Doctor of Philosophy (PhD) Program
PhD defence: Prashanth N S
PhD defence: Upendra Bhojani
PhD programmes is to develop research leaders and policy advocates in the field of health systems. The PhD programme focuses on training professionals to mature into leaders with academic stronghold and rich grassroots level experience.
There is deficit of strong public health academicians in both teaching and research. Very few institutions in our country offer a PhD in public health. IPH wants to build a cadre of public health academicians with the right values.
Meet the Present PhD Scholars
Dr Vijayashree Yellappa
Dr Vijayashree Yellappa started her PhD in December 2012. Her study focuses on understanding the modalities for optimizing the involvement of private practitioners in the National Health Programmes in India, using National Tuberculosis Control as a tracer condition. She is registered at Ghent University, Ghent, Belgium. Her promoters include Prof.Patrick Van der Styuft who teaches at Department of Medicine, Ghent University; Prof. Bart Criel, co-promoter from Department of Public Health, Institute of Tropical Medicine, Antwerp Belgium and local promoter Dr. N Devadasan, Director, Institute of Public Health, Bangalore, India. She is expected to complete her PhD by late 2016.
Duration:- December 2012- November 2016
Optimising the Involvement of Private Practitioners in National TB Control Programme, India
In India, the private health sector plays an important role in the provision of health care. Government of India has been involving the Private Sector Providers (PSPs) through Public Private Partnerships (PPPs) in realising public health goals through different partnership mechanisms such as contracting, franchising, social marketing, vouchers and social health insurance. Assessment of these PPPs have concluded that they are context specific, do not allow for easy generalisations and that in most of the cases, individual charismatic leadership seems to have played a critical role in achieving the success. Given this context, we proposed to study PPP in National Tuberculosis Control (NTP) in Tumkur District, situated in Karnataka, South India.
NTP draws special attention here, because of its long history of efforts to involve PSPs, which dates back to 1995. NTP has been making systematic efforts to involve PSPs through PPM (Public Private Mix)-DOTS (Directly Observed Short Treatment Short Course) strategy to effectively link NTP with PSPs, so as to detect Tuberculosis (TB) suspects timely and provide standardised treatment to TB patients. For this purpose, NTP has published PPM-DOTS guidelines in 2001-2002. Despite the promise shown by few PPM-DOTS models, uptake of PPM schemes by PSPs has been poor. Currently, the NTP claims that several thousands of Private Practitioners (PPs) are collaborating under various PPM schemes, but in 2014 only 13,150 formal allopathic PPs in the entire country were involved with NTP. The vision of the GoI is for a ‘TB free India’. But, given this state of affairs, we do not know much about the factors determining the performance of PPM-TB. Hence, we proposed to study ‘what’ determines the performance of PPM-DOTS in India and understand ‘how’ and ‘why’ certain PPM-DOTS work or fail. In this study, we particularly focused on for-profit, formally trained, private practitioners (PPs) practicing modern medicine.
The study consisted of two phases. Phase one employed mixed methods design (2012-2013). As a first step, we assessed the participation of PPs in the NTP for the year 2011 using secondary data. Since, comprehensive register of PPs practicing in the area was not available, we mapped the PPs using GPS. Quantitative analysis showed, none of the PPs had formally signed-up for any PPM scheme and only 24% of them had referred any case to NTP in in 2011 (Article can be accessed here). As a second step, we conducted a qualitative study in the same area with stakeholders like PPs, TB patients and NTP staff at sub district, district, state and national level to explore the barriers for collaboration.
In the Phase two (2014-2015), we designed an intervention package based on the recommendations given by various stakeholders in phase one research. The activities where aimed at improving the collaboration between PPs and the NTP. We chose quasi-experiment design to evaluate the intervention as it is delivered in a real world setting by proportionate random allocation of PPs (100 in each group) practicing in the study area to an intervention (receiving a package of interventions to improve referral and notification) and a control group. As main outcomes, we assessed the proportion of PPs referring presumptive TB cases to the NTP and the proportion of PPs notifying TB cases on private treatment to the NTP, in the intervention versus control group at the end of the intervention. The duration of the intervention was 13 months starting from November 2014.
Preliminary Results are presented in two international conferences:
- COLLOQUIUM 2013 – Health Systems and Control of Neglected Diseases in Asia – ITM 3rd International Colloquium; Vijayashree Holalkere Yellappa, Pierre Lefèvre; November 2013;71
- 44th World Conference on Lung Health of the International Union Against Tuberculosis and Lung Disease, Paris, France, November 2013. Vijayashree Yellappa, Tullia Battagluuoli, Narayanana Devadasan, Patrick Vab der Styuft. Assessment of Private health providers’ participation in National Tuberculosis Programme in South India. Internation Journal of TB and Lung Disease;2013;17(12):338.
Short Video on “Optimising the involvement of private practitioners in TB care: An implementation research”
- District TB office is closely associated with this research. This study has been acknowledgedas one of the top innovations by the “social Innovation in Health Initiative”. Our application is available on youtube (https://youtu.be/Pgo87hkz5Ok), This similar research is going to be expanded to Tumkur rural areas through a WHO-TDR grant that we will be receiving in 2016 (http://www.who.int/tdr/news/2015/impact-grant/en/)
Dr Dorothy Lall
She started her PhD in Aug 2015 and is registered at Maastricht University, School for Public Health and Primary Care. She is guided by Prof. Klasien Horstman (Maastrict University, The Netherlands) , Prof Bart Criel (Institute of Tropical Medicine, Antwerp), Dr Nora Engel (Maastricht university, The Netherlands) and Dr Devadasan (Institute of Public Health, Bengaluru). During her PhD she will be studying the organization and quality of health care service delivery for chronic Non Communicable Diseases such as diabetes and Hypertension in both the public and private sector using a contextual Chronic Care Model as a lens/ framework. Further, during the course of this 4 year PhD program she will develop and test effectiveness of interventions that are feasible to implement at the primary care level. This study will be conducted in Kolar District of Karnataka and will involve both private and public health care delivery services.
This research study aims to understand how health care services are organized and delivered in both public and private health care sectors and further how we can improve quality of care for persons with a chronic disease (Diabetes and Hypertension) at primary care level in rural Indian. Chronic Non Communicable diseases (NCDs) have emerged as a major public health challenge, in India, with a rapidly escalating burden within a health system that is still largely geared towards acute care. There is however a paucity of literature regarding how we can improve service delivery to provide quality care for a person with a chronic NCD in a middle income country like India. It is this gap in literature we hope to address in this research study. The study has 2 phases (1st phase of 15 months +2nd Phase of 18 months). The objective of this 1st phase of the study is to describe and critically analyze the current service delivery for diabetes and hypertension at primary health care both in the public and private health care delivery systems. In order to understand the organization and delivery of health care services for diabetes and hypertension at the primary health care level from both patient and provider perspectives, the study uses the Chronic Care Model (CCM) as a lens/ framework, complementing it, when deemed appropriate, with additional elements relevant to the Indian context, based on literature and field experiences. The CCM is a widely used framework to organize health services for chronic diseases, and is well supported with evidence of improved quality of care for persons with a chronic disease. It is not a prescriptive model, but identifies a number of domains to be addressed in planning delivery of services, such as having clearly identified roles and tasks for the team delivering care, the need for leadership of the team and support for clinical decision making and information systems to manage regular follow up. It also highlights the role of patients themselves in managing their illness, participating in decision making regarding clinical management, and utilizing community resources to support them. In addition to these domains, we further identified from literature other elements that impact quality of care such as training of the doctors in clinical management, availability of drugs and human resources, referral mechanism in caring for persons with a chronic Non Communicable disease (NCD) such as diabetes and hypertension.
We propose to use a mixed methods approach for this 1st phase. We will purposively select 7 health care facilities (4 public and 3 private) that are accessed for chronic NCDs, specifically Diabetes and Hypertension based on the availability of basic infrastructure and a medical doctor. The quantitative strand of the study is a survey of persons detected to have high blood glucose or high blood pressure during screening activities of the national control program to determine if they accessed care for treatment and if so where. This survey will enable us to identify persons who do not seek care and also the health facilities (public and private) most accessed for care. We will conduct semi structured interviews with the persons who did not seek care to understand barriers related to the health system that prevent them At the health care facilities selected we will collect data through participant observations and semi structured interviews with treating physicians and patients with a chronic NCD. Data will be thematically analyzed and findings will be compared with the theoretical assumptions/starting points and the implications for the theoretical framework will be discussed. The emerging results will be used to identify gaps in service delivery of the organization of care for Diabetes and Hypertension. Based on these findings, we shall develop interventions to strengthen care for patients with Diabetes and Hypertension and this will implemented and evaluated in the second phase of our research.
Data collection for Phase will begin in April 2016
Proposed timeline for the study
Meet the Past PhD Scholars
Dr N Devadasan
Deva completed his PhD from Ghent University, titled “Community health insurance contributes to universal health coverage in India”. His promoters were Prof. Dr. Patrick Van der Stuyft, Ghent University & Prof. Dr. Bart Criel, Institute of Tropical Medicine, Antwerp.
Some Indian non-governmental organisations (NGOs) have initiated community health insurance (CHI) schemes to address this problem. Experts define CHI as any not-for-profit insurance scheme aimed primarily at the informal sector, formed on the basis of a collective pooling of health risks, and in which the members participate in its management. The number of CHI schemes in India has grown exponentially in the past decade, partially fuelled by the micro-credit movement.
In theory, CHI is a relevant option for the informal sector with its combination of pre-payment and risk pooling mechanisms. However, there is little evidence that Indian CHI schemes increase access to care and protect against catastrophic health expenditures (CHE). The objective of our research was to investigate whether and under what conditions CHI improves access to hospital care, provides protection against CHE and increases patient satisfaction.
We first undertook a detailed case study of 10 purposively selected CHI schemes to improve our understanding of the variety of CHI schemes in India. Based on these findings, we selected three CHI schemes and studied them in greater detail. Each of the three chosen schemes (ACCORD, KKVS and SEWA)1 represented one of the types of CHI in India.
We conducted household surveys in randomly selected insured and uninsured households at ACCORD and KKVS. Data on socio-economic characteristics, morbidity patterns, health-seeking behaviour, health expenditures and patient satisfaction were collected. In addition, we conducted focus group discussions with insured and uninsured individuals, with hospital patients and providers in order to understand their perceptions of quality of care and of the CHI scheme. In all three schemes, we compiled secondary data on details of hospitalisations from existing registers and records. We measured access and the incidence of CHE.
All 10 CHI schemes studied were initiated by NGOs with the objective of increasing access to health care, preventing indebtedness and empowering communities. These CHI schemes explicitly targeted the poorest and most vulnerable households in Indian society, i.e., scheduled castes and tribes, as well as women. Further, all schemes used existing community organisations to introduce CHI, thereby building on prevailing social capital and trust. Three distinct types of CHI schemes can be distinguished based on the role of the NGO. In the provider type, the NGO was both the insurer and the provider of health care. In the mutual type, the NGO was the insurer and purchased care from providers. Finally, in the linked type, the NGO insured the community with an insurance company and purchased health care from providers.
Most of the schemes were based on voluntary enrolment, with the individual as the unit of enrolment. Membership levels in the schemes ranged from 1,000 to 100,000 individuals. Premiums were community-rated and ranged from US$0.5 to US$5 per person per year. All 10 schemes insured against hospitalisation expenses but only up to a certain amount. While most common diseases were covered, some conditions such as chronic ailments and pre-existing conditions were excluded. Very few of the schemes had proper documentation or monitoring systems. This lack of data meant that none of these schemes had empirical evidence to suggest that they increased access to hospital care or protected families from CHE.
The household survey at ACCORD demonstrated that 57% of insured and 58% of uninsured individuals experienced minor ailments during the period 2004-2005. The proportion of individuals with chronic ailments was 5% among the insured and 2% among the uninsured. The proportions of insured and uninsured individuals with major ailments were 14 and 8%, respectively.
The admission rates among the insured and uninsured were 92 and 42 per 1,000 people per year, respectively. Ninety percent of insured pregnant women delivered in a hospital, while the corresponding figure for the uninsured was 45% (χ2 = 8.6; df = 1). The study also revealed that 65% of insured patients with major ailments were admitted to a hospital, compared to 44% of uninsured patients (OR 2.2; 95% CI 1.31, 3.77). This higher admission rate among insured patients was also found in vulnerable groups, such as children, females, people of lower socioeconomic status and those living far from a hospital. In the lowest income quintile, the probability of admission for insured patients was 3.47 times higher than it was for the uninsured. Insurance status remained a significant determinant of increased utilisation of hospital services after controlling for confounding factors such as age, gender, distance from a hospital and the presence of pre-existing ailments.
This study clearly indicates that the ACCORD CHI was able to increase access to hospital care, even for the poorest and most vulnerable groups in society. Some reasons for this may be its comprehensive benefit package, affordable and subsidised premiums, credible and effective provider and a cashless system.
Our analysis of data extracted from the registers at ACCORD and SEWA showed that, in 2003 and 2004, there were 683 and 3,152 admissions, respectively. All of the patients insured by ACCORD were admitted to a not-for-profit hospital, while those insured by SEWA were mostly admitted (86%) to private-for-profit facilities. The median hospital bill per admission was US$12 for patients at ACCORD and US$46 for patients at SEWA. The median annual household income was US$630 for patients insured by ACCORD and US$545 for those insured by SEWA.
Overall, 74% of patients insured by ACCORD and 38% of patients insured by SEWA did not have to make any payments at the time of hospitalisation. The rest had to make out OOP payments because of co-payments, exclusions or both. Without health insurance, 8% of the families of patients insured by ACCORD and 49% of the families of patients insured by SEWA would have experienced CHE. The CHI scheme managed to reduce the incidence of CHE to 3.5% at ACCORD and 23% at SEWA. Not only was the incidence of CHE halved, but the intensity of the OOP payment also decreased. Without the CHI scheme, families of patients insured by both ACCORD and SEWA would have spent 14% of their annual income on hospital expenses, but the CHI scheme reduced this figure to 9% of annual income in both locations. The chances of experiencing a CHE for families of patients insured by SEWA were increased if the patient was poor, had gone to a private health care provider or needed surgery.
Our study of ACCORD and SEWA showed that in both of these schemes, CHI provided financial protection against OOP payments and CHE. However, this protection was only partial, and some patients enrolled in both of the schemes still experienced CHE. The main reasons for this were the low upper limits in both schemes and the exclusion of some clinical conditions at the SEWA scheme.
The analysis of household survey data from ACCORD indicated that 92 and 87% of insured and uninsured patients, respectively, were satisfied with the care that they received. At KKVS, the corresponding figures were 95 and 79%. While the difference in satisfaction between insured and uninsured patients was not statistically significant at ACCORD, it was at KKVS (χ2 = 7.65; df = 1).
At ACCORD, the main reasons for satisfaction among both the insured and uninsured were the health care infrastructure (84 and 78%, respectively), followed by the interpersonal interaction with the doctors and nurses. However, only about half of the patients, both insured and uninsured, were satisfied with the care process. This was because either they had to wait for a long time to receive care or their relatives were not allowed to visit them. Uninsured patients who sought care in private hospitals were less likely to be treated courteously and to receive medications from the hospital pharmacy.
At KKVS, the reasons for satisfaction were slightly different. Most of the patients, both insured and uninsured, were satisfied with the infrastructure (86 and 98%, respectively) and the doctors’ services (91 and 85%, respectively). However, a sizable number of insured and uninsured patients were dissatisfied with the nursing care they received (47 and 56%, respectively) and the care process (84 and 91%, respectively).
Our research indicates that there was little difference in satisfaction levels between insured and uninsured patients at both ACCORD and KKVS. This finding may be attributed to a lack of strategic purchasing by the respective NGOs. Also, we measured satisfaction levels on a dichotomous scale. Had we used a wider scale, we would probably have obtained a more nuanced response.
This study is one of few that have systematically evaluated the insurance functions of CHI schemes in India. Most of the CHI schemes in Africa and Asia adopt either the provider or the mutual model. However, in India, we observed the emergence of the linked model, where the risk-taker is an insurance company. This model is advantageous in that the risks are pooled more widely, both between the healthy and the ill as well as between the rich and poor.
The evidence from our study demonstrates that Indian CHI schemes can increase access to hospital care and at least partially protect families from CHE. However, to make them more effective, some critical issues must be addressed. Design features, such as minimal exclusions to reduce OOP payments, enrolment of families as a unit to control adverse selection and a referral system to prevent moral hazard, should be addressed. Simultaneously, the community must be empowered so that its members understand the complexity of the CHI and are given the space to make informed decisions. The capacity of the CHI management should be built up so that the organisers can purchase care strategically and monitor the scheme effectively. To increase financial viability, CHI schemes need to consider reinsurance with an insurance company.
However, another route to financial viability is to increase the size of the scheme by federating many CHI schemes into a single body. This provides the added advantage that such a federation will be able to negotiate effectively with both insurance companies and providers. Concomitantly, the government must create a more supportive policy environment for the development of CHI programmes in India. This could include giving legal recognition to these entities and providing the necessary subsidies to permit the poor to enrol.
The government of India recently introduced a fully subsidised national health insurance scheme (RSBY) to protect its poorest citizens from incurring hospital expenses. CHI schemes can complement the RSBY in two ways. CHI schemes can increase the depth of cover by covering ambulatory expenses for RSBY members. The second mechanism is by targeting the near-poor and low-income groups, who are also exposed to the challenges of reduced access and CHE. These changes would help with enhancing health security for a larger section of the Indian population.
To conclude, CHI schemes in India can increase access to hospital care and protect households from CHE, provided that they are properly designed and implemented. Premiums must be affordable, benefit packages must be comprehensive, providers must be regulated, and reimbursements must be cashless and effortless. Such a scheme can play a crucial role in increasing the depth and breadth of social health protection in India.
Dr Prashanth N S
Prashanth NS successfully defended his PhD thesis on April 21st, 2015 at Universite Catholique de Louvain in Brussels, entitled “Capacity building and performance in local health systems – A realist evaluation of a local health system strengthening intervention in Tumkur, India”. His promoters were Prof. Dr. Jean Macq, Universite Catholique de Louvain in Brussels and Bart Criel, Institute of Tropical Medicine, Antwerp.
A realist evaluation of a local health system strengthening intervention in Tumkur, India
In countries such as India, local health systems struggle to utilise their resources optimally and to deliver quality health services in an effective manner. While the reasons for these are many, poor health management capacity has been postulated to contribute to this problem. Understanding how public health organisations can move towards change through capacity building interventions is crucial to strengthening health systems. By studying a capacity building intervention of health managers in Tumkur district of southern India using a realist evaluation approach, we advance the understanding of how these interventions could contribute to organisational change. We find that capacity building programmes need to go much beyond transfer of knowledge and skills in order to effect organisational change and identify several individual and institutional factors and various alignments within decentralising local health systems that are crucial to achieving change. We conclude that human resources management strategies in Karnataka ought to invest in altering workplace conditions and organisational culture through restructuring the current health bureaucracy so that committed health managers could better utilise change opportunities presented by capacity building programmes.
- Video on PhD defence: Studying organisational change within local health system
- Prashanth is known to be a creative and prolific writer, and apart from writing his dissertation, he also wrote a poem about capacity building: http://www.publichealth.itg.be/2015/04/23/ns-prashanth-phd-photos-from-the-defense/
End of a PhD Journey-visit dakre.com : http://www.daktre.com/2015/05/studying-organisational-change-in-indian-district-health-systems/
- Sharing slideshare on realist evaluation of health managers capacity building programme http://www.slideshare.net/PrashanthSrinivas/phd-private-defence-realist-evaluation-of-a-capacity-building-programme-for-health-managers-in-tumkur-india
Dr Upendra Bhojani
Enhancing care for urban poor living with chronic conditions: role of local health systems
“Five-year research in a poor urban neighborhood in South India reveals a high burden of chronic conditions where the majority rely on private health facilities for care. Poverty hinders people from accessing health services and those who seek care get further impoverished. Socially defined roles and positions limit women and elderly in managing care. Fragmented services imply patients having to visit more than one facility for a single episode of care. The limited use of medical records and lack of a referral systems hinder continuity of care. Poor regulation of the private sector, lack of platforms for community engagement and corruption mark ineffective governance of the mixed local health system. The government sector fails to provide adequate care, whereas the private sector strives to maximize profits. Care for the poor is at best seen as charity. Our study unravels the complex nature of the local health system wherein implementing positive change requires careful consideration of local dynamics and opportunities.”
Click here to read more
We conducted a series of studies in KG Halli, a poor urban neighbourhood in Bangalore city in south India to analize the situation in the local health system and to understand how its role can be strengthened to improve chronic condition care for urban poor. We started with a house-to-house census using a questionnaire administered to 9299 households in KG Halli to understand self-reported illness profile, health seeking behavior and healthcare expenditure. We chose diabetes mellitus type-2 as a proxy for chronic conditions and conducted qualitative inquiries:
(1) in-depth interviews with diabetes patients from phenomenological approach to understand their experiences of living with and seeking care for diabetes; and
(2) semi-structured interviews with healthcare providers framed using health systems dynamics framework to understand gaps in organization of diabetes care in the local health system and their suggestions for feasible health service interventions to improve diabetes care.
We then conducted a quasi-experimental study in the same neighborhood where four health facilities delivered an intervention. The intervention included provision of culturally appropriate diabetes education to the patients and use of generic medications and standard treatment guidelines for diabetes management.
- Bhojani U, Beerenahalli TS, Devadasan R, Munegowda CM, Devadasan N, Criel B, Kolsteren P. No longer diseases of the wealthy: prevalence and health-seeking for self-reported chronic conditions among urban poor in Southern India. BMC Health Service Research 2013;13:306
- Bhojani U, Thriveni BS, Devadasan R, Munegowda CM, Devadasan N, Kolsteren P, Criel B. Out-of-pocket healthcare payments on chronic conditions impoverish urban poor in Bangalore, India. BMC Public Health 2012; 12(990)
- Bhojani U, Mishra A, Amruthavalli S, Devadasan N, Kolsteren P, De Henauw S, Criel B. Constraints faced by urban poor in managing diabetes care: patients’ perspectives from South India. Global Health Action 2013;6:22258
- Bhojani U, Devedasan N, Mishra A, De Henauw S, Kolsteren P, Criel B. Health system challenges in organizing quality diabetes care for urban poor in south India. PLoS ONE 2014;9(9):e106522
Bhojani U, Kolsteren P, Criel B, De Henauw S, Beerenahally TS, Verstraeten R, Devadasan N. Intervening in the local health system to improve diabetes care: lessons from a health service expirement in a poor urban neighborhood in India. Global Health Action 2015;8:28762