A total of 3,056 excess deaths epidemiologically linked to chikungunya occurred in 2006.

Since the beginning of the Safe Motherhood Initiative, India has accounted for at least a quarter of maternal deaths reported globally. India's goal is to lower maternal mortality to less than 100 per 100,000 livebirths but that is still far away despite its programmatic efforts and rapid economic progress over the past two decades. Geographical vastness and sociocultural diversity mean that maternal mortality varies across the states, and uniform implementation of health-sector reforms is not possible. The case study analyzes the trends in maternal mortality nationally, the maternal healthcare-delivery system at different levels, and the implementation of national maternal health programmes, including recent innovative strategies. It identifies the causes for limited success in improving maternal health and suggests measures to rectify them. It recommends better reporting of maternal deaths and implementation of evidence-based, focused strategies along with effective monitoring for rapid progress. It also stresses the need for regulation of the private sector and encourages further public-private partnerships and policies, along with a strong political will and improved management capacity for improving maternal health.

ObjectiveThe graduates of the diploma and degree programmes of nursing and midwifery in India are considered skilled birth attendants (SBAs). This paper aimed to assess the confidence of final-year students from pre-service education programmes (diploma and bachelor's) in selected midwifery skills from the list of midwifery competencies of the International Confederation of Midwives (ICM).DesignA cross-sectional survey was conducted in Gujarat, India, involving 633 final-year students from 25 educational institutions (private or government), randomly selected, stratified by the type of programme (diploma and bachelor's). Students assessed their confidence on a four-point scale, in four midwifery competency domains – antepartum, intrapartum, postpartum, and newborn care. Explorative factor analysis was used to reduce skill statements into separate subscales for each domain.ResultsOverall, 25–40% of students scored above the 75th percentile and 38–50% below the 50th percentile of confidence in all subscales for antepartum, intrapartum, postpartum, and newborn care. The majority had not attended the required number of births prescribed by the Indian Nursing Council.ConclusionsThe pre-service education offered in the diploma and bachelor's programmes in Gujarat does not prepare confident SBAs, as measured on selected midwifery competencies of the ICM. One of the underlying reasons was less clinical experience during their education. The duration, content, and pedagogy of midwifery education within the integrated programmes need to be reviewed.

This working paper describes the status of the health system, discusses critical areas of management concerns, suggests a few health sector reform measures, and concludes by identifying the roles and responsibilities of various stakeholders for building health systems that are responsive to the community needs, particularly for the poor.

Gujarat state of India has come a long way in improving the health indicators since independence, but progress in reducing maternal mortality has been slow and largely unmeasured or documented. This case study identified several challenges for reducing the maternal mortality ratio, including lack of the managerial capacity, shortage of skilled human resources, non-availability of blood in rural areas, and infrastructural and supply bottlenecks. The Gujarat Government has taken several initiatives to improve maternal health services, such as partnership with private obstetricians to provide delivery care to poor women, a relatively-short training of medical officers and nurses to provide emergency obstetric care (EmOC), and an improved emergency transport system. However, several challenges still remain. Recommendations are made for expanding the management capacity for maternal health, operationalization of health facilities, and ensuring EmOC on 24/7 (24 hours a day, seven days a week) basis by posting nurse-midwives and trained medical officers for skilled care, ensuring availability of blood, and improving the registration and auditing of all maternal deaths. However, all these interventions can only take place if there are substantially-increased political will and social awareness.

Blood-transfusion services are vital to maternal health because haemorrhage and anaemia are major causes of maternal death in South Asia. Unfortunately, due to continued governmental negligence, blood-transfusion services in India are a highly-fragmented mix of competing independent and hospital-based blood-banks, serving the needs of urban populations. This paper aims to understand the existing systems of blood-transfusion services in India focusing on Maharashtra and Gujarat states. A mix of methodologies, including literature review (including government documents), analysis of management information system data, and interviews with key officials was used. Results of analysis showed that there are many managerial challenges in blood-transfusion services, which calls for strengthening the planning and monitoring of these services. Maharashtra provides a good model for improvement. Unless this is done, access to blood in rural areas may remain poor.

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Strengthening good governance and preventing corruption in health care are universal challenges. The Karnataka Lokayukta (KLA), a public complaints agency in Karnataka state (India), was created in 1986 but played a prominent role controlling systemic corruption only after a change of leadership in 2001 with a new Lokayukta (ombudsman) and Vigilance Director for Health (VDH). This case study of the KLA (2001-06) analysed the:Scope and level of poor governance in the health sector; KLA objectives and its strategy; Factors which affected public health sector governance and the operation of the KLA. We used a participatory and opportunistic evaluation design, examined documents about KLA activities, conducted three site visits, two key informant and 44 semi-structured interviews and used a force field model to analyse the governance findings. The Lokayukta and his VDH were both proactive and economically independent with an extended social network, technical expertise in both jurisdiction and health care, and were widely perceived to be acting for the common good. They mobilized media and the public about governance issues which were affected by factors at the individual, organizational and societal levels. Their investigations revealed systemic corruption within the public health sector at all levels as well as in public/private collaborations and the political and justice systems. However, wider contextual issues limited their effectiveness in intervening. The departure of the Lokayukta, upon completing his term, was due to a lack of continued political support for controlling corruption. Governance in the health sector is affected by positive and negative forces. A key positive factor was the combined social, cultural and symbolic capital of the two leaders which empowered them to challenge corrupt behaviour and promote good governance. Although change was possible, it was precarious and requires continuous political support to be sustained.