Utilization of maternal health care services in Southern India

This paper examines the patterns and determinants of maternal health care utilization across different social settings in South India: in the states of Andhra Pradesh, Karnataka, Kerala and Tamil Nadu. Data from the National Family Health Survey (NFHS) carried out during 1992-93 across most states in India are used. Results show that utilization of maternal health care services is highest in Kerala followed by Tamil Nadu, Andhra Pradesh and Karnataka. Utilization of maternal health care services is not only associated with a range of reproductive, socio-economic, cultural and program factors but also with state and type of health service. The interstate differences in utilization could be partly due to variations in the implementation of maternal health care program as well as differences in availability and accessibility between the states. In the case of antenatal care, there was no significant rural-urban gap, thanks to the role played by the multipurpose health workers posted in the rural areas to provide maternal health care services. The findings of this study provide insights for planning and implementing appropriate maternal health service delivery programs in order to improve the health and well-being of both mother and child.     

Primary health care services through health centres

In South Madras, India, Voluntary Health Services (VHS) operates under the concepts that prevention is an important as cure, the family is the unit for medical care, and community participation. It uses a voluntary health plan as a means to provide preventive and curative health care for residents who pay a fee based on their income. Subscribing to this plan allows them access to preventive and curative services at the nearest VHS regional health center and hospital care at the VHS Medical Centre at Adyar, Madras, in India. Since the inception of this plan, VHS has expanded to rural areas using the Mini Health Centre (MHC) model. This model was developed at the St. Thomas Mount Community Development Block of Chingleput District of Tamil Nadu State in the mid-1960s and put into operation in the late 1960s. A male and female multipurpose worker in the MCH serves 5000 people. A physician is there at least 3 hours/day for 3 days/week. A lay worker staffs a health post and attends to 1000 people. The MHC provides maternal-child health, family planning, and referral services; health and nutrition education; control of communicable disease activities; curative care; and environmental sanitation. Community participation includes provision of buildings and minimal furniture, financial support (e.g., the community provides 33% of the total budget resources), and a nonpolitical local action committee. The state of Tamil Nadu and the central government provide financial incentives to other voluntary group to set up MHCs (as of June 1993, 261 MHCs existed). Vital statistics indicate that MHCs improve the health status of the population (e.g., infant mortality rate in 1977 = 134 and in 1989 = 36.5). Some weaknesses with MHCs are unmotivated medical officers, high turnover rate of staff due to low pay scales, and financial obstacles.     

IEEE (Institute of Electrical and Electronic Engineers) P1157 Medical Data Interchange (MEDIX): application of open systems to health care communications

IT offers the potential for controlling the rising costs of health care while continuing to improve the quality of health care delivery. Health care communications standards are a necessary condition to accelerating the diffusion of IT in health care. The IEEE P1157 standards, which are international in scope, are being developed by a process of open participation under the auspices of the IEEE EMBS to meet strict conformance to the ISO/OSI standards. The IEEE P1157 standards are being coordinated with related health care information systems and will make an important contribution in this area. The initial focus of the IEEE P1157 committee will provide a needed subset of the eventual standard in 1991. The long-term focus on the patient record will provide the groundwork for extension of the effort to cover communications in all of health care. Development of these standards is based upon voluntary effort. All health care professionals with an interest in this area are urged to participate actively in the process.     

Dental public health strategies and health care reform.

There are significant challenges that need to be met to improve oral health in this country. Even if access to clinical preventive dental services is increased through a national health care plan, substantial improvement in the country's oral health cannot be achieved without support and assistance of public health initiatives. In January 1993, the steering committee for the Core Functions Project, U.S. Public Health Service, issued a report, Health Care Reform and Public Health: Population-Based Core Functions, to address the health care needs and conditions of populations as opposed to the individual health care needs under consideration by the national health care reform initiative. By adapting the report's core functions to the public's oral health, this article lays a foundation for the prevention, protection, and promotion of America's oral health.     

Public health in India: issues and challenges

Health is determined not only by medical care but also by determinants outside the medical sector. Public health approach is to deal with all these determinants of health which requires multi sectoral collaboration and inter-disciplinary coordination. Although there have been major improvements in public health since 1950s, India is passing through demographic and environmental transition which is adding to burden of diseases. There is triple burden of diseases, viz. communicable, non-communicable and emerging infectious diseases. This high burden of disease, disability and death can only be addressed through an effective public health system. However, the growth of public health in India has been very slow due to low public expenditure on health, very few public health institutes in India and inadequate national standards for public health education. Recent years have seen efforts towards strengthening public health in India in the form of launch of NRHM, upgradation of health care infrastructure as per IPHS, initiation of more public health courses in some medical colleges and public health institutions and strengthening of public health functional capacity of states and districts under IDSP.     

Quality standards for health care delivery and management in publicly oriented health services

In 1999, the multidisciplinary Tavistock group prepared a generic statement of ethical principles to govern health care systems. This paper elaborates on these principles in two directions. First, it develops a set of quality standards, based on ethical principles, intended to regulate health care delivery and service management. Second, it focuses them on 'publicly oriented' (not necessarily governmental) as opposed to 'for profit' (not necessarily private) services. We propose ten principles or quality standards for these services, part of which relate to the individual patients, others to the community. They are political as well as technical, and can be used to inspire health policies, contracts issued by governments, and identification of partners by aid agencies. We analyse their application in key areas of health care by publicly oriented and for-profit health care organizations standards in developing countries, and conclude that the latter are unlikely to adopt the proposed standards. We further elaborate on the implications of the standards for publicly oriented services, focusing on care delivery and patient-centred care, family and community medicine, services management and disease control. Using these criteria for a renewed compact between authorities, health professionals and communities may help to motivate health professionals by bridging the gap between their professional and social-political identity.     

Medicaid and health information: current and emerging legal issues

Legal questions are an inevitable byproduct ofsignificant technology change in health care such as that underway as a result of health information technology (HIT). This article examines several important existing and emerging legal questions in a Medicaid context. First, do the Centers for Medicare & Medicaid Services (CMS) and State Medicaid agencies, have a fiduciary obligation to adopt and fully use health information technology given its potential to improve health care quality while reducing racial, ethnic, and socioeconomic disparities in health and health care? Second, how can Medicaid privacy standards be reconciled with the Health Insurance Portability and Accountability Act (HIPAA) privacy rule? Third, what actual or perceived legal barriers exist to ensuring that Medicaid information is interoperable with data produced under critical health care, educational, and social programs from which beneficiaries are simultaneously receiving care?     

Scope of health systems research in Child Survival and Safe Motherhood programme

Editorial commentary focused on several Health System Research (HSR) approaches which exemplified some of the key issues for application of HSR for further improvement in Maternal and Child Health (MCH) services in India. The goals of HSR are to delineate health policy which improves the operations of the health care delivery system for sustainability at the district level. HSR is part of a global effort of Health For All by 2000 AD and India's Child Survival and Safe Motherhood (CSSM) program, sponsored by IDA/UNICEF. CSSM aims also to end polio by 2000 AD, eliminate neonatal tetanus by 1995, and prevent deaths and morbidity from measles, diarrheal diseases, and acute respiratory infection. MCH services will be expanded at the village, subcenter, primary health center, and community health center levels in order to reduce maternal mortality to below 2/1000 from the 1990 5/1000 and to reduce mortality of children aged 1-4 years to less than 10/1000 live births from 80/1000 by 2000 AD. States with particularly high levels of child and maternal mortality are Bihar, Uttar Pradesh, Rajasthan, and Madhya Pradesh, which have about 40% of India's population. These states have low marriage ages, low female literacy, and few women in nonagricultural employment. There are about 90 districts in these states with particularly low demographic indicators. India policy directs all CSSM work to be carried out by existing staff; the program emphasis will be training, supervision, and logistics. IEC will need to be directed to attitudinal change in rural areas and urban slums. Research has found that coverage is uneven and quality of MCH services, poor. One study will evaluate the performance over 5 years in Gwalior district in a nutrition and school health program. Another research effort will perform quality assessment of MCH care at the primary health care level and promote community awareness and increased utilization. An ongoing study is evaluating nationally the family welfare services and MCH program at the primary health center level. The several agencies conducting HSR included the National Institute of Health and Family Welfare, the Indian Council of Medical Research, and the BJ Medical College. Multidisciplinary research is still needed in order to understand the malnutrition among pregnant mothers and use of health services by women.     

Decentralization and public delivery of health care services in India

This paper examines delivery of public health care services in India, in the broader context of decentralization. It provides an overview of the basic features and recent developments in intergovernmental fiscal relations and accountability mechanisms, and it examines the implications of these institutions for the quality of public service delivery. It then addresses recent policy proposals on the public provision of health care, in the context of decentralization. Finally, it makes suggestions for reform priorities to improve public health care delivery.     

Measuring the impact of health interventions: a review of available instruments.

Interest in the measurement of the impact of health services has been increasing for three main reasons. Policy makers and service providers wish to be reassured that they are: (i) benefitting the public for whom the service is provided; (ii) in times of economic recession and limited resources, achieving the 'best value for money'; and (iii) given the need to make economies in health expenditures, maintaining standards of the health care. Recent developments in information for the evaluation of health services have tended to emphasis the control and monitoring of expenditure in preference to the control and monitoring of quality. There is concern that this might lead to adverse consequences for patients and for the health service as a whole in that the quality of services provided might deteriorate. Health interventions are considered to be successful if they result in a beneficial change in the health of the population for whom they are provided. If the health of the population is not improved, or maintained, questions are raised about either the appropriateness of the intervention in relation to health policies which have been selected, or about the quality of the care which has been provided. Because of this, it is necessary to monitor both the outcome of a heath intervention in terms of the change in the level of health of the population, and also to measure the quality and the effectiveness of the care provided. Health services research has, over the years, developed a number of different types of measures which can be applied to health services and has suggested a number of applications for such measures in terms of the impact on the health of patients and the general population and the quality and effectiveness of health services. The first section of this paper reviews a selection of measures for both health and the effects of health interventions and discusses their applicability as management tools. The use to which such measures are put obviously depends upon the type of decisions which they are to inform, which in turn are dependent upon the organisational level at which the decision is to be made, and the policy objectives of the service to which they relate. The second part of the paper discusses factors which must be taken into account when choosing measures to monitor the impact of the health services. In examining the suitability of a management tool, a measure must be proven to provide information which is universally acceptable and which conforms to a number of scientific standards.(ABSTRACT TRUNCATED AT 400 WORDS)     

The attitude of health care professionals towards accreditation: A systematic review of the literature

Accreditation is usually a voluntary program, in which authorized external peer reviewers evaluate the compliance of a health care organization with pre-established performance standards. The aim of this study was to systematically review the literature of the attitude of health care professionals towards professional accreditation. A systematic search of four databases including Medline, Embase, Healthstar, and Cinhal presented seventeen studies that had evaluated the attitudes of health care professionals towards accreditation. Health care professionals had a skeptical attitude towards accreditation. Owners of hospitals indicated that accreditation had the potential of being used as a marketing tool. Health care professionals viewed accreditation programs as bureaucratic and demanding. There was consistent concern, especially in developing countries, about the cost of accreditation programs and their impact on the quality of health care services.     

Research in, about, and for health services: an international panorama and questions for health research in Brazil

Health systems and services are important determinants of health conditions and quality of life. Health services research is a multidisciplinary area aimed at deepening and widening knowledge on the area in specific contexts and focusing on system accessibility, impact, and performance and conditions and quality of health care in order to contribute to decisions by policy-makers, managers, and health professionals. This article analyzes the main characteristics and trends in recent output in the international literature and discusses several key questions for health services research in Brazil.     

Perspectives of the Tunisian health system reform

Perspectives of development of the Tunisian health system are presented, in reference to the conceptual framework recommended by the World Health Organization, while a project of health insurance reform of the social security regimes is submitted to a dialogue with the different concerned parts. Recommended orientations articulate around five axes: 1. The promotion of care provision by improving the accessibility to services, notably in zones under served, by introducing new modes of dispensation, organization and management of care provision in the framework of a continuous quality assurance strategy. 2. The financing of health care, with the implementation of the health insurance reform, has to allow an improvement of the financial accessibility of the population to health care, while supervising the evolution of total health expenditures and by developing the system's management capacities. 3. Proposals relative to the mobilization of resources are advanced in areas of medicine, training of health professionals and research on the health system. 4. Adaptation of the health system governance to the new context is necessary and would have to be developed around evolving standards for the health system, on evaluation of its performances and on information and communication with its users. 5. The health system responsiveness, new motion whose contours are again blurred, would have to be analysed and adapted to the specific context of the country.     

Micro-level planning using rapid assessment for primary health care services

This paper describes the use of a rapid assessment technique in micro-level planning for primary health care services which has been developed in India. This methodology involves collecting household-level data through a quick sample survey to estimate client needs, coverage of services and unmet need, and using this data to formulate micro-level plans aimed at improving service coverage and quality for a primary health centre area. Analysis of the data helps to identify village level variations in unmet need and develop village profiles from which general interventions for overall improvement of service coverage and targeted interventions for selected villages are identified. A PHC area plan is developed based on such interventions. This system was tried out in 113 villages of three PHC centres of a district in Gujarat state of India. It demonstrated the feasibility and utility of this approach. However, it also revealed the barriers in the institutionalization of the system on a wider scale. The proposed micro-level planning methodology using rapid assessment would improve client-responsiveness of the health care system and provide a basis for increased decentralization. By focusing attention on under-served areas, it would promote equity in the use of health services. It would also help improve efficiency by making it possible to focus efforts on a small group of villages which account for most of the unmet need for services in an area. Thus the proposed methodology seems to be a feasible and an attractive alternative to the current top-down, target-based health planning in India.     

Quality in public health

Based on the concepts of quality and public health and of public health organizations as service organizations, the advisability of establishing a reference model for quality in public health, incorporating objective criteria, indicators and standards, is discussed. The 2 main models of quality management in the field of service organizations, ISO 9001-2000 and EFQM, are reviewed and their advantages and disadvantages with respect to their application in public health services are contrasted. Based on the Institute of Medicine's definition of the functions of public health, we followed the approach of the Delphi study of the World Health Organization and the Assessment Protocol for Excellence in Public Health (APEX PH) model. The NPHPSP of the Centers for Disease Control is described in detail. We propose the use of this model as the reference model for quality management and improvement in public health organizations. Finally, we conclude that the approval of the Law of Cohesion and Quality of the National Health System by the Spanish parliament, which lays out the eight main health services that the National Health System should provide, would allow the NPHSPS to be adapted to our environment as a tool for quality management of Spanish public health services.     

Advent of occupational health services research

After lagging behind health services research in general health care, research is now examining health services provided to workers suffering occupational injuries and illnesses. The National Institute for Occupational Safety and Health, the Robert Wood Johnson Foundation Workers' Compensation Health Initiative, the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality), and the Canadian Institute for Work and Health co-sponsored a June, 1999, conference to explore research needs in this area. Fundamental tenets for advancing occupational health services research include: adopting the goal of improving occupational health care, including better integration of preventive and curative care; creating standardized interstate occupational health care data sets that include medical, economic, and patient perspectives; better defining quality in occupational care and developing appropriate performance measures; in addition to medical costs, assessing social, economic, medical and functional outcomes of care; considering the connections between work and health, including general health services; and addressing the need to train qualified occupational health services researchers. Am. J. Ind. Med. 40:291-294, 2001. Published 2001 Wiley-Liss, Inc.     

Public health situation and the control of communicable diseases

Health status has improved in India since the country achieved independence. Smallpox has been eradicated, plague has remained under control, guinea-worm and yaws have almost been eradicated, and cholera epidemics and related mortality are infrequent and fewer than they used to be. Diagnostic laboratory services have developed, communication facilities have improved considerably, health services infrastructure has expanded, and manpower has been developed. However, despite this progress, India still experiences malaria epidemics even after 40 years under its high priority National Malaria Control and Eradication Program (NMEP), diarrheal diseases and acute respiratory infections are responsible for 66% of under-5 child mortality, and other epidemics and tuberculosis continue to plague the country. India's failure to form a body of public health experts competent in management, epidemiology, and disease control has prevented the application of available knowledge and technology designed to thwart the spread of communicable disease-related morbidity and mortality in the country. Epidemiological surveillance is either absent or lacking at all levels. The central components of an effective public health care system are listed, together with recommendations for communicable disease control programs.     

Enhancing health programme efficiency: a Cambodian case study

In 1995, the Cambodian Urban Health Care Association (CUHCA) was set up as facilitator between private health care providers and patients, guaranteeing good quality health care and fair pricing to patients and providing training and logistic support to providers. Providers were engaged on a fee-for-service basis and competition encouraged. CUHCA's objectives followed the same line of thought as the 1993 World Development Report, aiming at influencing the unregulated private health care market through competition mechanisms. But soon after the start of the project the basic problem was recognized to be not the absence of effective government regulation but rather that consumers lack the requisite knowledge to make good choices in the market for health services. CUHCA had not adequately addressed the demand for health services. The original supply-side strategy of improving health services by increasing competition was a failure. In order to improve CUHCA's health programme efficiency the association's objectives were subsequently redefined and its functioning reorganized. CUHCA now tries to educate consumers and provides good quality services so that consumers will be able to act on the basis of their newly acquired knowledge. CUHCA's health centres serve as model clinics for first-line health care. Community educators organize information, education and communication (IEC) activities. Staff help school teachers to improve formal health education in schools and CUHCA assists local leaders in sanitation development. Only full-time personnel are employed, encouraging team spirit and communication with the target population. Salaries are based on team performance. The CUHCA programme demonstrates that, depending on the market situation, health programme models need to address both the supply and the demand for services in order to be efficient. Where consumers lack essential knowledge to make appropriate choices in the health service market, interventions should focus on health education and social marketing and provide models of quality care catering to informed consumer choice.     

Health care facility vulnerability in developing nations: strengthening health care policy-making and implementation

Background

In developing countries such as India, inadequate importance and consideration given to assessment of health care facilities negatively affects progress towards achieving health targets. India has focused on developing Primary Health Centres (PHCs) for rural basic laboratory and curative services. The local decision-makers do not have any national-level framework to evaluate the vulnerability of PHCs which are not meeting national PHC standards, nor do they have resources to meet national PHC standards.

Aim

The study proposed a framework to assess the public health care facilities for vulnerability.

Methods

A cross-sectional questionnaire survey was performed. The study used PHC laboratory services of 42 PHCs of Osmanabad District, India as a case study for proposed framework. The data assessment was carried out at district level, block level, PHC cluster level, and PHC level to provide flexibility to local decision-makers in taking remedial measures.

Results

Staff workload (73.17%), physician’s need (51.22%), and organization structure (36.59%) are the most prevalent challenges across PHCs. Multiple challenges are prevalent in the PHCs across districts. The PHCs with poor medical doctor (MD) capability or many challenges have shown poor laboratory performance.

Conclusion

Governance need to be strengthened in PHCs, followed by sustained support in resources and financing. Poor health status in developing nations necessitates a public health response based on health systems. Therefore, an assessment of health facility vulnerability in the form of laboratory services is essential in primary health care facilities.