Measuring spatial equity and access to maternal health services using enhanced two step floating catchment area method (E2SFCA) - a case study of the Indian Sundarbans.

INTRODUCTION: Inaccessibility due to terrain and lack of transport leaves mothers travelling for long hours before reaching a facility to deliver a child. In the present article we analyzed the issue of spatial inaccessibility and inequity of maternal health services in the Indian Sundarbans where complex topography and repeated climatic adversities make access to health services very difficult. METHODS: We based the article on the health-GIS study conducted in the Patharpratima Block of the Sundarbans in the year 2012. The region has 87 villages that are inhabited, of which 54 villages are in the deltaic (river locked) region and 33 villages are located in the non-deltaic region of the block. We mapped all public and private maternal health facilities and road and water transport network. For measuring inaccessibility, we use the enhanced two-step floating catchment area method (E2SFCA). For assessing inequity in spatial access, we developed an area-based socioeconomic score and constructed a concentration curve to depict inequity. We used ARC GIS 10.3.1 and Stata 11 software for our analysis. RESULTS: The maternal health facilities are primarily located in the non-deltaic region of the block. On an average it takes 33.81 min to reach the closest maternal health facility. Fifty-two villages out of eighty seven villages have access scores less than the score calculated using Indian Primary Health Standards. Ten villages cannot access any maternal health facility; twenty-six villages have access scores of less than one doctor for 1000 pregnant women; fifty-six villages have access scores less than the block average of 3.54. The access scores are lower among villages in the deltaic region compared to the non-deltaic region. The concentration curve is below the line of equality showing that access scores were lower among villages that were socio-economically disadvantaged. CONCLUSIONS: Maternal health facilities are not equitably accessible to the populations that are disadvantaged and living in the remote pockets of the study region. Provision of a referral transport system along with a resilient infrastructure of roads is critical to improve access in these islands.

Multiple shocks, coping and welfare consequences: natural disasters and health shocks in the Indian Sundarbans.

BACKGROUND: Based on a household survey in Indian Sundarbans hit by tropical cyclone Aila in May 2009, this study tests for evidence and argues that health and climatic shocks are essentially linked forming a continuum and with exposure to a marginal one, coping mechanisms and welfare outcomes triggered in the response is significantly affected. DATA & METHODS: The data for this study is based on a cross-sectional household survey carried out during June 2010. The survey was aimed to assess the impact of cyclone Aila on households and consequent coping mechanisms in three of the worst-affected blocks (a sub-district administrative unit), viz. Hingalganj, Gosaba and Patharpratima. The survey covered 809 individuals from 179 households, cross cutting age and gender. A separate module on health-seeking behaviour serves as the information source of health shocks defined as illness episodes (ambulatory or hospitalized) experienced by household members. KEY FINDINGS: Finding reveals that over half of the households (54%) consider that Aila has dealt a high, damaging impact on their household assets. Result further shows deterioration of health status in the period following the incidence of Aila. Finding suggests having suffered multiple shocks increases the number of adverse welfare outcomes by 55%. Whereas, suffering either from the climatic shock (33%) or the health shock (25%) alone increases such risks by a much lesser extent. The multiple-shock households face a significantly higher degree of difficulty to finance expenses arising out of health shocks, as opposed to their counterparts facing only the health shock. Further, these households are more likely to finance the expenses through informal loans and credit from acquaintances or moneylenders. CONCLUSION: This paper presented empirical evidence on how natural and health shocks mutually reinforce their resultant impact, making coping increasingly difficult and present significant risks of welfare loss, having short as well as long-run development manifestations.

Improving outcomes and reducing costs by modular training in infection control in a resource-limited setting.

OBJECTIVE: To study the impact of modular training and implementation of infection control practices on all health-care-associated infections (HAIs) in a cardiac surgery (CVTS) program of a tertiary care hospital. DESIGN: Baseline data were compared with post-intervention (with modular training) data. SETTING: This study was conducted in a cardiovascular surgical unit. PARTICIPANTS: In total, 2838 patients were admitted in cardiovascular surgical service. INTERVENTIONS: Two training modules and online continuous education were delivered to all health-care workers in CVTS unit. MAIN OUTCOME MEASURES: All four HAIs, such as surgical site infections (SSI), central line-associated blood stream infection (CLABSI), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CA-UTI), were studied. Additional outcome measures included average length of stay cost of avoidance mortality and readmission rates. RESULTS: The SSI rate had decreased in the post-intervention phase from 46 to 3.27% per 100 surgeries (P < 0.0001), CLABSI had decreased from 44 to 3.10% per 1000 catheter days (P < 0.009), VAP was reduced from 65 to 4.8% per 1000 ventilator days (P < 0.0001) and CA-UTI had reduced from 37 to 3.48% per 1000 urinary catheter days (P < 1.0). For every $1 spent on training, the return on investment was $236 as cost of avoidance of healthcare associated infections (HAIs). CONCLUSIONS: Standardization of infection control training and practices is the most cost-effective way to reduce HCAIs and related adverse outcomes.

Nutritional status of children in India: household socio-economic condition as the contextual determinant.

BACKGROUND: Despite recent achievement in economic progress in India, the fruit of development has failed to secure a better nutritional status among all children of the country. Growing evidence suggest there exists a socio-economic gradient of childhood malnutrition in India. The present paper is an attempt to measure the extent of socio-economic inequality in chronic childhood malnutrition across major states of India and to realize the role of household socio-economic status (SES) as the contextual determinant of nutritional status of children. METHODS: Using National Family Health Survey-3 data, an attempt is made to estimate socio-economic inequality in childhood stunting at the state level through Concentration Index (CI). Multi-level models; random-coefficient and random-slope are employed to study the impact of SES on long-term nutritional status among children, keeping in view the hierarchical nature of data. MAIN FINDINGS: Across the states, a disproportionate burden of stunting is observed among the children from poor SES, more so in urban areas. The state having lower prevalence of chronic childhood malnutrition shows much higher burden among the poor. Though a negative correlation (r = -0.603, p < .001) is established between Net State Domestic Product (NSDP) and CI values for stunting; the development indicator is not always linearly correlated with intra-state inequality in malnutrition prevalence. Results from multi-level models however show children from highest SES quintile posses 50 percent better nutritional status than those from the poorest quintile. CONCLUSION: In spite of the declining trend of chronic childhood malnutrition in India, the concerns remain for its disproportionate burden on the poor. The socio-economic gradient of long-term nutritional status among children needs special focus, more so in the states where chronic malnutrition among children apparently demonstrates a lower prevalence. The paper calls for state specific policies which are designed and implemented on a priority basis, keeping in view the nature of inequality in childhood malnutrition in the country and its differential characteristics across the states.

Regulating health care markets in China and India.

Health care markets in China and India have expanded rapidly. The regulatory response has lagged behind in both countries and has followed a different pathway in each. Using the examples of front-line health providers and health insurance, this paper discusses how their different approaches have emerged from their own historical and political contexts and have led to different ways to address the main regulatory questions concerning quality of care, value for money, social agreement, and accountability. In both countries, the challenge is to build trust-based institutions that rely less on state-dominated approaches to regulation and involve other key actors.

Exploring evidence-policy linkages in health research plans: a case study from six countries.

The complex evidence-policy interface in low and middle income country settings is receiving increasing attention. Future Health Systems (FHS): Innovations for Equity, is a research consortium conducting health systems explorations in six Asian and African countries: Bangladesh, India, China, Afghanistan, Uganda, and Nigeria. The cross-country research consortium provides a unique opportunity to explore the research-policy interface. Three key activities were undertaken during the initial phase of this five-year project. First, key considerations in strengthening evidence-policy linkages in health system research were developed by FHS researchers through workshops and electronic communications. Four key considerations in strengthening evidence-policy linkages are postulated: development context; research characteristics; decision-making processes; and stakeholder engagement. Second, these four considerations were applied to research proposals in each of the six countries to highlight features in the research plans that potentially strengthen the research-policy interface and opportunities for improvement. Finally, the utility of the approach for setting research priorities in health policy and systems research was reflected upon. These three activities yielded interesting findings. First, developmental consideration with four dimensions - poverty, vulnerabilities, capabilities, and health shocks - provides an entry point in examining research-policy interfaces in the six settings. Second, research plans focused upon on the ground realities in specific countries strengthens the interface. Third, focusing on research prioritized by decision-makers, within a politicized health arena, enhances chances of research influencing action. Lastly, early and continued engagement of multiple stakeholders, from local to national levels, is conducive to enhanced communication at the interface. The approach described has four main utilities: first, systematic analyses of research proposals using key considerations ensure such issues are incorporated into research proposals; second, the exact meaning, significance, and inter-relatedness of these considerations can be explored within the research itself; third, cross-country learning can be enhanced; and finally, translation of evidence into action may be facilitated. Health systems research proposals in low and middle income countries should include reflection on transferring research findings into policy. Such deliberations may be informed by employing the four key considerations suggested in this paper in analyzing research proposals.

Reproductive and child health accounts: an application to Rajasthan.

This paper describes resource flows for reproductive and child health (RCH) in the health care system of Rajasthan, India, using the integrating framework of health accounts. It analyzes sources and uses of RCH funds by provider and expenditure category. The paper provides policy options for redirecting current public and private expenditures to improve RCH indicators. Comparisons of the share of government expenditure in state gross domestic product (31%), of Rajasthan state government spending as a share of total health spending (21%) and of Rajasthan state government spending as a share of reproductive and child health spending (3%) suggest that there are imbalances to correct. Even a very large increase in RCH spending by the Government of Rajasthan, an increase bringing its share of RCH total spending up to the level of its share in health spending, would add only one percentage point to the state budget. The principal result of such an increase in public RCH spending would be a substantial reduction in currently high levels of fertility and of mortality among infants, children and women of reproductive age.