WHO South-East Asia Journal of Public Health
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   2016| July-December  | Volume 5 | Issue 2  
    Online since May 16, 2017

 
 
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ORIGINAL RESEARCH
Composition and distribution of the health workforce in India: estimates based on data from the National Sample Survey
Krishna D Rao, Renu Shahrawat, Aarushi Bhatnagar
July-December 2016, 5(2):133-140
DOI:10.4103/2224-3151.206250  PMID:28607241
Background: The availability of reliable and comprehensive information on the health workforce is crucial for workforce planning. In India, routine information sources on the health workforce are incomplete and unreliable. This paper addresses this issue and provides a comprehensive picture of India’s health workforce. Methods: Data from the 68th round (July 2011 to June 2012) of the National Sample Survey on the Employment and unemployment situation in India were analysed to produce estimates of the health workforce in India. The estimates were based on self-reported occupations, categorized using a combination of both National Classification of Occupations (2004) and National Industrial Classification (2008) codes. Results: Findings suggest that in 2011–2012, there were 2.5 million health workers (density of 20.9 workers per 10 000 population) in India. However, 56.4% of all health workers were unqualified, including 42.3% of allopathic doctors, 27.5% of dentists, 56.1% of Ayurveda, yoga and naturopathy, Unani, Siddha and homoeopathy (AYUSH) practitioners, 58.4% of nurses and midwives and 69.2% of health associates. By cadre, there were 3.3 qualified allopathic doctors and 3.1 nurses and midwives per 10 000 population; this is around one quarter of the World Health Organization benchmark of 22.8 doctors, nurses and midwives per 10 000 population. Out of all qualified workers, 77.4% were located in urban areas, even though the urban population is only 31% of the total population of the country. This urban–rural difference was higher for allopathic doctors (density 11.4 times higher in urban areas) compared to nurses and midwives (5.5 times higher in urban areas). Conclusion: The study highlights several areas of concern: overall low numbers of qualified health workers; a large presence of unqualified health workers, particularly in rural areas; and large urban–rural differences in the distribution of qualified health workers.
  2,356 429 6
PERSPECTIVE
Sustainable dengue prevention and control through a comprehensive integrated approach: the Sri Lankan perspective
Hasitha Tissera, Nimalka Pannila-Hetti, Preshila Samaraweera, Jayantha Weeraman, Paba Palihawadana, Ananda Amarasinghe
July-December 2016, 5(2):106-112
DOI:10.4103/2224-3151.206246  PMID:28607237
Dengue is a leading public health problem in Sri Lanka. All 26 districts and all age groups are affected, with high disease transmission; the estimated average annual incidence is 175/100 000 population. Harnessing the World Health Organization Global strategy for dengue prevention and control, 2012–2020, Sri Lanka has pledged in its National Strategic Framework to achieve a mortality from dengue below 0.1% and to reduce morbidity by 50% (from the average of the last 5 years) by 2020. Turning points in the country's dengue-control programme have been the restructuring and restrategizing of the core functions; this has involved establishment of a separate dengue-control unit to coordinate integrated vector management, and creation of a presidential task force. There has been great progress in disease surveillance, clinical management and vector control. Enhanced real-time surveillance for early warning allows ample preparedness for an outbreak. National guidelines with enhanced diagnostics have significantly improved clinical management of dengue, reducing the case-fatality rate to 0.2%. Proactive integrated vector management, with multisector partnership, has created a positive vector-control environment; however, sustaining this momentum is a challenge. Robust surveillance, evidence-based clinical management, sustainable vector control and effective communication are key strategies that will be implemented to achieve set targets. Improved early detection and a standardized treatment protocol with enhanced diagnostics at all medical care institutions will lead to further reduction in mortality. Making the maximum effort to minimize outbreaks through sustainable vector control in the three dimensions of risk mapping, innovation and risk modification will enable a reduction in morbidity.
  2,223 309 3
Healthy Lifestyle Centres: a service for screening noncommunicable diseases through primary health-care institutions in Sri Lanka
D S Virginie Mallawaarachchi, Shiranee C Wickremasinghe, Lakshmi C Somatunga, Vithanage TSK Siriwardena, Nalika S Gunawardena
July-December 2016, 5(2):89-95
DOI:10.4103/2224-3151.206258  PMID:28607234
The Ministry of Health in Sri Lanka initiated the Healthy Lifestyle Centres (HLCs) in 2011, to address the lack of a structured noncommunicable disease (NCD) screening service through the lowest level of primary health-care institutions. The main service objective of the HLCs is to reduce the risk of NCDs of 40–65 year olds by detecting risk factors early and improving access to specialized care for those with a higher risk of cardiovascular disease (CVD). The screened clients are managed at HLCs, based on the total-risk approach to assess their 10-year CVD risk, using the World Health Organization/International Society of Hypertension risk-prediction chart. Those with a 10-year CVD risk of more than 30% are referred to the specialized medical clinics, while others are managed with lifestyle modification and are requested to visit the HLC for rescreening, based on the levels of CVD risk and intermediate risk factors. Identified challenges to date include: underutilization of services, especially by men; weak staff adherence to protocols; lack of integration into pre-existing NCD-screening services; non-inclusion of screening for all the major NCDs; and human resources. The government plans to address these challenges as a priority, within the context of the National multisectoral action plan for the prevention and control of NCDs in Sri Lanka 2016–2020. Key interventions include: extended opening hours for HLCs, outreach activities in workplaces, and integration with “well woman clinics”. Costs related to actions have been realistically estimated. Some actions have already been initiated, while others are being designed with identified funds.
  1,481 301 3
Universal health coverage and the health Sustainable Development Goal: achievements and challenges for Sri Lanka
Amala de Silva, Thushara Ranasinghe, Palitha Abeykoon
July-December 2016, 5(2):82-88
DOI:10.4103/2224-3151.206257  PMID:28607233
With state-funded health care that is free at the point of delivery, a sound primary health-care policy and widespread health-care services, Sri Lanka seems a good example of universal health coverage. Yet, health transition and disparities in provision and financing threaten this situation. Sri Lanka did well on the Millennium Development Goal health indicators, but the Sustainable Development Goal (SDG) for health has a wider purview, which is to “ensure healthy lives and promote well-being for all at all ages”. The gender gap in life expectancy and the gap between life expectancy and healthy life expectancy make achievement of the health SDG more challenging. Although women and children do well overall, the comparative health disadvantage for men in Sri Lanka is a cause for concern. From a financing perspective, high out-of-pocket expenditure and high utilization of the private sector, even by those in the lowest income quintile, are concerns, as is the emerging “third tier”, where some individuals accessing state health care that is free at the point of delivery actually bear some of the costs of drugs, investigations and surgery. This cost sharing is resulting in catastrophic health expenditure for individuals, and delays in and non-compliance with treatment. These concerns about provision and financing must be addressed, as health transition will intensify the morbidity burden and loss of well-being, and could derail plans to achieve the health SDG.
  1,395 262 4
REVIEW
Scrub typhus in Bhutan: a synthesis of data from 2009 to 2014
Tshokey Tshokey, Tashi Choden, Ragunath Sharma
July-December 2016, 5(2):117-122
DOI:10.4103/2224-3151.206248  PMID:28607239
Scrub typhus is an acute, febrile illness, caused by the bacterium Orientia tsutsugamushi, that affects millions annually in the endemic Asia-Pacific region. In untreated cases, the case-fatality rates range from 6% to 35%. In Bhutan, there was a probable outbreak in Gedu in 2009, which resulted in heightened awareness of the disease. Nevertheless, information on scrub typhus in Bhutan is limited and scattered and the epidemiology has yet to be established. To report the current picture of scrub typhus in Bhutan, this review gathered data from scholarly databases, surveillance reports, the Annual health bulletin, research publications and laboratory test reports from hospitals. The weight of evidence indicates an increasing burden of scrub typhus since the Gedu incident, coupled with increased awareness and testing. Another outbreak in a rural primary school in 2014 resulted in two deaths. More hospitals now have testing facilities and laboratory-confirmed cases have been increasing since 2009, with seasonal trends. This review highlights the need for in-depth surveillance and reporting, increased awareness among health-care workers, and initiation of prevention and control programmes in the country.
  1,181 187 7
PERSPECTIVE
Sri Lanka takes action towards a target of zero rabies death by 2020
PA Lionel Harischandra, Amila Gunesekera, Navaratnasingam Janakan, Gyanendra Gongal, Bernadette Abela-Ridder
July-December 2016, 5(2):113-116
DOI:10.4103/2224-3151.206247  PMID:28607238
Rabies is a 100% vaccine-preventable and 100% fatal zoonotic, viral disease. It is usually spread to humans by saliva, through bites or scratches. Dogs are the source of the vast majority of human deaths from rabies. Political will and leadership have been the main drivers for success of the Sri Lankan effort to reduce the burden of disease attributable to rabies. Post-exposure prophylaxis, which is available in government health facilities, at no cost, to all bite patients, has been a main axis of the rabies-elimination strategy. To attain the last mile in rabies elimination in Sri Lanka by 2020, more will need to be done to scale up dog vaccination, enforce responsible dog ownership, strengthen surveillance for animals and humans and conduct mass awareness programmes. Sri Lanka is the first country in the World Health Organization South-East Asia Region to develop a national strategy for elimination of dog-mediated rabies and is a key country in sharing knowledge, expertise and capacity-building in the region, towards a global target of zero rabies deaths by 2030.
  1,158 184 7
ORIGINAL RESEARCH
Factors enabling women with pelvic organ prolapse to seek surgery at mobile surgical camps in two remote districts in Nepal: a qualitative study
Mala Chalise, Malinda Steenkamp, Binaya Chalise
July-December 2016, 5(2):141-148
DOI:10.4103/2224-3151.206251  PMID:28607242
Background: Pelvic organ prolapse (POP) is a major reproductive health problem in Nepal, though many women delay seeking treatment. To address this, the Nepalese government has been providing free vaginal hysterectomies with pelvic floor repair to women in mobile surgical camps. Studies exploring factors that enable women to attend these camp settings are limited. This study aimed to identify factors that affected women seeking surgical treatment for POP at mobile surgical camps. Methods: The study used a qualitative approach. Twenty-one women with POP were recruited in two week-long mobile surgical camps held in two remote districts in Nepal during April and May 2013. Data were collected from individual face-to-face interviews and were analysed thematically. Results: Three themes and six subthemes emerged from the analysis. The first theme, “health-system factors”, suggests that accessibility and affordability of the treatment, and the supportive role of female community health volunteers facilitate women to seek treatment in the camp. The second theme, “factors related to sociocultural norms”, reveals that reaching the end of reproductive years and approval by relevant influential family members empowers women to take up surgical treatment in the mobile surgical camp. Similarly, the third theme, “individual-level factors”, includes women's experience of POP, such as worsening symptoms and fear of development of cancer, as factors enabling women to seek treatment. Conclusion: Enablers to seeking treatment at mobile surgical camps for women are related to the Nepalese health system, sociocultural norms and individual experiences of women. Each of these factors should be considered when conducting mobile surgical camps, if women's uptake of treatment is to be enhanced.
  1,223 113 -
PERSPECTIVE
Meeting the current and future health-care needs of Sri Lanka’s ageing population
Dilhar Samaraweera, Shiromi Maduwage
July-December 2016, 5(2):96-101
DOI:10.4103/2224-3151.206259  PMID:28607235
Sri Lanka is one of the fastest-ageing countries in the world. This rapid demographic transition is expected to result in one quarter of the population being elderly by the year 2041. Profound challenges face the country as a result, especially with respect to planning adequate elderly-oriented services in the social-care and health-care sectors. In response to this need, many initiatives have been put in place to promote and protect the welfare of older people, and these rights have been inscribed in law. Within the health sector, despite the wealth of policies and initiatives in recent years, it is clear that the existing health infrastructure and systems still require strengthening, reorientation and coordination, to meet the needs of the growing population of elderly individuals. Lessons learnt from the successes in reducing the maternal mortality ratio can be applied to strengthening preventive services at the community level, to ensure active healthy ageing in Sri Lanka. Engagement of specialist medical officers of health and general practitioners to provide preventive and curative primary-care services would reduce current pressures on higher-level services. Expansion of dedicated elderly-care wards and units at the tertiary level would restructure care towards changing patient demographics. The key to success in these strategies will be increasing the proportions of the medical, nursing and allied professional cadres who have been trained in geriatric medicine. Such capacity-building in the care of the elderly will allow a move towards provision of multidisciplinary teams that can manage the complex physical, social and psychological needs of the older patient.
  1,087 189 2
POLICY AND PRACTICE
Opportunities in oral health policy for Timor-Leste
Lucio F Babo Soares, Silvana S Bettiol, Isaac J Dalla-Fontana, Penny Allen, Leonard A Crocombe
July-December 2016, 5(2):164-173
DOI:10.4103/2224-3151.206254  PMID:28607245
Timor-Leste faces an urgent set of challenges in oral health. The impact of oral diseases in terms of reduced quality of life and cost of treatment is considerable. This paper reviews progress on policy recommendations since the National Oral Health Survey in 2002, the first such national survey. Few proposals have been implemented to date, owing to (i) lack of local support for the recommendations, particularly on promotion of oral health; (ii) lack of financial and budgetary provisions for oral health; (iii) lack of focus on services, human resources and dental personnel; (iv) poor focus, design and implementation of policy and planning in oral health; and (v) lack of transport to facilitate health-care workers’ access to remote areas. Based on this assessment, the present paper presents a reconfigured set of policies and recommendations for oral health that take into consideration the reasons for low uptake of previous guidance. Key priorities are promotion of oral health, legislative interventions, education of the oral-health workforce, dental outreach programmes, targeted dental treatment, dental infrastructure programmes, and research and evaluation. Interventions include promotion of oral health for schoolchildren, salt fluoridation, fluoride toothpaste and banning sweet stalls and use of tobacco and betel nut in, or near, schools. Timor-Leste should strengthen the availability and quality of outreach programmes for oral health. Dental therapists and dental nurses who can supply preventive and atraumatic restorative dental care should continue to be trained, and the planned dentistry school should be established. Ongoing research and evaluation is needed to ensure that the approach being used in Timor-Leste is leading to improved outcomes in oral health.
  1,113 134 1
ORIGINAL RESEARCH
Social impacts on adult use of tobacco: findings from the International Tobacco Control Project India, Wave 1 Survey
Cecily S Ray, MS Pednekar, PC Gupta, M Bansal-Travers, ACK Quah, GT Fong
July-December 2016, 5(2):123-132
DOI:10.4103/2224-3151.206249  PMID:28607240
Background: Social impacts on tobacco use have been reported but not well quantified. This study investigated how strongly the use of smoked and smokeless tobacco may be influenced by other users who are close to the respondents. Methods: The International Tobacco Control Project (TCP), India, used stratified multistage cluster sampling to survey individuals aged ≥15 years in four areas of India about their tobacco use and that of their close associates. The present study used logistic regression to calculate odds ratios (ORs) for tobacco use for each type of close associate. Results: Among the 9780 respondents, tobacco use was significantly associated with their close associates’ (father’s, mother’s, friends’, spouse’s) tobacco use in the same form. After adjusting for confounding variables, women smokers were nine times more likely to have a mother who ever smoked (OR: 9.0; 95% confidence interval [CI]: 3.3–24.7) and men smokers five times more likely (OR: 5.4; 95% CI: 2.1–14.1) than non-smokers. Men smokers were seven times more likely to have close friends who smoked (OR: 7.2; 95% CI: 5.6–9.3). Users of smokeless tobacco (SLT) were five times more likely to have friends who used SLT (OR: 5.3; 95% CI: 4.4–6.3 [men]; OR: 5.0; 95% CI: 4.3–5.9 [women]) and four times more likely to have a spouse who used SLT (OR: 4.1; 95% CI: 3.0–5.8 [men]; OR: 4.3; 95% CI: 3.6–5.3 [women]), than non-users. The ORs for the association of the individuals’ tobacco use, whether smoked or smokeless, increased with the number of close friends using it in the same form. Conclusion: The influence of family members and friends on tobacco use needs to be appropriately addressed in tobacco-control interventions.
  1,052 86 1
POLICY AND PRACTICE
Policy opportunities and limitations of evidence-based planning for immunization: lessons learnt from a field trial in Bangladesh
John Grundy, Shukhrat Rakhimdjanov, Merina Adhikari
July-December 2016, 5(2):154-163
DOI:10.4103/2224-3151.206253  PMID:28607244
Despite success in scaling up immunization, the national immunization programme in Bangladesh remains challenged by persisting inequities in health access related to geographic location and social factors, including income and education status. In order to tackle these inequities in access, the national immunization programme has conducted a field trial of the evidence-based planning model in Bangladesh between 2011 and 2013, in 11 low-performing districts and 3 city corporations. The main elements of this intervention included bottleneck analysis in local areas, action planning and budgeting to correct the bottlenecks, and establishment of a monitoring system to track progress. Coverage improved in 8 out of 14 districts post intervention. The main success factors associated with the intervention included more analytic approaches to situation assessment and taking action on health inequities at the local level, as well as more considered use of local data to track immunization drop-outs. The main factors associated with coverage declines in trial areas (6 districts) included poor financial resourcing and supervisory support, and gaps and turnover in human resources. In order to sustain and improve coverage, it will be necessary in future to link pro-equity approaches to subdistrict planning to higher-level health-system-strengthening strategy and planning systems. This will ensure that local area planners have the required resources, comprehensive operational plans and political support to sustain implementation of corrective actions to address identified system bottlenecks and inequities in health access at the local level.
  986 88 1
ORIGINAL RESEARCH
Costing of immunization service provision in Kalutara district, Sri Lanka: a cross-sectional study
Hemali Jayasekara, Amala De Silva, Ananda Amarasinghe
July-December 2016, 5(2):149-154
DOI:10.4103/2224-3151.206252  PMID:28607243
Background: Immunization is regarded as the single most cost-effective way to prevent vaccine-preventable diseases. With the rising cost of the National Immunization Programme (NIP) in Sri Lanka, immunization costing studies could help programme managers to ensure sustainable immunization financing in the country. Methods: Four medical officer of health (MOH) divisions in Kalutara district were included, to estimate the cost incurred for the NIP programme. Fifteen immunization clinics from urban and rural settings were selected from the selected MOH divisions, by a simple random sampling method. Data were collected for a period of 3 months, using pretested check-lists. In addition, related data at national and district levels were also collected. Cost estimates were made for direct capital and recurrent costs. Results: The cost of vaccines under the national immunization schedule for infants was 1361.84 SL Rs (US$ 10.32). For children under 5 years of age, it was 1535.64 SL Rs (US$ 11.63). The majority of these costs were direct recurrent costs (93.4%). Vaccines (84.3%) and staff salaries (6.4%) were the main components of direct recurrent costs, while cold-chain equipment (5.3%) was the main contributor to direct capital cost. Conclusion: The cost of vaccine is the highest proportion among all other cost components in the NIP in Sri Lanka, and this is largely attributable to new costly vaccines. Staff payments are not significant, as they are a shared cost of public health service providers. Studies exploring the costing of the NIP in the country would be beneficial, to ensure sustainable immunization financing.
  882 89 1
PERSPECTIVE
Sri Lanka’s national assessment on innovation and intellectual property for access to medical products
Hemantha Beneragama, Manisha Shridhar, Thushara Ranasinghe, Vajira HW Dissanayake
July-December 2016, 5(2):102-105
DOI:10.4103/2224-3151.206245  PMID:28607236
In 2008, the Global strategy and plan of action on public health, innovation and intellectual property (GSPA-PHI) was launched by the World Health Organization, to stimulate fresh thinking on innovation in, and access to, medicines and to build sustainable research on diseases disproportionately affecting low- and middle-income countries. As part of the activities of the GSPA-PHI, Sri Lanka has been the first country to date to assess the national environment for medical technology and innovation. This year-long, multistakeholder, participative analysis facilitated identification of clear and implementable policy recommendations, for the government to increase its effectiveness in promoting innovation in health products through institutional development, investment and coordination among all areas relevant to public health. The assessment also highlighted areas for priority action, including closing the technology gap in development of health products, facilitating technology transfer, and building the health-research and allied workforces. The Sri Lankan experience will inform the ongoing independent external evaluation of the GSPA-PHI worldwide. The assessment process coincided with the passing of the National Medicines Regulatory Authority Act in 2015. In addition, there is growing recognition that regional cooperation will be critical to improving access to medical products in the future. Sri Lanka is therefore actively promoting cooperation to establish a regional regulatory affairs network. Lessons learnt from the Sri Lankan assessment may also benefit other countries embarking on a national GSPA-PHI assessment.
  729 58 -
FEATURE
Maintaining momentum in Sri Lanka to ensure that malaria is gone – but not forgotten

July-December 2016, 5(2):79-81
DOI:10.4103/2224-3151.206256  PMID:28607232
  733 53 2
EDITORIAL
Reorienting the focus towards the Sustainable Development Goals: challenges and opportunities for Sri Lanka
Palitha Mahipala
July-December 2016, 5(2):77-78
DOI:10.4103/2224-3151.206255  PMID:28607231
  644 83 -
FOREWORD
Foreword
Poonam Khetrapal Singh
July-December 2016, 5(2):0-0
DOI:10.4103/2224-3151.206260  
  459 25 -
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