Availability of Treatment for Eclampsia in Public Health Institutions in Maharashtra, India

Severe pre-eclampsia and eclampsia are common causes of maternal deaths worldwide and more so in developing countries. Magnesium sulphate (MgSO4) is now the most-recommended drug of choice to treat these conditions. Despite favourable policies for the use of MgSO4 treatment in India, eclampsia continues to take a high toll. This study examined the availability and use of MgSO4 treatment in the public health system and poor women's recent experiences with eclampsia treatment in Maharashtra state. A mix of qualitative and quantative methods was used. A facility-based survey of all secondary and tertiary healthcare facilities (n=44) in 3 selected districts and interviews with public and contracted-in private sector obstetricians, health officials, and programme managers were conducted. A list of recently-delivering women from marginalized communities, with up to two livebirths, was drawn through a community-level survey in 272 villages covered by 60 subcentres selected at random. Mothers were selected for interviews, using maximum variation sampling, and interviews were conducted with 17% of the mothers who reported having experienced eclampsia; 61% of facilities had no stock of MgSO4, the stock-out position continuing from a period ranging from 3 months to 3 years while another 20% had some stock, although less than the expected minimum quantity. No treatment for eclampsia was provided in the recent 3 months at 73% facilities. Our survey of recently-delivering mothers recorded a history of eclampsia in 3.2% pregnancies/ deliveries. Interviews with 10 such mothers revealed that treatment for eclampsia has been sought from public as well as private hospitals and from traditional healers. However, facilities where women have received medical treatment are exclusively in the private sector. Almost all public and private care providers were aware of MgSO4 as the gold standard to treat eclampsia; however, it is unclear if they knew of its use to treat severe pre-eclampsia. The private care providers routinely used MgSO4 for eclampsia treatment while the public care providers seemed hesitant to use it fearing risks of complications. We stress the need for improved inventory control practices to ensure sustained availability of supplies and building confidence of care providers in using MgSO4 treatment for severe pre-eclampsia and eclampsia in public facilities, in addition to teaching expectant mothers how to recognize symptoms of these conditions

What does quality of care mean for maternal health providers from two vulnerable states of India? Case study of Bihar and Jharkhand

Background: Quality instillation has its own challenges, facilitators and barriers in various settings. This paper focuses on exploration of quality components related to practices, health system challenges and quality enablers from providers\u2019 perspectives with a focus on maternal health studied through a pilot research conducted in 2012\u20132013 in two states of India\u2014Bihar and Jharkhand\u2014with relatively poor indicators for maternal health. Methods: Qualitative data through in-depth interviews of 49 health providers purposively selected from various cadres of public health system in two districts each from Bihar and Jharkhand states was thematically analysed using MAXQDA Version 10. Results: Maternity management guidelines developed by the National Health Mission, India, were considered as a tool to learn instillation of quality in provision of health services in various selected health facilities. Infrastructure, human resources, equipments and materials, drugs, training capacity and health information systems were described as health system challenges by medical and paramedical health providers. On a positive note, the study findings simultaneously identified quality enablers such as appreciation of public-private partnerships, availability of clinical guidelines in the form of wall posters in health facilities, efforts to translate knowledge and evidence through practice and enthusiasm towards value of guidelines. Conclusions: Against the backdrop of quality initiatives in the country to foster United Health Care (UHC), frontline health providers\u2019 perspectives about quality and safety need to be considered and utilized. The provision of adequate health infrastructure, strong health management information system, introduction of evidence-based education and training with supportive supervision must constitute parallel efforts

Pathway to care for drug resistant tuberculosis cases identified during a retrospective study conducted in high TB burden wards in Mumbai [version 2; referees: 2 approved]

Background: Mumbai is witnessing a rising incidence of all forms of drug resistant tuberculosis (DR-TB). Methods: A population-based, retrospective study was conducted between April and July 2014, in 15 high TB burden wards in Mumbai, to capture the patient pathways to TB care. A total of 23 DR-TB patients were identified and their pathways to access DR-TB care were recorded using semi-structured interviews. Results: The total DR-TB pathway time of new patients (who did not report any past episode of TB) (180 days; IQR 123,346) was found to be more than twice that of retreatment patients (who reported a past episode of TB) (69 days; IQR 42,128). Conclusions: The unacceptable delay for diagnosis and treatment of DR-TB in Mumbai advocates for consistent implementation of early screening of patients using rapid gene-based technologies

Correcting India's Chronic Shortage of Drug Inspectors to Ensure the Production and Distribution of Safe, High- Quality Medicines

Abstract Background: Good drug regulation requires an effective system for monitoring and inspection of manufacturing and sales units. In India, despite widespread agreement on this principle, ongoing shortages of drug inspectors have been identified by national committees since 1975. The growth of India's pharmaceutical industry and its large export market makes the problem more acute. Methods: The focus of this study is a case study of Maharashtra, which has 29% of India's manufacturing units and 38% of its medicines exports. India's regulations were reviewed, comparing international, national and state inspection norms with the actual number of inspectors and inspections. Twenty-six key informant interviews were conducted to ascertain the causes of the shortfall

Risk profiling of soil-transmitted helminth infection and estimated number of infected people in South Asia : a systematic review and Bayesian geostatistical analysis

In South Asia, hundreds of millions of people are infected with soil-transmitted helminths (Ascaris lumbricoides, hookworm, and Trichuris trichiura). However, high-resolution risk profiles and the estimated number of people infected have yet to be determined. In turn, such information will assist control programs to identify priority areas for allocation of scarce resource for the control of soil-transmitted helminth infection.; We pursued a systematic review to identify prevalence surveys pertaining to soil-transmitted helminth infections in four mainland countries (i.e., Bangladesh, India, Nepal, and Pakistan) of South Asia. PubMed and ISI Web of Science were searched from inception to April 25, 2019, without restriction of language, study design, and survey date. We utilized Bayesian geostatistical models to identify environmental and socioeconomic predictors, and to estimate infection risk at high spatial resolution across the study region.; A total of 536, 490, and 410 georeferenced surveys were identified for A. lumbricoides, hookworm, and T. trichiura, respectively. We estimate that 361 million people (95% Bayesian credible interval (BCI) 331-395 million), approximately one-quarter of the South Asia population, was infected with at least one soil-transmitted helminth species in 2015. A. lumbricoides was the predominant species. Moderate to high prevalence (>20%) of any soil-transmitted helminth infection was predicted in the northeastern part and some northern areas of the study region, as well as the southern coastal areas of India. The annual treatment needs for the school-age population requiring preventive chemotherapy was estimated at 165 million doses (95% BCI: 146-185 million).; Our risk maps provide an overview of the geographic distribution of soil-transmitted helminth infection in four mainland countries of South Asia and highlight the need for up-to-date surveys to accurately evaluate the disease burden in the region

Development of a Patient-Centred, Psychosocial Support Intervention for Multi-Drug-Resistant Tuberculosis (MDR-TB) Care in Nepal

Multi-drug-resistant tuberculosis (MDR-TB) poses a major threat to public health worldwide, particularly in low-income countries. The current long (20 month) and arduous treatment regime uses powerful drugs with side-effects that include mental ill-health. It has a high loss-to-follow-up (25%) and higher case fatality and lower cure-rates than those with drug sensitive tuberculosis (TB). While some national TB programmes provide small financial allowances to patients, other aspects of psychosocial ill-health, including iatrogenic ones, are not routinely assessed or addressed. We aimed to develop an intervention to improve psycho-social well-being for MDR-TB patients in Nepal. To do this we conducted qualitative work with MDR-TB patients, health professionals and the National TB programme (NTP) in Nepal. We conducted semi-structured interviews (SSIs) with 15 patients (10 men and 5 women, aged 21 to 68), four family members and three frontline health workers. In addition, three focus groups were held with MDR-TB patients and three with their family members. We conducted a series of meetings and workshops with key stakeholders to design the intervention, working closely with the NTP to enable government ownership. Our findings highlight the negative impacts of MDR-TB treatment on mental health, with greater impacts felt among those with limited social and financial support, predominantly married women. Michie et al's (2011) framework for behaviour change proved helpful in identifying corresponding practice- and policy-level changes. The findings from this study emphasise the need for tailored psycho-social support. Recent work on simple psychological support packages for the general population can usefully be adapted for use with people with MDR-TB

High levels of multidrug resistant tuberculosis in new and treatment-failure patients from the Revised National Tuberculosis Control Programme in an urban metropolis (Mumbai) in Western India

BACKGROUND: India, China and Russia account for more than 62% of multidrug resistant tuberculosis (MDRTB) globally. Within India, locations like urban metropolitan Mumbai with its burgeoning population and high incidence of TB are suspected to be a focus for MDRTB. However apart from sporadic surveys at watched sites in the country, there has been no systematic attempt by the Revised National Tuberculosis Control Programme (RNTCP) of India to determine the extent of MDRTB in Mumbai that could feed into national estimates. Drug susceptibility testing (DST) is not routinely performed as a part of programme policy and public health laboratory infrastructure, is limited and poorly equipped to cope with large scale testing. METHODS: From April 2004 to January 2007 we determined the extent of drug resistance in 724 {493 newly diagnosed, previously untreated and 231 first line treatment failures (sputum-smear positive at the fifth month after commencement of therapy)} cases of pulmonary tuberculosis drawn from the RNTCP in four suboptimally performing municipal wards of Mumbai. The observations were obtained using a modified radiorespirometric Buddemeyer assay and validated by the Swedish Institute for Infectious Disease Control, Stockholm, a supranational reference laboratory. Data was analyzed utilizing SPSS 10.0 and Epi Info 2002. RESULTS: This study undertaken for the first time in RNTCP outpatients in Mumbai reveals a high proportion of MDRTB strains in both previously untreated (24%) and treatment-failure cases (41%). Amongst new cases, resistance to 3 or 4 drug combinations (amplified drug resistance) including isoniazid (H) and rifampicin (R), was greater (20%) than resistance to H and R alone (4%) at any point in time during the study. The trend for monoresistance was similar in both groups remaining highest to H and lowest to R. External quality control revealed good agreement for H and R resistance (k = 0.77 and 0.76 respectively). CONCLUSION: Levels of MDRTB are much higher in both previously untreated and first line treatment-failure cases in the selected wards in Mumbai than those projected by national estimates. The finding of amplified drug resistance suggests the presence of a well entrenched MDRTB scenario. This study suggests that a wider set of surveillance sites are needed to obtain a more realistic view of the true MDRTB rates throughout the country. This would assist in the planning of an adequate response to the diagnosis and care of MDRTB

Factors governing the performance of Auxiliary Nurse Midwives in India: a study in Pune district

Background: The Auxiliary nurse midwife (ANM) cadre was created to focus on maternal and child health. ANMs are respected members of their communities and established providers of maternal and child health care within the community and at the facility level. Over time, additional roles and responsibilities have been added. Despite the importance of ANMs in the primary healthcare system in India, studies that consider factors governing the performance of ANMs in their workplaces are limited. We aimed to study factors governing performance of ANMs in Pune district, India. Methods: Semi-structured interviews were conducted with 13 purposely selected key informants at facility, district, state, and national levels. Focus group discussions were conducted with 41 ANMs and 25 members of the community. Non-participatory observations with eight ANMs provided information to expand on and scrutinise findings that emerged from the other lines of inquiry. A realist lens was applied to identify ANMs’ performance as a result of “mechanisms” (training, supervision, accountability mechanisms) within the given “context” (regulatory system, infrastructure and resources, ANMs’ expanded scope of work, gender roles and norms). Results: Weak enforcement of regulatory system led to poor standardisation of training quality among training institutions. Challenges in internal accountability mechanisms governing ANMs within the health system hierarchy made it difficult to ensure individual accountability. Training and supervision received were inadequate to address current responsibilities. The supervisory approach focused on comparing information in periodic reports against expected outputs. Clinical support in workplaces was insufficient, with very little problem identification and solving. Conclusion: Focusing on the tasks of ANMs with technical inputs alone is insufficient to achieve the full potential of ANMs in a changing context. Systematic efforts tackling factors governing ANMs in their workplaces can produce a useful cadre, that can play an important role in achieving universal health coverage in India