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Angell BJ, Prinja S, Gupt A, Jha V, Jan S. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana and the path to universal health coverage in India: Overcoming the challenges of stewardship and governance. PLoS Med 2019; 16:e1002759. [PMID: 30845199 PMCID: PMC6405049 DOI: 10.1371/journal.pmed.1002759] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In an Essay, Blake Angell and colleagues discuss ambitious reforms planned to expand coverage of the health system in India.
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Affiliation(s)
- Blake J. Angell
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- * E-mail:
| | - Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anadi Gupt
- National Health Mission, Government of Himachal Pradesh, Shimla, Himachal Pradesh, India
| | - Vivekanand Jha
- The George Institute for Global Health, University of New South Wales, New Delhi, India
- University of Oxford, Oxford, United Kingdom
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Salve S, Harris K, Sheikh K, Porter JDH. Understanding the complex relationships among actors involved in the implementation of public-private mix (PPM) for TB control in India, using social theory. Int J Equity Health 2018; 17:73. [PMID: 29880052 PMCID: PMC5991467 DOI: 10.1186/s12939-018-0785-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 05/29/2018] [Indexed: 11/29/2022] Open
Abstract
Background Public Private Partnerships (PPP) are increasingly utilized as a public health strategy for strengthening health systems and have become a core component for the delivery of TB control services in India, as promoted through national policy. However, partnerships are complex systems that rely on relationships between a myriad of different actors with divergent agendas and backgrounds. Relationship is a crucial element of governance, and relationship building an important aspect of partnerships. To understand PPPs a multi-disciplinary perspective that draws on insights from social theory is needed. This paper demonstrates how social theory can aid the understanding of the complex relationships of actors involved in implementation of Public-Private Mix (PPM)-TB policy in India. Methods Ethnographic research was conducted within a district in a Southern state of India over a 14 month period, combining participant observations, informal interactions and in-depth interviews with a wide range of respondents across public, private and non-government organisation (NGO) sectors. Results Drawing on the theoretical insights from Bourdieu’s “theory of practice” this study explores the relationships between the different actors. The study found that programme managers, frontline TB workers, NGOs, and private practitioners all had a crucial role to play in TB partnerships. They were widely regarded as valued contributors with distinct social skills and capabilities within their organizations and professions. However, their potential contributions towards programme implementation tended to be unrecognized both at the top and bottom of the policy implementation chain. These actors constantly struggled for recognition and used different mechanisms to position themselves alongside other actors within the programme that further complicated the relationships between different actors. Conclusion This paper demonstrates that applying social theory can enable a better understanding of the complex relationship across public, private and NGO sectors. A closer understanding of these processes is a prerequisite for bridging the gap between field-level practices and central policy intentions, facilitating a move towards more effective partnership strategies for strengthening local health systems. The study contributes to our understanding of implementation of PPP for TB control and builds knowledge to help policy makers and programme managers strengthen and effectively implement strategies to enable stronger governance of these partnerships.
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Affiliation(s)
- Solomon Salve
- Health Governance Hub Public Health Foundation of India, Plot No. 47, Sector 44, Institutional Area, Gurgaon, Haryana, 122002, India. .,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7H, UK.
| | - Kristine Harris
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7H, UK
| | - Kabir Sheikh
- Health Governance Hub, Public Health Foundation of India, Plot No. 47, Sector 44, Institutional Area, Gurgaon, Haryana, 122002, India
| | - John D H Porter
- Departments of Clinical Research and Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7H, UK
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Kojima N, Krupp K, Ravi K, Gowda S, Jaykrishna P, Leonardson-Placek C, Siddhaiah A, Bristow CC, Arun A, Klausner JD, Madhivanan P. Implementing and sustaining a mobile medical clinic for prenatal care and sexually transmitted infection prevention in rural Mysore, India. BMC Infect Dis 2017; 17:189. [PMID: 28264668 PMCID: PMC5338078 DOI: 10.1186/s12879-017-2282-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 02/22/2017] [Indexed: 11/20/2022] Open
Abstract
Background In rural India, mobile medical clinics are useful models for delivering health promotion, education, and care. Mobile medical clinics use fewer providers for larger catchment areas compared to traditional clinic models in resource limited settings, which is especially useful in areas with shortages of healthcare providers and a wide geographical distribution of patients. Methods From 2008 to 2011, we built infrastructure to implement a mobile clinic system to educate rural communities about maternal child health, train community health workers in common safe birthing procedures, and provide comprehensive antenatal care, prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV), and testing for specific infections in a large rural catchment area of pregnant women in rural Mysore. This was done using two mobile clinics and one walk-in clinic. Women were tested for HIV, hepatitis B, syphilis, and bacterial vaginosis along with random blood sugar, urine albumin, and anemia. Sociodemographic information, medical, and obstetric history were collected using interviewer-administered questionnaires in the local language, Kannada. Data were entered in Microsoft Excel and analyzed using Stata SE 14.1. Results During the program period, nearly 700 community workers and 100 health care providers were trained; educational sessions were delivered to over 15,000 men and women and integrated antenatal care and HIV/sexually transmitted infection testing was offered to 3545 pregnant women. There were 22 (0.6%) cases of HIV, 19 (0.5%) cases of hepatitis B, 2 (0.1%) cases of syphilis, and 250 (7.1%) cases of BV, which were identified and treated. Additionally, 1755 (49.5%) cases of moderate to severe anemia and 154 (4.3%) cases of hypertension were identified and treated among the pregnant women tested. Conclusions Patient-centered mobile medical clinics are feasible, successful, and acceptable models that can be used to provide quality healthcare to pregnant women in rural and hard-to-reach settings. The high numbers of pregnant women attending mobile medical clinics show that integrated antenatal care with PMTCT services were acceptable and utilized. The program also developed and trained health professionals who continue to remain in those communities.
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Affiliation(s)
- Noah Kojima
- David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, 90095, CA, USA
| | - Karl Krupp
- Public Health Research Institute of India, 89/B, Ambika, 2nd Cross, 2nd Main, Yadavagiri, Mysuru, Karnataka, 570020, India.,Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8th Street, Miami, 33199, FL, USA
| | - Kavitha Ravi
- Public Health Research Institute of India, 89/B, Ambika, 2nd Cross, 2nd Main, Yadavagiri, Mysuru, Karnataka, 570020, India
| | - Savitha Gowda
- Public Health Research Institute of India, 89/B, Ambika, 2nd Cross, 2nd Main, Yadavagiri, Mysuru, Karnataka, 570020, India
| | - Poornima Jaykrishna
- Public Health Research Institute of India, 89/B, Ambika, 2nd Cross, 2nd Main, Yadavagiri, Mysuru, Karnataka, 570020, India
| | - Caitlyn Leonardson-Placek
- Public Health Research Institute of India, 89/B, Ambika, 2nd Cross, 2nd Main, Yadavagiri, Mysuru, Karnataka, 570020, India
| | - Anand Siddhaiah
- Public Health Research Institute of India, 89/B, Ambika, 2nd Cross, 2nd Main, Yadavagiri, Mysuru, Karnataka, 570020, India
| | - Claire C Bristow
- Division of Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Dr, La Jolla, 92093, CA, USA
| | - Anjali Arun
- Public Health Research Institute of India, 89/B, Ambika, 2nd Cross, 2nd Main, Yadavagiri, Mysuru, Karnataka, 570020, India
| | - Jeffrey D Klausner
- David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, 90095, CA, USA.,Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8th Street, Miami, 33199, FL, USA
| | - Purnima Madhivanan
- Public Health Research Institute of India, 89/B, Ambika, 2nd Cross, 2nd Main, Yadavagiri, Mysuru, Karnataka, 570020, India. .,Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8th Street, Miami, 33199, FL, USA.
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Bhaskarabhatla A, Chatterjee C. The role of physicians in prescribing irrational fixed-dose combination medicines in India. Soc Sci Med 2016; 174:179-187. [PMID: 28064064 DOI: 10.1016/j.socscimed.2016.12.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 12/09/2016] [Accepted: 12/16/2016] [Indexed: 12/28/2022]
Abstract
Many irrational fixed-dose combination (FDC) medicines have been approved by the state and central regulatory authorities in India and their use is promoted extensively by pharmaceutical firms. In this study, we examine the previously-neglected role of physicians in India, as their prescriptions are essential for the continued proliferation of FDCs. Primarily using longitudinal data on prescriptions by 4600 physicians spanning 19 disciplinary categories for 48 months between 2008 and 2011 provided by IMS Medical Audit, we study 201 medicines in the cardiovascular and oral-antidiabetic markets. We find that 129.6 million (8.1%) prescriptions for irrational FDCs were written by the sample of physicians in India during the study period, half of which were written by cardiologists and consulting physicians. A further analysis of the regional markets reveals that cardiologists prescribe more irrational FDCs in the richer, metropolitan cities of western India. We also document the role of medical practitioners without an undergraduate degree in medicine in generating prescriptions for irrational FDCs. Our results suggest that an effective government strategy to curb irrational FDCs must recognize that spreading greater awareness about the perils of irrational FDCs is at best an incomplete solution to the problem in India as many who prescribe them are specialists. Organizations such as the Indian Medical Association must develop clear guidelines to stop prescribing such FDCs.
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Affiliation(s)
- Ajay Bhaskarabhatla
- Erasmus School of Economics, Burgemeester Oudlaan 50, P.O. Box 1738, Building H12-18, 3000 DR Rotterdam, Netherlands.
| | - Chirantan Chatterjee
- Indian Institute of Management Bangalore, Room A102, Bannerghatta Road, Bengaluru, 560076, India.
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