall prevalence of AMI needs urgent research attention.

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.

Engagement of National Board of Examinations in Strengthening Public Health Education in India: Present Landscape, Opportunities and Future Directions.

A trained and adequate heath workforce forms the crux in designing, implementing and monitoring health programs and delivering quality health services. Education is recognized as a critical instrument for creating such trained health professionals who can effectively address the 21st century health challenges. At present, the Public Health Education in India is offered through medical colleges and also outside the corridors of medical colleges which was not the scenario earlier. Traditionally, Public Health Education has been a domain of medical colleges and was open for medical graduates only. In order to standardize the Postgraduate Medical Education in India, the National Board of Examinations (NBE) was set up as an independent autonomous body of its kind in the country in the fi eld of medical sciences with the prime objective of improving the quality of the medical education. NBE has also played a signifi cant role in enhancing Public Health Education in India through its Diplomat of National Board (DNB) Programs in Social and Preventive Medicine, Health and Hospital Administration, Maternal and Child Health, Family Medicine and Field Epidemiology. It envisions creating a cadre of skilled and motivated public health professionals and also developing a roadmap for postgraduate career pathways. However, there still exists gamut of opportunities for it to engage in expanding the scope of Public Health Education. It can play a key role in accreditation of public health programs and institutions which can transform the present landscape of education of health professionals. It also needs to revisit and re-initiate programs like DNB in Tropical Medicine and Occupational Health which were discontinued. The time is imperative for NBE to seize these opportunities and take necessary actions in strengthening and expanding the scope of Public Health Education 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.

Dimensions of Nutritional Vulnerability: Assessment of Women and Children in Sahariya Tribal Community of Madhya Pradesh in India.

Background: Tribal communities are “at risk” of undernutrition due to geographical isolation and suboptimal utilization of health services. Objectives: The objective of this study was to assess the nutritional status of Sahariya tribes of Madhya Pradesh (MP), India. Materials and Methods: A cross-sectional study was conducted in villages inhabited by Sahariya tribal community (specifi cally women in reproductive age group and children under 5 years) in three districts of MP. Dietary surveys, anthropometric and biochemical assessments were carried out and descriptive statistics on the socio-economic and nutritional profi le were reported. Association between household (HH) food security and nutritional status of children was carried out using the logistic regression. Strength of effects were summarized by odd’s ratio. Results: Chronic energy defi ciency and anemia was observed in 42.4% and 90.1% of women respectively. Underweight, stunting and wasting among under fi ve children were 59.1%, 57.3% and 27.7% respectively. Low food security was found in 90% of HHs and the odds of children being underweight and stunted when belonging to HHs with low and very low food security was found to be signifi cant (P = 0.01 and 0.04 respectively). Calorie, fat, vitamin A, ribofl avin, vitamin C and folic acid intake among women was lower than recommended dietary allowance. Infant and young child feeding practices were suboptimal. Awareness on nutritional disorders and utilization of nutrition and health services was poor. Conclusion: A high prevalence of undernutrition and dietary defi ciency exists among Sahariyas. System strengthening, community empowerment and nutrition education may play a pivotal role in addressing this.

Transforming Public Health Education in India Through Networking and Collaborations: Opportunities and Challenges.

A competent and motivated health workforce is indispensable to achieve the best health outcomes possible through given available resources and circumstances. However, apart from the shortages and unequal distribution, the workforce has fallen short of responding to the public health challenges of 21st century also because of primarily the traditional training of health professionals. Although, health professionals have made enormous contributions to health and development over the past century, the 20th century educational strategies are unfi t to tackle 21st century challenges. One of the key recommendations of the Lancet Commission on Education of Health Professionals is to improve health through reforms of professional education by establishing networks and partnerships which takes advantage of information and communication linkages. The primary goal of this manuscript is to highlight the potential of networks and partnerships in advancing the agenda of educational reforms to revitalize public health education in India. It outlines the current status and expanding scope of public health education in India, existing networks of public health professionals and public health education institutions in the country, and opportunities, advantages and challenges for such networks. Although, we have networks of individuals and institutions in the country, there potential to bring about change has still not being utilized fully and effectively. Immediate collaborative efforts could be directed towards designing and adaptation of competency driven curriculum frameworks suitable of addressing public health challenges of 21st century, shifting the current focus of curriculum to multidisciplinary public health outlook, developing accreditation mechanisms for both the programs and institutions, engaging in creating job opportunities and designing career pathways for public health professionals in public and private sector. These efforts could certainly be facilitated through existing networks.