Upendra Bhojani completes PhD in health systems and chronic conditions.
Upendra Bhojani received a PhD fellowship as part of the institutional collaboration between the Institute of Public Health (Bangalore) and the Institute of Tropical Medicine (Antwerp). He successfully defended his thesis on December 16, 2016 at the Ghent University (Belgium). His doctoral study explored the role of the local health systems in enhancing care for urban poor living with chronic health conditions in a poor urban neighborhood in Bangalore city.
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.”

To read full thesis click here –https://biblio.ugent.be/publication/8084058/file/8084095

India is leading the epidemic of chronic conditions in south Asia with non-communicable diseases – a major contributor to chronic conditions – already a leading cause of deaths and disabilities, accounting for over 60% of total deaths. In most countries including India, health systems evolved in response to providing care for acute conditions on episodic basis while people with chronic conditions require a long-term, often life-long, care. Responding to the care demands of a large number of individuals, who are already suffering from chronic conditions, is a litmus test for already weak health systems in these countries. The agenda of strengthening the existing health systems, enabling them to respond to the care demands of people with chronic conditions, increasingly feature in advocacy by global health actors. However, there remains a huge gap between available knowledge and its implementation. However, there is dearth of research on how local health system at a level of city or rural area, where policies are adopted and responsive health services are provided, could be strengthened.

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.

The student has submitted the thesis to the university and the PhD Defense is likely to take place by mid-2016.
  1. 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
  2. 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)
  3. 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
  4. 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

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