IntroductionNon-communicable diseases (NCDs) have become a major public health challenge worldwide; they account for 28 million deaths per year in low-and-middle-income countries (LMICs). Like many other LMICs, India is struggling to organise quality care for a large NCD-affected population especially at the primary healthcare level. The aim of this study was to assess local health system preparedness in a south Indian primary healthcare setting for addressing diabetes and hypertension.MethodsThis paper draws on a mixed-methods research study on access to medicines conducted in Tumkur, Karnataka, India. We used quantitative data from household and health facility surveys, and qualitative data from focus group discussions and in-depth interviews with health workers and patients. We identified systemic drivers that influence utilisation of services at government primary health centres (PHCs) using thematic analysis of qualitative data and a systems framework on access to medicines to assess supply and demand side factors.ResultsMajority of households depend on private facilities for diabetes and hypertension care because of the lack of laboratory facilities and frequent medicine stockouts at PHCs. Financial and managerial resource allocation for NCDs and prioritisation of care and processes related to NCDs was suboptimal compared to the prominence of this agenda at global and national levels. Primary healthcare has a limited role even in the activities under the national programme that addresses diabetes and hypertension.DiscussionThe study finds critical gaps in the preparedness of PHCs and district health systems in organising and managing care for diabetes and hypertension. Due to the lack of continuous care organised through PHCs, patients depend on expensive and often episodic care in the private sector. There is a need to improve managerial and financial resource allocation towards diabetes and hypertension (and other NCDs) at the district level.Trial registration number CTRI/2015/03/005640; Pre-results.
BackgroundIndia has the distinction of financing its healthcare mainly through out-of-pocket expenses by individual families contributing to catastrophic health expenditure and impoverishment. Nearly 70 % of the expenditure is on medicines purchased at private pharmacies. Patients with chronic ailments are especially affected, as they often need lifelong medicines. Over the past years in India, there have been several efforts to improve drug availability at government primary health centres. In this study, we aim to understand health system factors that affect utilisation and access to generic medicines for people with non-communicable diseases.MethodsThis study aims to understand if (and how) a package of interventions targeting primary health centres and community participation platforms affect utilisation and access to generic medicines for people with non-communicable diseases in the current district context in India. This study will employ a quasi-experimental design and a qualitative theory-driven approach. PHCs will be randomly assigned to one of three arms of the intervention. In one arm, PHCs will receive inputs to optimise service delivery for non-communicable diseases, while the second arm will receive an additional package of interventions to strengthen community participation platforms for improving non-communicable disease care. The third arm will be the control. We will conduct household and facility surveys, before and after the intervention and will estimate the effect of the intervention by difference-in-difference analysis. Sample size for measuring effects was calculated based on obtaining at least 30 households for each primary health centre spread across three distance-based clusters. Primary outcomes include availability and utilisation of medicines at primary health centres and out-of-pocket expenditure for medicines by non-communicable disease households. Focus group discussions with patients and in-depth interviews with health workers will also be conducted. Qualitative and process documentation data will be used to explain how the intervention could have worked.DiscussionBy taking into consideration several health system building blocks and trying to understand how they interact, our study aims to generate evidence for health planners on how to optimise health services to improve access to medicines.Trial registrationProtocol registered on Clinical Trials Registry of India with registration identifier number CTRI/2015/03/005640 on 17th March 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1680-3) contains supplementary material, which is available to authorized users.
BACKGROUND Age of menarche is showing a declining trend in all parts of the world. The reasons for this decline is proposed to be related to improvement in nutritional status, environmental factors, heredity, and body mass index. Weight at birth of the child has also been considered to influence the onset of menarche. The aim of the study is to identify whether birth weight influenced the age of menarche in girls.
Introduction: Intersectoral Collaboration (ISC) is increasingly recognised as a critical aspect of global health and an important prerequisite for developing integrated public health policies. However, in practice, ISC has proven challenging due to its complexity. While studies have documented factors that have facilitated ISC (like shared vision, leadership and clear delineation of sectoral roles) and those that have hindered ISC (including resource constraints, competing priorities and a lack of accountability), there is a limited understanding of the role of power on collaboration effectiveness while implementing ISC interventions. Thus, the present review is expected to bridge this knowledge gap by synthesising evidence from the literature on exploring how, why, for whom, under what circumstances and to what extent power dynamics between different sectors influence the collaboration while implementation of intersectoral health programmes and policies in Low and Middle-Income Countries (LMICs). Method and analysis: A realist review will be conducted to explain the role of power dynamics in the implementation of intersectoral policies through following a number of iterative steps: (1) Eliciting initial programme theories by engaging key experts for input and feedback, (2) Performing systematic and purposive searches for grey and peer-reviewed literature on Medline, Embase, CINAHL and Web of Science databases along with Google Scholar (3) Selecting appropriate documents while considering rigour and relevance, (4) Extracting data, (5) Synthesising data and (6) Refining the initial programme theory into a middle range realist theory. By generating Context-Mechanism-Outcome (CMO) configurations, this review seeks to understand how power dynamics between different sectors influence the implementation of intersectoral health programmes and policies and explore the mechanisms that trigger specific outcomes (implementation success or failure) in LMICs. Discussion: Given the complex nature of power dynamics in ISCs, realist philosophy is well suited to address the aim of this study. The findings from this review (refined programme theory) will be tested through case studies of the national nutrition mission in Assam, India, which uses an ISC approach to implement nutrition interventions. The outcomes of this synthesis are also expected to guide the implementation of other ISC approaches in similar settings.
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