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Introduction: Legislative assemblies often provide a platform for legislators to question the government during question hours, which are crucial for governance However, question hours remain understudied, especially when addressing health policy and systems related issues in lower- and middle-income countries. This study assesses the 14th Kerala Legislative Assembly questions, focusing on health-related areas to provide insights for health policy formulation and decision-making processes. MATERIALS AND METHODS: We sourced and transcribed all starred questions (346) related to health that were answered by the health minister in the 14th Legislative Assembly between 2016 and 2021 from the archives of the assembly website. We conducted a thematic analysis of these questions and mapped them into various themes, guided by the World Health Organization building blocks framework. Results: About 7.8% of all questions (N = 4404) were related to health (N = 346). Of these questions, the majority were directly related to service delivery (43.4%), followed by health information (16.5%). Health financing, food safety, and human resources were the least discussed topics throughout the assessed period within the state. The legislators primarily focussed on health services and health information, with less attention given to health financing, food safety, and human resources regardless of constituency or political affiliation. Discussion: This study underscores the need for a balanced approach to public health issues, highlighting the importance of legislators to priortizing health services and information, while also addressing health financing, food safety, and human resources. This would enable a robust and resilient public health system to effectively address diverse health concerns.

Abstract Building capacity for Health Policy and Systems Research (HPSR) is critical for advancing the field in lower- and middle-income countries (LMICs). The India HPSR fellowship program is a home-grown capacity-building initiative, anchored at the Health Systems Transformation Platform (HSTP), New Delhi, and developed in collaboration with a network of institutes in India and abroad. In this practice-oriented commentary, we provide an overview of the fellowship program and critically reflect upon the learnings from working with three cohorts of fellows between 2020 and 2023. This commentary draws on routine program documentation (guidelines, faculty meeting reports, minutes of meetings of curricula and course development) as well as the perspectives of faculty and program managers associated with the fellowship. We have had several important learnings in the initial years of program implementation. One, it is important to iteratively modify globally available curricula and pedagogies on HPSR to suit country-specific requirements and include a strong component of ‘unlearning’ in such fellowships. Secondly, the goals of such fellowship programs need to be designed with country-specific contextual realities in mind. For instance, should publication of fellows’ work be an intended goal, then contextual deterrents to publication such as article processing fees, language barriers and work-related obligations of faculty and participants need to be addressed. Furthermore, to improve the policy translation of fellows’ work, such programs need to make broader efforts to strengthen research–policy–practice interfaces. Lastly, fellowship programs are cost-intensive, and outputs from them, such as papers or policy translation, are less immediate and less visible to donors. In the absence of these outputs, consistent funding can be a roadblock to sustaining these fellowships in LMICs. The experience of our fellowship program suggests that LMIC-led capacity-building initiatives on HPSR have the potential to influence changes in health systems and build the capacity of researchers to generate evidence for policy-making. The sharing of resources and teaching material through the fellowship can enable learning for all institutions involved. Furthermore, such initiatives can serve as a launchpad for the creation of regional and international HPSR communities of practice, with a focus on LMICs, thereby challenging epistemic injustice in teaching and learning HPSR.

Abstract Introduction Non-Communicable Diseases (NCDs) place a significant burden on India's healthcare system, accounting for approximately 62% of all deaths in the country in 2017. The southern Indian state - Kerala - has some of the highest rates of NCDs. Within the state, the fisherfolk community has a high prevalence of risk factors such as tobacco use and alcohol consumption. Working in the fisheries industry demands physical exertion, night shifts alongside extended periods of time at sea (for seafaring fisherfolk). Evidence is scant on how these conditions relate to the health-seeking experiences of fisherfolk, particularly in the context of NCDs. We conducted a qualitative study in two districts of Kerala to fill this gap. Methods In-depth individual and small group interviews– as per participant preference – with male and female fishing community members living with NCDs were conducted between October 2022 and February 2023 in two districts of Kerala. Interviews were conducted to explore community members’ experiences with health-seeking for NCDs. Transliterated English transcripts were coded using ATLAS.ti software and analysed using thematic analysis with inductive generation of codes, with indexing against Levesque, Harris, and Russell’s 2013 access to healthcare framework. Results Thirty-three interviews with 42 participants were conducted. We found that NCDs were usually diagnosed late- either when admitted/consulted for other illnesses or when the symptoms became unbearable. Health-seeking patterns differed between seafaring and inland fishing subgroups, who were sampled from two districts in the state. Seafaring fisherfolk preferred public facilities for regular checkups and medicines while in-land fisherfolk relied on private facilities, although it was considered expensive. Ability to seek care was impacted by the working hours of the health centre which did not suit their working hours. Health constaints and related expenses also impacted their financial status and occupation, with some opting for less strenuous jobs. Conclusion This study highlights the NCD-related health-seeking experiences of the fisherfolk community in Kerala, India. Fisherfolk reported self neglect, delayed diagnosis, cost and livelihood constraints owing to the onset of NCDs, even as dual practice and medicine access in the public sector were appreciated. Overall, larger studies and policymaking processes should consider in depth the experiences faced by particular economic groups like fisherfolk, who may face unique health and care-seeking challenges.

Abstract Background Kerala, a southern state in India, is known to be atypical due to its high literacy rate and advanced social development indicators. Facing competition from a dominant private healthcare system, recent government health system reforms have focused on providing free, high-quality universal healthcare in the public sector. We carried out an analysis to ascertain the initial impacts of these measures among ‘hard to reach groups’ as part of a larger health policy and systems research study, with a focus on public sector health service utilisation. Methods We conducted Focus Group Discussions (FGDs) among identified vulnerable groups across four districts of Kerala between March and August of 2022. The FGDs explored community perspectives on the use of public healthcare facilities including enablers and barriers to healthcare access. Transliterated English transcripts were coded using ATLAS.ti software and thematically analyzed using the AAAQ framework, supplemented with inductive code generation. Results A total of 34 FGDs were conducted. Availability and cost-effectiveness were major reasons for choosing public healthcare, with the availability of public insurance in inpatient facilities influencing this preference. However, accessibility of public sector facilities posed challenges due to long journeys and queues. Uneven roads and the non-availability of public transport further restricted access. Gaps in acceptability were also observed: participants noted the need for the availability of special treatments available, reduced waiting times for special groups like those from tribal communities or the elderly mindful of their relatively greater travel and need for prompt care. Although quality improvements resulting from health reform measures were acknowledged, participants articulated the need for further enhancements in the availability and accessibility of services so as to make public healthcare systems truly acceptable. Conclusion The ‘Kerala Model of Development’ has been applauded internationally for its success in recent years. However, this has not inured the state from the typical barriers to public sector health care use articulated by participants in the study, which match global evidence. In order to deepen the impact of public sector reforms, the state must try to meet service user expectations– especially among those left behind. This requires attention to quality, timeliness, outreach and physical access. Longer term impacts of these reforms – as we move to a post-COVID scenario - should also be evaluated.

Abstract Background The People’s Planning Campaign (PPC) in the southern Indian state of Kerala started in 1996, following which the state devolved functions, finances, and functionaries to Local Self-Governments (LSGs). The erstwhile National Rural Health Mission (NRHM), subsequently renamed the National Health Mission (NHM) was a large-scale, national architectural health reform launched in 2005. How decentralisation and NRHM interacted and played out at the ground level is understudied. Our study aimed to fill this gap, privileging the voices and perspectives of those directly involved with this history. Methods We employed the Witness Seminar (WS), an oral history technique where witnesses to history together reminisce about historical events and their significance as a matter of public record. Three virtual WS comprised of 23 participants (involved with the PPC, N(R)HM, civil society, and the health department) were held from June to Sept 2021. Inductive thematic analysis of transcripts was carried out by four researchers using ATLAS. ti 9. WS transcripts were analyzed using a realist approach, meaning we identified Contexts, Mechanisms, and Outcomes (CMO) characterising NRHM health reform in the state as they related to decentralised planning. Results Two CMO configurations were identified, In the first one, witnesses reflected that decentralisation reforms empowered LSGs, democratised health planning, brought values alignment among health system actors, and equipped communities with the tools to identify local problems and solutions. Innovation in the health sector by LSGs was nurtured and incentivised with selected programs being scaled up through N(R)HM. The synergy of the decentralised planning process and N(R)HM improved health infrastructure, human resources and quality of care delivered by the state health system. The second configuration suggested that community action for health was reanimated in the context of the emergence of climate change-induced disasters and communicable diseases. In the long run, N(R)HM’s frontline health workers, ASHAs, emerged as leaders in LSGs. Conclusion The synergy between decentralised health planning and N(R)HM has significantly shaped and impacted the health sector, leading to innovative and inclusive programs that respond to local health needs and improved health system infrastructure. However, centralised health planning still belies the ethos and imperative of decentralisation – these contradictions may vex progress going forward and warrant further study.

ABSTRACTIndia’s experience with the National Rural Health Mission (NRHM) is notable on account of nationally formalising – at scale – community action in service delivery, monitoring, and planning of health services. A study was undertaken to document and create a historical record of NRHM’s ‘communitization’ processes. The oral history method of the Witness Seminar was adopted and two virtual seminars with five and nine participants, respectively, were conducted, and supplemented with 4 in depth interviews. Analysis of transcripts was done using ATLAS.ti 22 with the broad themes of emergence, evolution, and evaluation and impact of ‘communitization’ under NRHM. This paper engages with the theme of ‘emergence’ and adopts the Multiple Streams Framework (MSF) conceptualised by John Kingdon for analysis. Key findings include the pioneering role of boundary spanning decision makers and the Jan Swasthya Abhiyan (JSA) in advocacy and design of ‘communitization’ structures, and the legacy of rights based social mobilizations and state-civil society partnerships in health during the 1990s influencing the ethos underlying ‘communitization’. Democracy, leadership from the civil society in policy design and implementation, and state-civil society partnerships are linked to the positive results witnessed as part of ‘communitization’ in NRHM.

Abstract Background Despite a commendable rise in the number of women seeking delivery care at public health institutions in South India, it is unclear if the benefit accrues to wealthier or poorer socio-economic groups. The study’s aim was to investigate at how the public subsidy is distributed among Indian women who give birth in public hospitals in the southern regions. Methods Data from the Indian Demographic Health Survey’s fifth wave (NFHS-5, 2019–21) was used in this study. A total of 22, 403 were institutional deliveries across all the southern states of India were included. Out-of-pocket expenditure (OOPE) on childbirth in health institutions was the outcome variable. We used summary statistics, Benefits Incidence Analysis (BIA), concentration index (CI), and concentration curve (CC) were used. Results Most women in the lowest, poorest, and medium quintiles of wealth opted to give birth in public facilities. In contrast, about 69% of mothers belonging to highest quintile gave birth in private health institutions. The magnitude of CI and CC of institutional delivery indicates that public sector usage was concentrated among poorer quintiles [CIX: − 0.178; SE: 0.005; p

Background As the Sustainable Development Goals deadline of 2030 draws near, greater attention is being given to health beyond the health sector, in other words, to the creation of healthy societies. However, action and reform in this area has not kept pace, in part due to a focus on narrower interventions and the lack of upstream action on health inequity. With an aim to guide action and political engagement for reform, we conducted a thematic analysis of concepts seeking to arrive at healthy societies.Methods This paper drew on a qualitative thematic analysis of a purposive sample of 68 documents including political declarations, reports, peer reviewed literature and guidance published since 1974. Three independent reviewers extracted data to identify, discuss and critique public policy levers and ‘enablers’ of healthy societies, the “how.”Results The first lever concerned regulatory and fiscal measures. The second was intersectoral action. The final lever a shift in the global consensus around what signifies societal transformation and outcomes. The three enablers covered political leadership and accountability, popular mobilization and the generation and use of knowledge.Conclusion Documents focused largely on technical rather than political solutions. Even as the importance of political leadership was recognized, analysis of power was limited. Rights-based approaches were generally neglected as was assessing what worked or did not work to pull the levers or invest in the enablers. Frameworks typically failed to acknowledge or challenge prevailing ideologies, and did not seek to identify ways to hold or governments or corporations accountable for failures. Finally, ideas and approaches seem to recur again over the decades, without adding further nuance or analysis. This suggests a need for more upstream, critical and radical approaches to achieve healthy societies.

Background While support for the idea of fostering healthy societies is longstanding, there is a gap in the literature on what they are, how to beget them, and how experience might inform future efforts. This paper explores developments since Alma Ata (1978) to understand how a range of related concepts and fields inform approaches to healthy societies and to develop a model to help conceptualize future research and policy initiatives.Methods Drawing on 68 purposively selected documents, including political declarations, commission and agency reports, peer-reviewed papers and guidance notes, we undertook qualitative thematic analysis. Three independent researchers compiled and categorised themes describing the domains of a potential healthy societies approach.Results The literature provides numerous frameworks. Some of these frameworks promote alternative endpoints to development, eschewing short-term economic growth in favour of health, equity, well-being and sustainability. They also identify values, such as gender equality, collaboration, human rights and empowerment that provide the pathways to, or underpin, such endpoints. We categorize the literature into four “components”: people; places; products; and planet. People refers to social positions, interactions and networks creating well-being. Places are physical environments — built and natural — and the interests and policies shaping them. Products are commodities and commercial practices impacting population health. Planet places human health in the context of the ‘Anthropocene.’ These components interact in complex ways across global, regional, country and community levels as outlined in our heuristic.Conclusion The literature offers little critical reflection on why greater progress has not been made, or on the need to organise and resist the prevailing systems which perpetuate ill-health.

Abstract Background Publicly Funded Health Insurance Schemes (PFHIS) are intended to play a role in achieving Universal Health Coverage (UHC). In countries like India, PFHISs have low penetrance and provide limited coverage of services and of family members within households, which can mean that women lose out. Gender inequities in relation to financial risk protection are understudied. Given the emphasis being placed on achieving UHC for all in India, this paper examined intersecting gender inequalities and changes in PFHIS coverage in southern India, where its penetrance is greater and of longer duration. Data and methods This study used the fourth (NFHS-4, 2015–16) and fifth (NFHS-5, 2019–21) rounds of India’s National Family Health Survey for five southern states: namely, Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, and Telangana. The World Health Organization’s Health Equity Assessment Toolkit (HEAT) Plus and Stata were used to analyse PFHIS coverage disaggregated by seven dimensions of inequality. Ratios and differences for binary dimensions; Between Group Variance and Theil Index for unordered dimensions; Absolute and Relative Concentration Index (RCI) for ordered dimensions were computed separately for women and men. Results Overall, PFHIS coverage increased significantly (p

The year 2024 marks the 50th anniversary of the World Health Organization (WHO) Expanded Program on Immunization (EPI) [...]

Abstract Background Increasing financial risk protection is a key feature of Universal Health Coverage and the path towards health for all. Publicly Funded Health Insurance Schemes (PFHIS) have been considered as one of the pathways to safeguard against financial shocks and potentially reduce Out-of-Pocket Expenditure (OOPE). The south Indian state of Kerala has roughly a decade-long experience in implementing PFHIS. To date, there have been very few assessments of the coverage of these schemes and their impact on expenditure. Aiming to fill this gap, we explored the extent of and inequalities in insurance coverage, as well as choice of providers, and median cost of hospitalization in Kerala among insured and uninsured individuals. Methods A cross-sectional household survey was conducted in four districts of Kerala as part of a larger health systems research study from July–October 2019. We employed multistage random sampling to collect data from 13,064 individuals covering 3234 households in the catchment area of eight primary health care facilities. We used descriptive statistics, bivariate and multivariate analysis. We evaluated socioeconomic disparities using an absolute measure of inequality—the Slope Index of Inequality (SII) and a relative measure—the Relative Concentration Index (RCI). Results A substantial proportion of our study respondents reported that they were covered by PFHIS (45.8%). Respondents belonging to lowest and middle wealth quintiles of household had significantly greater odds of being covered by insurance than respondents belonging to the richest wealth quintile. The negative magnitude of RCI [-16.8% (95%CI: -25.3, -8.4)] and SII [-21.5% (95%CI: -36.1, -7.0)] suggest a higher concentration of PFHIS coverage among the poor. Median OOPE for hospitalisation at private health facilities was INR 9000 (approx. USD 108.70) among those covered by PFHIS, whereas it was INR 10500 (approx. USD 126.82) at private health facilities among those not covered by insurance. Conclusion While PFHIS seems to be appropriately targeting poorer populations, among the insured, OOPE for hospitalization persists. Among the uninsured, population subgroups with advantage are spending the greatest amount, raising questions about whether those facing relative disadvantage are forgoing care altogether or seeking care using cheaper, public avenues. Further policy action to more effectively reduce financial burden among left behind eligible populations under PFHIS will be essential to UHC progress in the state.

Immunization through vaccines among children has contributed to improved childhood survival and health outcomes globally. However, vaccine coverage among children is unevenly distributed across settings and populations. The measurement of inequalities is essential for understanding gaps in vaccine coverage affecting certain sub-populations and monitoring progress towards achieving equity. Our study aimed to characterize the methods of reporting inequalities in childhood vaccine coverage, inclusive of the settings, data source types, analytical methods, and reporting modalities used to quantify and communicate inequality. We conducted a scoping review of publications in academic journals which included analyses of inequalities in vaccination among children. Literature searches were conducted in PubMed and Web of Science and included relevant articles published between 8 December 2013 and 7 December 2023. Overall, 242 publications were identified, including 204 assessing inequalities in a single country and 38 assessing inequalities across more than one country. We observed that analyses on inequalities in childhood vaccine coverage rely heavily on Demographic Health Survey (DHS) or Multiple Indicator Cluster Surveys (MICS) data (39.3%), and papers leveraging these data had increased in the last decade. Additionally, about half of the single-country studies were conducted in low- and middle-income countries. We found that few studies analyzed and reported inequalities using summary measures of health inequality and largely used the odds ratio resulting from logistic regression models for analyses. The most analyzed dimensions of inequality were economic status and maternal education, and the most common vaccine outcome indicator was full vaccination with the recommended vaccine schedule. However, the definition and construction of both dimensions of inequality and vaccine coverage measures varied across studies, and a variety of approaches were used to study inequalities in vaccine coverage across contexts. Overall, harmonizing methods for selecting and categorizing dimensions of inequalities as well as methods for analyzing and reporting inequalities can improve our ability to assess the magnitude and patterns of inequality in vaccine coverage and compare those inequalities across settings and time.

Abstract Background Demand for rapid evidence-based syntheses to inform health policy and systems decision-making has increased worldwide, including in low- and middle-income countries (LMICs). To promote use of rapid syntheses in LMICs, the WHO’s Alliance for Health Policy and Systems Research (AHPSR) created the Embedding Rapid Reviews in Health Systems Decision-Making (ERA) Initiative. Following a call for proposals, four LMICs were selected (Georgia, India, Malaysia and Zimbabwe) and supported for 1 year to embed rapid response platforms within a public institution with a health policy or systems decision-making mandate. Methods While the selected platforms had experience in health policy and systems research and evidence syntheses, platforms were less confident conducting rapid evidence syntheses. A technical assistance centre (TAC) was created from the outset to develop and lead a capacity-strengthening program for rapid syntheses, tailored to the platforms based on their original proposals and needs as assessed in a baseline questionnaire. The program included training in rapid synthesis methods, as well as generating synthesis demand, engaging knowledge users and ensuring knowledge uptake. Modalities included live training webinars, in-country workshops and support through phone, email and an online platform. LMICs provided regular updates on policy-makers’ requests and the rapid products provided, as well as barriers, facilitators and impacts. Post-initiative, platforms were surveyed. Results Platforms provided rapid syntheses across a range of AHPSR themes, and successfully engaged national- and state-level policy-makers. Examples of substantial policy impact were observed, including for COVID-19. Although the post-initiative survey response rate was low, three quarters of those responding felt confident in their ability to conduct a rapid evidence synthesis. Lessons learned coalesced around three themes – the importance of context-specific expertise in conducting reviews, facilitating cross-platform learning, and planning for platform sustainability. Conclusions The ERA initiative successfully established rapid response platforms in four LMICs. The short timeframe limited the number of rapid products produced, but there were examples of substantial impact and growing demand. We emphasize that LMICs can and should be involved not only in identifying and articulating needs but as co-designers in their own capacity-strengthening programs. More time is required to assess whether these platforms will be sustained for the long-term.

BackgroundAccredited Social Health Activists (ASHA) are Community Health Workers (CHWs) employed by the National Health Mission of the Government of India to link the population to health facilities and improve maternal and child health outcomes in the country. The government of Kerala launched primary health reform measures in 2016 whereby Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The COVID-19 pandemic in 2020 impacted essential health service delivery, including primary care services. The CHWs network of Kerala played a crucial role in implementing the primary care reforms and COVID-19 management efforts that followed. We carried out a study to understand the perspectives of the CHWs in Kerala about their role in the recent primary healthcare reforms and during the COVID-19 pandemic management efforts.MethodsWe conducted in-depth interviews (IDI) with 16 ASHAs from 8 primary care facilities in Kerala from July to October 2021. We further conducted Focus Group Discussions (FGDs) (N = 34) with population subgroups in these eight facility catchment areas and asked their opinion about the ASHAs working in their community. We obtained written informed consent from all the participants, and interview transcripts were thematically analysed by a team of four researchers using ATLAS.ti 9 software.ResultsOur study participants were women aged about 45 years with over 10 years of work experience as CHWs. Their job responsibilities as a frontline health worker helped them build trust in the community and local self-governments. CHWs were assigned roles of outpatient crowd management, and registration duties in FHCs. The COVID-19 pandemic increased their job roles manifold. Community members positively mentioned the home visits, delivery of medicines, and emotional support offered by the CHWs during the pandemic. The CHWs noted that the honorarium of INR 6,000 (US$73) was inconsistent and very low for the volume of work done.ConclusionThe CHWs in Kerala play a crucial role in primary care reforms and COVID-19 management. Despite their strong work ethic and close relationship with local self-governments, low and irregular wages remain the biggest challenge.

The movement towards systems thinking and complexity-informed monitoring and evaluation has been ongoing for some time. Covid-19 has accelerated this shift and increased the salience of contextually aware, adaptive forms of evaluation. Drawing from our experience over three years of providing monitoring, evaluation, research and learning (MERL) to a large international philanthropic organization’s health systems portfolio of work in India, we identify three types of evaluator capacities and associated set of competencies that derive from complexity-driven practice in a developing country. The first type of capacity relates to deriving evidence in contexts where there are very few traditional forms of data. The MERL portfolio related to health systems outcomes of access, financial protection, and equity even as the health programs themselves were evolving in a period of rapid transformation and dynamism of policy priorities and implementation mechanisms. This required an integration of traditional performance indicators drawn from government datasets with qualitative ‘signals’ focused on drivers of change within the system. Assessment of signals in turn required synthesizing different sources of information, including informal channels of obtaining evidence such as partner meetings or government-sponsored events. The evaluating team thus consciously empowered different kinds of researchers with differential expertise with the goal of building a much more pixelated picture. The goal was not to identify a single source of truth but rather a patchwork of validated information where the relevance of different pieces of data were dependent on evolving outcomes of interest. The second set of competencies related to the skills required to play a convening role for donors and implementing partners, supporting better understanding of the changing operating context and help inform decision-making by program officers and partners. This involved building and sustaining relationships across different stakeholders at different stages of the project – from proposal development to review. Competencies relating to effective dialogue and developing an understanding of the core interests of international, national and sub-national partners as well as international donors and experts could only be developed iteratively and over time, but this was crucial in a distributed health decision-making ecosystem like India. The third and final set of competencies relate to operational adaptiveness, while evaluating an ecosystem with few constants. This can be the hardest competency to acquire because it is the farthest from the traditional notions embedded in the training of evaluation scientists and MERL practitioners. We found that the degree of buy-in and commitment to previously agreed upon frames of reference for evaluation can be shifted by changes in personnel or internal organizational structures. These shifts can lead to chain reactions of mismatched expectations that needed to be understood and managed in real time by MERL partners. The pandemic further created a natural experiment that on the one hand required a reexamination of program priorities and on the other depended on reliability of donor support. Each of these three types of capacities – synthesizing nuanced evidence for adaptive action, relationship building and communication, and managing operational discontinuities are in fact inter-dependent. Building evaluator competencies isn’t simply about capacity-building but rather a recognition of the diversity of skills and worldviews that need to be encompassed within our monitoring and evaluation functions for today’s complex, discontinuous health systems.

Abstract Background Among the core principles of the 2030 agenda of Sustainable Development Goals (SDGs) is the call to Leave no One behind (LNOB), a principle that gained resonance as the world contended with the COVID-19 pandemic. The south Indian state of Kerala received acclaim globally for its efforts in managing COVID-19 pandemic. Less attention has been paid, however, to how inclusive this management was, as well as if and how those “left behind” in testing, care, treatment, and vaccination efforts were identified and catered to. Filling this gap was the aim of our study. Methods We conducted In-depth interviews with 80 participants from four districts of Kerala from July to October 2021. Participants included elected local self-government members, medical and public health staff, as well as community leaders. Following written informed consent procedures, each interviewee was asked questions about whom they considered the most “vulnerable” in their areas. They were also asked if there were any special programmes/schemes to support the access of “vulnerable” groups to general and COVID related health services, as well as other needs. Recordings were transliterated into English and analysed thematically by a team of researchers using ATLAS.ti 9.1 software. Results The age range of participants was between 35 and 60 years. Vulnerability was described differentially by geography and economic context; for e.g., fisherfolk were identified in coastal areas while migrant labourers were considered as vulnerable in semi-urban areas. In the context of COVID-19, some participants reflected that everyone was vulnerable. In most cases, vulnerable groups were already beneficiaries of various government schemes within and beyond the health sector. During COVID, the government prioritized access to COVID-19 testing and vaccination among marginalized population groups like palliative care patients, the elderly, migrant labourers, as well as Scheduled Caste and Scheduled Tribes communities. Livelihood support like food kits, community kitchen, and patient transportation were provided by the LSGs to support these groups. This involved coordination between health and other departments, which may be formalised, streamlined and optimised in the future. Conclusion Health system actors and local self-government members were aware of vulnerable populations prioritized under various schemes but did not describe vulnerable groups beyond this. Emphasis was placed on the broad range of services made available to these “left behind” groups through interdepartmental and multi-stakeholder collaboration. Further study (currently underway) may offer insights into how these communities – identified as vulnerable – perceive themselves, and whether/how they receive, and experience schemes designed for them. At the program level, inclusive and innovative identification and recruitment mechanisms need to be devised to identify populations who are currently left behind but may still be invisible to system actors and leaders.

Abstract Background In 2016, the Government of the southern Indian state of Kerala launched the Aardram mission, a set of reforms in the state’s health sector with the support of Local Self Governments (LSG). Primary Health Centres (PHCs) were slated for transformation into Family Health Centres (FHCs), with extended hours of operation as well as improved quality and range of services. With the COVID-19 pandemic emerging soon after their introduction, we studied the outcomes of the transformation from PHC to FHC and how they related to primary healthcare service delivery during COVID-19. Methods A qualitative study was conducted using In-depth interviews with 80 health system actors (male n = 32, female n = 48) aged between 30–63 years in eight primary care facilities of four districts in Kerala from July to October 2021. Participants included LSG members, medical and public health staff, as well as community leaders. Questions about the need for primary healthcare reforms, their implementation, challenges, achievements, and the impact of COVID-19 on service delivery were asked. Written informed consent was obtained and interview transcripts – transliterated into English—were thematically analysed by a team of four researchers using ATLAS.ti 9 software. Results LSG members and health staff felt that the PHC was an institution that guarantees preventive, promotive, and curative care to the poorest section of society and can help in reducing the high cost of care. Post-transformation to FHCs, improved timings, additional human resources, new services, fully functioning laboratories, and well stocked pharmacies were observed and linked to improved service utilization and reduced cost of care. Challenges of geographical access remained, along with concerns about the lack of attention to public health functions, and sustainability in low-revenue LSGs. COVID-19 pandemic restrictions disrupted promotive services, awareness sessions and outreach activities; newly introduced services were stopped, and outpatient numbers were reduced drastically. Essential health delivery and COVID-19 management increased the workload of health workers and LSG members, as the emphasis was placed on managing the COVID-19 pandemic and delivering essential health services. Conclusion Most of the health system actors expressed their belief in and commitment to primary health care reforms and noted positive impacts on the clinical side with remaining challenges of access, outreach, and sustainability. COVID-19 reduced service coverage and utilisation, but motivated greater efforts on the part of both health workers and community representatives. Primary health care is a shared priority now, with a need for greater focus on systems strengthening, collaboration, and primary prevention.

Abstract Background Inequalities in access to and utilization of maternal and child health (MCH) care are hampering progress on the path to achieving the Sustainable Development Goals. In a number of Low- and Middle-Income Countries (LMICs) population subgroups at disproportionate risk of being left behind are the urban poor. Within this neglected group is the further neglected group of the homeless. Concomitantly, a number of interventions from the antenatal period onward have been piloted, tested, and scaled in these contexts. We carried out an overview of systematic reviews (SRs) to characterize the evidence around maternal and child health interventions relevant to urban poor homeless populations in LMICs. Methods We searched Medline, Cochrane Library, Health Systems Evidence and EBSCOhost databases for SRs published between January 2009 and 2020 (with an updated search through November 2021). Our population of interest was women or children from urban poor settings in LMICs; interventions and outcomes corresponded with the World Health Organization’s (WHO) guidance document. Each SR was assessed by two reviewers using established standard critical appraisal checklists. The overview was registered in PROSPERO (ID: CRD42021229107). Results In a sample of 33 high quality SRs, we found no direct relevant evidence for pregnant and lactating homeless women (and children) in the reviewed literature. There was a lack of emphasis on evidence related to family planning, safe abortion care, and postpartum care of mothers. There was mixed quality evidence that the range of nutritional interventions had little, unclear or no effect on several child mortality and development outcomes. Interventions related to water, sanitation, and hygiene, ensuring acceptability of community health services and health promotion type programs could be regarded as beneficial, although location seemed to matter. Importantly, the risk of bias reporting in different reviews did not match, suggesting that greater attention to rigour in their conduct is needed. Conclusion The generalizability of existing systematic reviews to our population of interest was poor. There is a clear need for rigorous primary research on MCH interventions among urban poor, and particularly homeless populations in LMICs, as it is as yet unclear whether the same, augmented, or altogether different interventions would be required.

Introduction: Kerala, a south Indian state, has often been cited globally as a model for better health outcomes at low cost but faces unique challenges in achieving Universal Health Coverage (UHC). To propel the efforts in achieving UHC, the Government of Kerala announced the “Aardram” health reform initiative, emphasising improving the quality of primary care service delivery. The reforms started in 2017, and in the first stage, 170 of 848 Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The facilities were provided with additional doctors, nurses, and paramedical staff; the working hours were extended, and the range of services offered increased. In support of these processes, we carried out a facility assessment to assess differences between upgraded FHCs and existing PHCs. Materials and Methods: We conducted a facility-based cross-sectional assessment in eight primary care facilities of Kerala, FHC (N=4) and PHCs (N=4) from June to October 2019. A structured questionnaire covering utilisation and coverage of selected priority services for various populations and health outcome data was filled out by health staff to report data for the financial year 2018-19. Data were analysed in Microsoft Excel spreadsheets for easy analysis and replication by state stakeholders. Results: Coverage indicators such as full antenatal care and full immunization coverage were not appreciably different in FHCs as compared to PHCs. However, key reform-related differences were observed. On average, FHCs had 0.8 medical officers and one staff nurse per 10,000 population, whereas PHCs had 0.7 medical officers and less than 0.4 staff nurses per 10,000 population, even as the size of populations served by these human resources varied greatly across both types of facilities. The number of outpatient department visits per 10,000 population annually was 11,343 persons in FHCs and 9,580 persons in PHCs. FHCs also provided additional services such as screening for depression and chronic obstructive pulmonary disorders. Conclusion: Aardram primary healthcare reforms are still in their early days and appear to be associated with improved service coverage at the institutional level. However, some patterns are uneven: reforms should be carefully documented, and population-level impacts monitored over time.

Abstract Since the 2008 publication of the reports of the Commission on Social Determinants of Health and its nine knowledge networks, substantial research has been undertaken to document and describe health inequities. The COVID-19 pandemic has underscored the need for a deeper understanding of, and broader action on, the social determinants of health. Building on this unique and critical opportunity, the World Health Organization is steering a multi-country Initiative to reduce health inequities through an action-learning process in ‘Pathfinder’ countries. The Initiative aims to develop replicable and reliable models and practices that can be adopted by WHO offices and UN staff to address the social determinants of health to advance health equity. This paper provides an overview of the Initiative by describing its broad theory of change and work undertaken in three regions and six Pathfinder countries in its first year-and-a-half. Participants engaged in the Initiative describe results of early country dialogues and promising entry points for implementation that involve model, network and capacity building. The insights communicated through this note from the field will be of interest for others aiming to advance health equity through taking action on the social determinants of health, in particular as regards structural determinants.

Abstract Background Hysterectomy, particularly when conducted in women younger than 45 years, has been associated with increased risk of non-communicable diseases. In India, research indicates that hysterectomy is a common procedure for women, but there have been no studies on its long-term effects. We examined patterns of hysterectomy amongst women in India and associations with their health and well-being in later life. Methods This analysis utilised the first wave of the Longitudinal Study on Aging in India, a nationally representative study of adults that included a module on health and well-being. We analysed data on 35,083 women ≥45 years in India. We estimated prevalence of hysterectomy and performed multivariable logistic regression to identify associated risk factors and to examine the association between hysterectomy status and eight self-reported chronic conditions, hospitalisation and mobility. Results The prevalence of hysterectomy among women >=45 years was 11.4 (95% CI: 10.3, 12.6), with higher odds among urban women (aOR: 1.39; 1.17,1.64) and higher economic status (highest compared to lowest quintile: aOR: 1.95; 1.44, 2.63). Hysterectomy history was associated with four chronic conditions: hypertension (aOR: 1.51; 95% CI: 1.28, 1.79), high cholesterol (aOR: 1.43; 1.04, 1.97), diabetes (aOR: 1.69; 1.28, 2.24), and bone/joint disease (aOR: 1.54; 1.20, 1.97) and higher odds of any hospitalisation in the past year (aOR: 1.69; 1.36, 2.09). Conclusions In India, evidence suggests that hysterectomy is associated with major chronic conditions. The assessment for hysterectomy as a treatment option for gynaecological morbidity should consider potential health consequences in later life.

Abstract Background The COVID-19 pandemic has helped shine the spotlight on the role of women’s leadership in tackling the world’s health and health system challenges. The proportion of women occupying senior leadership positions in the health sector is less compared to males, even as they constitute a vast majority of the work force. The South Indian state of Kerala is an exception to this trend, a phenomenon that we sought to understand and contextualise. We undertook a study to understand the personal and professional journeys of some women leaders in the Kerala health sector to determine the antecedents of their leadership positions, the challenges that came their way in leadership, and strategies adopted to overcome these challenges. We also investigated into how these experiences shaped their styles and approaches to leadership. Methods We conducted a qualitative study involving semi-structured in-depth interviews with women leaders. Sixteen women leaders were identified from public records and through peer nomination and interviewed in their language of preference following written informed consent procedures. Interviews focused on participants’ professional and personal trajectories, work-life balance, style of leadership, challenges, enablers, lessons learned in their path, and their vision for the health system. The interviews conducted in Malayalam were transliterated into English and thematically analysed using Atlas.Ti8 software by three researchers. Results Our study participants were aged 40 to around 80 years, from 8 out of 14 districts of the state. Women leaders in Kerala’s health sector faced challenges through the life-course: during their early school education, in professional service as well as in their roles as leaders. There were myriad experiences – including gender stereotyping and discrimination at the intersection of gender and other social identities. Women developed manifold ways of overcoming them and evolve unique – and again myriad—leadership styles. Conclusions Women leaders in Kerala have faced shared challenges through their life-course to climb up the ranks of leadership; each leader has adopted unique ways of overcoming them and developed similarly unique leadership styles. At each life stage there were bargains with patriarchy – involving family members (often as allies), against formal and informal institutional rules, managers, peers and subordinates., which in turn suggests a feminist consciousness on the part of Kerala women leaders as well as the society in which they are seeking to lead.

Abstract Background Health inequality monitoring can generate important evidence to inform and motivate changes to policy, programmes and practices. However, the potential of health inequality monitoring practices to quantify inequalities between population subgroups and track progress on the advancement of health equity is under-realized. Capacity strengthening on health inequality monitoring can play an important role in enhancing political will for the generation and use of disaggregated data and for wider adoption of this practice to inform health decision-making. There is a lack of widely available and accessible training materials related to health inequality monitoring that may be used by a range of stakeholders. Objective In this paper, we describe the design, development and implementation of the Health Inequality Monitoring channel on the OpenWHO eLearning platform. We discuss the anticipated impact and potential opportunities for these eLearning courses to contribute to strengthened health inequality monitoring practices. Results The Health Inequality Monitoring channel on the OpenWHO platform is a self-directed learning environment, designed to meet the immediate learning needs of users. The channel contains three series of courses: health inequality monitoring foundations courses; topic-specific health inequality monitoring courses; and health inequality monitoring skill building courses. Courses are primarily targeted to monitoring and evaluation officers, data analysts, academics and researchers, public health professionals, medical and public health students, and others with a general interest in health data and inequality monitoring. Conclusions WHO eLearning courses on health inequality monitoring are addressing the need for capacity strengthening in the collection, analysis and reporting of inequality data. They introduce learners to the foundational concepts, best practices, tools and skills required to conduct health inequality monitoring. The courses on the Health Inequality Monitoring channel demonstrate how technical information can be simplified and presented to broad audiences in a manner that is highly accessible to learners. The Health Inequality Monitoring channel on OpenWHO is an innovative and necessary addition to existing tools and resources to support the advancement of health equity.

Abstract Background Non-Communicable Diseases (NCDs) constitute a significant danger to the nation’s public health system, both in terms of morbidity and mortality, as well as the financial burden they inflict. Kerala is undergoing an epidemiologic transition, which has significantly impacted the state’s morbidity and mortality figures. For decades, the state has been putting in place myriad programs to reduce the burden of NCDs across population groups. Socioeconomic inequalities in NCD testing have been documented in India, although they are understudied in Kerala. The study aimed to estimate and characterize districtwise socioeconomic inequality in Blood Pressure (BP) and Blood Glucose (BG) testing. Methods A cross-sectional household survey was conducted between July–October 2019 in Kasaragod, Alappuzha, Kollam and Thiruvananthapuram districts of Kerala, India. A total of 6383 participants aged 30 years and above were interviewed using multistage random sampling. Descriptive statistics were derived district-wise. We computed ratios, differences, equiplots, and Erreygers concentration indices for each district to measure socioeconomic inequality in BP and BG testing. Erreygers decomposition techniques were used to estimate the relative contribution of covariates to socioeconomic inequality. Results There was a significant concentration of BP and BG testing favouring wealthier quintiles in Alappuzha, Kollam, and Thiruvananthapuram districts. The inequality in BP and BG testing was highest in Thiruvananthapuram (0.087 and 0.110), followed by Kollam (0.077 and 0.090), Alappuzha (0.083 and 0.073) and Kasaragod (0.026 and 0.056). Decomposition analysis revealed that wealth quintile and education contributed substantially to socioeconomic inequality in BP and BG testing in all four districts. It was also found that family history of NCDs significantly contributed to observed socioeconomic inequality in BP testing (29, 11, 16, and 27% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram, respectively). Similarly, in BG testing, family history of NCDs substantially contributed to observed socioeconomic inequality, explaining 16–17% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram respectively of the total inequality. Conclusion While the magnitude of socioeconomic inequality in NCD risk factor testing did not appear to be very high in four Kerala districts, although levels were statistically significant in three of them. Greater exploration is needed on how education and caste contribute to these inequalities and their relationship to NCD risk factors such as family history. From such analyses, we may be able to identify entry points to mitigate inequalities in testing access, as well as burden.

Objective This study assesses educational inequalities in measured as well as self-reported high blood pressure (BP) and high blood glucose (BG) in the southern Indian state of Kerala, which is known to have high chronic disease morbidity.Design The present findings are drawn from a large-scale, nationally representative cross-sectional study.Settings and participants India’s Demographic and Health Survey (conducted in 2019–2021) had data on 36 526 individuals aged 15 years and above in the state of Kerala, India.Primary and secondary outcomes measures Measured high BP and BG; self-reported high BP and BG; as well as self-reported BP and BG testing. Descriptive statistics, bivariate analysis, along with multivariate statistics, were used. Educational inequalities were assessed through absolute and relative complex measures of inequality, namely the Slope Index of Inequality (SII) and Relative Concentration Index (RCI), respectively, with 95% CIs.Results The largest margin of inequality in Kerala, between the least and the most educated groups, was observed for measured high BP (57.7% and 17.6%). Measured high BP (SII −45.4% (95% CI –47.3% to –43.4%); RCI −26.6% (95% CI –27.9% to –25.3%)), self-reported high BP (SII −34.5% (95% CI –36.3% to –32.7%); RCI −19.0% (95% CI –20.1% to –17.9%)). High BG levels were concentrated among those with lower educational attainment (SII −26.6% (95% CI –28.6% to –24.7%); RCI −15.7% (95% CI –16.9% to –14.5%)), represented by negative SII and RCI values.Conclusions The study findings suggest that research and programme efforts need to be redoubled to determine what is driving greater vulnerability to non-communicable diseases among population with lower educational attainment on the one hand and the possible role that improving education access can be on health outcomes, on the other hand. Further research should explore relevant intersections with low education.

Objective Older male and female adults differ in key characteristics such as disease-specific life expectancy, health behaviours and clinical presentations and non-communicable disease multimorbidity (NCD-MM). Therefore, examining the sex differences in NCD-MM among older adults is vital, as this issue is understudied in low-income and middle-income country (LMIC) contexts such as India, and has been growing in the past few decades.Design Large scale nationally representative cross-sectional study.Settings and participants Longitudinal Ageing Study in India (LASI 2017–2018) had data on 27 343 men and 31 730 women aged 45+, drawn from a sample of 59 073 individuals across India.Primary and secondary outcomes measures We operationalised NCD-MM based on prevalence of the presence of two or more long-term chronic NCD morbidities. Descriptive statistics and bivariate analysis along with multivariate statistics were used.Results Women aged 75+ had a higher prevalence of multimorbidity as compared with men (52.1% vs 45.17%). NCD-MM was more common among widows (48.5%) than widowers (44.8%). The female-to-male ratios of ORs (RORs) for NCD-MM associated with overweight/obesity and prior history of chewing tobacco were 1.10 (95% CI: 1.01 to 1.20) and 1.42 (95% CI: 1.12 to 1.80), respectively. The female-to-male RORs show that the odds of NCD-MM were greater in formerly working women (1.24 (95% CI: 1.06 to 1.44)) relative to formerly working men. The effect of increasing NCD-MM on limitations in activities of daily living and instrumental ADL was greater in men than women but reversed for the hospitalisation.Conclusions We found significant sex differences in NCD-MM prevalence among older Indian adults, with various associated risk factors. The patterns underlying these differences warrant greater study, given existing evidence on differential longevity, health burdens and health-seeking patterns all of which operate in a larger structural context of patriarchy. Health systems in turn must respond to NCD-MM mindful of these patterns and aim to redress some of the larger inequities they reflect.

Abstract Background Non-Communicable Diseases (NCDs) are among India’s top burdens, particularly in states like Kerala, which is at an advanced stage of the epidemiological transition. Evidence in India points towards intersectional inequalities in risk factors of NCDs and testing, both of which are understudied in Kerala. We estimated the self-reported testing and prevalence of key NCD risk factors—blood pressure (BP) and blood glucose (BG) comparing Kerala men and women across educational, wealth, religion, as well as caste and tribal status subgroups. Method A multistage random sample survey of 3398 women and 2982 men aged 30 years and over was administered in 4 districts of Kerala from July to October 2019. Descriptive analysis for men and women was undertaken using survey weights. Slope index of Inequality and Relative Concentration Index for wealth and education related inequalities, and, Weighted Mean Difference from Mean and Index of Disparity for caste and tribal status, as well as religion related inequalities were calculated using World Health Organisation’s Health Equity Assessment Toolkit Plus and Stata 12. Results A significantly higher proportion of women reported BP and BG testing by medical personnel in the previous year than men (BP Testing among Women (BPTw): 90.3% vs BP Testing among Men (BPTM):80.8%, BG Testing among Women (BGTw): 86.2% vs BG Testing among Women (BGTM):78.3%). Among those tested, more women (11.2%) than men (7.9%) reported High Blood Pressure (HBP) but not High Blood Glucose (HBG). Testing for BP was concentrated among less-educated women while BG testing was concentrated among both less educated women and men. HBP and HBG were concentrated among less educated and wealthier groups. Although sex differences were insignificant across caste and tribal status and religion subgroups, magnitude of inequalities was high for HBP and HBG. Conclusion Distinct patterns of sex inequalities were present in self-reported testing and prevalence of NCD risk factors in Kerala. Education and wealth seem to be associated with testing while prevalence appeared to vary by religious groups. Given the low rates of illiteracy, it is encouraging but maybe a data artefact that a small population of less-educated persons was getting tested; however, exclusion of poor groups and inequalities by other dimensions raise concerns. Further exploration is needed to understand underlying mechanisms of these inequalities to ensure we leave no one behind.

BackgroundKerala, a south Indian state, has a long and strong history of mobilisation of people's participation with institutionalised mechanisms as part of decentralisation reforms introduced three decades ago. This history formed the backdrop of the state's COVID-19 response from 2020 onwards. As part of a larger health equity study, we carried out an analysis to understand the contributions of people's participation to the state's COVID-19 response, and what implications this may have for health reform as well as governance more broadly.MethodsWe employed in-depth interviews with participants from four districts of Kerala between July and October, 2021. Following written informed consent procedures, we carried out interviews of health staff from eight primary health care centres, elected Local Self Government (LSG, or Panchayat) representatives, and community leaders. Questions explored primary health care reforms, COVID responses, and populations left behind. Transliterated English transcripts were analysed by four research team members using a thematic analysis approach and ATLAS.ti 9 software. For this paper, we specifically analysed codes and themes related to experiences of community actors and processes for COVID mitigation activities.ResultsA key feature of the COVID-19 response was the formation of Rapid Response Teams (RRTs), groups of lay community volunteers, who were identified and convened by LSG leaders. In some cases, pre-pandemic 'Arogya sena' (health army) community volunteer groups were merged with RRTs. RRT members were trained and supported by the health departments at the local level to distribute medicine and essential items, provided support for transportation to health facilities, and assisted with funerary rites during lockdown and containment period. RRTs often comprised youth cadres of ruling and opposition political parties. Existing community networks like Kudumbashree (Self Help Groups) and field workers from other departments have supported and been supported by RRTs. As pandemic restrictions eased, however, there was concern about the sustainability of this arrangement as well.ConclusionParticipatory local governance in Kerala allowed for the creation of invited spaces for community participation in a variety of roles as part of the COVID 19 response, with manifest impact. However, the terms of engagement were not decided by communities, nor were they involved more deeply in planning and organising health policy or services. The sustainability and governance features of such involvement warrant further study.

Abstract Background The burden of mental health in India, as in other Low- and Middle-Income Countries (LMICs), is substantial. Secondary Analysis of survey data provides insight into trends in mental health morbidity over time, while administrative data can indicate corresponding trends in availability of infrastructure and services. We compared data from three national level surveys conducted in India to analyse trends in mental health morbidity and available institutional mechanisms to address mental health needs in Kerala, a south Indian state. Methods We compiled data from national and state level population surveys which reported mental health morbidity from 2002 to 2018. We compared the prevalence of mental health illness and disability reported in Kerala with national estimates. We also mapped the most recently available health human resource and infrastructure available in Kerala for mental health care. Basic descriptive statistics were computed for both sets of indicators using Microsoft Excel. Results In 2002, Kerala had 194 persons per hundred thousand population with mental retardation and intellectual disability which increased to 300 persons per hundred thousand population in 2018. The number of individuals with mental health illness in the state increased from 272 person per hundred thousand to 400 persons per hundred thousand in the time period of 2002 to 2018. There were 5.53 beds available per ten thousand persons for treatment in Kerala in 2018. Conclusion Kerala experienced a rapid rise in mental health morbidity between 2002 and 2018. The most recently reported health human resource and infrastructure availability in the state appears to be inadequate to cater to the requirements of mental health care, even as improvements and upgradations are underway. Service and system design changes will have to be mapped and evaluated over time.

Civil Society Organisations (CSO) have played a significant role globally in improving access of under-served populations to healthcare, including the homeless. In India, while there exist small-scale initiatives such as night shelters and recovery shelters run by the urban local government in coordination with CSOs to support homeless people, evidence on how these services function and are experienced is lacking. This analysis sought to describe the roles played by CSOs – alone and in partnership with the government – as well as how these were experienced by homeless people. A qualitative study consisting of five Focus Group Discussions, 24 In Depth Interviews, and non-participant observation was carried out among homeless people staying in shelters and the streets in India's national capital, Delhi. Data analysis was done using a grounded theory approach with inductive generation of themes. CSOs provided various forms of support - ranging from the provision of night shelters for temporary accommodation, recovery shelters for ailing homeless people requiring support and provisional accommodation for convalescence, drinking water and sanitation, to basic health services, first aid treatment, diagnostic tests, mental health counselling, support with treatment costs, and patient navigation. Notwithstanding constraints of funding and networks that hampered continuity and comprehensiveness of care, CSOs are key in ensuring access to health services and social determinants among the urban poor; their impact and the possibility of networking and scaling up their efforts warrant further study.

Abstract Background Breast cancer incidence rates are increasing in developing countries including India. With 1.3 million new cases of cancer been diagnosed annually, breast cancer is the most common women’s cancer in India. India’s National Family Health Survey (NFHS-4) data 2015–2016 shows that only 9.8% of women between the ages of 15 and 49 had ever undergone breast examination (BE). Further, access to screening and treatment is unequally distributed, with inequalities by socio-economic status. It is unclear, however, if socio-economic inequalities in breast examination are similar across population subgroups. Methods We compared BE coverage in population sub-groups categorised by place of residence, religion, caste/tribal groups, education levels, age, marital status, and employment status in their intersection with economic status in India. We analysed data for 699,686 women aged 15–49 using the NFHS-4 data set conducted during 2015–2016. Descriptive (mean, standard errors, and confidence intervals) of women undergoing BE disaggregated by dimensions of inequality (education, caste/tribal groups, religion, place of residence) and their intersections with wealth were computed with national weights using STATA 12. Chi-square tests were performed to assess the association between socio-demographic factors and breast screening. Additionally, the World Health Organisation’s Health Equity Assessment Toolkit Plus was used to compute summary measures of inequality: Slope index for inequality (SII) and Relative Concentration Indices (RCI) for each intersecting dimension. Results BE coverage was concentrated among wealthier groups regardless of other intersecting population subgroups. Wealth-related inequalities in BE coverage were most pronounced among Christians (SII; 20.6, 95% CI: 18.5–22.7), married (SII; 14.1, 95% CI: 13.8–14.4), employed (SII: 14.6, 95%CI: 13.9, 15.3), and rural women (SII; 10.8, 95% CI: 10.5–11.1). Overall, relative summary measures (RCI) were consistent with our absolute summary measures (SII). Conclusions Breast examination coverage in India is concentrated among wealthier populations across population groups defined by place of residence, religion, age, employment, and marital status. Apart from this national analysis, subnational analyses may also help identify strategies for programme rollout and ensure equity in women’s cancer screening.

Abstract 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.

Applications of systems thinking in the context of Health Policy and Systems Research have been scarce, particularly in Low- and Middle-Income Countries (LMICs). Given the urgent need for addressing implementation challenges, the WHO Alliance for Health Policy and Systems Research, in collaboration with partners across five global regions, recently initiated a global community of practice for applied systems thinking in policy and practice contexts within LMICs. Individual one on one calls were conducted with 56 researchers, practitioners & decision-makers across 9 countries in Southeast Asia to elucidate key barriers and opportunities for applying systems thinking in individual country settings. Consultations presented the potential for collaboration and co-production of knowledge across diverse stakeholders to strengthen opportunities by applying systems thinking tools in practice. While regional nuances warrant further exploration, there is a clear indication that policy documentation relevant to health systems will be instrumental in advancing a shared vision and interest in strengthening capacities for applied systems thinking in health systems across Southeast Asia.

Immunization, hailed as one of the most successful public health interventions in the world, has contributed to major advancements in health as well as social and economic development [...]

Abstract Background Latin America (LA) has experienced constant economic and political crises that coincide with periods of greater inequality. Between 1996 and 2007 Ecuador went through one of the greatest political and socio-economic crises in Latin America, a product of neo-liberal economic growth strategies. Between 2007 and 2012 it regained political stability, promoted redistributive policies, and initiated greater social spending. To understand the possible influence on the political and economic context, we analyzed the coverage and inequalities in five Reproductive, Maternal, and Child Health (RMNCH) and two water and sanitation interventions using survey data from a broad time window (1994–2012), at a national and subnational level. Methods The series cross-sectional study used data from four representative national health surveys (1994, 1999, 2004 and 2012). Coverage of RMNCH and sanitary interventions were stratified by wealth quintiles (as a measure of the socio-economic level), urban-rural residence and the coverage for each province was mapped. Mean difference, Theil index and Variance-weighted least squares regression were calculated to indicate subnational and temporal changes. Results From 1994 to 2004, Ecuador evidenced large inequalities whose reduction becomes more evident in 2012. Coverage in RMNCH health service-related interventions showed a rather unequal distribution among the socioeconomic status and across provinces in 1994 and 2004, compared to 2012. Sanitary interventions on the contrary, showed the most unequal interventions, and failed to improve or even worsened in several provinces. While there is a temporary improvement also at the subnational level, in 2012 several provinces maintain low levels of coverage. Conclusions The remarkable reduction of inequalities in coverage of RMNCH interventions in 2012 clearly coincides with periods of regained political stability, promoted redistributive policies, and greater social spending, different from the former neo-liberal reforms which is consistent with observations made in other Latin American countries. Territorial heterogeneity and great inequalities specially related with sanitation interventions persists. It is necessary to obtain high quality information with sharper geographic desegregation that allows to identify and understand local changes over time. This would help to prioritize intervention strategies, introduce multisectoral policies and investments that support local governments.

Summary: Background: Analysis of health inequalities by ethnicity is critical to achieving the Sustainable Development Goals. In Ecuador, similar to other Latin American countries, indigenous and afro-descendant populations have long been subject to racism, discrimination, and inequitable treatment. Although in recent years, Ecuador has made progress in health indicators, particularly those related to the coverage of Reproductive, Maternal, Neonatal and Child Health (RMNCH) interventions, little is known as to whether inequalities by ethnicity persist. Methods: Analysis was based on two nationally representative health surveys (2004 and 2012). Ethnicity was self-reported and classified into three categories (Indigenous/Afro-Ecuadorian/Mixed ancestry). Coverage data for six RMNCH health interventions were stratified for each ethnic group by level of education, area of residence and wealth quintiles. Absolute inequality measures were computed and multivariate analysis using Poisson regression was undertaken. Findings: In 2012, 74.4% of women self-identifying as indigenous did not achieve the secondary level of education and 50.7% were in the poorest quintile (Q1); this profile was relatively unchanged since 2004. From 2004 to 2012, the coverage of RMNCH interventions increased for all ethnic groups, and absolute inequality decreased. However, in 2012, regardless of education level, area of residence and wealth quintiles, ethnic inequalities remained for almost all RMNCH interventions. Indigenous women had 24% lower prevalence of modern contraceptive use (Prevalence ratio [PR] = 0.76; 95% IC: 0.7–0.8); 28% lower prevalence of antenatal care (PR = 0.72; 95% IC: 0.6–0.8); and 35% lower prevalence of skilled birth attendance and institutional delivery (PR = 0.65; 95% IC: 0.6–0.7 and PR = 0.65; 95% IC: 0.6–0.7 respectively), compared with the majority ethnic group in the country. Interpretation: While the gaps have narrowed, indigenous people in Ecuador continue in a situation of structural racism and are left behind in terms of access to RMNCH interventions. Strategies to reduce ethnic inequalities in the coverage services need to be collaboratively redesigned/co-designed. Funding: This paper was made possible with funds from the Bill & Melinda Gates Foundation [Grant Number: INV-007,594/OPP1148933].

Abstract Introduction The tea estate sector of India is one of the oldest and largest formal private employers. Workers are dependent on plantation estates for a range of basic services under the 1951 Plantation Labour Act and have been subject to human rights violations. Ad hoc reports related to poor health outcomes exist, yet their determinants have not been systematically studied. This study in Assam, situated in Northeast India, sought to understand the Social Determinants of Health (SDH) of women plantation workers with an aim to offer directions for policy action. Methods As part of a larger qualitative study, 16 FGDs were carried out with women workers in three plantations of Jorhat district covering permanent and non-permanent workers. Informed consent procedures were carried out with all participants individually. Data were analyzed thematically using Ritchie and Spencer’s framework based on an adapted conceptual framework drawing from existing global conceptual models and frameworks related to the SDH. Results Determinants at structural, intermediary and individual levels were associated with health. Poverty and poor labour conditions, compounded by the low social position of women in their communities, precluded their ability to improve their economic situation. The poor quality of housing and sanitation, inadequate food and rations, all hampered daily living. Health services were found wanting and social networks were strained even as women were a critical support to each other. These factors impinged on use of health services, diet and nutrition as well as psychosocial stress at the individual level. Conclusion Years of subjugation of workers have led to their deep distrust in the system of which they are part. Acting on SDH will take time, deeper understanding of their relative and/or synergistic contribution, and require the building of stakeholdership. Notwithstanding this, to have heard from women workers themselves has been an important step in visibilizing and building accountability for action on the health and SDH of women in plantation estates.

As a key step in advancing the sustainable development goals, the World Health Organisation (WHO) has placed emphasis on building capacity for measuring and monitoring health inequalities. A number of resources have been developed, including the Health Equity Assessment Toolkit (HEAT), a software application that facilitates the assessment of within-country health inequalities. Following user demand, an Upload Database Edition of HEAT, HEAT Plus, was developed. Launched in July 2017, HEAT Plus allows users to upload their own databases and assess inequalities at the global, national or subnational level for a range of (health) indicators and dimensions of inequality. The software is open-source, operates on Windows and Macintosh platforms and is readily available for download from the WHO website. The flexibility of HEAT Plus makes it a suitable tool for both global and national inequality assessments. Further developments will include interactive graphs, maps and translation into different languages.

Background: Inequalities in health represent a major problem in many countries, including Indonesia. Addressing health inequality is a central component of the Sustainable Development Goals and a priority of the World Health Organization (WHO). WHO provides technical support for health inequality monitoring among its member states. Following a capacity-building workshop in the WHO South-East Asia Region in 2014, Indonesia expressed interest in incorporating health-inequality monitoring into its national health information system. Objectives: This article details the capacity-building process for national health inequality monitoring in Indonesia, discusses successes and challenges, and how this process may be adapted and implemented in other countries/settings. Methods: We outline key capacity-building activities undertaken between April 2016 and December 2017 in Indonesia and present the four key outcomes of this process. Results: The capacity-building process entailed a series of workshops, meetings, activities, and processes undertaken between April 2016 and December 2017. At each stage, a range of stakeholders with access to the relevant data and capacity for data analysis, interpretation and reporting was engaged with, under the stewardship of state agencies. Key steps to strengthening health inequality monitoring included capacity building in (1) identification of the health topics/areas of interest, (2) mapping data sources and identifying gaps, (3) conducting equity analyses using raw datasets, and (4) interpreting and reporting inequality results. As a result, Indonesia developed its first national report on the state of health inequality. A number of peer-reviewed manuscripts on various aspects of health inequality in Indonesia have also been developed. Conclusions: The capacity-building process undertaken in Indonesia is designed to be adaptable to other contexts. Capacity building for health inequality monitoring among countries is a critical step for strengthening equity-oriented national health information systems and eventually tackling health inequities.

Background: Achieving the Sustainable Development Goal of ‘ensuring healthy lives and promoting well-being for all at all ages’ necessitates regular monitoring of inequality in the availability of health-related infrastructure and access to services, and in health risks and outcomes. Objectives: To quantify subnational regional inequality in Indonesia using a composite index of public health infrastructure, services, behavioural risk factors and health outcomes: the Public Health Development Index (PHDI). Methods: PHDI is a composite index of 30 public health indicators from across the life course and along the continuum of care. An overall index and seven topic-specific sub-indices were calculated using data from the 2013 Indonesian Basic Health Survey (RISKESDAS) and the 2011 – Village Potential Survey (PODES). These indices were analysed at the national, province and district levels. Within-province inequality was calculated using the Weighted Index of Disparity (IDISW). Results: National average PHDI overall index was 54.0 (out of a possible 100); scores differed between provinces, ranging from 43.9 in Papua to 65.0 in Bali. Provinces in western regions of Indonesia tended to have higher overall PHDI scores compared to eastern regions. Large variations in province averages were observed for the non-communicable diseases sub-index, environmental health sub-index and infectious diseases sub-index. Provinces with a similar number of districts and with similar overall scores on the PHDI index showed different levels of relative within-province inequality. Greater within-province relative inequalities were seen in the environmental health and health services provisions sub-indices as compared to other indices. Conclusions: Achieving the goal of ensuring healthy lives and promoting well-being for all at all ages in Indonesia necessitates having a more focused understanding of district-level inequalities across a wide range of public health infrastructure, service, risk factor and health outcomes indicators, which can enable geographical comparison while also revealing areas for intervention to address health inequalities.

The task of health inequality monitoring is not possible without the availability of appropriate and high-quality data at various levels. Data source mapping – a process by which data sources are systematically enlisted, their properties detailed and each source appraised for the purposes of monitoring – is an essential initial step for health inequality monitoring. We outline a simple process along with a template for data source mapping and its application in Indonesia, concluding with the lessons learned from this process, in terms of both challenges as well as the opportunities and advantages arising from the use of equity-related data from the Indonesian health information system.

The recent growth of medicine sales online represents a major disruption to pharmacy markets, with COVID-19 encouraging this trend further. While e-pharmacy businesses were initially the preserve of high-income countries, in the past decade they have been growing rapidly in low-income and middle-income countries (LMICs). Public health concerns associated with e-pharmacy include the sale of prescription-only medicines without a prescription and the sale of substandard and falsified medicines. There are also non-health-related risks such as consumer fraud and lack of data privacy. However, e-pharmacy may also have the potential to improve access to medicines. Drawing on existing literature and a set of key informant interviews in Kenya, Nigeria and India, we examine the e-pharmacy regulatory systems in LMICs. None of the study countries had yet enacted a regulatory framework specific to e-pharmacy. Key regulatory challenges included the lack of consensus on regulatory models, lack of regulatory capacity, regulating sales across borders and risks of over-regulation. However, e-pharmacy also presents opportunities to enhance medicine regulation—through consolidation in the sector, and the traceability and transparency that online records offer. The regulatory process needs to be adapted to keep pace with this dynamic landscape and exploit these possibilities. This will require exploration of a range of innovative regulatory options, collaboration with larger, more compliant businesses, and engagement with global regulatory bodies. A key first step must be ensuring that national regulators are equipped with the necessary awareness and technical expertise to actively oversee this e-pharmacy activity.

Background: Healthcare services, in many countries, are increasingly being provided by cadres not trained as physicians, and these substitute health workers are referred to as mid-level health providers (MLHPs). The objective of this study was to rapidly synthesise evidence on the effectiveness of MLHPs involved in the delivery of healthcare, with a perspective on low- and middle-income countries. Methods: The review team performed an overview of systematic reviews assessing various outcomes for participants receiving care from MLHPs. The team evaluated systematic reviews for methodological quality and certainty of the evidence. Also, the review team consulted relevant stakeholders in India. Results: The final report included seven systematic reviews, with six assessed as moderate to high methodological quality. Mortality outcomes concerning pregnancy and childbirth care services showed no significant differences in care provided by MLHPs when compared with doctors. Pregnancy care provided by midwives was found to improve the quality of care slightly. The risk of failure or incomplete abortion for surgical abortion procedures provided by MLHPs was twice when compared to the procedures provided by doctors. Moderate to high certainty evidence showed that initiation and maintenance of antiretroviral therapy for HIV-infected patients by a nurse or clinical officer slightly reduced mortality. High certainty evidence showed that chronic disease management by non-medical prescribers reduced some important physiological measures compared to medical prescribing by doctors. Conclusions: To date, this is the first rapid overview of the evidence on MLHPs. Low-quality evidence suggests that MLHPs might be suitable to deliver quality pregnancy care. Moderate and high-quality evidence from trials suggests that MLHPs are helpful for chronic disease management and initiation and maintenance of antiretroviral therapy in people with HIV/AIDS. However, the roles and subsequent training and regulation of MLHPs might be different for different care domains.

IntroductionIndia's Pradhan Mantri Jan Arogya Yojana (PM-JAY) is the world's largest health assurance scheme providing health cover of 500,000 INR (about USD 6,800) per family per year. It provides financial support for secondary and tertiary care hospitalization expenses to about 500 million of India's poorest households through various insurance models with care delivered by public and private empanelled providers. This study undertook to describe the provider empanelment of PM-JAY, a key element of its functioning and determinant of its impact.MethodsWe carried out secondary analysis of cross-sectional administrative program data publicly available in PM-JAY portal for 30 Indian states and 06 UTs. We analysed the state wise distribution, type and sector of empanelled hospitals and services offered through PM-JAY scheme across all the states and UTs.ResultsWe found that out of the total facilities empanelled (N = 20,257) under the scheme in 2020, more than half (N = 11,367, 56%) were in the public sector, while 8,157 (40%) facilities were private for profit, and 733 (4%) were private not for profit entities. State wise distribution of hospitals showed that five states (Karnataka (N = 2,996, 14.9%), Gujarat (N = 2,672, 13.3%), Uttar Pradesh (N = 2,627, 13%), Tamil Nadu (N = 2315, 11.5%) and Rajasthan (N = 2,093 facilities, 10.4%) contributed to more than 60% of empanelled PMJAY facilities: We also observed that 40% of facilities were offering between two and five specialties while 14% of empanelled hospitals provided 21-24 specialties.ConclusionA majority of the hospital empanelled under the scheme are in states with previous experience of implementing publicly funded health insurance schemes, with the exception of Uttar Pradesh. Reasons underlying these patterns of empanelment as well as the impact of empanelment on service access, utilisation, population health and financial risk protection warrant further study. While the inclusion and regulation of the private sector is a goal that may be served by empanelment, the role of public sector remains critical, particularly in underserved areas of India.