This study aimed to understand access to maternal health care and the factors shaping it amongst poor migrants in Mumbai, India. A cross-sectional mixed methods approach was used. It included multistage cluster sampling and face-to-face interviews, through structured interview schedules, of 234 migrant women who had delivered in the two years previous to the date they were interviewed. Qualitative in-depth interviews of migrant women, health care providers and health officials were also conducted to understand community and provider perspectives. The results showed that access to antenatal care was poor among migrants with less than a third of them receiving basic antenatal care and a quarter delivering at home. Multivariate analysis highlighted that amongst migrant women those who stayed in Mumbai during pregnancy and delivery had better access to maternal health care than those who went back to their home towns. Poor maternal health care was also due to weaker demand for health care as a result of the lack of felt-need among migrants due to socio-cultural factors and lack of social support for, and knowledge of, health facilities in the city. Supply-side factors such as inadequate health infrastructure at primary and secondary levels, lack of specific strategies to improve access to health care for migrants and cumbersome administrative procedures that exclude migrants from certain government programmes all need to be addressed. Migrants should be integral to the urban development process and policies should aim at preventing their exclusion from basic amenities and their entitlements as citizens.

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Background: The difference between ‘policy as promised’ and ‘policy as practiced’ can be attributed to implementation gaps. Actor relationships and power struggles are central to these gaps but have been studied using only a handful of theoretical and analytical frameworks. Actor interface analysis provides a methodological entry point to examine policy implementation and practices of power. As this approach has rarely been used in health policy analysis, this article aims, first, to synthesise knowledge about use of actor interface analysis in health policy implementation and, second, to provide guiding steps to conduct actor interface analysis. Methods: We conducted an interpretive synthesis of literature using a set of 6 papers, selected using purposeful searches and focusing on actor dynamics and practices of power in policy experiences. Drawing upon the framework synthesis approach and using a guiding framework, the synthesis focused on 4 questions – the type of actor interfaces formed, the power practices observed, the effect of such power practices on implementation and the underpinning factors for the power practices. Results: Multiple interface encounters and power practices were identified which included domination, control, contestation, collaborations, resistance, and negotiations. The lifeworlds of actors that underpinned the power practices, were rooted in social-organisational power relationships, personal experiences and interests, and social-ideological standpoints like values and beliefs of actors. The power practices influenced implementation both positively and negatively. Conclusion: Based on the learnings from synthesis, this paper provides guiding steps for conducting actor interface analysis. Additionally, it presents 2 useful tools for power analysis: (1) ‘actor lifeworlds,’ to understand underpinning factors for power practices and (2) relationships of lifeworlds, interface encounters and power practices with their effect on policy implementation. We suggest that interface analysis should be applied in more empirical settings and across varied health policy experiences to nuance the method better.

ObjectivesAn intervention to improve migrants’ access to healthcare was piloted in Mumbai with purpose of informing health policy and planning. This paper aims to describe the process of building partnership for improving migrants’ access to healthcare of the pilot intervention, including the role played by different stakeholders and the contextual factors affecting the intervention.MethodsThe process evaluation was based on Baranowski and Stables’ framework. Observations in community and conversations with stakeholders as recorded in daily diaries, minutes of pre-intervention workshops, and stakeholder meetings served as data sources. Data were coded using the framework and descriptive summaries of evaluation components were prepared.ResultsRecruitment of stakeholders was easier than sustaining their interest. Community representatives led the intervention assisted by government officials. They planned community-level interventions to improve access to healthcare that involved predominantly information, education, and communication activities for which pre-existing formal and informal social networks and community events were used. Although the intervention reached migrants living with families, single male migrants neither participated nor did the intervention reach them consistently. Contextual factors such as culture differences between migrants and native population and illegality in the nature of the settlement, resulting in the exclusion from services, were the barriers.ConclusionInclusive multi-stakeholder partnership, including migrants themselves and using both formal and informal networks in community is a feasible strategy for health education and has potential to improve the migrants’ access to healthcare. However, there are challenges to the partnership process and new strategies to overcome these challenges need to be tested such as peer-led models for involvement of single male migrants. For sustaining such efforts and mainstreaming migrants, addressing contextual factors and having formal mechanisms for their inclusion are equally important.

Asbestos-related diseases (ARDs) are incurable but entirely preventable. Due to India's continuing use of asbestos, ARD patients will increase to a high number in the next three to four decades. This will increase the burden on palliative care system which is in nascent stage presently. Palliative care is the mainstay of the management of ARDs. Unfortunately, the burden on palliative care is likely to increase due to multiple factors contributed by India's demographic and economic changes. In the near future, there will be at least 12.5 million ARD patients and 1.25 million asbestos-related cancer patients worldwide, and half of these will be in India. It is high time to introspect about our ability to engage with this future problem. The paper also discusses the organization of this future problem of ARDs and possible action points toward future access to palliative care for ARD patients.

Context:There is conflicting evidence of effect of diabetes on treatment of tuberculosis (TB). There is a need to investigate effect of diabetes on outcomes of TB treatment under field conditions in India.Aims:To compare treatment outcomes among TB patients with diabetes with those without diabetes.Setting and Design:Study was conducted in Cuddalore, Tamil Nadu, among patients registered with Revised National TB Control Programme. Prospective observational study design was used.Materials and Methods:Registered TB patients aged 30 and above were invited to participate in the study. Those who were not aware of their diabetic status were diagnosed using oral glucose tolerance test. A total of 89 diabetic and 120 non-diabetic patients were recruited in the study. They were followed up till the end of treatment and outcomes were recorded.Statistical Analysis Used:Treatment outcomes in the two groups were compared using bi-variate and multi-variate analysis.Results:Bi-variate (unadjusted) analysis showed similar treatment success rates in the two groups. But, the adjusted odds ratios for successful treatment among diabetic patients were significantly lower (0.191, 95% CI 0.04-0.90) for pulmonary TB patients and for smear positive pulmonary TB patients (odds ration 0.099, 0.013-0.761). Diabetes was found to be predictor for sputum positivity at end of treatment.Conclusions:Diabetes increases risk of poor treatment outcomes among pulmonary TB patients. The study highlights need of screening of TB patients for diabetes. There is need to see the effect of glycemic control on treatment outcomes among diabetics.

This study aims to assess the effectiveness and cost-effectiveness of a public-private mix (PPM) project with private sector as sole provider of services in an urban area under India's Tuberculosis (TB) Control Programme in Tamil Nadu. Methods: Directly observed treatment, short-course (DOTS) was provided exclusively by a nongovernmental organization (NGO) in one area which was compared with another area served by public sector. Data on cost and effectiveness were collected from records and interviews of patients. Cost and effectiveness of non-DOTS treatment was based on previous literature and market rates. Costs for 2011 in US$ were assessed for PPM and non-PPM areas with both public provider and societal perspective. Effectiveness was measured as proportion of cases successfully treated.

Exploring the implementation blackbox from a perspective that considers embedded practices of power is critical to understand the policy process. However, the literature is scarce on this subject. To address the paucity of explicit analyses of everyday politics and power in health policy implementation, this article presents the experience of implementing a flagship health policy in India. Janani Shishu Suraksha Karyakram (JSSK), launched in the year 2011, has not been able to fully deliver its promises of providing free maternal and child health services in public hospitals. To examine how power practices, influence implementation, we undertook a qualitative analysis of JSSK implementation in one state of India. We drew on an actor-oriented perspective of development and used ‘actor interface analysis’ to guide the study design and analysis. Data collection included in-depth interviews of implementing actors and JSSK service recipients, document review and observations of actor interactions. A framework analysis method was used for analysing data, and the framework used was founded on the constructs of actor lifeworlds, which help understand the often neglected and lived realities of policy actors. The findings illustrate that implementation was both strengthened and constrained by practices of power at various interface encounters. The implementation decisions and actions were influenced by power struggles such as domination, control, resistance, contestation, facilitation and collaboration. Such practices were rooted in: Social and organizational power relationships like organizational hierarchies and social positions; personal concerns or characteristics like interests, attitudes and previous experiences and the worldviews of actors constructed by social and ideological paradigms like their values and beliefs. Application of ‘actor interface analysis’ and further nuancing of the concept of ‘actor lifeworlds’ to understand the origin of practices of power can be useful for understanding the influence of everyday power and politics on the policy process.