Enhancing public health practice through a capacity-building educational programme:an evaluation

BACKGROUND: The Post-Graduate Diploma in Public Health Management, launched by the Govt. of India under the aegis of the National Rural Health Mission in 2008, aims to enhance the managerial capabilities of public health professionals to improve the public health system. The Govt. of India invested enormous resources into this programme and requested an evaluation to understand the current processes, assess the graduates’ work performance and identify areas for improvement. METHODS: Quantitative telephone surveys as well as qualitative in-depth interviews were used. Graduates from the first three batches, their supervisors, peers and subordinates and faculty members were interviewed. Quantitative data were analysed using proportions, means and interpretative descriptions. Qualitative analyses involved transcription, translation, sorting, coding and filing into domains. RESULTS: Of the 363 graduates whose contact details were available, 138 could not be contacted. Two hundred twenty-three (223) graduates (61.43% of eligible participants) were interviewed by telephone; 52 in-depth interviews were conducted. Of the graduates who joined, 63.8% graduates were motivated to join the programme for career advancement and gaining public health knowledge. The content was theoretically good, informative and well-designed. Graduates expressed need for more practical and group work. After graduating, they reported being equipped with some new skills to implement programmes effectively. They reported that attitudes and healthcare delivery practices had improved; they had better self-esteem, increased confidence, better communication skills and implementation capacity. While they were able to apply some skills, they encountered some barriers, such as governance, placements, lack of support from the system and community, inadequate implementation authority and lack of planning by the state government. Incentives (both monetary and non-monetary) played a major role in motivating them to deliver public health services. They suggested that states should nominate candidates expected to make a significant contribution to the health system, recognition from a relevant authoritative national body and need for a placement cell, especially for the self-sponsored candidates. CONCLUSIONS: A continuous mechanism for interaction and dialogue with the graduates during and after completion of the programme should be designed. This evaluation helped by providing inputs for refining the programme

Impact of the Drug Prices Control Order (2013) on the Utilization of Anticancer Medicines in India: An Interrupted Time-Series Analysis.

Objectives The National Pharmaceutical Pricing Authority introduced a series of Drug Prices Control Orders since 1970 to regulate the prices of essential medicines in India. This study evaluated the impact of the Drug Prices Control Order of 2013 on the utilization of anticancer medicines in the Indian private sector. Methods We used monthly sales audit data for a period of 2012-15, provided by Intercontinental Medical Statistics (IMS) Health. Through interrupted time series design and segmented regression models, we estimated the change in utilization of anticancer medicines following the drug pricing policy implementation. Results Of 1556 anticancer drug packs, 22.3% (n= 347) were price-controlled. The policy led to an immediate monthly reduction of 27.3% (95% CI -38.6%, -13.9%; p=0.001) and a long-term monthly reduction of 0.7% (95% CI -1.6%, 0.3%; p=0.16) in price-controlled formulation's utilization. In the final study month, the price-controlled formulation's utilization was 5.03 thousand standard units lower than what would have been expected without the policy. Melphalan showed the highest immediate reduction, and alpha-interferon showed the highest long-term reduction in utilization. Conclusion Drug prices control order 2013 caused an immediate and long-term decline in the utilization of anticancer medicines in the Indian private sector. However, study data was limited to a specific part of the Indian anticancer drug market, which must be considered when interpreting findings

Why women choose to give birth at home: a situational analysis from urban slums of Delhi

Objectives: Increasing institutional births is an important strategy for attaining Millennium Development Goal -5. However, rapid growth of low income and migrant populations in urban settings in low-income and middle-income countries, including India, presents unique challenges for programmes to improve utilisation of institutional care. Better understanding of the factors influencing home or institutional birth among the urban poor is urgently needed to enhance programme impact. To measure the prevalence of home and institutional births in an urban slum population and identify factors influencing these events. Design: Cross-sectional survey using quantitative and qualitative methods. Setting: Urban poor settlements in Delhi, India. Participants: A house-to-house survey was conducted of all households in three slum clusters in north-east Delhi (n=32 034 individuals). Data on birthing place and sociodemographic characteristics were collected using structured questionnaires (n=6092 households). Detailed information on pregnancy and postnatal care was obtained from women who gave birth in the past 3 months (n=160). Focus group discussions and in-depth interviews were conducted with stakeholders from the community and healthcare facilities. Results: Of the 824 women who gave birth in the previous year, 53% (95% CI 49.7 to 56.6) had given birth at home. In adjusted analyses, multiparity, low literacy and migrant status were independently predictive of home births. Fear of hospitals (36%), comfort of home (20.7%) and lack of social support for child care (12.2%) emerged as the primary reasons for home births. Conclusions: Home births are frequent among the urban poor. This study highlights the urgent need for improvements in the quality and hospitality of client services and need for family support as the key modifiable factors affecting over two-thirds of this population. These findings should inform the design of strategies to promote institutional births

Size, composition and distribution of human resource for health in India: new estimates using National Sample Survey and Registry data

Objectives We provide new estimates on size, composition and distribution of human resource for health in India and compare with the health workers population ratio as recommended by the WHO. We also estimate size of non-health workers engaged in health sector and the size of technically qualified health professionals who are not a part of the health workforce. Design Nationally representative cross-section household survey and review of published documents by the Central Bureau of Health Intelligence. Setting National Participants Head of household/key informant in a sample of 101 724 households. Interventions Not applicable. Primary and secondary outcome measures The primary outcome was the number and density of health workers,and the secondary outcome was the percentage of health workers who are technically qualified and the percentage of individuals technically qualified and not in workforce. Results The total size of health workforce estimated from the National Sample Survey (NSS) data is 3.8 million as of January 2016, which is about 1.2 million less than the total number of health professionals registered with different councils and associations. The density of doctors and nurses and midwives per 10 000 population is 20.6 according to the NSS and 26.7 based on the registry data. Health workforce density in rural India and states in eastern India is lower than the WHO minimum threshold of 22.8 per 10 000 population. More than 80% of doctors and 70% of nurses and midwives are employed in the private sector. Approximately 25% of the currently working health professionals do not have the required qualifications as laid down by professional councils, while 20% of adequately qualified doctors are not in the current workforce. Conclusions Distribution and qualification of health professionals are serious problems in India when compared with the overall size of the health workers. Policy should focus on enhancing the quality of health workers and mainstreaming professionally qualified persons into the health workforce

Building public health capacity in Madhya Pradesh through academic partnership

Engaging in partnerships is a strategic means of achieving objectives common to each partner. The Post Graduate Diploma in Public Health Management (PGDPHM) partners in consultation with the government and aims to strengthen the public health managerial capacity. This case study examines the PGDPHM program conducted jointly by the Public Health Foundation of India and the Government of Madhya Pradesh (GoMP) at the State Institute of Health Management and Communication, Gwalior, which is the apex training and research institute of the state government for health professionals. This is an example of collaborative partnership between an academic institution and the Department of Public Health and Family Welfare, GoMP. PGDPHM is a 1-year, fully residential course with a strong component of field-based project work, and aims to bridge the gap in public health managerial capacity of the health system through training of health professionals. The program is uniquely designed in the context of the National Rural Health Mission and uses a multidisciplinary approach with a focus on inter-professional education. The curriculum is competency driven and health systems connected and the pedagogy uses a problem-solving approach with multidisciplinary faculty from different programs and practice backgrounds that bring rich field experience to the classroom. This case study presents the successful example of the interface between academia and the health system and of common goals achieved through this partnership for building capacity of health professionals in the state of Madhya Pradesh over the past 3 years

Developing core competencies for monitoring and evaluation tracks in South Asian MPH programs

Background: Monitoring and evaluation (M&E) provides vital information for decision-making and its structures, systems and processes are expected to be integrated throughout the life-cycle of public health programs. The acquisition of these skills should be developed in a structured manner and needs educational systems to identify core competencies in M&E teaching. This article presents our work on harmonizing M&E competencies for Masters level programs in the South Asian context and undertaking the global review of M&E track/ concentration offered in various Masters of Public Health (MPH) programs. Methods: Through an online search and snow-balling, we mapped institutions offering M&E tracks/ concentrations in Masters of Public Health (MPH) programs globally. We obtained detailed information about their M&E curriculum from university websites and brochures. The data on curricular contents was extracted and compiled. We analyzed the curricular contents using the framework for core competencies developed by the Association of Schools of Public Health (ASPH); and the Miller’s triangle. This data was then used to inform a consultative exercise aimed at identifying core competencies for an M&E track/ concentration in MPH programs in the South Asian context. Results: Our curricular review of M&E content within MPH programs globally showed that different domains or broad topic areas relating to M&E are covered differently across the programs. The quantitative sciences (Biostatistics and Epidemiology) and Health Policy and Management are covered in much greater depth than the other two domains (Social & Behavioral Sciences and Environmental Health Sciences). The identification of core competencies for an M&E track/ concentration in the South Asian context was undertaken through a consultative group exercise involving representation from 11 institutions across Bangladesh, India, Nepal and Sri Lanka. During the consultation, the group engaged in a focused discussion to reach consensus on a set of 15 core competencies for an M&E track in South Asian MPH programs. Conclusion: This work presents an opportunity for institutions to identify and re-examine their M&E competencies as a part of their specialized tracks within MPH programs. Our curricular analysis approach has the potential for adaptation and further use in curriculum analysis across different academic specialties

Rapid assessment of facilitators and barriers related to the acceptance, challenges and community perception of daily regimen for treating tuberculosis in India

Introduction: The Revised National Tuberculosis Control Program (RNTCP) is the largest tuberculosis (TB) control program in the world based on Directly Observed Treatment Short-Course (DOTS) strategy. Globally, most countries have been using a daily regimen and in India a shift towards a daily regimen for TB treatment has already begun. The daily strategy is known to improve program coverage along with compliance. Such strategic shifts have both management and operational implications. We undertook a rapid assessment to understand the facilitators and barriers in adopting the daily regimen for TB treatment in three Indian states. Methods: In-depth interviews were planned across six districts of three purposively selected states of Maharashtra, Bihar and Sikkim, among health system personnel at various levels to identify their perspectives on adoption of a daily regimen for TB. These districts were sampled on the basis of TB notification rates. Thematic analysis of the qualitative data was undertaken. Results: 62 respondents were interviewed from these 6 districts. During the analysis, it was observed that an easily accessible, patient-centred and personalized outreach is an enabling factor for adherence to treatment. Lack of transportation facilities, out-of-pocket expenses and loss of wages for accessing DOTS at institutions are major identified barriers for treatment adherence at individual level. At program level, lack of trained service providers, poor administration of treatment protocols and inadequate supervision by health care providers and program managers are key factors that influence program outcomes. Conclusion: A major observation that emerged from the interviews is that the key to achieve a relapse-free cure is ensuring that a patient receives all doses of the prescribed treatment regimen. However, switching to a daily regimen makes adherence difficult and thus new strategies are needed for its implementation at patient and health provider levels. Most stakeholders appreciate the reasons for switching to a daily regimen. The stakeholders recognised the efforts of the Ministry of Health & Family Welfare (MoHFW) in spearheading the program. Strategies like the 99 DOTS call-centre approach may also further ensure treatment adherence

India's public health management cadre policy

The 21st century witnessed a rise in life expectancy from 68 years (in 2001) to 73 years (in 2020) globally.1 Several nations continue to face challenges in addressing the Social Determinants of Health (SDHs) and other health determinants. A multidisciplinary public health workforce is often encountered in several countries influencing the health systems’ landscape.2 Within this landscape, public health management competencies are at the intersection of ‘public health’ and ‘management’ with focus on wider determinants of health, access to health services, towards the improvement of population health.3 Public Health Management skills are invaluable in administrative positions and functional roles that involve planning, communication, community partnership, analysis, organizational leadership, basic public health sciences & practice, budget and financial planning skills, emergency planning and preparedness.4 Within India, medical colleges have traditionally produced public health professionals. In the last two decades, training framework of public health professionals has evolved within the country.5 In 2012, the High Level Expert Group for Universal Health Coverage for India recommended creation of career trajectories in public health and health management.6 In 2017, the National Health Policy proposed creation of a public health management cadre7 based on which it was estimated that if the public health cadre is implemented from 2020 with roll-out until 2026 then 33,236 posts will be created to serve in the public health management cadre.8 In 2022, the Ministry of Health and Family Welfare (MoHFW) proposed a multidisciplinary Public Health Management Cadre (PHMC) to augment the capability of public health system for disease burden estimation, planning for preventive health services and strengthening public health surveillance to reduce public health emergencies. The MoHFW released Guidelines for Implementation of the PHMC across India (link to Public Health Management Cadre Booklet).9 It calls for creation of diverse public health cadres across states. Since public health is a state subject in India, thestate governments are entrusted with institutionalising PHMC. The policy guidelines distinguish the clinical cadre from the public health cadre, freeing clinical providers from administrative tasks. PHMC aims to ensure ‘health for all’ as well as supporting the delivery of all national health programs including those under the National Health Mission, Pradhan Mantri Jan Arogya Yojana (PMJAY), Pradhan Mantri Swasthya Suraksha Yojana etc. As per the policy document, states will independently develop and implement a plan of action to develop their own (customised) public health management structures for the new cadre based on the Government's guidelines. These guidelines fully empower states and suggest several initiatives like scaling up and expanding public health courses, preparing a roadmap for public health training of in-service candidates etc. However, within the state governments the biggest challenge towards implementation of these guidelines would be availability of the trained technical expertise in public health and broader health workforce management related issues. The states would need to develop appropriate plans for setting up these cadres with appropriately structured entry into the cadre, career progression, staffing norms (including numbers, human resource policies etc.). To overcome these barriers and supporting states in implementing the rollout, a dedicated team would be needed with experience of working closely with the public health system. This team may liaise with the states and offer individualized support and handholding through its representatives located at the state capitals. Additionally at state level, collaboration with public health agencies and experts (who are primarily engaged in public health research and service delivery) will also be necessary and helpful. A PHMC advisory unit at the Central level will be helpful in formally interacting with the State Health Department and other stakeholders and help building coalitions for developing a health need based public health workforce at the state-level. Another immediate challenge is related to, educational planning for public health professionals.10 At the state level, planning for public health education institutes can be evidence-driven and needs-based, focussing on development of public health focussed professional competencies (within the local context). To enhance the ability of public health professionals and achieve wider health goals, there is a need to focus on health systems issues such as equity (of access to health services) and ethics (moral problems in health services) which may be taught within public health courses offered at medical and public health schools. The PHMC should also be encouraged to drive research process within core public health functions such as: planning, monitoring, evaluation, surveillance, investigation, and analysis. This research capacity will help develop our competence in health workforce related domains such as staffing, skills mix, equitable distribution of health human resources, development of rural pipeline etc. The release of this policy document is an important milestone for the Indian public health system as it provides a transformational opportunity for shaping the future design of health systems, from local to national level. We hope that PHMC will contribute towards realizing Universal Health Coverage and achieving the Sustainable Development Goals