Infectious disease burden in Gujarat (2005–2011): comparison of selected infectious disease rates with India

Background India is known to be endemic to numerous infectious diseases. The infectious disease profile of India is changing due to increased human environmental interactions, urbanisation and climate change. There are also predictions of explosive growth in infectious and zoonotic diseases. The Integrated Disease Surveillance Project (IDSP) was implemented in Gujarat in 2004. Methods We analysed IDSP data on seven laboratory confirmed infectious diseases from 2005–2011 on temporal and spatial trends and compared this to the National Health Profile (NHP) data for the same period and with other literature. We chose laboratory cases data for Enteric fever, Cholera, Hepatitis, Dengue, Chikungunya, Measles and Diphtheria in the state since well designed vertical programs do not exist for these diseases. Statistical and GIS analysis was done using appropriate software. Results Our analysis shows that the existing surveillance system in the state is predominantly reporting urban cases. There are wide variations among reported cases within the state with reports of Enteric fever and Measles being less than half of the national average, while Cholera, Viral Hepatitis and Dengue being nearly double. Conclusions We found some limitations in the IDSP system with regard to the number of reporting units and cases in the background of a mixed health system with multiplicity of treatment providers and payment mechanisms. Despite these limitations, IDSP can be strengthened into a comprehensive surveillance system capable of tackling the challenge of reversing the endemicity of these diseases and preventing the emergence of others

Perceptions of quality of care during birth at private Chiranjeevi facilities in Gujarat: lessons for Universal Health Coverage

Abstract: The Indian national health policy encourages partnerships with private providers as a means to achieve universal health coverage. One of these was the Chiranjeevi Yojana (CY), a partnership since 2006 with private obstetricians to increase access to institutional births in the state of Gujarat. More than a million births have occurred under this programme. We studied women’s perceptions of quality of care in the private CY facilities, conducting 30 narrative interviews between June 2012 and April 2013 with mothers who had birthed in 10 CY facilities within the last month. The commonly agreed upon characteristics of a “good (sari) delivery” were: giving birth vaginally, to a male child, with the shortest period of pain, and preferably free of charge. But all this mattered only after the primary outcome of being “saved” was satisfied. Women ensured this by choosing a competent provider, a “good doctor”. They wanted a quick delivery by manipulating “heat” (intensifying contractions) through oxytocics. There were instances of inadequate clinical care for serious morbidities although the few women who experienced poor quality of care still expressed satisfaction with their overall care. Mothers’ experiences during birth are more accurate indicators of the quality of care received by them, than the satisfaction they report at discharge. Improving health literacy of communities regarding the common causes of severe maternal morbidity and mortality must be addressed urgently. It is essential that cashless CY services be ensured to achieve the goal of 100% institutional births

Determinants of Breastfeeding Practices and Its Association With Infant Anthropometry: Results From a Prospective Cohort Study in South India.

Introduction: Despite national efforts for promoting exclusive breastfeeding (EBF) during the first 6 months of the infants' life, breastfeeding rates are low in India. Evidence on the interference of supplementary food on optimal nourishment and growth of the infant has also been well-established. Our study was undertaken to assess the effect of breastfeeding practices on infant anthropometry and determine the various factors affecting breastfeeding practices. Methods: A prospective cohort study - Maternal antecedents of adiposity and studying the transgenerational role of hyperglycemia and insulin (MAASTHI) was conducted at a tertiary care public hospital in Bengaluru, South India. From the consenting women, data such as obstetric history, infant feeding practices, anthropometry of mother and child, the psychosocial status of the women using the Edinburgh Postnatal Depression Scale (EPDS), was collected at baseline and subsequent follow-up: post-delivery and 14 weeks after birth. In this study, we analyzed data collected from April 2016 to April 2018, with descriptive statistics presented in mean and standard deviation, and logistic regression adjusting for confounders. Results: Among the 240 women enrolled in the study, 33% (n= 80) were using supplementary food for their infants at 14 weeks of infants age. Infants who received supplementary feeding at age 14 weeks had nearly 2.5 times higher odds of being wasted (OR: 2.449, p-value: 0.002) as compared to exclusively breastfed infants. Conclusion: Infants between 14 to 16 weeks of age who received supplementary feeding were at risk of wasting as compared to exclusively breastfed infants. Despite strong evidence in support of the benefits of exclusive breastfeeding, awareness in urban women in India is low. Increased focus on promoting exclusive breastfeeding is necessary to ensure proper nutritional intake and healthy growth of infants

Statewide program to promote institutional delivery in Gujarat, India: who participates and the degree of financial subsidy provided by the Chiranjeevi Yojana program

Background: The Chiranjeevi Yojana (CY) is a large public-private partnership program in Gujarat, India, under which the state pays private sector obstetricians to provide childbirth services to poor and tribal women. The CY was initiated statewide in 2007 because of the limited ability of the public health sector to provide emergency obstetric care and high out-of-pocket expenditures in the private sector (where most qualified obstetricians work), creating financial access barriers for poor women. Despite a million beneficiaries, there have been few reports studying CY, particularly the proportion of vulnerable women being covered, the expenditures they incur in connection with childbirth, and the level of subsidy provided to beneficiaries by the program. Methods: Cross-sectional facility based the survey of participants in three districts of Gujarat in 2012\u20132013. Women were interviewed to elicit sociodemographic characteristics, out-of-pocket expenditures, and CY program details. Descriptive statistics, chi square, and a multivariable logistic regression were performed. Results: Of the 901 women surveyed in 129 facilities, 150 (16 %) were CY beneficiaries; 336 and 415 delivered in government and private facilities, respectively. Only 36 (24 %) of the 150 CY beneficiaries received a completely cashless delivery. Median out-of-pocket for vaginal/cesarean delivery among CY beneficiaries was $7/$71. The median degree of subsidy for women in CY who delivered vaginally/cesarean was 85/71 % compared to out-of-pocket expenditure of $44/$208 for vaginal/cesarean delivery paid by non-program beneficiaries in the private health sector. Conclusions: CY beneficiaries experienced a substantially subsidized childbirth compared to women who delivered in non-accredited private facilities. However, despite the government\u2019s efforts at increasing access to delivery services for poor women in the private sector, uptake was low and very few women experienced a cashless delivery. While the long-term focus remains on strengthening the public sector\u2019s ability to provide emergency obstetric care, the CY program is a potential means by which the state can ensure its poor mothers have access to necessary care if uptake is increased

A Retrospective Audit of Widal Testing For Enteric Fever in the City Of Ahmedabad

Introduction: Widal test has been used extensively for the sero-diagnosis of Enteric fever in India, however, its accuracy and reliability are debatable. We studied widal testing and widal positivity rates in the entire city of Ahmedabad for the diagnosis of Enteric Fever. Methods We screened all 1700 possible diagnostic laboratory facilities, in Ahmedabad, in the public and private sector. We performed telephonic surveys for the initial filtering of facilities that could be conducting widal testing. It was followed by physical visits to probable facilities to confirm testing methods and preservation of reports of widal testing. We followed a systematic process for screening and selection of 23 laboratories, which conducted widal tests and had reliable data. While 14 laboratories refused to share data, data provided by three of them were inappropriate and couldn’t be used.  We finally analyzed data from four large public hospitals, one private trust hospital and one corporate laboratory for variable periods in a span of 15 years (2000 – 2015). Result: The Widal testing rate was found to be 8.7% and widal positivity as 12.5% in a sample of 1.2 million clinically suspected in-patients. In 15 years, the private hospital had admitted 1/10th as many cases as all the public hospitals together. However, the widal testing and positivity rates were similar in both. We observed a lower proportion of widal positivity among children below 12 years and a disproportionate, but insignificant, gender distribution of widal positivity. Conclusion: This study indicates that the widal test, which is meant to be an initial screening test, is widely used in the city. We propose linkage of testing and reporting of widal with other more reliable and accurate tests such as Typhidot and blood culture in order to strengthen our knowledge of enteric fever epidemiology in India

Nations within a nation: variations in epidemiological transition across the states of India, 1990–2016 in the Global Burden of Disease Study

18% of the world's population lives in India, and many states of India have populations similar to those of large countries. Action to effectively improve population health in India requires availability of reliable and comprehensive state-level estimates of disease burden and risk factors over time. Such comprehensive estimates have not been available so far for all major diseases and risk factors. Thus, we aimed to estimate the disease burden and risk factors in every state of India as part of the Global Burden of Disease (GBD) Study 2016

Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015 : a systematic analysis for the Global Burden of Disease Study 2015

Background Improving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures. Methods We estimated all-cause mortality by age, sex, geography, and year using an improved analytical approach originally developed for GBD 2013 and GBD 2010. Improvements included refinements to the estimation of child and adult mortality and corresponding uncertainty, parameter selection for under-5 mortality synthesis by spatiotemporal Gaussian process regression, and sibling history data processing. We also expanded the database of vital registration, survey, and census data to 14 294 geography-year datapoints. For GBD 2015, eight causes, including Ebola virus disease, were added to the previous GBD cause list for mortality. We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model (CODEm) generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies. First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality. Finally, we attributed changes in life expectancy to changes in cause of death. We documented each step of the GBD 2015 estimation processes, as well as data sources, in accordance with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Findings Globally, life expectancy from birth increased from 61.7 years (95% uncertainty interval 61.4-61.9) in 1980 to 71.8 years (71.5-72.2) in 2015. Several countries in sub-Saharan Africa had very large gains in life expectancy from 2005 to 2015, rebounding from an era of exceedingly high loss of life due to HIV/AIDS. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence. From 2005 to 2015, male life expectancy in Syria dropped by 11.3 years (3.7-17.4), to 62.6 years (56.5-70.2). Total deaths increased by 4.1% (2.6-5.6) from 2005 to 2015, rising to 55.8 million (54.9 million to 56.6 million) in 2015, but age-standardised death rates fell by 17.0% (15.8-18.1) during this time, underscoring changes in population growth and shifts in global age structures. The result was similar for non-communicable diseases (NCDs), with total deaths from these causes increasing by 14.1% (12.6-16.0) to 39.8 million (39.2 million to 40.5 million) in 2015, whereas age-standardised rates decreased by 13.1% (11.9-14.3). Globally, this mortality pattern emerged for several NCDs, including several types of cancer, ischaemic heart disease, cirrhosis, and Alzheimer's disease and other dementias. By contrast, both total deaths and age-standardised death rates due to communicable, maternal, neonatal, and nutritional conditions significantly declined from 2005 to 2015, gains largely attributable to decreases in mortality rates due to HIV/AIDS (42.1%, 39.1-44.6), malaria (43.1%, 34.7-51.8), neonatal preterm birth complications (29.8%, 24.8-34.9), and maternal disorders (29.1%, 19.3-37.1). Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders. Age-standardised death rates due to injuries significantly declined from 2005 to 2015, yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. In 2015, rotaviral enteritis (rotavirus) was the leading cause of under-5 deaths due to diarrhoea (146 000 deaths, 118 000-183 000) and pneumococcal pneumonia was the leading cause of under-5 deaths due to lower respiratory infections (393 000 deaths, 228 000-532 000), although pathogen-specific mortality varied by region. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause. Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI. Country patterns of premature mortality (measured as years of life lost [YLLs]) and how they differ from the level expected on the basis of SDI alone revealed distinct but highly heterogeneous patterns by region and country or territory. Ischaemic heart disease, stroke, and diabetes were among the leading causes of YLLs in most regions, but in many cases, intraregional results sharply diverged for ratios of observed and expected YLLs based on SDI. Communicable, maternal, neonatal, and nutritional diseases caused the most YLLs throughout sub-Saharan Africa, with observed YLLs far exceeding expected YLLs for countries in which malaria or HIV/AIDS remained the leading causes of early death. Interpretation At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. Despite progress in reducing age-standardised death rates, population growth and ageing mean that the number of deaths from most non-communicable causes are increasing in most countries, putting increased demands on health systems. Copyright (C) The Author(s). Published by Elsevier Ltd.Peer reviewe

The Chiranjeevi Yojana (CY) : a public-private-partnership to promote institutional births in Gujarat, India : studies of providers and users

Introduction: National, regional and local governments, particularly in lower middleincome countries, are encouraged to pursue partnerships with the pool of private providers available to them, in order to achieve the Sustainable Development Goal for maternal health. The state of Gujarat in India (population 60 million) has been a pioneer in designing a large-scale Public-Private-Partnership (PPP), the Chiranjeevi Yojana (CY), for emergency obstetric care (EmOC) for vulnerable women through qualified obstetricians. The program was instituted in 2006-07 and 865 obstetricians partnered with the state at the time. Methodology: The papers in this thesis examine this CY program through three quantitative and one qualitative study. The studies were conducted in three districts of Gujarat state, Sabarkantha, Surendranagar and Dahod. The methods included two crosssectional surveys (i.e., a facility survey and a facility-based survey of women who gave birth) and in-depth interviews. These four studies elucidate characteristics of CY providers and CY beneficiaries, as well as outcomes in the health system environment and the population. In order to synthesise these results coherently, I adapted the Anderson’s theoretical model to synthesise, explain and discuss the findings in my studies. In the adapted model, I present my findings in three clear and linked domains – (1) Environment – Health system and population environment in which the CY program was implemented (2) Enabler – Characteristics of the health system and population that were enabled, i.e., made eligible, as per program criteria to participate in the CY program and (3) Outcomes – in the health system and population environment, examined through (a) Health system and provider behaviours (b) Users’ behaviours (c) Health status of the mothers and (d) Financial status of households with respect to using obstetric services. Results: The CY program influenced the health system’s environment towards increasing the availability of free CEmOC by 10 times, from 0.32 to 3.65 per 500,000 population, but actual performance of notionally free CEmOC functions was only 2 per 500,000 population (Study I). Providers’ behaviour was reflected in the en masse participation or non-participation of providers in ten out of seventeen urban centres. The facilities that participated in the CY program had a significantly higher likelihood, independently, of being general facilities (PR 1.9, 95% CI 1.3–2.9), or conducting lower proportion of caesarean births (PR 2.1, 95% CI 1.2–3.5) or having obstetricians new in private practice (PR 1.9, 95% CI 1.2–3.1) or being less expensive (PR 1.8, 95% CI 1.1–3.0) (Study II). The CY program criteria influenced the population environment by enabling mothers to become eligible for CY benefit. These mothers were significantly more likely to be vulnerable - rural, multiparous, scheduled tribe, and less educated. Users’ behaviours showed that eligible mothers had significantly less prevalence of ante-natal visits, as well as shorter hospital stay after birth. The evaluated health status showed low caesarean rates among eligible vulnerable mothers (6%) and high caesarean (40%) and episiotomy (63%) rates among ineligible mothers (Study III). The perceived health status of the population was reflected in the fact that most mothers and families were very happy with the care they had received and none reported any preferential treatment of paying mothers over CY beneficiary mothers. However, a few mothers who experienced instances of poor quality of care or rude behaviour, reflected back on their experience and still reported it as a “good (sari) delivery”. The financial status of the population showed only 15% of eligible mothers were CY beneficiaries, and only 4 % of them received a completely cashless birth. The median degree of subsidy for women in CY who birthed vaginally was 85% and by caesarean section was 71 % compared to out-of-pocket expenditure sustained by non-beneficiaries in the private health sector. Mothers without formal education were significantly less likely (OR 0.4, 95% CI 0.3–0.7) to receive CY benefit. Only having CY program knowledge (OR 4.7, 95% CI 2.6–8.4) and showing proof of poverty (OR 2.6, 95% CI 1.3–5.4) increased the likelihood of receiving the benefit. (Study III). Discussion: Although the CY program increased the availability of free emergency obstetric care to 10 times more than the UN standards, their actual performance increased by only twice. This indicated poor management mechanisms within the state authorities. Although the CY program criteria recognised vulnerable mothers adequately accurately, their behaviours, health status and financial status showed mixed outcomes. Vulnerable populations behaviours to ensure improved maternal health and access to the CY program were varied, despite the program being in effect for seven years before our study. The health status of the vulnerable population, in terms of low caesarean rates, were below established norms in the literature, and among the non-vulnerable populations was much higher. The financial status of the eligible population was not much eased by the program since 85% of them did not receive the CY benefit. However, the highest median expenditure in our study (INR 7224) was well below the mean cost in private facilities across the nation (INR 15000) thus indicating a possible partial protection from out-of-pocket cost due to the CY program activity in the region. Conclusion: The recently established Prime Minister’s People’s Health Program in India depends on PPPs for secondary and tertiary care all over the country. As revealed in this thesis, improved, adequate and effective health systems through PPPs requires better contract designing and managing capacities within in the state system. The health status and users’ behaviours could be assisted by the ongoing digitization of health systems such that (a) maternal health data is collected by both public and private sectors in enough detail to be able to categorise it by Robson’s criteria and thus monitor BEmOC and CEmOC performance, ante-natal visits, length of stay in hospital and other relevant variables (b) user feed-back is collected in a manner that captures actual experiences of women during birth, and that of their families during their interactions with the health system

The Story Underlying the Numbers A Simple Approach to Comprehensive Financial Statements Analysis

When faced with financial statements of a firm, very often students and even practitioners are seen to be at a loss where to begin with analysis. Most simply compute every ratio they know and interpret them in a standalone manner. They are unable to thread them together to spin a meaningful story that can completely or at least substantially explain what might be happening at the firm. Decision making of any kind based on such a piecemeal approach will remain flawed. This book uses a logical, top-down approach to unraveling the underlying story of the firm. It can be used by students and working executives who have a rudimentary prior idea of financial statements as well as familiarity with the very basic financial ratios. It is a myth that only executives in the finance function need to understand financial statements. Every decision within a firm has implications for the financial statements, and the need for such knowledge increases as one goes up the corporate ladder. The book is intended to be free flowing, with minimum jargon so as to be understood and appreciated especially by non-finance executives and students of business and management