Challenges and opportunities for policy decisions to address health equity in developing health systems: case study of the policy processes in the Indian state of Orissa

<p>Abstract</p> <p>Introduction</p> <p>Achieving health equity is a pertinent need of the developing health systems. Though policy process is crucial for planning and attaining health equity, the existing evidences on policy processes are scanty in this regard. This article explores the magnitude, determinants, challenges and prospects of 'health equity approach' in various health policy processes in the Indian State of Orissa - a setting comparable with many other developing health systems.</p> <p>Methods</p> <p>A case-study involving 'Walt-Gilson Policy Triangle' employed key-informant interviews and documentary reviews. Key informants (n = 34) were selected from the departments of Health and Family Welfare, Rural Development, and Women and Child Welfare, and civil societies. The documentary reviews involved various published and unpublished reports, policy pronouncements and articles on health equity in Orissa and similar settings.</p> <p>Results</p> <p>The 'health policy agenda' of Orissa was centered on 'health equity' envisaging affordable and equitable healthcare to all, integrated with public health interventions. However, the subsequent stages of policy process such as 'development, implementation and evaluation' experienced leakage in the equity approach. The impediment for a comprehensive approach towards health equity was the nexus among the national and state health priorities; role, agenda and capacity of actors involved; and existing constraints of the healthcare delivery system.</p> <p>Conclusion</p> <p>The health equity approach of policy processes was incomprehensive, often inadequately coordinated, and largely ignored the right blend of socio-medical determinants. A multi-sectoral, unified and integrated approach is required with technical, financial and managerial resources from different actors for a comprehensive 'health equity approach'. If carefully geared, the ongoing health sector reforms centered on sector-wide approaches, decentralization, communitization and involvement of non-state actors can substantially control existing inequalities through an optimally packaged equitable policy. The stakeholders involved in the policy processes need to be given orientation on the concept of health equity and its linkage with socio-economic development.</p

Agricultural and empowerment pathways from land ownership to women's nutrition in India.

Land size is an important equity concern for the design of 'nutrition-sensitive' agricultural interventions. We unpack some of the pathways between land and nutrition using a cross-sectional baseline survey data set of 4,480 women from 148 clusters from the 'Upscaling Participatory Action and Videos for Agriculture and Nutrition' trial in Keonjhar district in Odisha, India. Variables used are household ln-land size owned (exposure) and maternal dietary diversity score out of 10 food groups and body mass index (BMI; kg/m2 ) (outcomes); and mediators investigated are production diversity score, value of agricultural production, and indicators for women's empowerment (decision-making in agriculture, group participation, work-free time and land ownership). We assessed mediation using a non-parametric potential outcomes framework method. Land size positively affects maternal dietary diversity scores [β 0.047; 95% confidence interval (CI) (0.011, 0.082)] but not BMI. Production diversity, but not value of production, accounts for 17.6% of total effect mediated. We observe suppression of the effect of land size on BMI, with no evidence of a direct effect for either of the agricultural mediators but indirect effects of β -0.031 [95% CI (-0.048, -0.017)] through production diversity and β -0.047 [95% CI (-0.075, -0.021)] through value of production. An increase in land size positively affects women's decision-making, which in turn negatively affects maternal BMI. The positive effect of work-free time on maternal BMI is suppressed by the negative effect of household land size on work-free time. Agriculture interventions must consider land quality, women's decision-making and implications for women's workload in their design

Iron and folic acid consumption and changing social norms: cluster randomized field trial, Odisha, India

OBJECTIVE: To assess whether improvements in social norms related to iron and folic acid consumption are associated with increased iron and folic acid consumption. METHODS: In a cluster randomized trial in Odisha, India, we implemented an intervention to improve descriptive norms (people’s perceptions about how many other people take iron and folic acid), injunctive norms (social pressures people feel to take iron and folic acid) and collective norms (actual levels of iron and folic acid consumption). We assessed changes in these norms and self-reported iron and folic acid consumption in control and intervention arms after 6 months (September 2019–February 2020). We collected data from control (n = 2048) and intervention (n = 2060) arms at baseline and follow-up (n = 1966 and n = 1987, respectively). FINDINGS: At follow-up, mean scores in self-reported iron and folic acid consumption in the control arm had decreased from 0.39 to 0.31 (21% decrease; not significant). In the intervention arm, mean scores increased from 0.39 to 1.62 (315% increase; P < 0.001). The difference between the two arms was statistically significant (P < 0.001). Each of the three norms also improved at significantly higher rates in the intervention than in the control arm (P < 0.001 for each norm). Changes in descriptive and collective norms (but not injunctive norms) were associated with changes in self-reported iron and folic acid consumption (P < 0.001 for both norms). CONCLUSION: Our results show that social norms can be improved and that these improvements are associated with positive behavioural changes. A social norms-based approach may help promote iron and folic acid consumption in India.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8542261/pdf/BLT.20.278820.pd

Economic evaluation of nutrition-sensitive agricultural interventions to increase maternal and child dietary diversity and nutritional status in rural Odisha, India

BACKGROUND: Economic evaluations of nutrition-sensitive agriculture (NSA) interventions are scarce, limiting assessment of their potential affordability and scalability. OBJECTIVE: We conducted cost-consequence analyses of three participatory video-based interventions of fortnightly women's group meetings using: 1) NSA videos; 2) NSA and nutrition-specific videos; or 3) NSA videos with a nutrition-specific Participatory Learning and Action (PLA) cycle. METHODS: Interventions were tested in a 32-month, four-arm cluster-randomized controlled trial, UPAVAN, in Keonjhar district, Odisha, India. Impacts were evaluated in children aged 0-23 months and their mothers. We estimated program costs using data collected prospectively from expenditure records of implementing and technical partners, and societal costs using expenditure assessment of households with a child aged 0-23 months and key informant interviews. Costs were adjusted for inflation, discounted, and converted to 2019 US${\$}$. RESULTS: Total program costs of each intervention ranged from US${\$}$272,121 to US${\$}$386,907. Program costs per pregnant woman or mother of a child aged 0-23 months were US${\$}$62 for NSA videos, US${\$}$84 for NSA and nutrition-specific videos, and US${\$}$78 for NSA videos with PLA (societal costs: US${\$}$125, US${\$}$143, and US${\$}$122 respectively). Substantial shares of total costs constituted developing and delivering the videos and PLA (52-69%) and quality assurance (25-41%). Relative to control, children's minimum dietary diversity was higher in the intervention incorporating nutrition-specific videos (adjusted relative risk [95% CI] 1.19 [1.03, 1.37]) and PLA (1.27 [1.11, 1.46]). Relative to control, mothers' minimum dietary diversity was higher in NSA video (1.21 [1.01, 1.45]), and NSA with PLA (1.30 [1.10, 1.53]) interventions. CONCLUSION: NSA videos with PLA can increase both maternal and child dietary diversity and has the lowest cost per unit increase in diet diversity. Building on investments made in developing UPAVAN, cost-efficiency at scale could be increased with less intensive monitoring, reduced start-up costs, and integration within existing government programs.Trial registration: ISRCTN65922679

Effect of nutrition-sensitive agriculture interventions with participatory videos and women's group meetings on maternal and child nutritional outcomes in rural Odisha, India (UPAVAN trial): a four-arm, observer-blind, cluster-randomised controlled trial.

BACKGROUND: Almost a quarter of the world's undernourished people live in India. We tested the effects of three nutrition-sensitive agriculture (NSA) interventions on maternal and child nutrition in India. METHODS: We did a parallel, four-arm, observer-blind, cluster-randomised trial in Keonjhar district, Odisha, India. A cluster was one or more villages with a combined minimum population of 800 residents. The clusters were allocated 1:1:1:1 to a control group or an intervention group of fortnightly women's groups meetings and household visits over 32 months using: NSA videos (AGRI group); NSA and nutrition-specific videos (AGRI-NUT group); or NSA videos and a nutrition-specific participatory learning and action (PLA) cycle meetings and videos (AGRI-NUT+PLA group). Primary outcomes were the proportion of children aged 6-23 months consuming at least four of seven food groups the previous day and mean maternal body-mass index (BMI). Secondary outcomes were proportion of mothers consuming at least five of ten food groups and child wasting (proportion of children with weight-for-height Z score SD <-2). Outcomes were assessed in children and mothers through cross-sectional surveys at baseline and at endline, 36 months later. Analyses were by intention to treat. Participants and intervention facilitators were not blinded to allocation; the research team were. This trial is registered at ISRCTN, ISRCTN65922679. FINDINGS: 148 of 162 clusters assessed for eligibility were enrolled and randomly allocated to trial groups (37 clusters per group). Baseline surveys took place from Nov 24, 2016, to Jan 24, 2017; clusters were randomised from December, 2016, to January, 2017; and interventions were implemented from March 20, 2017, to Oct 31, 2019, and endline surveys done from Nov 19, 2019, to Jan 12, 2020, in an average of 32 households per cluster. All clusters were included in the analyses. There was an increase in the proportion of children consuming at least four of seven food groups in the AGRI-NUT (adjusted relative risk [RR] 1·19, 95% CI 1·03 to 1·37, p=0·02) and AGRI-NUT+PLA (1·27, 1·11 to 1·46, p=0·001) groups, but not AGRI (1·06, 0·91 to 1·23, p=0·44), compared with the control group. We found no effects on mean maternal BMI (adjusted mean differences vs control, AGRI -0·05, -0·34 to 0·24; AGRI-NUT 0·04, -0·26 to 0·33; AGRI-NUT+PLA -0·03, -0·3 to 0·23). An increase in the proportion of mothers consuming at least five of ten food groups was seen in the AGRI (adjusted RR 1·21, 1·01 to 1·45) and AGRI-NUT+PLA (1·30, 1·10 to 1·53) groups compared with the control group, but not in AGRI-NUT (1·16, 0·98 to 1·38). We found no effects on child wasting (adjusted RR vs control, AGRI 0·95, 0·73 to 1·24; AGRI-NUT 0·96, 0·72 to 1·29; AGRI-NUT+PLA 0·96, 0·73 to 1·26). INTERPRETATION: Women's groups using combinations of NSA videos, nutrition-specific videos, and PLA cycle meetings improved maternal and child diet quality in rural Odisha, India. These components have been implemented separately in several low-income settings; effects could be increased by scaling up together. FUNDING: Bill & Melinda Gates Foundation, UK AID from the UK Government, and US Agency for International Development

Molecular phylogenetic relationships among four species of the mangrove tree genus Bruguiera (Rhizophoraceae), as revealed by chromosome and RAPD markers

Analysis of karyotype, nuclear DNA content and RAPD markers were performed in four species of Bruguiera (Rhizophoraceae) of Bhitarkanika mangrove forests, Orissa, India. Detailed karyotype analysis revealing 2n=34 in B. cylindrica and 2n=36 in B. gymnorrhiza was reported for the first time and 2n=34 in B. parviflora and B. sexangula was confirmed. On the basis of the common types of chromosomes present among Bruguiera, two distinct groups were found; one consists of B. cylindrica and B. parviflora and the other of B. gymnorrhiza and B. sexangula. The symmetrical karyotype with same chromosome types grouped B. cylindrica and B. parviflora together and presence of Type E chromosomes placed B. gymnorrhiza and B. sexangula in a separate group, suggesting their closer affinity in their respective group. Analysis of chromosome length, volume, INV and 4C DNA content confirmed this division. Nuclear DNA content was two-fold higher (~17.0 pg) in the second group than in the first (~8.0 pg). The amplification products generated through RAPD revealed 1-9 amplicons with size variations from 600 bp to 2 500 bp with 49.31% genetic similarity between B. gymnorrhiza and B. sexangula and 47.10% in between B. cylindrica and B. parviflora. The high copy number marker band (~ 1 100 bp) yielded in OPN-15 primer in B. parviflora the characteristic DNA marker, which was cloned and used as probes for assessment of genetic diversity, and demonstrated its close genetic affinity to B. cylindrica. B. gymnorrhiza and B. sexangula also produced similar marker bands of ~600 bp and ~2 200 bp in the same primer. All of the cytological, 4C DNA content and RAPD data confirmed the existence of two taxonomically distinct groups of Bruguiera: one consisting of B. cylindrica and B. parviflora and the other of B. gymnorrhiza and B. sexangula as placed earlier (1862) in the tribe Rhizophoreae by Bentham and Hooker, on the basis of the flowering habits of Bruguiera. Genetically, the B. sexangula and B. gymnorrhiza group was found to be very closely, rather than distantly, related to B. parviflora and B. cylindrica. Our results demonstrate that molecular markers together with cytological evidence provide an effective tool to access the existing interspecific genetic polymorphism in mangrove species, to solve the taxonomic problems and to design their conservation strategy

Male engagement as a strategy to improve the delivery and use of maternal, newborn, and child health services

Background: In response to persistently poor maternal and child health in rural India, the National Rural Health Mission (NRHM) was launched in 2005 as a framework for the provision of accessible, affordable, and quality health care in deprived and underserved communities. At the centre of the programme are the accredited social health activists—local women trained as health educators and promoters to generate demand for, and facilitate access to, maternal, newborn, and child health (MNCH) services in their communities. In this study, we aimed to examine the effect of a male community health worker project on the delivery and uptake of MNCH care in a rural district of India. The specific research questions are: did male community health workers complement the work of the accredited social health activists and fill important gaps in community MNCH service delivery? Further, what is the perceived effect of male community health workers' engagement with men? Methods: We recruited and trained male community health workers, referred to as male health activists, to complement the work of the female social health activists and extend community-based delivery of MNCH services. The project was implemented between February, 2011, and March, 2013, in Keonjhar district in the state of Odisha, which is one of the six states in India with high rates of maternal and child deaths. We conducted in-depth interviews with 11 social health activists, 11 women who had recently delivered in a health facility, and seven husbands of women who had recently delivered. The interviews were conducted by locally based interviewers in the local language. Responses were audio-recorded, transcribed verbatim and translated to English, then coded manually. Findings: From the interview responses, we identified three main gender-based divisions of work and space in three areas of delivery and use of MNCH services: the escorting of women to health facilities for MNCH care; awareness raising among men on MNCH and family planning; and mobilisation of parents and children to attend village health and nutrition days and immunisation days. The narratives from virtually all respondents pointed to the crucial roles played by male health activists around and during delivery, especially at night when they facilitate transport and provide security, a role that female community health workers would rarely assume. Women and social health activist respondents were appreciative of the increased engagement of male health activists with men, which they reported resulted in some positive behaviour changes, including on family planning. Finally, the accredited social health activists identified tangible constraints, such as the cost of transport, to the implementation of village health and nutrition days and immunisation days that could only be addressed by male health activists. Interpretation: These findings highlight the potential for trained and equipped male community health workers to improve outcomes in maternal, newborn, and child health. Funding: The project and its evaluation and data analysis for this study were funded by a grant from the Bill and Melinda Gates Foundation

Mobile Interventions for Upscaling Participatory Action and Videos for Agriculture and Nutrition (m-UPAVAN): Qualitative Interview Data

These data were collected to assess the feasibility, acceptability, and equity of a nutrition-sensitive agriculture intervention from the UPAVAN trial (see: 10.1016/S2542-5196(21)00001-2) adapted to a mobile intervention (m-UPAVAN) during the COVID-19 pandemic in rural Odisha, India. We used a convergent parallel mixed-method design. This data collection includes 38 transcripts of qualitative interviews conducted among women with a child <2 years of age at the end of the m-UPAVAN intervention. Interviews were conducted to understand women’s experiences of the m-UPAVAN intervention, factors that affected its feasibility and acceptability, and the potential for realising change in nutrition-sensitive agricultural and nutrition-specific practices. Participants from the UPAVAN intervention areas were asked whether they participated in the UPAVAN interventions, and if so, questions on preferences for m-UPAVAN vs UPAVAN were additionally administered. Interviews also enquired into women's general phone usage and gender norms in phone access and use. Quantitative data collected as part of the same study are available from: 10.17037/DATA.00003635