Size, composition and distribution of health workforce in India: why, and where to invest?

BACKGROUND: Investment in human resources for health not only strengthens the health system, but also generates employment and contributes to economic growth. India can gain from enhanced investment in health workforce in multiple ways. This study in addition to presenting updated estimates on size and composition of health workforce, identifies areas of investment in health workforce in India. METHODS: We analyzed two sources of data: (i) National Health Workforce Account (NHWA) 2018 and (ii) Periodic Labour Force Survey 2017-2018 of the National Sample Survey Office (NSSO). Using the two sources, we collated comparable estimates of different categories of health workers in India, density of health workforce and skill-mix at the all India and state levels. RESULTS: The study estimated (from NHWA 2018) a total stock of 5.76 million health workers which included allopathic doctors (1.16 million), nurses/midwives (2.34 million), pharmacist (1.20 million), dentists (0.27 million), and traditional medical practitioner (AYUSH 0.79 million). However, the active health workforce size estimated (NSSO 2017-2018) is much lower (3.12 million) with allopathic doctors and nurses/midwives estimated as 0.80 million and 1.40 million, respectively. Stock density of doctor and nurses/midwives are 8.8 and 17.7, respectively, per 10,000 persons as per NHWA. However, active health workers' density (estimated from NSSO) of doctor and nurses/midwives are estimated to be 6.1 and 10.6, respectively. The numbers further drop to 5.0 and 6.0, respectively, after accounting for the adequate qualifications. All these estimates are well below the WHO threshold of 44.5 doctor, nurses and midwives per 10,000 population. The results reflected highly skewed distribution of health workforce across states, rural-urban and public-private sectors. A substantial proportion of active health worker were found not adequately qualified on the one hand and on the other more than 20% of qualified health professionals are not active in labor markets. CONCLUSION: India needs to invest in HRH for increasing the number of active health workers and also improve the skill-mix which requires investment in professional colleges and technical education. India also needs encouraging qualified health professionals to join the labor markets and additional trainings and skill building for already working but inadequately qualified health workers

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

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

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

Ethnic differences in Glycaemic control in people with type 2 diabetes mellitus living in Scotland

Background and Aims: Previous studies have investigated the association between ethnicity and processes of care and intermediate outcomes of diabetes, but there are limited population-based studies available. The aim of this study was to use population-based data to investigate the relationships between ethnicity and glycaemic control in men and women with diabetes mellitus living in Scotland.<p></p> Methods: We used a 2008 extract from the population-based national electronic diabetes database of Scotland. The association between ethnicity with mean glycaemic control in type 2 diabetes mellitus was examined in a retrospective cohort study, including adjustment for a number of variables including age, sex, socioeconomic status, body mass index (BMI), prescribed treatment and duration of diabetes.<p></p> Results: Complete data for analyses were available for 56,333 White Scottish adults, 2,535 Pakistanis, 857 Indians, 427 Chinese and 223 African-Caribbeans. All other ethnic groups had significantly (p<0.05) greater proportions of people with suboptimal glycaemic control (HbA1c >58 mmol/mol, 7.5%) compared to the White Scottish group, despite generally younger mean age and lower BMI. Fully adjusted odds ratios for suboptimal glycaemic control were significantly higher among Pakistanis and Indians (1.85, 95% CI: 1.68–2.04, and 1.62,95% CI: 1.38–1.89) respectively.<p></p> Conclusions: Pakistanis and Indians with type 2 diabetes mellitus were more likely to have suboptimal glycaemic control than the white Scottish population. Further research on health services and self-management are needed to understand the association between ethnicity and glycaemic control to address ethnic disparities in glycaemic control.<p></p&gt

A horizon scan of priorities for coastal marine microbiome research

Research into the microbiomes of natural environments is changing the way ecologists and evolutionary biologists view the importance of microbes in ecosystem function. This is particularly relevant in ocean environments, where microbes constitute the majority of biomass and control most of the major biogeochemical cycles, including those that regulate the Earth's climate. Coastal marine environments provide goods and services that are imperative to human survival and well-being (e.g. fisheries, water purification), and emerging evidence indicates that these ecosystem services often depend on complex relationships between communities of microorganisms (the ‘microbiome’) and their hosts or environment – termed the ‘holobiont’. Understanding of coastal ecosystem function must therefore be framed under the holobiont concept, whereby macroorganisms and their associated microbiomes are considered as a synergistic ecological unit. Here we evaluated the current state of knowledge on coastal marine microbiome research and identified key questions within this growing research area. Although the list of questions is broad and ambitious, progress in the field is increasing exponentially, and the emergence of large, international collaborative networks and well-executed manipulative experiments are rapidly advancing the field of coastal marine microbiome research

High methylmercury in Arctic and subarctic ponds is related to nutrient levels in the warming eastern Canadian Arctic

Permafrost thaw ponds are ubiquitous in the eastern Canadian Arctic, yet little information exists on their potential as sources of methylmercury (MeHg) to freshwaters. They are microbially active and conducive to methylation of inorganic mercury, and are also affected by Arctic warming. This multiyear study investigated thaw ponds in a discontinuous permafrost region in the Subarctic taiga (Kuujjuarapik-Whapmagoostui, QC) and a continuous permafrost region in the Arctic tundra (Bylot Island, NU). MeHg concentrations in thaw ponds were well above levels measured in most freshwater ecosystems in the Canadian Arctic (>0.1 ng L−1). On Bylot, ice-wedge trough ponds showed significantly higher MeHg (0.3−2.2 ng L−1) than polygonal ponds (0.1−0.3 ng L−1) or lakes (<0.1 ng L−1). High MeHg was measured in the bottom waters of Subarctic thaw ponds near Kuujjuarapik (0.1−3.1 ng L−1). High water MeHg concentrations in thaw ponds were strongly correlated with variables associated with high inputs of organic matter (DOC, a320, Fe), nutrients (TP, TN), and microbial activity (dissolved CO2 and CH4). Thawing permafrost due to Arctic warming will continue to release nutrients and organic carbon into these systems and increase ponding in some regions, likely stimulating higher water concentrations of MeHg. Greater hydrological connectivity from permafrost thawing may potentially increase transport of MeHg from thaw ponds to neighboring aquatic ecosystems

A horizon scan of priorities for coastal marine microbiome research

Research into the microbiomes of natural environments is changing the way ecologists and evolutionary biologists view the importance of microbes in ecosystem function. This is particularly relevant in ocean environments, where microbes constitute the majority of biomass and control most of the major biogeochemical cycles, including those that regulate the Earth's climate. Coastal marine environments provide goods and services that are imperative to human survival and well-being (e.g. fisheries, water purification), and emerging evidence indicates that these ecosystem services often depend on complex relationships between communities of microorganisms (the ‘microbiome’) and their hosts or environment – termed the ‘holobiont’. Understanding of coastal ecosystem function must therefore be framed under the holobiont concept, whereby macroorganisms and their associated microbiomes are considered as a synergistic ecological unit. Here we evaluated the current state of knowledge on coastal marine microbiome research and identified key questions within this growing research area. Although the list of questions is broad and ambitious, progress in the field is increasing exponentially, and the emergence of large, international collaborative networks and well-executed manipulative experiments are rapidly advancing the field of coastal marine microbiome research

Pyrosequencing of Bacterial Symbionts within Axinella corrugata Sponges: Diversity and Seasonal Variability

Background: Marine sponge species are of significant interest to many scientific fields including marine ecology, conservation biology, genetics, host-microbe symbiosis and pharmacology. One of the most intriguing aspects of the sponge ‘‘holobiont’’ system is the unique physiology, interaction with microbes from the marine environment and the development of a complex commensal microbial community. However, intraspecific variability and temporal stability of sponge-associated bacterial symbionts remain relatively unknown. Methodology/Principal Findings: We have characterized the bacterial symbiont community biodiversity of seven different individuals of the Caribbean reef sponge Axinella corrugata, from two different Florida reef locations during variable seasons using multiplex 454 pyrosequencing of 16 S rRNA amplicons. Over 265,512 high-quality 16 S rRNA sequences were generated and analyzed. Utilizing versatile bioinformatics methods and analytical software such as the QIIME and CloVR packages, we have identified 9,444 distinct bacterial operational taxonomic units (OTUs). Approximately 65,550 rRNA sequences (24%) could not be matched to bacteria at the class level, and may therefore represent novel taxa. Differentially abundant classes between seasonal Axinella communities included Gammaproteobacteria, Flavobacteria, Alphaproteobacteria, Cyanobacteria, Acidobacter and Nitrospira. Comparisons with a proximal outgroup sponge species (Amphimedon compressa), and the growing sponge symbiont literature, indicate that this study has identified approximately 330 A. corrugata-specific symbiotic OTUs, many of which are related to the sulfur-oxidizing Ectothiorhodospiraceae. This family appeared exclusively within A. corrugata, comprising \u3e34.5% of all sequenced amplicons. Other A. corrugata symbionts such as Deltaproteobacteria, Bdellovibrio, and Thiocystis among many others are described. Conclusions/Significance: Slight shifts in several bacterial taxa were observed between communities sampled during spring and fall seasons. New 16 S rDNA sequences and concomitant identifications greatly expand the microbial community profile for this model reef sponge, and will likely be useful as a baseline for any future comparisons regarding sponge microbial community dynamics