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The World Health Organization (WHO) recommends the requirement of human resource for health (HRH) stands at 44.5 skilled health workers per 10,000 population. WHO recognizes India as one of the countries which has HRH crisis. Karnataka, a southern state in India, has the highest number of medical colleges yet faces the shortage of specialists in the public hospitals. We conducted desk review to understand the HRH crisis, particularly the medical specialists in India. Simultaneously, we conducted secondary research to explore the initiatives taken by the Government of Karnataka (GoK) to mitigate the shortage of medical specialists in the rural areas. GoK scaled up the National Board of Examination in Medical Sciences (NBEMS) postgraduate and super-speciality courses such as Diplomate of National Board (DNB), Diploma, and Doctorate of National Board (DrNB) in district hospitals (minimum 250--500 bedded) and taluk hospitals (minimum 100 bedded) by utilizing the existing resources. Karnataka is the first state in India to expand the NBEMS (DNB and Diploma) courses in taluk hospitals and to begin DrNB courses in district hospitals. The paper documents the process of implementation of the NBEMS courses at district and taluk hospitals of Karnataka, which has supported in strengthening these hospitals in the state. [ABSTRACT FROM AUTHOR]

Background: "CoviSainik Program" was implemented in collaboration with the Ambuja Cement Foundation and Community Medicine Department in rural districts of eight states of India from May to December 2021 to create a cadre of volunteers. The aim of the present paper is to describe the program and evaluate it so that the findings can be the guiding tool for policymakers to replicate a similar program. Material and Method: A cross-sectional, mixed-method – concurrent study design was adopted to evaluate the program for its short-term outcomes such as gain in the basic knowledge of COVID-19 amongst master trainers and their feedback and program output viz – the proportion of volunteers trained and their profile by census sampling. Motivational factors, experiences of volunteers, and outcomes of COVID-19 work in their villages were explored by purposive with maximum diversity sampling with 62 online in-depth interviews and 8 online focus group discussions (FGDs). Results: There was a statistically significant difference in the pre-test (12.8 ± 5.6) and post-test (25.9 ± 9.3) scores of the Master Training Program evaluation test. Out of 6534 trained volunteers, 5901 worked as volunteers, and amongst those, 47.1%, 35.1%, and 17.8% worked for ≤3 months, 3 to 6 months, and ≥6 months, respectively, in their villages. The major themes generated for motivational factors to join the program were altruism, savior nature, generating awareness, and concern for others. The major outcomes generated by trained volunteers COVID-19 vaccination were in raising awareness on COVID-19 appropriate behavior and early identification of COVID-19 cases in their villages. Conclusion: The "CoviSainik Program" was successful in creating cadres of trained volunteers. [ABSTRACT FROM AUTHOR]

A resilient health system necessitates strong governance, political commitment, effective administrative entities and inter-organisational collaboration. This paper examines India's current health policy landscape and explores the analytical and operational capacities required to establish a robust post-pandemic health system using the policy capacity framework described by Wu et al. (2015). We emphasised the need for a coordinated policy response to strengthen health information systems, health service management, human resource management and healthcare financing. The role that the planned implementation of Indian public health management cadres would play in the coming era, the importance of a comprehensive health information management system and the need for operational coordination between government and non-governmental organisations has also been emphasised. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic restricted movement, closed businesses, and economic activities which disproportionately affected people globally. This pandemic has resurfaced the existing cracks in the societal set-up and has pushed the vulnerable and marginalized communities like migrant workers, people with disabilities, geriatric population, and commercial sex workers (CSWs) to an edge for their existence. Materials and Methods: Due to the paucity of peer-reviewed research publications on CSWs, formative research was conducted to identify the determinants and attributes of the challenges faced by CSWs during COVID-19 situation in India. Media scanning approach was used to collate literature from newspaper and magazine reporting, and peer-reviewed articles were referred from research-based search engines. Results: In total, 31 articles were included for content analysis and four domains of issues i.e., economic, social, psychological and health related challenged faced by them were identified which are supported with the verbatims of the community members as reported in the data sources considered for this study. It was identified that the CSWs adopted several protective measures and coping strategies to deal with the pandemic situation. Conclusion: This research highlighted that there is a need for further exploration of issues among CSWs by conducting studies among the communities. Furthermore, this paper provides a scope for future implementation research by identifying the key priorities and determinants of the challenges among the personal livelihood of CSWs in the country. [ABSTRACT FROM AUTHOR]

Introduction: There is a paucity of research on conducting written formative assessment with constructive feedback for theory paper writing for postgraduates of Community Medicine in India. The concept of "Written Formative assessments with Peer-Assisted Learning Program" was implemented to improve the first 2 levels of Miller's Pyramid and assess its impact on the summative assessment. Materials and Methods: The program was conducted for 2 batches of postgraduate students in the Community Medicine enrolled for the academic session of 2016–2019 and 2017–2020. The written formative assessment was conducted every Saturday for 1 h from August to March month in 2018 and 2019. After each test, answer papers were evaluated by the peer and faculty from the department. Written and oral feedback was given by the peer. After IEC approval, we planned to assess the program's effect on level 1 and level 2 Kirkpatrick's framework. The data were analyzed using SPSS statistical package version 24 (SPSS Inc., Chicago, IL, USA). P < 0.05 was considered statistically significant. Results: Total 23 formative written assessments were conducted per year. The proportions of knowledge, comprehension, and analytical type of questions asked were 47%, 32%, and 21%, respectively. The mean attendance rate was 76.28% ±16.4%. There was no statistically significant difference in the average percentage of marks in formative (weekly test) and summative assessment (university final examination). There was a statistically significant positive co-relation of projected mean marks and summative assessment marks with the co-efficient of the determination being 22.6%. There was overall positive feedback of the formative and peer-assisted learning (PAL) from post graduate students. Conclusions: Written Formative Assessment with PAL program is one of the effective programs for postgraduate students to gain confidence in writing and presentation skills and to score higher in theory examination. [ABSTRACT FROM AUTHOR]

High burden of acute malnutrition among children less than 5 years is a major public health problem in India. A "Two-days National Consultation on Addressing Acute Malnutrition" was organized to gather experiences and evidence from 13 states of India on prevention and management of acute malnutrition among children and documenting viewpoints from experts and government counterparts on the same. The consultation centered around five key themes of addressing acute malnutrition: 1) capacity building, 2) strengthening screening, 3) nutritional care of wasting, 4) tracking progress, and 5) scale-up. The paper highlights the experiences and key recommendations around the above key themes. It emerged that there is a need to further accelerate the efforts toward strengthening existing platforms and services to address acute malnutrition among children. Regular trainings of the frontline workers, increased convergence, regular monitoring, and continued service delivery during the pandemic should be undertaken for better outcomes. [ABSTRACT FROM AUTHOR]

Background: The socio-environmental aspects of southern Assam reflect a general pattern of backwardness. Moreover, child healthcare resources in the region are inadequately used, leading to low vaccination coverage. Given this background, this paper attempted to comprehend wealth-based inequality in full vaccination in rural areas of southern Assam. Methodology: Based on a multistage cluster sampling approach, 360 children of 12–23 months were selected from the study area. To identify the predictors of a child, a non-linear model was estimated by using the generalized linear model (GLM) approach followed by Erreygers decomposition technique to quantify the wealth inequality in the obtained predictors in explaining the disparity in full vaccination. Result: The Bacillus Calmette–Guérin (BCG) vaccination recorded the highest vaccination coverage, at nearly 90% and the lowest was observed for the measles vaccine, around 61 percent. Slightly more than half of the eligible children (54 percent) were vaccinated against all the Universal Immunization Programme (UIP)-recommended vaccines. The decomposition analysis revealed that the occupation of the child's father, maternal age, birth order of the child, and health-seeking behavior such as antenatal care (ANC) were the prime factors related to inequality in full vaccination in the region. Conclusion: Vaccination coverage in the region has improved over time, however, full vaccination is concentrated towards the economically advantaged section of the society in rural southern Assam. Targeted, context-specific, and expanded government initiatives could aid in addressing the overall wealth-related full vaccination inequalities in the valley. [ABSTRACT FROM AUTHOR]

Background: COVID-19 has proven to be the worst pandemic in the history of mankind. While the pandemic still continues to perplex scientists globally, attempts are being made to quantify the mortality caused by the pandemic. Official COVID-19 figures in India grossly understate the true scale of the pandemic in the country. Fatality rates help us understand the severity of a disease, identify at risk populations, and evaluate quality of healthcare. Official COVID-19 mortality figures in India grossly understate the true scale of the pandemic in the country. A COVID-19 death is defined for surveillance purposes as a death resulting from a clinically compatible illness in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID-19 disease (e.g., trauma) and excess mortality is defined as the difference in the total number of deaths in a crisis compared to those expected under normal conditions. Materials and Methods: We did a systematic review of multiple papers on PubMed, Medline, Embase, MedRxiV pre print on excess mortality. Differentiation between model based estimated excess mortality and data based excess mortality was studied. Results: All the studies showed that the excess mortality was to the tune of almost three times the official figures. The model based excess mortality assumptions showed higher deaths as compared to the data based one. However, there were a lot of discrepancies in the data provided by various states along with variations observed between the two waves as well. Health survey data suggested higher mortality rate as compared to data compiled from the civil registration system. Additionally, in the second wave, a small but a significant number of deaths occurred due to non availability of oxygen and beds in the hospitals. Conclusions: Official COVID-19 deaths have entirely failed to capture the scale of pandemic excess mortality in India. If most excess deaths were, indeed, from COVID-19 then under ascertainment of COVID-19 deaths has been high, with around 8-10 excess deaths for every recorded COVID-19 death. [ABSTRACT FROM AUTHOR]

Background: Properly constructed single best-answer multiple choice questions (MCQs) or items assess higher-order cognitive processing of Bloom's taxonomy and accurately discriminate between high and low achievers. However, guidelines for writing good test items are rarely followed, leading to generation and application of faulty MCQs. Materials and Methods: During lockdown period in 2020, internal assessment was taken through online mode using Google Forms. There were 60 'single response type' MCQs, each consisting of single stem and four options including one correct answer and three distractors. Each item was analyzed for difficulty index (Dif I), discrimination index (DI), and distractor efficiency (DE). Results: The mean of achieved marks was 42.92± (standard deviation [SD], 5.07). Dif I, DI, and DE were 47.95± (SD 16.39) in percentage, 0.12± (SD 0.10), and 18.42± (SD 15.35), respectively. 46.67% of the items were easy and 21.66% were of acceptable discrimination. Very weak negative correlation was found between Dif I and DI. Out of total 180 distractors, 51.66% were nonfunctional one. Conclusion: Item analysis and storage of MCQs with their indices provides opportunity for an examiner to select MCQs of appropriate difficulty level as per the need of assessment and decide their placement in the question paper. [ABSTRACT FROM AUTHOR]

Background: Vitamin A deficiency (VAD) and Anemia are important public health nutritional problems in India. Objective: To assess nutritional status and prevalence and correlates of undernutrition, anemia, and VAD among children. Materials and Methods: A community-based cross-sectional study was carried out adopting systematic random sampling. Information on socio-demographic particulars was collected and 20 µL blood was collected for hemoglobin and free-flowing drop on Whatman filter paper for Vitamin A estimation. Hemoglobin was estimated using indirect cyanmethemoglobin and Vitamin A by high-pressure liquid chromatography. Nutritional status was assessed using the WHO Child Growth Standard. Results: The overall prevalence of anemia and VAD was 68% and 59%, respectively, while underweight, stunting, and wasting was 30%, 55%, and 11%, respectively, among under 5 year children. Stepwise logistic regression analysis revealed no significant association of anemia and VAD with any sociodemographic variables, while the odd of stunting was four times higher among children of mothers engaged in labor and two times among children from low-income group, while underweight was two times higher among children from households not having sanitary latrine. Exclusive breastfeeding was observed to be associated with undernutrition among infants. Conclusions: Anemia, VAD, and stunting were high among children. Low intakes of green leafy vegetables and milk and milk product may be the reasons for the higher prevalence of anemia and VAD. There is a need to strengthen supplementation of iron and folic acid tablets and Vitamin A and also public distribution system. [ABSTRACT FROM AUTHOR]

Introduction: Prosocial behaviour is one of the key features of the development of school-going adolescents. Therefore, the current paper focuses on the prosocial behaviour of school-going adolescents in Kollam District, Kerala. Methodology: A cross-sectional descriptive study where 600 school-going adolescents, their parents and 60 class teachers were selected through cluster sampling method. English and Malayalam version of the Strength and Difficulties Questionnaire (SDQ) was administered among respondents. Chi-square and multiple linear regression models were used for analysing the data. Results: Self-report of prosocial behaviour predictors were significantly associated with gender (P < 0.01), urban-rural settings (P < 0.001) and government-private schools (P < 0.001). Parents' report shows highly significant relationship with gender (P < 0.001) whereas teachers' report is significantly related to urban-rural settings (P < 0.01). Conclusion: The current study found that one-fifth of school-going adolescents had borderline to abnormal (self – 17.4%; parents' – 16.9%; teachers' report – 20.8%) prosocial behaviour. School-going adolescents should involve in volunteer activities and campaigns for better development in society. [ABSTRACT FROM AUTHOR]

Background: In India, Nutrition Rehabilitation Centers (NRCs) established at public health facilities provide residential medical nutrition therapy for severe acute malnutrition (SAM) children with complications. A large proportion of their mothers are also malnourished. NRCs do not provide services to such mothers as part of routine practice. However, technical algorithm for delivering Maternal Nutrition (MN) services in facility settings is available. Objectives: To test the practical feasibility of layering the MN services in NRC as a routine service. Methods: The MN services were delivered by a nutrition counselor using a triage approach (assess, classify, supplement/counsel/treat). All mothers received diet, micronutrients, and group counseling, those at nutritional risk received individual counseling and SAM mothers also received catch-up diet during their stay. Program data were collected from mothers during January 1 to August 31, 2019 at the NRC in Kalawati Saran Children Hospital. To gain operational insights, a structured interview with nutrition counselor was conducted. Results: Out of 168 mothers, 8% were found to be pregnant and 89% were at nutrition or medical risk. The prevalence of short stature was 18%, severe/ thin 21%, overweight/obese 34%, and anemic 72%. Feedback from the nutrition counselor indicated no operational challenges, however, further efforts to ensure that mothers keep coming back for follow-up visits is needed. Conclusion: The findings indicated that existing staffs were able to deliver the MN services within the time, cost, and regime of the routine NRC. This paper provides four recommendations for layering the MN services in NRCs. [ABSTRACT FROM AUTHOR]

Background: In the climate change discourse, a body of scholarship focusing on how people perceive climate change and its impact is increasing. However, in the Indian context, such scholarship is limited. Objective: This paper aims to describe the perceptions of people on climate change and its health impacts, which were captured as part of a larger study. Methodology: A cross-sectional study was conducted in randomly selected 983 households in four districts spread across Madhya Pradesh and Jammu and Kashmir. A semi-structured questionnaire was used to collect the data. Results: For 72% of respondents, the perception was not related to climate change per se. Their perceptions were contextual and were based on the anomalies which are observed in the immediate weather conditions. The health impacts of climate change were also not understood at the first place, but with probing 64% of respondents were able to report seasonal diseases. Conclusion: Perceptions of the people regarding climate change are more linked to their own experiences with their local weather conditions rather than the overall concept. This also explains their lack of comprehension about the health impact of climate change, but a sound understanding of seasonal diseases. [ABSTRACT FROM AUTHOR]

Introduction: Till 2016, India was the second largest consumer of tobacco in the world, second only to China. However, in June 2017, the factsheet release of Global Adult Tobacco Survey-2 showed a 6% point decline in the prevalence of tobacco use among adults (>15 years) in the country. Materials and Methods: This is a form of ecological study where trends in aggregate prevalence of tobacco use at country level (using secondary data) were studied in relation to corresponding policy actions over a period of two decades. Results: The results have shown that initial policy actions since the cigarettes act of 1975 till prevention of food adulteration Amendment act of 1995 were largely targeting cigarettes, and so smoking prevalence among men was constantly declining. On the other hand, smokeless tobacco use was increasing among both men and women and reached a peak in 2009--2010. After that, the government took strict policy actions including Food Safety and Standards Authority of India Gutka ban in 2011. There were other persistent efforts, which are discussed in this paper. As a result, a transition has occurred in relation to tobacco epidemic in India. Conclusion: The paper has been concluded with a note that there is no room for complacence and we have a noncommunicable disease action goal to further decline the prevalence of tobacco use in the country to <24.22% by the year 2025. [ABSTRACT FROM AUTHOR]

Background: Micronutrient deficiencies such as iron, Vitamin A, and iodine are important public health problems in India. Objective: The objective of the study was to assess subclinical Vitamin A deficiency (VAD) and anemia among women and preschool children from Northeast India. Methodology: A community-based cross-sectional study was carried out by adopting systematic sampling in Phek district of Nagaland. Data were collected from women on sociodemographic particulars, and finger prick blood was collected for hemoglobin and free-flowing drop for Vitamin A estimation on Whatman no. 1 filter paper. Results: The overall prevalence of anemia was 27%, 40%, 44%, and 52% among preschool children, nonpregnant nonlactating women, lactating mothers, and pregnant women, respectively, whereas VAD was 37% among preschool children and 24%-32% among adult women. The prevalence of VAD was observed high among those living in kutcha house, illiteracy of head of households, big family size, and low per capita income. Conclusions: Anemia and VAD are important public health problems among tribal population in spite of the rich biodiversity. [ABSTRACT FROM AUTHOR]

The development in the country's health status has not kept pace with its economic development. Although India along with most countries of the world was a signatory to the Alma Ata Declaration of 1978, its performance particularly on health equity and quality issues, so far, has been far from satisfactory. There are vast variations in health-care status by states, by ethnic groups, gender, and urban-rural difference. Till recently, government policies and people's perceptions also seemed to be on the wrong track. Our priorities seemed to be all wrong - we seemed to prefer setting up of high-cost tertiary health institutions at the expense of the primary health centers. The recently launched Swachh Bharat and Ayushman Bharat schemes offer hope of addressing these asymmetries. This paper briefly dwells on these issues. [ABSTRACT FROM AUTHOR]

Background: Condom is an integral part of all interventions for female sex workers (FSWs). However, certain situations hinder them from practicing consistent condom use. This paper aims at identifying the situations that predict inconsistent condom use by FSWs of Sonagachi red-light area, Kolkata. Subjects and Methods: The cross-sectional community-based observational study was conducted among 296 brothel-based FSWs of Sonagachi. Outcome variable, that is, inconsistent condom use was said to be present if any sex act with any type of partner was not protected by condom. Association with sociodemographic, occupational, and behavioral characteristics of FSWs was examined. Results: Inconsistent condom use was present among 37.5% of the study participants, and this was predicted by the presence of a nonpaying partner (NPP) (adjusted odds ratio [AOR] [95% confidence interval (CI)]: 15.04 [7.52-30.08]), violence (AOR [95% CI]: 2.08 [1.07-4.03]) and sexual intercourse under the influence of alcohol (AOR [95% CI]: 1.86 [1.02-3.39]). The major cause behind nonuse of condom as reported by the participants was trust on partner. Conclusion: NPPs need to be given emphasis in program strategies for FSWs. The FSWs should constantly be motivated for safe sex emphasizing the fact that trust on partner may be detrimental for their health. [ABSTRACT FROM AUTHOR]

Background: The implementers of the tobacco control policy in the field have been neglected by the policymakers. They are the ones who have first-hand knowledge and their experiences in the field are not being used to bring about changes in the area of tobacco control. Objective: The objective of this paper is to critically examine how Michael Lipsky's concept of street-level bureaucracy can be used to address tobacco control in the health department in district Jalandhar of Punjab. Methods: Semi-structured interview schedules were used to interview Senior Medical Officers/Nodal Officers and Health Supervisors/Sanitary inspectors in four out of ten Community Health Centers and District hospital in Jalandhar. Data so collected were subjected to the process of inductive analysis and themes developed within the framework given by Lipsky. Results: The street-level bureaucrats (SLBs) were not given adequate training, and various organizational resources for tobacco control are missing in the district. There are threats and challenges which are faced by them in the field, and they do not exercise decision-making power to handle these barriers for effective implementation of the tobacco control program. Conclusion: The government needs to be inclusive in the process of policymaking meaning that it can be more accommodative of the suggestions given by the SLBs and provide them with discretionary powers to exercise their role efficiently. [ABSTRACT FROM AUTHOR]

Background: The immunization coverage in India is far away from satisfactory with full immunization coverage being only 62% at national level. Targeting the intensive efforts to poor performing areas and addressing the determinants of nonimmunization and dropouts offers a quick solution. In this paper, we assess the inter-district variations in Haryana state, and the association of social determinants with partial and no immunization. Methodology: This analysis is based on data collected as part of a large household survey undertaken in the state of Haryana to measure the extent of Universal Health Coverage. A multistage stratified random sampling design was used to select primary sampling units (i.e., subcenters), villages, and households. A total of 11,594 mothers with a child between 12 and 23 months were interviewed on receipt of immunization services. Determinants of nonimmunization and partial immunization were assessed using multiple logistic regression. Results: About 21% of children aged 12-23 months were partially immunized, while 4.3% children aged 12-23 months had received "no immunization." While the coverage of full immunization was 74.7% at the state level, it varied from 95% in best performing district to 38% in poorest performing district. Odds of a partially immunized child were significantly higher in urban area (odds ratio [OR] = 1.23; 95% confidence interval [CI] = 1.1-1.38), among Muslim household (OR = 3.52; 95% CI = 3.03-4.11), children of illiterate parents (OR = 1.58; 95% CI = 1.22-2.05), and poorest quintile (OR = 1.61; 95% CI = 1.36-1.89). Conclusions: Wide interdistrict variations call for a need to consider changes in resource allocation and strengthening of the government initiatives to improve routine immunization in these districts. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular diseases (CVDs) are the leading causes of death globally (nearly 17.5 million deaths/year). Hypertension and coronary heart disease (CHD) are two of the most important CVDs. There is a dearth of studies at a large scale in India to ascertain the factors as well as social differentials in the prevalence of heart disease associated with hypertension. This paper attempts to bridge the gap in the relevant area. Methodology: Secondary analysis of the data obtained from India Human Development Survey (IHDS), conducted in two rounds in 2004-2005 and 2011-2012, was done (n = 147,201). Bivariate and logistic regression analyses have been used. Results: In India, the prevalence for CHD is 1.1% for 2011-2012. Findings showed that persons with hypertension are 11 times (odds ratio [OR] = 11.58, P < 0.01) more likely to be affected by CHD among adults (15 and above years) as compared to nonhypertensive adults. When the odds are adjusted for socioeconomic and demographic variables, hypertensives are found to be 5 times more likely (OR = 5.096, P < 0.01) to be having CHD as compared to nonhypertensives. Conclusions: The unadjusted odds of suffering from CHD when hypertension is a predictor are much higher than when the odds are adjusted for socioeconomic and demographic variables. Along with hypertension, age, education, and place of residence have also been found to be important determinants of CHD. [ABSTRACT FROM AUTHOR]

Background: Injuries have become a major public health concern. Recent data show that globally over 5 million people lose their life due to injury every year. Especially in low- and middle-income countries, people living below the poverty line are drastically scathed due to injuries. Objective: The objective of this paper is to find the magnitude and risk factors of fall among the elderly in India. Materials and Methods: A systematic search was done by using Google Scholar and PubMed. Results: The selected studies revealed that the prevalence of fall ranges from 26% to 37% across various regions, fall injuries are associated with poor vision, vertigo, imbalance, fear of falling, history of fall, presence of osteoarthritis, visual impairment, hearing impairment, and depression. This study has shown the risk of fall was higher among female elderly population. Conclusion: The major contributing factors for fall injuries are aging, visual impairment, previous history of fall, depression, and gait problem. Females have a higher risk of fall comparatively to males. [ABSTRACT FROM AUTHOR]

Background: While the roles and responsibilities of nursing professionals have multiplied over the years, but there are huge concerns with regard to the development of the nursing workforce and human resources (HR) issues for their career growth. The major lacuna is in not involving the nursing professionals in policy framing and decision-making. As a result, there is a leadership crisis of the nursing workforce across India. Objectives: The paper, is part of the WHO supported study, entitled "Study on Nursing and Midwifery in India: a critical review", is developed with the objective to review the current organizational and management structure for the nursing positions at the State Directorates in India and obtain a Leadership perspective to strengthen nursing management capacities to address maternal health issues. Materials and Methods: The study descriptive and qualitative in nature and the sources of information were both primary and secondary collected from 16 states of India. Results: Since none of the states have neither a Nursing Cell nor the post of Director Nursing, final decision-making powers rest with state health secretaries and medical directors. The nursing management structure majorly managed by senior policy makers from the medical fraternity, and provides very little scope for nursing professionals to participate in policy decision making to bring about reforms. There is no uniformity on HR issues concerning career graphs and pay structures across the states. Conclusions: In order to strengthen nursing as a profession and for facilitating their role at the policy level, more powers and autonomy needs to be given to them and this requires HR policy guidelines for nurses. Setting up a separate nursing directorate, to be headed by a senior nursing professional, is suggested in every state along with a strong nursing division at the National level. This total paradigm shift will empower nursing professionals to take up the leadership role at the policy level to bring about necessary reforms. Across the country, nursing professionals repeatedly echoed one requirement: To reframe nursing leadership at all levels. [ABSTRACT FROM AUTHOR]