Joseph Matovu from Makerere University shares his experience at the e-learning workshop, 2015

Joseph Matovu from Makerere University shares his experience at the e-learning workshop, 2015

 

 

Joseph Matovu from Makerere University shares his experience at the e-learning workshop, “Get Started, Keep Moving” hosted by Institute of Public Health, Bengaluru & Institute of Tropical Medicine, Belgium. The workshop acquainted participants with various distance/blended formats.

He is a Training Manager for the CDC-­‐ funded MakSPH Fellowship Program based at Makerere University School of Public Health (MakSPH) in Kampala, Uganda. The MakSPH Fellowship Program is a public health leadership and management training program aimed at building the capacity of public health managers to manage public health challenges in Uganda.

 

Right to clean air: By Ajeet Pal Singh

Right to clean air: By Ajeet Pal Singh

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The effects of air pollution on the lungs and heart are now widely appreciated, with more incriminating evidence of its role in cardiac disease.  Air quality is represented by the annual mean concentration of fine particulate matter: PM10 and PM2.5, referring to particles smaller than 10 or 2.5 microns. The Global Burden of Disease Study identified fine particulate matter (PM2.5) in outdoor air and household air pollution from use of solid fuels as the ninth and fourth leading risk factors, respectively, for disease worldwide, and the World Health Organization attributes one in every eight deaths to air pollution. This research stems from improved understanding of the role of air pollution in initiating systemic inflammation, a response that may affect multiple organ systems.

ajeetSimilarly a study conducted in India found that average pollution levels were up to eight times higher on city roads.They reported that the exposures that one experiences on and near roads can substantially exceed what one would measure at an official monitoring site.

There is growing evidence that air pollution is an important risk factor for an increasing number of common diseases; in a recent systematic analysis study, it was found that the increase in each of the common gaseous and particulate air pollutants were significantly associated with admission to hospital for stroke or stroke related mortality, with associations strongest for strokes on the same day as exposure.

Need for political will

To curb the problem of bad air quality, a strong political will is required. It is the lack on information and knowledge about air quality due to obsolete technology and limited number of monitoring stations, which often leads to a poor decision-making. Moreover, lax standards is a major impediment. So it is important to chalk out an effective plan for thorough monitoring fulfilling the minimum requirement of monitoring for at least 104 days in a year along with that an increase in the number of monitoring sites too. This is because effective air quality planning requires accurate data. Parameters like network design of monitoring sites, maintenance, calibration of equipment and quality audits of data should be given urgent attention. Capacity for autonomous air quality planning free from industry bias is something that is needed from state regulatory authorities. Monitoring is also important to formulate policies to control it, to create awareness and sensitise people to prepare them for hard decisions. Last but not the least, decision makers should come up with plans for proactive climate change preparedness. For example, instituting policies that make bicycle commuting more accessible and convenient will help to reduce carbon emissions, improve air quality, and decrease obesity rates by facilitating physical activity.

Health system preparedness

Health systems have a major role to play in dealing with the consequences of several diseases. For this, a trained and competent workforce is central to the success of health system. Medical care providers should be trained to recognise and manage emerging health threats that may be associated with climate change. Furthermore, respiratory health should be promoted through better prevention, detection, treatment and education efforts. Besides this, allocating a unit for respiratory illness with adequate resources in terms of medicines, masks, nebulizers, ventilators and so on is something that can help to deal with the load of patients coming in times of climate change with several respiratory problems.

Increasing the number of a specialised professional i.e Pulmonologists is something that should be thought about. Moreover, training sessions should be organized for all levels of healthcare providers – from paramedics to doctors –  to deal with patients on urgent basis. Timely referrals to higher health centre with effective transportation can also another issue that needs to be looked in to.

Measures that can be undertaken

1. Diesel vehicles which are more than 10 years old should not be permitted to ply, especially in cities

2. Tightening vehicle emissions standards to world-class levels and extensive adoption of cleaner fuels in passenger vehicles (CNG, low-sulfur diesel).

3. Cleaning up the high emitting trucks that ply at night, reducing urban burning of wood and wastes, reducing emissions from  diesel backup generators, and cleaning up rural industries such as brick kilns.

4.  Switch to polluting methods, whenever possible. For example, solar electricity is now price competitive with imported coal power in the Indian market.

Scope for public health involvement

Public health practitioners have a responsibility to effectively engage with policy makers about the need for proactive climate change preparedness .By providing a critical health perspective, public health professionals can communicate the significant health impact that are likely to occur if adequate preparedness measures are not adopted. Public health professionals can educate policymakers about the health benefits that will result from sound climate preparedness planning. Public health department and agencies should take help of communication tools tailored to community,and population which would have greater impact on community members. Few are as follows –

1. Use variety of media outreach strategies that would be effective for different age groups (like radio,local news,social media sites,etc.)

2. Have brochures and media outreach in multiple languages

3. Door to door outreach may be more effective for some communities

4. Use non-traditional outlets of education and outreach(like meals on wheels,celebrities, sporting events etc.)

Ajeet Pal Singh  was a  student of e-learning course in Public Health Management(ePHM) conducted by Institute of Public Health, Bangalore, India.

Disclaimer: IPH blogs provide a platform for ePHM students to share their reflections on different public health topics. The views expressed here are solely those of the authors and not necessarily represent the views of IPH.

Generating demand for Health programmes leading to its success: an example of  Tuberculosis from northern India: By Moumita Biswas

Generating demand for Health programmes leading to its success: an example of Tuberculosis from northern India: By Moumita Biswas

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In India, only 20% people with minor illness, and only 50% people with serious illness come to Government hospitals. Thus, there is a need to understand the reasons influencing health care seeking practices to generate demand for health programmes. Amongst rural and tribal communities in Madhya Pradesh, it has been generally noticed that the first point of contact for any illness is a private provider, many-a-times an untrained practitioner, since they are easily accessible. Literacy level is quite low in the state, particularly in rural and tribal communities, resulting in being unaware of the basic symptoms of Tuberculosis (TB) and availability of free treatment and diagnostics at Government health facilities. Some TB patients also discontinue treatment, due to lack of awareness. At times these people also get required medications from a local pharmacist, since they have low faith in Government health system and when condition worsens (both in terms of health as well as finances), they visit a Government health facility. Also these communities are generally dependent on daily labour, leading to delayed TB diagnosis and treatment, in fear of loss of wages. Alcoholism & tobacco use of all forms is predominant in these communities, thus affecting the treatment adherence.

Barriers & constrainMoumita's photots

With reference to the programme delivery, a number of barriers play a role in influencing health care seeking behaviour of rural and tribal communities of Madhya Pradesh, such as unavailability of health staff, poor accessibility due to distance, unavailability of medicines and other requirements, to name a few. A major proportion of rural and tribal communities are residing far off from the Government health facilities, and thus even if the PHC is open and there are health staff providing services round the clock, it is difficult for a sick person to reach the PHC.

Beliefs influencing TB health seeking behaviour

Rural people in India and tribal populations in particular, have their own beliefs and practices regarding health. Some tribal groups still believe that a disease is always caused by hostile spirits or by the breach of some taboo. They therefore seek remedies through magic and religious practices.

Amongst tribals in Madhya Pradesh, evil spirits are attributed to be the cause of TB. The belief that TB occurs due to supernatural powers lead to the concept of seeking relief through magic, keeping the allopathic medical practitioner as a last resort. There are also beliefs that they cannot get TB, hence leading to delayed treatment seeking.

Lessons learnt and way forward

To summarize, there are many reasons for people to go to a particular health provider. Most important reasons include awareness, money, distance and availability of staff. These factors play a role in creating demand for any health programme, particularly the Revised National TB Control Programme (RNTCP). Hence, there is a need to address the issues that influence TB health seeking behavior such as improving the availability of trained staff at health facilities, enhance level of awareness amongst the community about TB – IEC activities to be increased, regular patient provider meetings to ensure treatment adherence as well as improved faith in Government health system. Also in RNTCP, there is a scope for involvement of NGOs in the programme – since most of the rural and tribal habitations are quite interior, Sputum collection centres can be established through NGOs nearer to these communities.

Moumita Biswas was a  student of e-learning course in Public Health Management(ePHM) conducted by Institute of Public Health, Bangalore, India.

Disclaimer: IPH blogs provide a platform for ePHM students to share their reflections on different public health topics. The views expressed here are solely those of the authors and not necessarily represent the views of IPH.

Role of NRCs (Nutrition Rehabilitation centre) in preventing malnutrition related deaths among under 5 children in Odisha: By Niranjan Bariyar

Introduction

Acute malnutrition or wasting is a failure to gain weight or actual weight loss caused by inadequate food intake, incorrect feeding practices, infections or a combination of these. Considered both a medical and social disorder, Severe Acute Malnutrition (SAM) is defined by very low weight for height (Z-score below -3 SD of the median WHO child growth standards), or a mid-upper arm circumference <115 mm/<11.5cm, or by the presence of bipedal nutritional edema.

Case fatality rate of SAM children with complications can be reduced by 90% through standard case management protocol like specialized treatment and prevention interventions at NRCs (Nutritional Rehabilitation Centres). Under national health programme in India, SAM cases are divided into two categories – those with medical complications such as diarrhea, fever, and pneumonia, needing facility based care and those without complications who can be managed in the community. Not more than 10% of SAM children require facility based care, after which follow up in the community is required to prevent relapse.

Nutritional Rehabilitation Centres in Odisha

Odisha is an underprivileged state in Eastern India and is categorized as an Empowered Action Group (EAG) state. It means it is among the nine states of India characterized with relatively higher fertility and mortality and accounts for 48% of the country’s population. Infant Mortality Rate of Odisha is 56 and Under 5 mortality rate stands at 75 (AHS 2012 – 13). Under-nutrition is the underlying cause in 55% of all the under 5 deaths. In Odisha, severe wasting among under 5 children is 5.2%, whereas in non-EAG states it ranges from 2 -4%. Scheduled caste and tribes comprise 40% of the state’s population who are socio economically the most challenged community. Various data sources like NFHS-31,AHS- 20132, Census 20113 and DLHS-34 show that Odisha still has high poverty levels, low female literacy, high incidence of malaria and diarrhea and poor IYCF practices. All these contribute to the poor nutritional status including SAM among under fives.

NRCs have been started under the National Rural Health Mission (NRHM) in Odisha and so far, 44 have been established with uniform bed strength of 10 per NRC. Currently around 75% of children are discharged as cured.

Challenges faced

Data from 16 NRCs of Western Odisha from July to December 2014 reveals several challenges faced by the NRCs

1. Poor bed occupancy rate (just over 50%) – this is due to poor detection of SAM in the field due to low levels of use of Mid-Upper Arm Circumference (MUAC tape) and poor detection of SAM with complications even at the Community Health Centers (CHC).

2. Few admissions of SAM children with complications (from case sheets maintained at the NRCs. Data on fever, diarrhea and ARI are not captured in the NRC MIS). SAM children with complications are admitted to the pediatric ward in larger hospitals and not to the NRC though there is a pediatrician in charge to manage such children.

3. High default rate (12.5%). Undernutrition being so prevalent in the community, it is considered normal and many mothers think it is un-necessary to admit children for being “thin”, especially when they fail to recognize symptoms of complications. Other responsibilities at home, loss of wages, cost of transport to and from the centre – all contribute to the default rate as well as to poor follow-up after discharge.

4. Poor follow up after discharge (less than 10% attend 3 follow up visits after discharge)

Therefore NRCs in Odisha mostly manage children who were low birth weight and fail to gain weight even after two months; mothers following poor IYCF practices; non-breastfed children and SAM children without complications referred by ICDS (Integrated Child Development Services) workers and supervisors.

The perception of severe under-nutrition as an abnormal condition can only be changed through intense nutrition education of the community, regular weighing of children and discussion of weights with the parents, and through proper counseling at the NRCs. NRC activities also needs to be more interactive and engage mothers. SAM children with complications mostly come from remote and vulnerable tribal pockets. Pressure for livelihood generation and household management do not allow mothers to get admitted in NRCs along with their children. Hence, wage loss compensation for mothers admitted in NRC should be increased to the current minimum wage, along with increased attention to improve nutritional status of tribal women through life cycle approach. Innovative strategies like working with self-help groups (SHGs), and the National Rural Livelihoods Mission (NRLM) groups can also be adopted.

NRCs will reduce child mortality but will not improve the general nutritional status of children in the community. Therefore preventive and promotive efforts must be continued.Strengthening of community based mechanisms for identification, prevention and management of severe acute malnutrition is a must, in the absence of which NRCs will not be effective. Facility based approach may prevent some under 5 deaths, but will not be useful in addressing this problem in the community

1 National Family Health Survey, 2005-06.

2 Annual Health Survey, Odisha 2013, Registrar General of India.

3 Census 2011, Registrar General of India

4 District Level Health Survey 3, Registrar General of India

Niranjan Bariyar was a  student of e-learning course in Public Health Management(ePHM) conducted by Institute of Public Health, Bangalore, India.

Disclaimer: IPH blogs provide a platform for ePHM students to share their reflections on different public health topics. The views expressed here are solely those of the authors and not necessarily represent the views of IPH.

Harnessing ICT in health care services in India: By Ajay Goel

Harnessing ICT in health care services in India: By Ajay Goel

AjayIndia with a current population of 1.25 billion is posed to be the highest populated country with 1.6 billion by 2050. Indian public health planners have a huge challenge ahead – to serve and keep population healthy. Health care service resources will not increase in proportion to this population increase. The situation of high geographical disparities in health and wellbeing of population in addition to the demographic and epidemiological transitions taking place during this period will demand continuous spatiotemporal adjustments in plans and realignment of health care resources allocation. To address these challenges, health-planning process needs to evolve by provisioning maximum use of Information and Communication Technology (ICT) in health care delivery and public health decision making at every level. This is to deliver right health services to right people at right place and on right time.

Many academic literatures point to the importance of strategic partnerships between the ICT and healthcare sectors. To transform conventional information system into modern, real time and contextual public health information system, there is a need to strengthen health care data/ information collection, exchange and analysis using range of following available ICT areas: application service provision, database and software support, electronic health records, health information systems, intelligence systems, Geographic information systems, security services and tele-health systems.

Despite having a big ICT talent pool, infrastructure and other resources advantage, use of ICT in health care in India has not been successful and varies state to state. Low use of ICT in health care contributes to poor patient care, poor and slow data reporting to HMIS lead to delayed, inefficient and insufficient public health response. In a BMJ blog the authors documented their experience with vital registration system in Karnataka state in India. Though Karnataka has 90% vital registration recording, full potential of such data for public health decision and policy making remains unachieved. It is a general perception among health system researchers in India that private and unorganized health care sectors possess biggest challenge in successful use of ICT in health care. Many success stories both at international level and within India show that improvement in health care delivery owing to successful use of ICT. It boosts the utilization of state run health services; encourages private sector to join ICT wagon and will minimize or gradually eliminate unorganized and uncertified health care sector. In Tamil Nadu, HMS was launched in May 2005 that contributed to improved health care and allowed health workers, even in remote areas, immediately report disease incidence data to health officials. In turn, health managers were able to quickly analyze information about suspected cases, share technical information and resources, and initiate an informed response.

A careful and systematic review of documentation of various health care information systems around the world provides insight into factors contributing to the ineffective ICT and HMIS implementation. These factors include failure to take into account the social and professional cultures of healthcare organizations; inadequate attention to the need for education of users; underestimation of the complexity of routine clinical and managerial processes by IT developers; lack of commitment among stakeholders due to different expectations; not learning from past project failures; low understanding of ICT for patient care and in clinical setting by clinicians and health care practitioners and similarly missing health care context knowledge among IT professionals and data analysts; and not linking various health care and demographic information systems.

To reap the benefits of ICT in health care and public health, some fundamental measures are required to create ICT awareness and data culture among health care provider and public health decision maker. Measures as simple as introduction of curriculum on best use of ICT in medical courses can have huge influence on aspiring clinicians and health workers to record, organize, use and share patient information. Other successful measures being used around the world include developing a dedicated cadre of public health data scientist (Computer science + Statistics + Epidemiology + Public health + medical knowledge) – to collect, analyse, synthesize and transform public health data into intelligence to support timely evidence-based decision making at every level; establishing a national level health intelligence unit which collect information in real time from different sources; expanding and including the use of Geographical Information system to create public health geo-intelligence for rapid detection of health event of major concern ; improving health risk communication to public using various m-health initiatives; and integrating various health information system including census and vital registration system.

In conclusion I would like to say, careful, smart and contextual integration of ICT in health care service delivery and resulting improved HMIS should be core and prioritized strategies to response complex health need of a country of over billion people with diversified social and cultural practices. India needs to do it and do it now.

Ajay Goel was a  student of e-learning course in Public Health Management(ePHM) conducted by Institute of Public Health, Bangalore, India.

Disclaimer: IPH blogs provide a platform for ePHM students to share their reflections on different public health topics. The views expressed here are solely those of the authors and not necessarily represent the views of IPH.