Abhimanyu Singh Chauhan

A study of organizational versus individual needs related to recruitment, deployment and promotion of doctors working in the government health system in Odisha state, India

BackgroundAn effective health workforce is essential for achieving health-related new Sustainable Development Goals. Odisha, one of the states in India with low health indicators, faces challenges in recruiting and retaining health staff in the public sector, especially doctors. Recruitment, deployment and career progression play an important role in attracting and retaining doctors. We examined the policies on recruitment, deployment and promotion for doctors in the state and how these policies were perceived to be implemented.MethodsWe undertook document review and four key informant interviews with senior state-level officials to delineate the policies for recruitment, deployment and promotion. We conducted 90 in-depth interviews, 86 with doctors from six districts and four at the state level to explore the perceptions of doctors about these policies.ResultsDespite the efforts by the Government of Odisha through regular recruitments, a quarter of the posts of doctors was vacant across all institutional levels in the state. The majority of doctors interviewed were unaware of existing government rules for placement, transfer and promotion. In addition, there were no explicit rules followed in placement and transfer. More than half (57%) of the doctors interviewed from well-accessible areas had never worked in the identified hard-to-reach areas in spite of having regulatory and incentive mechanisms. The average length of service before the first promotion was 26 (±3.5) years. The doctors expressed satisfaction with the recruitment process. They stated concerns over delayed first promotion, non-transparent deployment policies and ineffective incentive system. Almost all doctors suggested having time-bound and transparent policies.ConclusionsAdequate and appropriate deployment of doctors is a challenge for the government as it has to align the individual aspirations of employees with organizational needs. Explicit rules for human resource management coupled with transparency in implementation can improve governance and build trust among doctors which would encourage them to work in the public sector.

Assessment of factors influencing retention of health workforce in rural and remote areas of Odisha, India

Background: The scarcity of qualified health workers in rural areas is directly affecting delivery of health services and their quality. Diverse interventions have been instituted by central and state governments to attract health workers to rural areas and to enhance the retention of qualified workers. However the reasons for not willing to remain in rural and remote areas are still poorly understood. This study explores factors influencing health workers retention in rural and remote Odisha. Methods: We carried out the study in six districts of Odisha selected randomly from three geographic and administrative regions of the state. We used a mixed methods approach to study this question using both quantitative and qualitative data. A total of 226 semi-structured interviews were conducted with doctors, nurses, pharmacists, multipurpose health workers (MPHW) and laboratory technicians. A multi stage stratified random sampling was used for selecting study participants working at sub centers, primary health centers and community health centers. Results: We found that excepting few districts, the ratio of MPHW (F) to population is around 5000 in the state which is at par with the prescribed norms. The ratio of government allopathic doctor, laboratory technician and staff nurses to population are: 13000, 40000 and 15000, respectively. Majority of health staffs perceive “strong personal will to serve people”, “physical infrastructure”, “training opportunities”, “support by seniors”, “good schooling for their children” and “promotion avenues after certain years of rural service” is very important for continuing to work in rural and remote areas. Most of the participants were found to be satisfied with the support they received from their seniors and the local community, and respect and trust of their patients.The major dissatisfiers for working in rural areas included existing promotional avenues after rural service, physical infrastructure, and schooling facility for their children. Five primary reasons ranked in order of priority cited by the study participants for continuing at the same place were, namely, permanent government service, pension facility, social service, source of regular income and job satisfaction Discussion/Recommendations: Professional growth in the form of promotion and skill development, suitable physical infrastructure at workplace and schooling for their children along with additional monetary incentives were the key and inter-relating factors influencing the retention of health workforce in rural and remote areas. Hence a combination of interventions like monetary incentives with enhanced career opportunities for professional growth (training, higher studies and promotion), scholarships and preference of seats in reputed (residential) schools to the children of staff working in rural and remote areas and suitable physical infrastructure at workplace would be more effective than financial incentives alone. There is a need for clearly defined human resource policy for health personnel across all cadres with defined parameters for performance appraisal, transfer and promotion.

How supportive supervision influences immunization session site practices: a quasi-experimental study in Odisha, India

Background Routine immunization (RI) is a key child survival intervention. Ensuring acceptable standards of RI service delivery is critical for optimal outcomes. Accumulated evidences suggest that ‘supportive supervision’ improves the quality of health care services in general. During 2009–2010, the Government of Odisha and UNICEF jointly piloted this strategy in four districts to improve RI program outcomes. The present study aims to assess the effect of this strategy on improvement of skills and practices at immunization session sites. Design A quasi-experimental ‘post-test only’ study design was adopted to compare the opinion and practices of frontline health workers and their supervisors in four intervention districts (IDs) with two control districts (CDs). Altogether, we interviewed 111 supervisor–supervisee (health worker) pairs using semi-structured interview schedules and case vignettes. We also directly observed health workers’ practices during immunization sessions at 111 sites. Data were analyzed with SPSS version 16.0. Results The mean knowledge score of supervisors in CDs was significantly higher than in intervention groups. Variegated responses were obtained on case vignettes. The control group performed better in solving certain hypothetically asked problems, whereas the intervention group scored better in others. Health workers in IDs gave a lower rating to their respective supervisors’ knowledge, skill, and frequency of supervision. Logistics and vaccine availability were better in CDs. Conclusion Notwithstanding other limitations, supportive supervision may not have independent effects on improving the quality of immunization services. Addressing systemic issues, such as the availability of essential logistics, supply chain management, timely indenting, and financial resources, could complement the supportive supervision strategy in improving immunization service delivery.

Effect of Supportive Supervision on Routine Immunization Service Delivery-A Randomized Post-Test Study in Odisha

Introduction: Routine immunization is a key child survival intervention. Issues related to quality of service delivery pose operational challenges in delivering effective immunization services. Accumulated evidences suggest that “supportive supervision” improves the quality of health care services. During 2009-10, Govt. of Odisha (GoO) and UNICEF jointly piloted this strategy in four districts to improve routine immunization. The present study aims to assess the effect of supportive supervision strategy on improvement of knowledge and practices on routine immunization among service providers. Materials and Methods: We adopted a ‘post-test only’ study design to compare the knowledge and practices of frontline health workers and their supervisors in four intervention districts with that of two control districts. Altogether we interviewed 170 supervisors and supervisees (health workers), each, using semi-structured interview schedules. We also directly observed 25 ice lined refrigerator (ILR) points in both groups of districts. The findings were compared with the baseline information, available only for the intervention districts. Results: The health workers in the intervention districts displayed a higher knowledge score in selected items than in the control group. No significant difference in knowledge was observed between control and intervention supervisors. The management practices at ILR points on key routine immunization components were found to have improved significantly in intervention districts. Conclusion and Recommendations: The observed improvements in the ILR management practices indicate positive influence of supportive supervision. Higher level of domain knowledge among intervention health workers on specific items related to routine immunization could be due to successful transfer of knowledge from supervisors. A ‘pre-post’ study design should be undertaken to gain insights into the effectiveness of supportive supervision in improving routine immunization services.

Is Public Private Partnership an Effective Alternative to Government in the Provision of Primary Health Care? A Case Study in Odisha

Existing public health services are inadequate to cater to the growing demands of quality health care. Public Private Partnership (PPP) has evolved over the last decade as a newer arrangement. This study aimed to understand the breadth and depth of services in primary health centres (PHC) under government (PHC-GOV), NGO (PHC-NGO) and corporate (PHC-COR) management in Kendrapara district of Odisha. One PHC from each model was selected at random. Compliance with Indian Public Health Standards (IPHS), programme performance of last one year and perception of end-users about quality of services were studied. The Government of India (GOI) prescribed IPHS checklist, a performance indicator matrix and a semi-structured interview schedule, respectively, were used for data collection. There were no significant differences in the breadth and depth of services across all three models of PHC management. Comprehensive primary health care including immunization services, health promotion, treatment of common ailments, malaria management and delivery services were almost non-existent in these facilities. PHC-GOV had better accessibility, infrastructure, behaviour of doctors and availability of medicines, whereas laboratory service was better in PHC-NGO and PHC-COR. Human resources and programme performance of last one year was grossly inadequate across all three models. There is no remarkable improvement in the quality of services provided by PPP models. It may not serve as a substitute to inadequate recruitment and retention of staff, erratic programme review and poor capacity building, for attainment of optimal outcomes.

Physicians' nutritional counselling practices: A study in district hospitals of Chhattisgarh

Introduction: Nutrition counseling is an important tool for fostering healthy nutrition behavior among individuals. Physicians play a strategic role in imparting nutrition advice to their patient during daily encounters in healthcare settings. Present study explored nutritional counseling practices and attitudes of physicians working at district hospitals in Chhattisgarh state in India. Materials and Methods: A cross-sectional study was conducted to explore present scenario of nutritional counseling practices by Physicians from 1 st April to 30 th June 2011. Questionnaires and observation guides were framed based on previous studies. Both 3-point and 5-point Likert scale were used to explore the knowledge, satisfaction, and attitude related statements. Results: Majority of the respondents (76%) were strongly in favor of training in nutrition counseling and 35% believed that they should spend more time exploring dietary habit of patients in routine practice. Fifty-four percent of practitioners were of the opinion that counseling is futile and 62% considered counseling as time-consuming process. Majority of physician expressed their willingness to undergo additional training in nutrition. Discussion: In view of emerging burden of chronic disease related to nutrition and life style, it is imperative that physician should be trained adequately so as to advice their patients appropriately, pertaining to nutrition.

Weaved into the cultural fabric : a qualitative exploration of alcohol consumption during pregnancy among tribal women in Odisha, India

BackgroundEvidence-based research has documented the association between alcohol intake during pregnancy and increased risk of miscarriage, stillbirth and congenital birth defects. Alcohol consumption is a complex behavior whose origins lay in cultural norms and the social structure. In tribal communities in India, alcohol misuse among women is a public health problem. This study is intended to explore perceptions and beliefs among tribal women and the community towards alcohol consumption during pregnancy.MethodsA qualitative study was conducted in a tribal-dominated district of Odisha, India. The WHO AUDIT tool was used to identify women who consumed alcohol during their pregnancies. In-depth interviews were conducted with 19 eligible women and 18 family members. Additionally, two focused group discussions were held with local community leaders and health workers. The data was transcribed, systematically coded and analyzed following the thematic framework approach.ResultsThe findings suggest that a complex interplay of drivers contributes to the unrestricted intake of alcohol by pregnant women. This could be attributed to: a lack of social monitoring, easy access to alcohol, low alcohol literacy and alcohol’s normative status in daily customs and traditions. Another contributing factor is a community-wide perception that home-made alcohol poses no ill effects.ConclusionAlcohol consumption is deeply embedded in the daily rituals of indigenous tribal women. To address this issue, community counselling utilizing platforms of RMNCHA and VHND could be Ideal. A well-designed, culture-based intervention encompassing alcohol researchers, mental health specialists, public health workers and anthropologists is necessary.

Antimicrobial resistance in South East Asia: time to ask the right questions

ABSTRACT Antimicrobial resistance (AMR) has emerged as a major public health concern, around which the international leadership has come together to form strategic partnerships and action plans. The main driving force behind the emergence of AMR is selection pressure created due to consumption of antibiotics. Consumption of antibiotics in human as well as animal sectors are driven by a complex interplay of determinants, many of which are typical to the local settings. Several sensitive and essential realities are tied with antibiotic consumption – food security, livelihoods, poverty alleviation, healthcare access and national economies, to name a few. That makes one-size-fits-all policies, framed with the developed country context in mind, inappropriate for developing countries. Many countries in the South East Asian Region have some policy structures in place to deal with AMR, but most of them lack detailed implementation plans or monitoring structures. In this current debates piece, the authors argue that the principles driving the AMR agenda in the South East Asian countries need to be dealt with using locally relevant policy structures. Strategies, which have successfully reduced the burden of AMR in the developed countries, should be evaluated in the developing country contexts instead of ad hoc implementation. The Global Action Plan on AMR encourages member states to develop locally relevant National Action Plans on AMR. This policy position should be leveraged to develop and deploy locally relevant strategies, which are based on a situation analysis of the local systems, and are likely to meet the needs of the individual member states.

PRACTICING HEALTH PROMOTION IN PRIMARY CARE – A REFLECTIVE ENQUIRY

Summary Introduction Health promotion is an integral part of routine clinical practice. The physicians’ role in improving the health status of the general population, through effective understanding and delivery of health promotion practice, is evident throughout the international literature. Data from India suggest that physicians have limited skills in delivering specific health promotion services. However, the data available on this is scarce. This study was planned to document the current health promotion knowledge, perception and practices of local primary care physicians in Odisha. Methods An exploratory study was planned between the months of January – February 2013 in Odisha among primary care physicians working in government set up. This exploratory study was conducted, using a two-step self-administered questionnaire, thirty physicians practicing under government health system were asked to map their ideal and current health promotion practice, and potential health promotion elements to be worked upon to enhance the practice. Results The study recorded a significant difference between the mean of current and ideal health promotion practices. The study reported that physicians want to increase their practice on health education. Conclusion We concluded that inclusion of health promotion practices in routine care is imperative for a strong healthcare system. It should be incorporated as a structured health promotion module in medical curriculum as well.

One Health/EcoHealth capacity building programs in South and South East Asia: a mixed method rapid systematic review

BackgroundAlthough One Health (OH) or EcoHealth (EH) have been acknowledged to provide comprehensive and holistic approaches to study complex problems, like zoonoses and emerging infectious diseases, there remains multiple challenges in implementing them in a problem-solving paradigm. One of the most commonly encountered barriers, especially in low- and middle-income countries, is limited capacity to undertake OH/EH inquiries. A rapid review was undertaken to conduct a situation analysis of the existing OH/EH capacity building programs, with a focused analysis of those programs with extensive OH engagement, to help map the current efforts in this area.MethodsA listing of the OH/EH projects/initiatives implemented in South Asia (SA) and South East Asia (SEA) was done, followed by analysis of documents related to the projects, available from peer-reviewed or grey literature sources. Quantitative data was extracted using a data extraction format, and a free listing of qualitative themes was undertaken.ResultsIn SEA, 13 unique OH/EH projects, with 37 capacity building programs, were identified. In contrast, in SA, the numbers were 8 and 11 respectively. In SA, programs were oriented to develop careers in program management, whereas, in SEA, the emphasis was on research. Two thirds of the programs in SEA had extensive OH engagement, whereas only one third of those in SA did. The target for the SEA programs was wider, including a population more representative of OH stakes. SEA program themes reveal utilization of multiple approaches, usually in shorter terms, and are growing towards integration with the traditional curricula. Such convergence of themes was lacking in SA programs. In both regions, the programs were driven by external donor agencies, with minimal local buy-in.ConclusionsThere is limited investment in research capacity building in both SA and SEA. The situation appears to be more stark in SA, whilst SEA has been able to use the systematic investment and support to develop the OH/EH agenda and strategize capacity building in the core competencies. In order to effectively address the disease emergence hotspots in these regions, there needs to be strategic funding decisions targeting capacity building in the core OH/EH competencies especially related to transdisciplinarity, systems thinking, and adaptive management.