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Background: In the 75th World Health Assembly (WHA) (2022) – Accreted Social Health Activists (ASHAs) have been recognised for their outstanding contribution towards protecting and promoting health at World Health Organization’s (WHO) Global Health Leaders Award. However, marginal attempts have been made to understand how geographical context can influence incentive and its effect on performance of ASHAs. This study seeks to address the gap by analysing the interplay between the geographical context, incentives, and performance of ASHA in the state of Odisha. Methods: A mixed method (quantitative & qualitative) approach was used to understand the effect of monetary and non-monetary incentives on performance of ASHAs. The effect of incentives on ASHA’s performance in terms of motivation and job satisfaction as human resource management outcomes and service delivery targets and achievement as organizational outcome using the Vroom’s expectancy theory. A total of 54 key informant interviews were conducted in Balasore and Rayagada districts. Results: The mean annual total incentives per ASHA in the block nearest to district headquarter in plain area district was INR 77,762 (~996 USD) and INR 66,201 (~847 USD) for distant block from district headquarter in the same district. In contrast, the mean annual total incentives per ASHA in the district in remote areas was INR 50,663 (~648 USD) for a nearest block to district and INR 58,725 (~752 USD) for distant block. Conclusions: Along with cash incentives, more support should be given to ASHAs through capacity building, integration of ASHAs with other community stakeholders and appropriate mentoring and motivation which is greatly influenced by the varying geographical context.

Provision of primary healthcare in India received thrust of National Health Policy 2017. Vacancy, chronic absenteeism and non-availability of allopathic doctors is a chronic problem of the public health system. Engagement of alternative human resources could get the ailing health system rid of this shortage. AYUSH doctors in Odisha are involved in clinical and public health activities since 1970s. This study aims to examine perspectives of key stakeholders on ‘task shifting’ as a possible policy alternative. We reviewed the policies and guidelines of government of Odisha on human resources deployment, recruitment, retention and terms of reference of their engagement in the public health sector. Further, 76 AYUSH doctors and 30 key informants were interviewed. Ethical clearance was obtained beforehand. Most AYUSH doctors were involved in monitoring and supervising community-based public health programmes and village-level health service providers, respectively. Their involvement in the implementation of national health programmes was found to range from 8% to 62%. A sizeable proportion of AYUSH doctors had not been trained on management of national vector borne disease control, Tuberculosis control, immunisation (RI) and disease surveillance. More than 70% of respondents showed interest in implementing and managing public health programmes. Almost all key informants recommended for improved involvement of AYUSH doctors in public health activities. Inadequate logistics support, insufficient training on public health and unequal administrative authorities was perceived to be systemic bottlenecks. Job enrichment, management capacity development, and pre-deployment orientation of AYUSH doctors may precede the opportunity of ‘task-shifting’ of public health functions.

Background Reaching hard to reach populations is key to reduce health inequities. Despite targeted interventions, status of crucial public health indicators like neonatal and maternal mortality is still far from optimal. Complex interplay of social determinants can influence both communities and health care workers to effectively access each other. We argue that culturally sensitive and contextually relevant healthcare provision has potential to increase health care utilization by the vulnerable communities living in remote areas. Methods The study is an exploratory case study using rapid ethnographic techniques to understand the interplay of social determinants in hard to reach areas of Odisha state, India. We used in-depth interviews, focus group discussion, participatory action research and key informant interviews as tools for data collection. The analysis of data has been guided by thematic analysis approach. Results We found that there are further layers within the designated hard to reach areas and those can be designated as-i) extremely remote ii) remote and iii) reachable areas. Degree of geographic difficulties and cultural dynamics are deciding the ‘perceived’ isolation and interaction with health care providers in hard to reach areas. This ultimately leads to impacting the utilization of the facilities. At extremely remote areas, felt health needs are mainly fulfilled by traditional healers and ethno-medical practices. In reachable areas, people are more prone to seek care from the public health facilities because of easy accessibility and outreach. Being in middle people in remote areas, diversify health care seeking depending upon social (e.g. patient’s gender) economic (e.g. avoid catastrophic expenditure) and health system (timely availability of health human resources, language barriers) factors. Conclusion Our research highlights the need to value and appreciate different worldviews, beliefs and practices, and their understanding of and engagement with the pluralistic health care system around them. Other than pursuing the ‘mainstreaming’ of a standardized health system model across hard to reach areas, strategies need to be adaptive as per local factors. To handle that existing policies need revision with a focus on culturally sensitive and contextual care provision.

Caste, a stratifying axis of the Indian society, is associated with wealth and health. However, to what extent caste-based health inequality is explained by wealth disparities, is not clear. Therefore, we aimed to examine the caste-based differences in anaemia (haemoglobin < 11 gm/dl) and self-reported sickness absenteeism in schoolchildren and the mediating role of economic disparity. Students (n = 1764) were surveyed from 54 government schools of Dhenkanal and Angul, Odisha state. Socioeconomic data, anaemia and absenteeism were recorded. The relative risks of anaemia among Scheduled Tribe (least advantaged) and Scheduled Caste (second least advantaged) students were 1.19 (95% CI: 1.08, 1.26) and 1.13 (1.03, 1.20), respectively, as compared to students of the most advantaged caste and that for sickness absenteeism were 2.78 (2.03, 3.82) and 2.84 (2.13, 3.78); p < 0.05, with marginal attenuation when controlled for inter-caste economic disparities. Caste had an independent effect on anaemia and sickness absenteeism in school children, unexplained by inter-caste economic disparities.

Background\ud An effective health workforce is essential for achieving health-related new Sustainable Development Goals. Odisha, one of the states in India with low health indicators, faces challenges in recruiting and retaining health staff in the public sector, especially doctors. Recruitment, deployment and career progression play an important role in attracting and retaining doctors. We examined the policies on recruitment, deployment and promotion for doctors in the state and how these policies were perceived to be implemented.\ud \ud Methods\ud We undertook document review and four key informant interviews with senior state-level officials to delineate the policies for recruitment, deployment and promotion. We conducted 90 in-depth interviews, 86 with doctors from six districts and four at the state level to explore the perceptions of doctors about these policies.\ud \ud Results\ud Despite the efforts by the Government of Odisha through regular recruitments, a quarter of the posts of doctors was vacant across all institutional levels in the state. The majority of doctors interviewed were unaware of existing government rules for placement, transfer and promotion. In addition, there were no explicit rules followed in placement and transfer. More than half (57%) of the doctors interviewed from well-accessible areas had never worked in the identified hard-to-reach areas in spite of having regulatory and incentive mechanisms. The average length of service before the first promotion was 26 (±3.5) years. The doctors expressed satisfaction with the recruitment process. They stated concerns over delayed first promotion, non-transparent deployment policies and ineffective incentive system. Almost all doctors suggested having time-bound and transparent policies.\ud \ud Conclusions\ud Adequate and appropriate deployment of doctors is a challenge for the government as it has to align the individual aspirations of employees with organizational needs. Explicit rules for human resource management coupled with transparency in implementation can improve governance and build trust among doctors which would encourage them to work in the public sector.

The number of diabetic people in India is increasing. A vast gap of health service need and provision exists. However, the proposed agenda of promotion and recognition of diabetes educators may translate into diabetes effective management at individual level to the maximum possibility. Managing diabetes is a unique and on-going process. As such, self-management of the disease is crucial. Diabetes patients should receive support to help them to manage diabetic condition as effectively as possible. This study proposes conceptual approach to diabetes self-management education. This framework further articulates the short term and long term outcomes. DSME promotion through educational intervention in a sustained manner has long-term benefits. DSME in an Indian context as optimally trained, effective, efficient, viable health human resource allocation across different levels is not a feasible solution in a low resource setting. This study proposes that a need exists for further research in an Indian context about the scientific credibility of DSME, financial feasibility, cultural acceptability and operation stability of the policy initiative.

The study was aimed at evaluating immunization coverage against Tuberculosis, Poliomyelitis, Diphtheria, Tetanus, Pertussis and Measles. The data was taken from a sufficiently large study that adopted multi stage and systematic random sampling. The current paper aims at reporting the evaluated coverage in Bellary district and discusses addressing gaps in coverage of vaccine preventable diseases. We have reported in our earlier papers that parental recall was better than immunization card for reflecting immunization coverage, and improvement in immunization coverage was due to special immunization sessions (catch up sessions) and supportive supervision. In this paper, we present the estimates of vaccine coverage under national program. We also discuss the shortfalls responsible for drop in immunization coverage.

Little information is available on multimorbidity in primary care in India. Because primary care is the first contact of health care for most of the population and important for coordinating chronic care, we wanted to examine the prevalence and correlates of multimorbidity in India and its association with health care utilization. Using a structured multimorbidity assessment protocol, we conducted a cross-sectional study, collecting information on 22 self-reported chronic conditions in a representative sample of 1,649 adult primary care patients in Odisha, India. The overall age- and sex-adjusted prevalence of multimorbidity was 28.3% (95% CI, 24.3-28.6) ranging from 5.8% in patients aged 18 to 29 years to 45% in those aged older than 70 years. Older age, female sex, higher education, and high income were associated with significantly higher odds of multimorbidity. After adjusting for age, sex, socioeconomic status (SES), education, and ethnicity, the addition of each chronic condition, as well as consultation at private hospitals, was associated with significant increase in the number of medicines intake per person per day. Increasing age and higher education status significantly raised the number of hospital visits per person per year for patients with multiple chronic conditions. Our findings of higher prevalence of multimorbidity and hospitalizations in higher SES individuals contrast with findings in Western countries, where lower SES is associated with a greater morbidity burden.

It is essential to have a capable and motivated health workforce for building an effective, responsive health system and in turn achieve national health goals. The present cross sectional study was conducted in Chhattisgarh, India to assess the level of motivation and job satisfaction among multipurpose health workers (MPWs) and to study factors influencing them. A pre-tested semistructured questionnaire was used to obtain information about the respondents' perceived importance of various job characteristics and perceived job satisfaction. The majority of MPWs were not satisfied with their existing job conditions. Motivators or satisfiers like career advancement and achievement had low scores for all the participants. Working conditions and salary were found to be the dissatisfiers with low scores. The present study suggests that, although financial incentives are important, they are not sufficient to motivate personnel to perform better.

Background: The scarcity of qualified health workers in rural areas is directly affecting delivery of health services and their quality. Diverse interventions have been instituted by central and state governments to attract health workers to rural areas and to enhance the retention of qualified workers. However the reasons for not willing to remain in rural and remote areas are still poorly understood. This study explores factors influencing health workers retention in rural and remote Odisha. Methods: We carried out the study in six districts of Odisha selected randomly from three geographic and administrative regions of the state. We used a mixed methods approach to study this question using both quantitative and qualitative data. A total of 226 semi-structured interviews were conducted with doctors, nurses, pharmacists, multipurpose health workers (MPHW) and laboratory technicians. A multi stage stratified random sampling was used for selecting study participants working at sub centers, primary health centers and community health centers. Results: We found that excepting few districts, the ratio of MPHW (F) to population is around 5000 in the state which is at par with the prescribed norms. The ratio of government allopathic doctor, laboratory technician and staff nurses to population are: 13000, 40000 and 15000, respectively. Majority of health staffs perceive “strong personal will to serve people”, “physical infrastructure”, “training opportunities”, “support by seniors”, “good schooling for their children” and “promotion avenues after certain years of rural service” is very important for continuing to work in rural and remote areas. Most of the participants were found to be satisfied with the support they received from their seniors and the local community, and respect and trust of their patients.The major dissatisfiers for working in rural areas included existing promotional avenues after rural service, physical infrastructure, and schooling facility for their children. Five primary reasons ranked in order of priority cited by the study participants for continuing at the same place were, namely, permanent government service, pension facility, social service, source of regular income and job satisfaction Discussion/Recommendations: Professional growth in the form of promotion and skill development, suitable physical infrastructure at workplace and schooling for their children along with additional monetary incentives were the key and inter-relating factors influencing the retention of health workforce in rural and remote areas. Hence a combination of interventions like monetary incentives with enhanced career opportunities for professional growth (training, higher studies and promotion), scholarships and preference of seats in reputed (residential) schools to the children of staff working in rural and remote areas and suitable physical infrastructure at workplace would be more effective than financial incentives alone. There is a need for clearly defined human resource policy for health personnel across all cadres with defined parameters for performance appraisal, transfer and promotion.

In 2007, the Indian state of Andhra Pradesh introduced the Rajiv Aarogyasri community health insurance scheme (RAS) in order to break the vicious cycle of ill health, poverty, indebtedness and bankruptcy among families who are below the poverty line (BPL). The purpose of the scheme was to improve access to treatment of certain medical and surgical conditions for BPL families through a network of health care providers. We conducted a rapid evaluation of RAS at the request of government of Andhra Pradesh. The purpose of the evaluation was to provide insights into the current performance of the scheme, to examine whether it is meeting the overall objectives and to suggest ways by which it may be further strengthened.

Background Lymphatic filariasis is targeted for elimination in India through mass drug administration (MDA) with diethylcarbamazine (DEC) combined with albendazole (ABZ). For the strategy to be effective, >65% of those living in endemic areas must be covered by and compliant to MDA. Post the MDA 2011 campaign in the endemic district of Odisha, we conducted a survey to assess: (i) the filariasis knowledge in the community, (ii) the coverage and compliance of MDA from the community perspective, and (iii) factors affecting compliance, as well as the operational issues involved in carrying out MDA activities from the drug distributor’s perspective. Methods A sample of 691 participants – both male and female, aged two years or above – were selected through multistage stratified sampling and interviewed using a semi-structured questionnaire. Additionally, drug distributors and the medical officers in charge of the MDA were also interviewed to understand some of the operational issues encountered during MDA. Results Ninety-nine percent of the study participants received DEC and ABZ tablets during MDA, of which only just above a quarter actually consumed the drugs. The cause of non-compliance was mostly due to fear of side effects, lack of awareness of the benefits of MDA, and non-attendance of health staff in the villages. Lack of adequate training of drug distributors and poor health communication activities before the MDA campaign commenced and the absence of follow-up by health workers following MDA were a few of the operational difficulties encountered during the MDA campaign. Conclusion Currently MDA is restricted to the distribution of drugs only and the key issues of implementation in compliance, health education, managing side effects, and logistics are not given enough attention. It is therefore essential to address the issues linked to low compliance to make the program more efficient and achieve the goal of filariasis elimination.