Engaging Actors for Integrating Health Policy and Systems Research into Policy Making: Case Study from Haryana State in India

Background & objective: Good examples of evidence generation using Health Policy and Systems Research (HPSR) in low and middle income countries (LMIC); and its application in policy making are scarce. In this paper, we describe the experience of establishing a system of HPSR from the Haryana state in India, outline how the HPSR is being utilized for policy making and programmatic decision making, and analyse the key factors which have been critical to the implementation and uptake of HPSR. \ud Methods: Multiple methods are employed in this case study, ranging from unstructured in-depth interviews, review of the program and policy documents, and participatory notes from the meetings. The steps towards creation of a knowledge partnership between stakeholders are outlined. Four case studies i.e. development of a plan for universal health care (UHC), nutrition policy, centralized drug procurement system and use of RAPID appraisal method highlight the use of research evidence in agenda setting, policy formulation and policy implementation respectively. \ud Results: Our analysis shows that the most important factor which contributed to Haryana model of HPSR was the presence of a dedicated and motivated team in National Rural Health Mission (NRHM) at state level, many of whom were researchers by previous training. Overall, we conclude by highlighting the need for establishing an institutional mechanism at Central and State level where health service administrators and managers, academicians and researchers working in the field of health system from medical colleges, public health schools, management and technology institutions and social science universities can identify health system research priorities. Increased budgetary allocation for HPSR is required

Inequalities in nutritional status among under five children in Haryana state, India: Role of social determinants

Background: Under-nutrition is a major cause of ill health and childhood mortality in India. So far, little attempt has been made to assess whether improvements in nutritional status have masked widening socioeconomic inequalities or produced slower progress among the poor and the disadvantaged. Aims & objective: We undertook this study to estimate the burden of under-nutrition among children less than five years in four districts of Haryana and explore the inequalities in rates of malnutrition across different social and economic groups. Material & Methods: A community based cross-sectional survey was carried out in four districts of Haryana namely Ambala, Karnal, Panchkula and Yamunanagar. Multi-stage stratified random sampling technique was used to select 2763 children under 5 years of age. Standard anthropometric methods were used. Rates of underweight (WAZ ≤ -2 z-score), wasting (WHZ ≤ -2 z-score) and stunting (HAZ ≤ -2 z-score) were estimated. Multivariate logistic regression was used to determine risk factors and evaluate inequalities across population by social and economic sub-groups. Results: The prevalence of underweight, stunting and wasting in four districts of Haryana was 37.4%, 38.2% and 16.4% respectively. Similarly, 12.7%, 13.2% and 3.5% of under-weight children were severely underweight, stunted and wasted respectively. Age of the child, social group and wealth status were significant predictors of malnutrition. The odds of underweight and stunting increased among the poorest by 2.3 and 1.8 times respectively as compared to the richest category. Conclusion: There is persistent problem of under-nutrition in Haryana mostly among the poor, uneducated, and among children of women who do not take ANC care/ breastfeed. Actions on social determinants need urgent prioritization

District level analysis of routine immunization in Haryana State: Implications for mission indradhanush under universal immunization programme

Background: The immunization coverage in India is far away from satisfactory with full immunization coverage being only 62% at national level. Targeting the intensive efforts to poor performing areas and addressing the determinants of nonimmunization and dropouts offers a quick solution. In this paper, we assess the inter-district variations in Haryana state, and the association of social determinants with partial and no immunization. Methodology: This analysis is based on data collected as part of a large household survey undertaken in the state of Haryana to measure the extent of Universal Health Coverage. A multistage stratified random sampling design was used to select primary sampling units (i.e., subcenters), villages, and households. A total of 11,594 mothers with a child between 12 and 23 months were interviewed on receipt of immunization services. Determinants of nonimmunization and partial immunization were assessed using multiple logistic regression. Results: About 21% of children aged 12–23 months were partially immunized, while 4.3% children aged 12–23 months had received “no immunization.” While the coverage of full immunization was 74.7% at the state level, it varied from 95% in best performing district to 38% in poorest performing district. Odds of a partially immunized child were significantly higher in urban area (odds ratio [OR] = 1.23; 95% confidence interval [CI] = 1.1–1.38), among Muslim household (OR = 3.52; 95% CI = 3.03–4.11), children of illiterate parents (OR = 1.58; 95% CI = 1.22–2.05), and poorest quintile (OR = 1.61; 95% CI = 1.36–1.89). Conclusions: Wide interdistrict variations call for a need to consider changes in resource allocation and strengthening of the government initiatives to improve routine immunization in these districts

An alternative approach for supportive supervision and skill measurements of health workers for integrated management of neonatal and childhood illnesses program in 10 districts of Haryana

Context: “Integrated Management of Neonatal and Childhood Illnesses” (IMNCI) needs regular supportive supervision (SS). Aims: The aim of this study was to find suitable SS model for implementing IMNCI. Settings and Design: This was a prospective interventional study in 10 high-focus districts of Haryana. Subjects and Methods: Two methods of SS were used: (a) visit to subcenters and home visits (model 1) and (b) organization of IMNCI clinics/camps at primary health center (PHC) and community health center (CHC) (model 2). Skill scores were measured at different time points. Routine IMNCI data from study block and randomly selected control block of each district were retrieved for 4 months before and after the training and supervision. Statistical Analysis Used: Change in percentage mean skill score difference and percentage difference in median number of children were assessed in two areas. Results: Mean skill scores increased significantly from 2.1 (pretest) to 7.0 (posttest 1). Supportive supervisory visits sustained and improved skill scores. While model 2 of SS could positively involve health system officials, model 1 was not well received. Outcome indicator in terms of number of children assessed showed a significant improvement in intervention areas. Conclusions: SS in IMNCI clinics/camps at PHC/CHC level and innovative skill scoring method is a promising approach

Government-led initiative increased the effective use of Kangaroo Mother Care in a region of North India

Aim To learn how to achieve high-quality, effective coverage of Kangaroo Mother Care (KMC), defined as 8 hours or more of skin-to-skin contact per day and exclusive breastfeeding in district Sonipat in North India, and to develop and evaluate an implementation model. Methods We conducted implementation research using a mixed-methods approach, including formative research, followed by repeated, rapid cycles of implementation, evaluation and refinement until a model with the potential for high and effective coverage was reached. Evaluation of this model was conducted over a 12-month period. Results Formative research findings informed the final implementation model. Programme learning was critical to achieve high coverage. The model included improving the identification of small babies, creating KMC wards, modification in hospitalisation criteria, private sector engagement and in-built programme learning to refine implementation progress. KMC was initiated in 87% of eligible babies. At discharge, 85% received skin-to-skin contact care, 60% effective KMC and 80% were exclusively breastfed. At home, 7-day post discharge, 81% received skin-to-skin care and 79% were exclusively breastfed in the previous 24 hours. Conclusion Achieving high KMC coverage is feasible in the study setting using a model responsive to the local context and led by the Government.publishedVersio

Impact of community-initiated Kangaroo Mother Care on survival of low birth weight infants: Study protocol for a randomized controlled trial

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Community initiated kangaroo mother care and early child development in low birth weight infants in India - a randomized controlled trial

Background: In a randomized controlled trial (RCT) with 8402 stable low birthweight (LBW) infants, majority being late preterm or term small for gestational age, community-initiated KMC (ciKMC) showed a significant improvement in survival. However, the effect of ciKMC on neurodevelopment is unclear. This is important to elucidate as children born with low birth weight are at high risk of neurodevelopmental deficits. In the first 552 stable LBW infants enrolled in the above trial, we evaluated the effect of ciKMC on neurodevelopmental outcomes during infancy. Method: This RCT was conducted among 552 stable LBW infants, majorly late preterm or term small for gestational age infants without any problems at birth and weighing 1500–2250 g at birth. The intervention comprised of promotion of skin-to-skin contact and exclusive breastfeeding by trained intervention delivery team through home visits. The intervention group mother-infant-dyads were supported to practice ciKMC till day 28 after birth or until the baby wriggled-out. All infants in the intervention and control groups received Home Based Post Natal Care (HBPNC) visits by government health workers. Cognitive, language, motor and socio-emotional outcomes were assessed at infant-ages 6- and 12-months using Bayley Scale of Infant Development (BSID-III). Other outcomes measured were infant temperament, maternal depression, maternal sense of competence, mother-infant bonding and home-environment. We performed post-hoc equivalence testing using two one-sided tests of equivalence (TOST) to provide evidence that ciKMC does not do harm in terms of neurodevelopment. Results: In the intervention arm, the median (IQR) time to initiate ciKMC was 48 (48 to 72) hours after birth. The mean (SD) duration of skin-to-skin-contact was 27.9 (3.9) days with a mean (SD) of 8.7 (3.5) hours per day. We did not find significant effect of ciKMC on any of the child developmental outcomes during infancy. The TOST analysis demonstrated that composite scores for cognitive, language and motor domains at 12 months among the study arms were statistically equivalent. Conclusion: Our study was unable to capture any effect of ciKMC on neurodevelopment during infancy in this sample of stable late preterm or term small for gestational age infants. Long term follow-up may provide meaningful insights