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Introduction: Outpatient services are crucial for strengthening primary healthcare and reducing out-of-pocket spending, which has been one of the major causes of impoverishment. So it is also critical to comprehend the people's preferences in accessing primary healthcare facilities, as government primary healthcare facilities in India are underutilized. The current paper explores the factors that construct the individual's decision to seek outpatient care in primary healthcare facilities in India's largest state Rajasthan. Methods: It was a cross-sectional survey conducted in 72 primary sample units of 24 primary health centers in 11 districts of Rajasthan, India, from November 2019 to January 2020. The study selected 368 households through purposive sampling. Out of 368 households, 460 people reported any illness and 326 reported outpatient visit to any health facility in the last 30 days from the date of the survey. Analysis: The focus was on analyzing the data in the context of public and private health facilities to understand the factors influencing people's choice to access outpatient services. The principal component analysis is used to understand the relationship between facility preparedness and OPD uptake. Also, multivariate logistic regression is applied to assess the significant predictors in using primary health facility services. Result: Except for the 29% of patients who received no care, the proportion of patients attended public health facilities was 35%, and the rest were utilizing private health facilities. Those who sought care at PHCs were mostly over 45 years age, non-literate, and from the lowest wealth quintile. Logistic regression suggests that people belong to upper wealth quintile (OR = 0.298; 95% 0.118–0.753) are less likely to visit PHCs for treatment. Also, increase in distance of PHC (OR = 0.203; 95% CI 0.076–0.539) reduces the likelihood of their visit outpatient care. People are 9.7 times (OR = 9.740; 95% CI 2.856–33.217) more likely to visit a PHCs that are better equipped in terms of human resources, equipment, and medicine. Conclusion: The uptake of PHCs depends on several factors, which should be considered to ensure that all segments of society have equitable access to them. Through improved accessibility and quality of service, PHCs can be made more appealing to the larger population. [ABSTRACT FROM AUTHOR]

Background: In the last two decades, cesarean section (CS) deliveries in India have increased by six-fold and created economic hardship for families and households. Although several schemes and policies under the National Health Mission (NHM) have reduced the inequality in the use of maternal care services in India, the distributive effect of public health subsidies on CS deliveries remains unclear. In this context, this paper examines the usage patterns of CS delivery and estimates the share of public health subsidies on CS deliveries among mothers by different background characteristics in India.Data: Data from the fourth round of the National Family Health Survey (NFHS-4) was used for the study. Out-of-pocket (OOP) payment for CS delivery was used as a dependent variable and was analyzed by level of care that is, primary (PHC, UHC, other) and secondary (government/municipal, rural hospital). Descriptive statistics, binary logistic regression, benefit incidence analysis, concentration curve and concentration index were used for the analysis.Results: A strong economic gradient was observed in the utilization of CS delivery from public health facilities. Among mothers using any public health facility, 23% from the richest quintile did not pay for CS delivery compared to 13% from the poorest quintile. The use of the public subsidy among mothers using any type of public health facility for CS delivery was pro-rich in nature; 9% in the poorest quintile, 16.1% in the poorer, 24.5% in the middle, 27.5% among richer and 23% in the richest quintile. The pattern of utilization and distribution of public subsidy was similar across the primary and secondary health facilities but the magnitude varied. The findings from the benefit-incidence analysis are supported by those obtained from the inequality analysis. The concentration index of CS was 0.124 for public health centers and 0.291 for private health centers. The extent of inequality in the use of CS delivery in public health centers was highest in the state of Mizoram (0.436), followed by Assam (0.336), and the lowest in Tamil Nadu (0.060), followed by Kerala (0.066).Conclusion: The utilization of CS services from public health centers in India is pro-rich. Periodically monitoring and evaluating of the cash incentive schemes for CS delivery and generating awareness among the poor would increase the use of CS delivery services in public health centers and reduce the inequality in CS delivery in India. [ABSTRACT FROM AUTHOR]

Introduction: It is well acknowledged that India's community health workers known as Accredited Social Health Activists (ASHA) are the bedrock of its health system. Many ASHAs are currently working in fragile and conflict-affected settings. No efforts have yet been made to understand the challenges and vulnerabilities of these female workers. This paper seeks to address this gap by bringing attention to the situation of ASHAs working in the fragile and conflict settings and how conflict impacts them and their work.Methods: Qualitative fieldwork was undertaken in four conflict-affected villages in two conflict-affected districts -Kokrajhar and Karbi Anglong of Assam state situated in the North-East region of India. Detailed account of four ASHAs serving roughly 4000 people is presented. Data transliterated into English were analysed by authors by developing a codebook using grounded theory and thematic organisation of codes.Results: ASHAs reported facing challenges in ensuring access to health services during and immediately after outbreaks of conflict. They experienced difficulty in arranging transport and breakdown of services at remote health facilities. Their physical safety and security were at risk during episodes of conflict. ASHAs reported hostile attitudes of the communities they served due to the breakdown of social relations, trauma due to displacement, and loss of family members, particularly their husbands.Conclusions: Conflict must be recognised as an important context within which community health workers operate, with greater policy focus and research devoted to understanding and addressing the barriers they face as workers and as persons affected by conflict. [ABSTRACT FROM AUTHOR]

Background: Birthing in health facilities in India has increased over the last few years, yet maternal and neonatal mortality rates remain high. Clinical mentoring with case sheets or checklists for nurses is viewed as essential for on-going knowledge transfer, particularly where basic training is inadequate. This paper summarizes a study of the effect of such a programme on staff knowledge and skills in a randomized trial of 295 nurses working in 108 Primary Health Centres (PHCs) in Karnataka, India.Methods: Stratifying by district, half of the PHCs were randomly assigned to be intervention sites and provided with regular mentoring visits where case sheet/checklists were a central job and teaching aid, and half to be control sites, where no support was provided except provision of case sheets. Nurses' knowledge and skills around normal labour, labour complications and neonate issues were tested before the intervention began and again one year later. Univariate and multivariate analyses were conducted to examine the effect of mentoring and case sheets.Results: Overall, on none of the 3 measures, did case sheet use without mentoring add anything to the basic nursing training when controlling for other factors. Only individuals who used both case-sheets and received mentoring scored significantly higher on the normal labour and neonate indices, scoring almost twice as high as those who only used case-sheets. This group was also associated with significantly higher scores on the complications of labour index, with their scores 2.3 times higher on average than the case sheet only control group. Individuals from facilities with 21 or more deliveries in a month tended to fare worse on all 3 indices. There were no differences in outcomes according to district or years of experience.Conclusions: This study demonstrates that provision of case sheets or checklists alone is insufficient to improve knowledge and practices. However, on-site mentoring in combination with case sheets can have a demonstrable effect on improving nurse knowledge and skills around essential obstetric and neonatal care in remote rural areas of India. We recommend scaling up of this mentoring model in order to improve staff knowledge and skills and reduce maternal and neonatal mortality in India.Trial Registration: This study is registered at clinicaltrials.gov, Identifier No. NCT02004912 , November 27, 2013. [ABSTRACT FROM AUTHOR]

Background: Health service and health outcome data collection across many low- and middle-income countries (LMICs) is, to date largely paper-based. With the development and increased availability of reliable technology, electronic tablets could be used for electronic data collection in such settings. This paper describes our experiences with implementing electronic data collection methods, using electronic tablets, across different settings in four LMICs.Methods: Within our research centre, the use of electronic data collection using electronic tablets was piloted during a healthcare facility assessment study in Ghana. After further development, we then used electronic data collection in a multi-country, cross-sectional study to measure ill-health in women during and after pregnancy, in India, Kenya and Pakistan. All data was transferred electronically to a central research team in the UK where it was processed, cleaned, analysed and stored.Results: The healthcare facility assessment study in Ghana demonstrated the feasibility and acceptability to healthcare providers of using electronic tablets to collect data from seven healthcare facilities. In the maternal morbidity study, electronic data collection proved to be an effective way for healthcare providers to document over 400 maternal health variables, in 8530 women during and after pregnancy in India, Kenya and Pakistan.Conclusions: Electronic data collection provides an effective platform which can be used successfully to collect data from healthcare facility registers and from patients during health consultations; and to transfer large quantities of data. To ensure successful electronic data collection and transfer between settings, we recommend that close attention is paid to study design, data collection, tool design, local internet access and device security. [ABSTRACT FROM AUTHOR]

Background: To achieve the Sustainable Development Goals, Indian States have implemented different strategies to arrest high out-of-pocket expenditure (OOPE) and to increase equity into healthcare system. Tamil Nadu (TN) and Rajasthan have implemented free medicine scheme in all public hospitals and West Bengal (WB) has devised Fair Price Medicine Shop (FPMS) scheme, a public-private-partnership model in the state. In this background, the objectives of the paper are to - 1. Study the utilization pattern of public in-patient care facilities for the states, 2. Examine the effectiveness of the strategies adopted by the states to arrest high OOPE and 3. Analyze the extent of equity in public in-patient care services in the states.Methods: National Sample Survey (71st and 60th round) data, Detailed Demand for Grants of the state governments and the National Rural/Urban Health Mission data have been used for the study. Exploratory data analysis and benefit incidence analysis have been applied to estimate the utilization, OOPE and extend of equity in the states.Results: The results show that overall utilization of public facilities in TN and Rajasthan has increased substantially; whereas, utilization of public facility has decreased in WB even among the poorest. In addition, OOPE for both medical and medicine is the highest in WB among three states for public sector hospitalizations. Surprisingly, OOPE on medicine is the highest for the poorest class of WB. Analysis showed that the mismatch between actual need and FPMS drug-list has led to high OOPE in the state. Overall, benefit incidence of public subsidy is the highest among the poorest class in all the states. However, geographical sector-wise inequity in public subsidy distribution persists in the states. Analysis of cost of inpatient care shows that TN provides the maximum subsidy for hospitalization and WB provides the minimum. An inverse relationship between utilization of inpatient care and public subsidy has been observed from the analysis.Conclusion: In conclusion we could say that TN & Rajasthan have successfully implemented their health financing strategies to reduce the health expenditure burden. However, policy-level changes are required to improve the situation in WB. [ABSTRACT FROM AUTHOR]