Correction: Challenging drug-resistant TB treatment journey for children, adolescents and their care-givers: A qualitative study.

[This corrects the article DOI: 10.1371/journal.pone.0248408.].

Efficacy of Government-Sponsored Community Health Programs for Older Adults: A Systematic Review of Published Evaluation Studies.

Objective: Population aging is an ongoing challenge for global health policy and is expected to have an increasing impact on developing economies in years to come. A variety of community health programs have been developed to deliver health services to older adults, and evaluating these programs is crucial to improving service delivery and avoiding barriers to implementation. This systematic review examines published evaluation research relating to public and community health programs aimed at older adults throughout the world. Methods: A literature search using standardized criteria yielded 58 published articles evaluating 46 specific programs in 14 countries. Results: Service models involving sponsorship of comprehensive facilities providing centralized access to multiple types of health services were generally evaluated the most positively, with care coordination programs appearing to have generally more modest success, and educational programs having limited effectiveness. Lack of sufficient funding was a commonly-cited barrier to successful program implementations. Conclusion: It is important to include program evaluation as a component of future community and public health interventions aimed at aging populations to better understand how to improve these programs.

Challenging drug-resistant TB treatment journey for children, adolescents and their care-givers: A qualitative study.

BACKGROUND: Childhood multidrug-resistant TB (MDR-TB) still affects around 25000 children every year across the globe. Though the treatment success rates for drug-resistant TB (DR-TB) in children are better than adults, children and adolescents face unique hurdles during DR-TB (MDR-TB, Pre-XDR TB and XDR-TB) treatment. This study aimed to understand the patients, guardians and healthcare providers' perspectives about DR-TB treatment journey of patients and caregivers. METHODS: This is a qualitative study involving in depth-interviews of purposively selected adolescents (n = 6), patients guardians (for children and adolescents, n = 5) and health care providers (n = 8) of Médecins Sans Frontières (MSF) clinic, Mumbai, India. In-depth face to face interviews were conducted in English or Hindi language using interview guides during September-November 2019. The interviews were audio-recorded after consent. Thematic network analysis was used to summarize textual data. ATLAS.ti (version 7) was used for analysis. RESULT: The age of adolescent patients ranged from 15-19 years and four were female. Five guardians (of three child and two adolescent patients) and eight healthcare providers (including clinicians- 2, DOT providers-2, counselors-2 and programme managers-2) were interviewed. The overarching theme of the analysis was: Challenging DR-TB treatment journey which consisted of four sub-themes: 1) physical-trauma, 2) emotional-trauma, 3) unavailable social-support and 4) non-adapted healthcare services. Difficulties in compounding of drugs were noted for children while adolescents shared experiences around disruption in social life due to disease and treatment. Most of the patients and caregivers experienced treatment fatigue and burnout during the DR-TB treatment. Participants during interviews gave recommendations to improve care. DISCUSSION: The TB programmes must consider the patient and family as one unit when designing the package of care for paediatric DR-TB. Child and adolescent friendly services (paediatric-formulations, age-specific counselling tools and regular interaction with patients and caregivers) will help minimizing burnout in patients and caregivers.

Treatment outcomes of children and adolescents receiving drug-resistant TB treatment in a routine TB programme, Mumbai, India.

BACKGROUND: Childhood and adolescent drug-resistant TB (DR-TB) is one of the neglected infectious diseases. Limited evidence exists around programmatic outcomes of children and adolescents receiving DR-TB treatment. The study aimed to determine the final treatment outcomes, culture conversion rates and factors associated with unsuccessful treatment outcome in children and adolescents with DR-TB. METHODS: This is a descriptive study including children (0-9 years) and adolescents (10-19 years) with DR-TB were who were initiated on ambulatory based treatment between January 2017-June 2018 in Shatabdi hospital, Mumbai, India where National TB elimination programme(NTEP) Mumbai collaborates with chest physicians and Médecins Sans Frontières(MSF) in providing comprehensive care to DR-TB patients. The patients with available end-of-treatment outcomes were included. The data was censored on February 2020. RESULT: A total of 268 patients were included; 16 (6%) of them were children (0-9 years). The median(min-max) age was 17(4-19) years and 192 (72%) were females. Majority (199, 74%) had pulmonary TB. Most (58%) had MDR-TB while 42% had fluoroquinolone-resistant TB. The median(IQR) duration of treatment (n = 239) was 24(10-25) months. Median(IQR) time for culture-conversion (n = 128) was 3(3-4) months. Of 268 patients, 166(62%) had successful end-of-treatment outcomes (cured-112; completed treatment-54). Children below 10 years had higher proportion of successful treatment outcomes (94% versus 60%) compared to adolescents. Patients with undernutrition [adjusted odds-ratio, aOR (95% Confidence Interval, 95%CI): 2.5 (1.3-4.8) or those with XDR-TB [aOR (95% CI): 4.3 (1.3-13.8)] had higher likelihood of having unsuccessful DR-TB treatment outcome. CONCLUSION: High proportion of successful treatment outcome was reported, better than global reports. Further, the nutritional support and routine treatment follow up should be strengthened. All oral short and long regimens including systematic use of new TB drugs (Bedaquiline and Delamanid) should be rapidly scaled up in routine TB programme, especially for the paediatric and adolescent population.

Does decentralization influence efficiency of health units? A study of opinion and perception of health workers in Odisha.

BACKGROUND: Health systems in low and middle income countries are struggling to improve efficiency in the functioning of health units of which workforce is one of the most critical building blocks. In India, Rogi Kalyan Samiti (RKS) was established at every health unit as institutions of local decision making in order to improve productive efficiency and quality. Measuring efficiency of health units is a complex task. This study aimed at assessing the perception (opinion and satisfaction) of health workers about influence of RKS on improving efficiency of peripheral decision making health units (DMHU); examining differences between priority and non-priority set-ups; identifying predictors of satisfaction at work; and discussing suggestions to improve performance. METHODS: Following a cross-sectional, comparative study design, 130 health workers from 30 institutions were selected through a multi-stage stratified random sampling. A semi-structured questionnaire was administered to assess perception and opinion of health workers about influence of RKS on efficiency of decision making at local level, motivation and performance of staff, and availability of funds; improvement of quality of services, and coordination among co-workers; and participation of community in local decision making. Three districts with highest infant mortality rate (IMR), one each, from 3 zones of Odisha and 3 with lowest IMR were selected on the basis of IMR estimates of 2011. The former constituted priority districts (PD) and the latter, non-priority districts (NPD). Composite scores were developed and compared between PD and NPD. Adjusted linear regression was conducted to identify predictors of satisfaction at work. RESULTS: A majority of respondents felt that RKS was efficient in decision making that resulted in improvement of all critical parameters of health service delivery, including quality; this was significantly higher in PD. Further, higher proportion of respondents from PD was highly satisfied with the current set of provisions and manners of functioning of the sample health units. Active community engagement, participation of elected representatives, selection of a pro-active Chairman, and training to RKS members were suggested as the immediate priority action points for the state government. Mean scores differed significantly between PD and NPD with regard to: influence of RKS on individual-centric, organizational-centric and patient-centric performance, and the responsibilities to be entrusted with RKS. Absenteeism was strongly associated with satisfaction and local self-governance. Work-related factors, systemic factors, local accountability and patients' involvement were found to be the key predictors of satisfaction of health workforce. CONCLUSION: The understanding on quality improvement strategies was found to be very poor among the health workers. Tailor-made capacity building measures at district and sub-district levels could be critical to equip the peripheral health units to achieve the universal health coverage goals. Work environment, systemic factors and accountability need to be addressed on priority for retention of health workforce. The hypothesized link between efficient local decision making, perception of health workers about efficiency of health units and the health status of population needs further investigation.

Local self governance in health - a study of it's functioning in Odisha, India.

BACKGROUND: Local decision making is linked to several service quality improvement parameters. Rogi Kalyan Samitis (RKS) at peripheral decision making health units (DMHU) are composite bodies that are mandated to ensure accountability and transparency in governance, improve quality of services, and facilitate local responsiveness. There is scant literature on the nature of functioning of these institutions in Odisha. This study aimed to assess the perception of RKS members about their roles, involvement and practices with respect to local decision making and management of DMHUs; it further examined perceptual and functional differences between priority and non-priority district set-ups; and identified predictors of involvement of RKS members in local governance of health units. METHODS: As members of RKS, health service providers, officials in administrative/managerial role, elected representatives, and officials from other departments (including independent members) constituted our study sample. A total of 112 respondents were interviewed across 6 districts, through a multi-stage stratified random sampling; we used a semi-structured interview schedule that comprised mainly of close-ended and some open-ended questions. Descriptive and inferential statistics were used to compare 3 priority (PD) and 3 non-priority districts (NPD), categorized on the basis of Infant Mortality Rate (IMR) estimates of 2011 as proxy of population health. Governance, human resource management, financial management and quality improvement functions were studied in detail. Opinion about various individual and organizational factors in local self-governance and predictors of involvement were identified. RESULTS: The socio-demographic profile and composition of respondents were comparable between PD and NPD. Majority of respondents were 'satisfied' with their current roles in the governance of local health institutions. About one-fourth opined that the amount of funds allocated to RKS under National Health Mission (NHM) was 'grossly insufficient'. Fifty percent of respondents said they requested for additional funds, last year, and 38.8 % informed that they requested additional funds for purchase of drugs. About 87 % respondents were satisfied with their role in the local governance of the health units (PD = 94.3 % vs. NPD = 80.7 %). Almost all (PD = 98 % vs. NPD = 80.7 %) opined that local decision making helped in improving the performance of health units. For most of the open-ended questions the responses were non-specific. Staggering differences were found between PD and NPD with respect to their involvement in district plan preparation (NPD = 78.9 % vs. PD = 58.5 %), training in plan preparation (NPD = 47.4 % vs. PD = 27.5 %), participation of officials from other departments (PD = 96.9 % vs. NPD = 45.5 %), and inclusion of activities of other sectors (PD = 70.8 % vs. NPD = 41.8 %). Whereas, no significant PD-NPD difference was found about their perceived 'involvement' in undertaking the 12 designated responsibilities. Composite scores on various individual and organizational factors were compared and found to be varying significantly. Through regression, we inferred work experience, qualification and non-monetary incentives as strong determinants of current level of involvement of RKS members in governance and management of health units. CONCLUSION: Poor knowledge/expectation of RKS members was diluting the decision making process at DMHUs. There is an urgent need to improve their knowledge, understanding and expertise in areas of governance and management practices. A locally-monitored and time-bound capacity building plan could achieve this. Yearly resource allocation for drug procurement needs revision. Specific eligibility criteria based on work experience and qualification may be fixed for RKS membership. Further research may focus on identifying the underlying individual and systemic factors behind such large PD-NPD differences.

Decentralization and health system performance - a focused review of dimensions, difficulties, and derivatives in India.

INTRODUCTION: One of the principal goals of any health care system is to improve health through the provision of clinical and public health services. Decentralization as a reform measure aims to improve inputs, management processes and health outcomes, and has political, administrative and financial connotations. It is argued that the robustness of a health system in achieving desirable outcomes is contingent upon the width and depth of 'decision space' at the local level. Studies have used different approaches to examine one or more facets of decentralization and its effect on health system functioning; however, lack of consensus on an acceptable framework is a critical gap in determining its quantum and quality. Theorists have resorted to concepts of 'trust', 'convenience' and 'mutual benefits' to explain, define and measure components of governance in health. In the emerging 'continuum of health services' model, the challenge lies in identifying variables of performance (fiscal allocation, autonomy at local level, perception of key stakeholders, service delivery outputs, etc.) through the prism of decentralization in the first place, and in establishing directed relationships among them. METHODS: This focused review paper conducted extensive web-based literature search, using PubMed and Google Scholar search engines. After screening of key words and study objectives, we retrieved 180 articles for next round of screening. One hundred and four full articles (three working papers and 101 published papers) were reviewed in totality. We attempted to summarize existing literature on decentralization and health systems performance, explain key concepts and essential variables, and develop a framework for further scientific scrutiny. Themes are presented in three separate segments of dimensions, difficulties and derivatives. RESULTS: Evaluation of local decision making and its effect on health system performance has been studied in a compartmentalized manner. There is sparse evidence about innovations attributable to decentralization. We observed that in India, there is very scant evaluative study on the subject. We didn't come across a single study examining the perception and experiences of local decision makers about the opportunities and challenges they faced. The existing body of evidences may be inadequate to feed into sound policy making. The principles of management hinge on measurement of inputs, processes and outputs. In the conceptual framework we propose three levels of functions (health systems functions, management functions and measurement functions) being intricately related to inputs, processes and outputs. Each level of function encompasses essential elements derived from the synthesis of information gathered through literature review and non-participant observation. We observed that it is difficult to quantify characteristics of governance at institutional, system and individual levels except through proxy means. CONCLUSION: There is an urgent need to sensitize governments and academia about how best more objective evaluation of 'shared governance' can be undertaken to benefit policy making. The future direction of enquiry should focus on context-specific evidence of its effect on the entire spectrum of health system, with special emphasis on efficiency, community participation, human resource management and quality of services.

Characteristics of childhood tuberculosis patients registered under RNTCP in Varanasi, Uttar Pradesh.

Childhood tuberculosis (TB) reflects on-going transmission. Data on childhood TB from TB registers under Revised National Tuberculosis Control Program of 2008 and 2009 in Varanasi district was analyzed. Proportion of childhood TB was 8.3% of total registered cases 12,242. It was lower than estimated 10-20% in endemic areas. In rural Tuberculosis Units childhood case detection was poor. Case detection in ≤5 years was very less. The childhood cases were detected mainly in adolescent age group. Thus, childhood TB is remaining a under diagnosed/under reported disease in India. It needs attention to increase the detection of childhood TB cases to control TB in general population.