Innovation Dynamics in Tuberculosis Control in India: The Shift to New Partnerships

Innovation dynamics in Tuberculosis control in India: The shift to new partnerships Tuberculosis remains the biggest infectious killer in India and worldwide, and it has recently regained substantial international attention with its come-back in drug resistant forms. The environment, the disease and the societal response to it are changing and with it challenges and opportunities to control the disease. Innovation in a variety of areas such as improved diagnostic tests, drugs, delivery mechanisms, service processes, institutions and treatment regimes is needed in order to be able to respond to the changing public health challenge. Recent developments in the literature emphasize that innovation is a complex endeavour that includes processes of negotiation, learning and alignment amongst researchers, health practitioners, firms and public authorities. The ground level realities for innovation in countries such as India where TB is a social as much as a clinical problem are complicated with challenges and constraints inherent to the health and wider social system that hamper learning, experimenting and thus innovation. Based on preliminary results from qualitative fieldwork in India this paper will examine the innovation dynamics in one of the recent policy changes in TB control in India: the emergence of new partnerships between private medical providers, NGOs and the government. The paper traces where new ideas come from, how they make their way through the existing control structure and how the existing efforts to control TB respond to and cope with these new developments. The central argument is that the dynamics of innovation in a complex, conflicting and confusing setting like TB control can be understood as a continuous evolution of problems, promises and solutions.Innovation dynamics, public-private mix, Tuberculosis, India

Flexibility and innovation in response to emerging infectious diseases: Reactions to multi-drug resistant Tuberculosis in India

Emerging infectious diseases regained substantial international attention in recent years and it has been argued that flexibility and innovation in public health systems is needed in order to react to changing challenges. This paper will take these policy claims as a starting point to examine the case of multi-drug resistant Tuberculosis (MDR-TB) in India. Based on fieldwork results it will be examined how the existing control efforts of TB in India respond to the emergence of MDR-TB, what solutions are discussed for diagnosing, treating and preventing MDR-TB and what can be learned from that with regard to innovation and flexibility of a public health system in a country like India. The discussions and reactions to MDR-TB indicate that arguments for flexibility meet constraints of the existing control system and the Indian public health and wider social system. However, the flexibility that is argued for goes beyond what has been envisaged in international policy arenas (mainly focusing on preparation of various capacities in surveillance, detection and research). Rather it involves localized learning and experimenting within existing control structures that are claimed to have become too rigid in trying to keep up quality standards faced with a weakening public health system. Furthermore, the case shows that existing challenges in TB control resurface with the emergence of MDR-TB and reflect a difficult balancing act between biomedical values, socio-cultural values and operational feasibility. However, various actors are striving for change and it is in these instances that one can start to understand what flexibility and innovation could mean for a public health challenge such as TB in India. The paper concludes with an argument for a detailed analysis of these changes from an innovation perspective.Tuberculosis, Multi-drug resistance, India, Innovation, Flexibility

Drivers and Barriers of Innovation Dynamics in Healthcare - Towards a framework for analyzing innovation in Tuberculosis control in India

Tuberculosis remains the biggest infectious killer in India and worldwide, and it has recently regained substantial international attention with its come-back in drug resistant forms. The environment, the disease and the societal response to it are changing and with it challenges and opportunities to control the disease. Innovation in a variety of areas such as improved diagnostic tests, drugs, delivery mechanisms, service processes, institutions and treatment regimes is needed in order to be able to respond to the changing public health challenge. This paper reviews theoretical approaches to innovation of direct relevance to the case and examines what theoretical framework is useful to look at the problem of innovation in public health in India. Such an analysis can reveal drivers and barriers of change within the context of the Indian health system in a comprehensive, problem-oriented way and is thus able to add to existing research done on TB. However, given that TB control is a public health challenge, concerned with problems of delivery and implementation, the concept of innovation has to go beyond technological innovation and the private sector. Therefore it is argued that the case can simultaneously contribute to innovation theory in order to better understand what change processes and innovation for concrete public health challenges in a country such as India mean. After a short description of recent changes in TB control based on fieldwork in India the paper proceeds with an examination of existing frameworks on healthcare innovation upon their usefulness for such a case. The paper concludes with a proposal for a theoretical framework and areas for further empirical fieldwork.Innovation, Healthcare, Tuberculosis, Disease control, India

A little good is good enough: Ethical consumption, cheap excuses, and moral self-licensing

This paper explores the role of cheap excuses in product choice. If agents feel that they fulfill one ethical aspect, they may care less about other independent ethical facets within product choice. Choosing a product that fulfills one ethical aspect may then suffice for maintaining a high moral self-image in agents and render it easier to ignore other ethically relevant aspects they would otherwise care about more. The use of such cheap excuses could thus lead to a “static moral self-licensing” effect, and this would extend the logic of the well-known dynamic moral self-licensing. Our experimental study provides empirical evidence that the static counterpart of moral self-licensing exists. Furthermore, effects spill over to unrelated, ethically relevant contexts later in time. Thus, static moral self-licensing and dynamic moral self-licensing can exist next to each other. However, it is critical that agents do not feel that they fulfilled an ethical criterion out of sheer luck, that is, agents need some room so that they can attribute the ethical improvement at least partly to themselves. Outsiders, although monetarily incentivized for correct estimates, are completely oblivious to the effects of moral self-licensing, both static and dynamic

A little good is good enough: ethical consumption, cheap excuses, and moral self-licensing

We explore the role of cheap excuses in product choice. If a product improves upon one ethically relevant dimension, agents may care less about other, completely independent ethical facets of the product. This 'static moral self-licensing' would extend the logic of the well-studied moral self-licensing over time. Our data document that static moral self-licensing exists. Furthermore, effects spill over to later, unrelated but ethically relevant contexts. Thus, static moral self-licensing and moral self-licensing over time amplify each other. Outsiders, though incentivized for correct estimates, are completely oblivious to effects of moral selflicensing, both, static and over time

Enhancer-driven chromatin interactions during development promote escape from silencing by a long non-coding RNA

<p>Abstract</p> <p>Background</p> <p>Gene regulation in eukaryotes is a complex process entailing the establishment of transcriptionally silent chromatin domains interspersed with regions of active transcription. Imprinted domains consist of clusters of genes, some of which exhibit parent-of-origin dependent monoallelic expression, while others are biallelic. The <it>Kcnq1 </it>imprinted domain illustrates the complexities of long-range regulation that coexists with local exceptions. A paternally expressed repressive non-coding RNA, <it>Kcnq1ot1</it>, regulates a domain of up to 750 kb, encompassing 14 genes. We study how the <it>Kcnq1 </it>gene, initially silenced by <it>Kcnq1ot1</it>, undergoes tissue-specific escape from imprinting during development. Specifically, we uncover the role of chromosome conformation during these events.</p> <p>Results</p> <p>We show that <it>Kcnq1 </it>transitions from monoallelic to biallelic expression during mid gestation in the developing heart. This transition is not associated with the loss of methylation on the <it>Kcnq1 </it>promoter. However, by exploiting chromosome conformation capture (3C) technology, we find tissue-specific and stage-specific chromatin loops between the <it>Kcnq1 </it>promoter and newly identified DNA regulatory elements. These regulatory elements showed <it>in vitro </it>activity in a luciferase assay and <it>in vivo </it>activity in transgenic embryos.</p> <p>Conclusions</p> <p>By exploring the spatial organization of the <it>Kcnq1 </it>locus, our results reveal a novel mechanism by which local activation of genes can override the regional silencing effects of non-coding RNAs.</p

Does doctors’ workload impact supervision and ward activities of final-year students? A prospective study

<p><b>Abstract</b></p> <p><b>Background</b></p> <p>Hospital doctors face constantly increasing workloads. Besides caring for patients, their duties also comprise the education of future colleagues. The aim of this study was to objectively investigate whether the workload arising from increased patient care interferes with student supervision and is associated with more non-medical activities of final-year medical students.</p> <p><b>Methods</b></p> <p>A total of 54 final-year students were asked to keep a diary of their daily activities over a three-week period at the beginning of their internship in Internal Medicine. Students categorized their activities – both medical and non-medical - according to whether they had: (1) only watched, (2) assisted the ward resident, (3) performed the activity themselves under supervision of the ward resident, or (4) performed the activity without supervision. The activities reported on a particular day were matched with a ward specific workload-index derived from the hospital information system, including the number of patients treated on the corresponding ward on that day, a correction factor according to the patient comorbidity complexity level (PCCL), and the number of admissions and discharges. Both students and ward residents were blinded to the study question.</p> <p><b>Results</b></p> <p>A total of 32 diaries (59 %, 442 recorded working days) were handed back. Overall, the students reported 1.2 ± 1.3 supervised, 1.8 ±1.6 medical and 3.6 ± 1.7 non-medical activities per day. The more supervised activities were reported, the more the number of reported medical activities increased (p < .0001). No relationship between the ward specific workload and number of medical activities could be shown.</p> <p><b>Conclusions</b></p> <p>There was a significant association between ward doctors’ supervision of students and the number of medical activities performed by medical students. The workload had no significant effect on supervision or the number of medical or non-medical activities of final-year students.</p

Städtebauliche und sozioökonomische Implikationen neuer Mobilitätsformen. Beiträge aus: Profilregion Mobilitätssysteme Karlsruhe

Viele Experten gehen davon aus, dass sich urbane Mobilität, und damit auch das städtische Umfeld, in Zukunft stark wandeln werden, unter anderem aufgrund neuer, digital-gestützter Mobilitätsangebote. Es ist deshalb wichtig zu verstehen, wie dieser Wandel aussehen und gestaltet werden kann. Dazu möchten die im vorliegenden Band enthaltenen Papiere aus verschiedenen Perspektiven einen Beitrag leisten. Alle Beiträge sind im Vorhaben „Profilregion Mobilitätssysteme Karlsruhe“ entstanden