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WHO South-East Asia Journal of Public Health
Volume 4, Issue 1, January—June 2015, 1–105

Inside ISSN 2224-3151 Volume 4, Issue 1, January—June 2015, 1–105
Editorial Inequality in maternal health-care services and
safe delivery in eastern India 54
Towards sustainable access to safe drinking water Arabinda Ghosh
in South-East Asia 1
Prevalence of household drinking-water contamination
Perspective and of acute diarrhoeal illness in a periurban
community in Myanmar 62
Family Planning – friendly Health facility Initiative Su Latt Tun Myint, Thuzar Myint, Wah Wah Aung,
to promote contraceptive utilization 3 Khin Thet Wai
Moazzam Ali, Vinit Sharma, Arvind Mathur,
Marleen Temmerman Innovative social protection mechanism for alleviating
catastrophic expenses on multidrug-resistant
tuberculosis patients in Chhattisgarh, India 69
WHO
Review Debashish Kundu, Vijendra Katre,
A review of the Sri Lankan health-sector response Kamalpreet Singh, Madhav Deshpande,
to intimate partner violence: looking back, moving Priyakanta Nayak, Kshitij Khaparde,
forward 6 Arindam Moitra, Sreenivas A Nair, Malik Parmar
Sepali Guruge, Vathsala Jayasuriya-Illesinghe, A cross-sectional survey of the models in Bihar
Nalika Gunawardena and Tamil Nadu, India for pooled procurement of
South-East Asia
National nursing and midwifery legislation in medicines 78
countries of South-East Asia with high HIV burdens 12 Maulik Chokshi, Habib Hasan Farooqui,
Nila K Elison, Andre R Verani, Carey McCarthy Sakthivel Selvaraj, Preeti Kumar
Mosquito-borne diseases in Assam, north-east India:
current status and key challenges 20 Policy and practice
V Dev, VP Sharma, K Barman Barriers and facilitators to development of
Journal of
standard treatment guidelines in India 86
Original research Sangeeta Sharma, Gulshan R Sethi,
Usha Gupta, Ranjit Roy Chaudhury
Association between household air pollution and

neonatal mortality: an analysis of Annual Health Demand–supply gaps in human resources to combat
Survey results, India 30 vector-borne disease in India: capacity-building
Sutapa Bandyopadhyay Neogi, Shivam Pandey, measures in medical entomology 92
Public Health
Jyoti Sharma, Maulik Chokshi, Anuja Pandey, Sanjay Zodpey, Raj Kumar
Monika Chauhan, Sanjay Zodpey, Vinod K Paul
The validity of self-reported helmet use among Report from the field
motorcyclists in India 38 Challenges in conducting community-based trials
Shirin Wadhwaniya, Shivam Gupta, of primary prevention of cardiovascular diseases in
Shailaja Tetali, Lakshmi K Josyula, resource-constrained rural settings 98
Gopalkrishna Gururaj, Adnan A Hyder Twinkle Agrawal, Farah Naaz Fathima,
A cross-sectional study of exposure to mercury in Shailendra Kumar B Hegde, Rajnish Joshi,
schoolchildren living near the eastern seaboard Nallasamy Srinivasan, Dominic Misquith
industrial estate of Thailand 45
Punthip Teeyapant, Siriwan Leudang, WHO Publications 104
Sittiporn Parnmen
ISSN 2224315-1
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WHO
South-East Asia Journal of Public Health
(World Health Organization, Regional Office for South-East Asia)
ISSN 2224-3151 January-June| Volume 4 | Issue 1

E-ISSN 2304-5272
CONTENTS
Editorial
Towards sustainable access to safe drinking water in South-East Asia............................................1
Perspective
Family Planning – friendly Health facility Initiative to promote contraceptive utilization..............3
Moazzam Ali, Vinit Sharma, Arvind Mathur, Marleen Temmerman
Review
A review of the Sri Lankan health-sector response to intimate partner violence:
looking back, moving forward......................................................................................................6
Sepali Guruge, Vathsala Jayasuriya-Illesinghe, Nalika Gunawardena
National nursing and midwifery legislation in countries of

South-East Asia with high HIV burdens.......................................................................................12
Nila K Elison, Andre R Verani, Carey McCarthy
Mosquito-borne diseases in Assam, north-east India: current status and key challenges..............20
V Dev, VP Sharma, K Barman
Original research
Association between household air pollution and neonatal mortality: an analysis of Annual
Health Survey results, India........................................................................................................30
Sutapa Bandyopadhyay Neogi, Shivam Pandey, Jyoti Sharma, Maulik Chokshi,
The validity of self-reported helmet use among motorcyclists in India........................................38

Shirin Wadhwaniya, Shivam Gupta, Shailaja Tetali, Lakshmi K Josyula, Gopalkrishna Gururaj, Adnan A Hyder
A cross-sectional study of exposure to mercury in schoolchildren living

near the eastern seaboard industrial estate of Thailand...............................................................45
Punthip Teeyapant, Siriwan Leudang, Sittiporn Parnmen
Inequality in maternal health-care services and safe delivery in eastern India.............................54

Arabinda Ghosh
WHO South-East Asia Journal of Public Health | January–June 2015 | 4 (1) i

Prevalence of household drinking-water contamination and of acute diarrhoeal
illness in a periurban community in Myanmar............................................................................62
Su Latt Tun Myint, Thuzar Myint, Wah Wah Aung, Khin Thet Wai
Innovative social protection mechanism for alleviating catastrophic expenses

on multidrug-resistant tuberculosis patients in Chhattisgarh, India..............................................69
Debashish Kundu, Vijendra Katre, Kamalpreet Singh, Madhav Deshpande, Priyakanta Nayak,
Kshitij Khaparde, Arindam Moitra, Sreenivas A Nair, Malik Parmar
A cross-sectional survey of the models in Bihar and Tamil Nadu, India

for pooled procurement of medicines.........................................................................................78
Maulik Chokshi, Habib Hasan Farooqui, Sakthivel Selvaraj, Preeti Kumar
Policy and practice

Barriers and facilitators to development of standard treatment guidelines in India.......................86
Sangeeta Sharma, Gulshan R Sethi, Usha Gupta, Ranjit Roy Chaudhury
Demand–supply gaps in human resources to combat vector-borne disease in India:

capacity-building measures in medical entomology....................................................................92
Anuja Pandey, Sanjay Zodpey, Raj Kumar
Report from the field

Challenges in conducting community-based trials of primary prevention of
cardiovascular diseases in resource-constrained rural settings.....................................................98
Twinkle Agrawal, Farah Naaz Fathima, Shailendra Kumar B Hegde, Rajnish Joshi,
Nallasamy Srinivasan, Dominic Misquith
Recent WHO Publications..................................................................................... 104
ii WHO South-East Asia Journal of Public Health | January–June 2015 | 4 (1)

Access this article online
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Towards sustainable access to safe
drinking water in South-East Asia
2015 is a landmark year in international development, with point-of-consumption. Effective and consistent application
the ending of the Millennium Development Goal (MDG) of household water treatment and safe storage can have a
period and the advent of the Sustainable Development Goals substantial effect in reducing diarrhoeal disease, depending on
(SDGs). This transition will be formalized in September with the type of water supply.5 Achieving the SDG target on access
the adoption of the 17 proposed SDGs and their 169 subtargets to safe drinking water will, therefore, require a concerted
that will challenge and shape global development for the next continuation of work done to date. Key to these efforts are
15 years. The sixth proposed SDG, on ensuring availability water safety plans, recommended by the WHO guidelines
and sustainable management of water and sanitation, has as its for drinking-water quality as the most effective means of
first target: “By 2030, achieve universal and equitable access to consistently ensuring the safety of a drinking-water supply.6
safe and affordable drinking-water for all”.1 Water safety plans use a risk-based and risk management
approach to prevent contamination of water sources, water
The end of the MDG era marks commendable progress made treatment, distribution till it reaches its consumers. Intersectoral
by the World Health Organization (WHO) South-East Asia collaboration between the health sector, water suppliers and
Region in meeting its target for access to improved drinking sanitation, agriculture and industrial sector is essential to the
water. More than 92% of the region’s population now has successful implementation, since contamination of drinking
access to improved drinking-water sources, 95% in urban areas water is linked to the activities of these sectors. Health can
and 88% in rural areas. Nevertheless, even with high levels play a major role in ensuring water quality surveillance and
of access, the safety of drinking water from improved water water safety plans are implemented as per WHO guidelines
sources is not guaranteed unless additional measures are taken and national water quality standards.
to ensure integrity of the water supply.
With funding support from the Australian Government, WHO
In early 2013, WHO convened experts from 14 collaborating has been supporting Member States to implement water safety
research institutions to produce a series of studies to update plans since 2005. In areas where concerns about water have
previous WHO estimates on the burden of diarrhoeal disease traditionally focused on water quantity, WSPs raise awareness
from inadequate water, sanitation and hygiene in 145 low- of the importance of water quality and empower communities
and middle-income countries. For the WHO South-East Asia to identify hazards and reduce risks with minimum resources
Region, they concluded that an estimated annual 207 773 deaths and simple techniques. To date, major efforts in Bangladesh,7
and 10 748 disability-adjusted life years lost due to diarrhoea Bhutan8 and Nepal9 have resulted in significant successes.
were attributable to inadequate drinking water.2 With respect Building on these foundations, the Regional Office for South-
to the microbial quality, Robert Bain and colleagues estimated East Asia is now supporting other countries to introduce water
that 1.8 billion people worldwide use a source of drinking safety planning to ensure drinking-water safety.
water that is faecally contaminated and 60% drink water that
is of at least so-called moderate risk (> 10 Escherichia coli or Continued support of these and related initiatives will strengthen
thermotolerant [faecal] coliforms per 100 mL). Their modelling regional capacity to meet the SDG target on drinking water
of data from nationally randomized studies suggested that 10% and thereby help reduce the burden of waterborne and water-
of water from improved sources may be so-called high risk (≥ related diseases in the region.
100 per 100 mL) and that drinking-water contamination is most
prevalent in Africa (53%) and South-East Asia (35%).3 In this Payden
issue of the WHO South-East Asia Journal of Public Health, Regional Adviser, Water and Sanitation,
the study by Su Latt Tun Myint and colleagues in an expanding WHO Regional Office for South-East Asia
periurban neighbourhood in Myanmar provides a clear example
of the type of challenges faced in the region where drinking-
water sources are improved but faecal contamination is high.4 Address for correspondence:
Payden,
In the WHO expert review, several evidence-based Regional Adviser for Water and Sanitation,
interventions were identified, notably that diarrhoea can be WHO Regional Office for South-East Asia,
reduced significantly if water quality can be ensured up to the New Delhi, India. Email: payden@who.int
WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 1

Payden: Towards sustainable access to safe drinking water in South-East Asia
REFERENCES 5. Wolf J, Prüss-Ustün A, Cumming O, Bartram J, Bonjour S, Cairncross S

et al. Assessing the impact of drinking water and sanitation on diarrhoeal
1. Open Working Group proposal for sustainable development goals. New disease in low- and middle-income settings: systematic review and
York: United Nations, 2014 (https://sustainabledevelopment.un.org/ meta-regression. Trop Med Int Health. 2014;19(8):928–42.
content/documents/1579SDGs%20Proposal.pdf, accessed June 30 6. WHO guidelines for drinking-water quality, fourth edition. Geneva:
2015). World Health Organization; 2011 (http://whqlibdoc.who.int/
2. Preventing diarrhoea through better water, sanitation and hygiene: publications/2011/9789241548151_eng.pdf?ua=1, accessed July 4
exposures and impacts in low- and middle-income countries. 2015).
Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 7. Bangladesh case study. Delhi: WHO Regional Office for South-
bitstream/10665/150112/1/9789241564823_eng.pdf?ua=1/&ua=1, East Asia; 2015 (http://www.searo.who.int/entity/water_sanitation/
accessed June 30 2015). bangladesh.pdf?ua=1, accessed June 30 2015).
3. Bain R, Cronk R, Hossain R, Bonjour S, Onda K, Wright J et al. Global 8. Bhutan case study. Delhi: WHO Regional Office for South-East Asia;
assessment of exposure to faecal contamination through drinking-water 2015 (http://www.searo.who.int/entity/water_sanitation/bhutan_final.
based on a systematic review. Trop Med Int Health. 2014;19(8):917–27. pdf?ua=1, accessed June 30 2015).
4. Su Latt Tun Myint, Thazar Myint, Wah Wah Aung, Khin Thet Wai. 9. Nepal case study. Delhi: WHO Regional Office for South-East Asia;
Prevalence of household drinking-water contamination and of acute 2015 (http://www.searo.who.int/entity/water_sanitation/nepal_final.
diarrhoeal illness in a periurban community in Myanmar. WHO South- pdf?ua=1, accessed June 30 2015).
East Asia J Public Health. 2015;4(1–2): 62–68.
2 WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

Perspective Website: www.searo.who.int/

Family Planning – friendly Health
facility Initiative to promote
contraceptive utilization
Moazzam Ali,1 Vinit Sharma,2 Arvind Mathur,3 Marleen Temmerman1
1
Department of Reproductive
Health and Research, World Health
Despite extensive global efforts and investment to reduce the Organization (WHO), Geneva,
problem, maternal mortality remains high in many low- and Switzerland,
middle-income countries.1 About 225 million women in low- 2
Asia and Pacific Regional Office,
and middle-income countries are thought to have an unmet United Nations Population Fund,
need for a modern method of family planning.2 It has been Bangkok, Thailand,
estimated that up to one third of maternal deaths could be 3
WHO Regional Office for South-
averted through the use of effective contraception by women East Asia, New Delhi, India
wishing to postpone or limit further childbearing.3
Address for correspondence:
In some low- and middle-income countries, increased Dr Moazzam Ali, Department of
contraceptive use has already reduced the annual number of Reproductive Health and Research,
maternal deaths by 40% over the past 20 years and has led World Health Organization,
to a decrease in the maternal mortality ratio (the number of Avenue Appia 20, 1211 Geneva 27,
maternal deaths per 100 000 live births) by about 26% in a little Switzerland
more than a decade.4 It has been estimated that a further 30% of Email: alimoa@who.int
the maternal deaths still occurring in these countries could be
avoided if the unmet need for contraception could be fulfilled.4 A study noted that the general increase in breastfeeding
This paper proposes that the Baby-friendly Hospital Initiative in Switzerland since 1994 can be interpreted in part as a
(BFHI),5,6 which has successfully increased the uptake of consequence of an increasing number of “Baby-friendly”
breastfeeding, might be used as a model for a new Family health facilities, where clients breastfeed their babies for
Planning – friendly Health facility Initiative to draw lessons in longer.10 Several countries have reported a positive impact of
terms of process and procedures that would promote access to this initiative, and breastfeeding rates have generally improved
contraceptive information and services. even in non-“Baby-friendly” health facilities, which may have
been an indirect consequence of the BFHI.3,11,12 Publicity for
the BFHI, and its training programmes for health professionals,
The Baby-Friendly Hospital Initiative has raised public awareness of the benefits of breastfeeding,
The BFHI is considered one of the more successful international and the number of professional lactation counsellors has
efforts to protect, promote and support breastfeeding.7 This increased continuously.10
World Health Organization (WHO)/United Nations Children’s
Fund (UNICEF) initiative was launched in 1991, in an attempt
to ensure that all mothers are provided with sound information Benefits of the Baby-Friendly Hospital
regarding their infant-feeding choices and that those electing Initiative and accreditation to the hospitals
to breastfeed their infants are given physiologically sound,
evidence-based advice and skilled assistance prenatally and Since the launch of the BFHI in 1991, the movement has
during their postpartum period.5,6 The initiative is based on 10 grown, with more than 20 000 hospitals having been accredited
policy or procedural statements, the “Ten steps”, which were and designated as “Baby-friendly” in 156 countries around the
jointly developed in consultation with international experts.5 world.6 There is a rigorous system in place to accredit hospitals
These summarize the maternity-care practices recommended as “Baby-friendly”. Maternity centres become accredited
to provide optimal breastfeeding support for women, and help when they demonstrate that they meet the WHO/UNICEF
mothers to initiate early and exclusive breastfeeding. criteria for a “Baby-friendly” hospital. Maternity providers
have to demonstrate 80% compliance with each of the BFHI
The BFHI has had a measurable and proven impact on several “Ten steps to successful breastfeeding”,13 and the process is
indicators of breastfeeding and has led to increased rates of repeated at predefined intervals to maintain accreditation.
exclusive breastfeeding for the first 6 months, which are Additionally, many of the “Ten steps” are easily adaptable as
reflected in the improved health and survival of infants.8,9 quality-improvement projects.14

Ali et al.: Initiative to promote contraceptive utilization
Hospitals can experience numerous benefits by becoming 4. ensure health-care staff at the facility possess the necessary
“Baby-friendly”.14 It has been noted that “Baby-friendly” skills to implement this policy;
hospitals actively use their certification as a promotional
5. foster the establishment of quality and standards in care
asset.10 Over the years, the BFHI has become synonymous with
with regular in-service training, programme monitoring
good quality of maternity care and has been shown to inculcate
and supportive supervision;
a sense of pride in both health-care and administrative staff.14
6. make available a wide range of contraceptive choices to
all clients, including those who are marginalized and
Applying lessons from the Baby-friendly underserved (e.g. young people), and create an atmosphere
Hospital Initiative to family planning for clients to select the method freely and as appropriate to
their needs, within their cultural settings;
Following the pattern of the “Ten steps” of the BFHI,5 we
7. utilize all possible opportunities to reach out to girls and
propose the following steps for a Family Planning – friendly
women, especially during postpartum and postabortion-
Health facility Initiative (FPFHFI). The vision is as stated by
care visits (a “no missed opportunities” approach);
WHO:
8. identify mechanisms to prevent stock-outs of essential
The attainment by all people of the highest possible level of reproductive health commodities, especially in
sexual and reproductive health. We strive for a world where contraceptive supply systems, including quality
all women’s and men’s rights to enjoy sexual and reproductive maintenance of contraceptive records;
health are promoted and protected, and all women and men,
including adolescents and those who are underserved and 9. provide continuous quality control in contraceptive services
marginalized, have access to sexual and reproductive health by training staff to be client friendly and caring, and to treat
information and services.15 all people with dignity and respect;
10. ensure provision of flexible service hours for the
We propose that every facility providing family planning/ convenience of clients, including men.
contraceptive services and care to women and men of
reproductive age groups should:
1. have a written family planning/contraception policy that is Accreditation for the proposed Family
displayed prominently and routinely communicated to all Planning – friendly Health facility Initiative
health-care staff;
Implementation and accreditation of the FPFHFI would be
2. ensure that WHO/National guidelines and tools are made a desirable quality-assurance strategy for committed health
available to service providers and are used to provide centres from both the public and private sectors.
routine family planning/contraception services;
3. implement measures to ensure the availability of guidelines A suitable accreditation process is outlined in Figure 1. In brief,
for structured counselling, and inform all women and men it starts with self-appraisal by the health service facility. This
of reproductive age about the benefits of birth spacing initial self-assessment includes an analysis of the practices that
between children, emphasizing the benefits to health of encourage or hinder provision of family planning/contraception
both mothers and children; services, and then identifies the actions that will help to make
Staff
availability
and training
Health facility
Inspection,
initiative:
Implementation approval
assess and
of of status:
analyse the Health Provision Yearly
recommended Minimum
readiness of centres’ of FPFHFI re-evaluation
“Ten Steps” 80%
the health application for certification for FPFHFI
standard compliance
centre to FPFHFI status and logo status
criteria in the with
offer quality
health facility recommended
contraceptive
“Ten Steps”
services
Ensuring
availability of
commodities
Figure 1: Accreditation process for the proposed Family Planning – friendly Health facility Initiative

Ali et al.: Initiative to promote contraceptive utilization
the necessary changes. After a facility is satisfied that it meets 4. Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception
a high standard, this achievement is confirmed objectively by and health. Lancet. 2012;380(9837):149–56. http://www.ncbi.nlm.nih.
gov/pubmed/22784533 - accessed 25 April 2015.
an external assessment (by the Health Ministry in collaboration
5. World Health Organization. Baby-Friendly Hospital Initiative. Geneva:
with partners such as WHO or the United Nations Population WHO. http://www.who.int/nutrition/topics/bfhi/en/ - accessed 25 April
Fund [UNFPA]) of whether the facility has achieved, or nearly 2015.
achieved, the “standard criteria” for the FPFHFI and can thus 6. United Nations Children’s Fund. The Baby-Friendly Hospital Initiative.
be awarded the “Family Planning/Contraception-friendly http://www.unicef.org/programme/breastfeeding/baby.htm - accessed
Health facility” designation and plaque. At predefined intervals 25 April 2015.
the re-evaluation process is repeated to ensure that standards 7. Naylor AJ. Baby-friendly hospital initiative. Protecting, promoting, and
are maintained. supporting breastfeeding in the twenty-first century. Pediatr Clin North
Am. 2001;48(2):475–83.
8. Venancio SI, Saldiva SR, Escuder MM, Giugliani ER. The Baby-
Friendly Hospital Initiative shows positive effects on breastfeeding
CONCLUSION indicators in Brazil. J Epidemiol Community Health. 2012; 66(10):914–
8. http://www.ncbi.nlm.nih.gov/pubmed/22080818 - accessed 25 April
After a decade, when investment in family planning waned, 2015.
there is now a resurgence of interest and investment. The 9. Saadeh R, Casanovas C. Implementing and revitalizing the Baby-
Government of the United Kingdom of Great Britain and Friendly Hospital Initiative. Food Nutr Bull. 2009;30(2):S225–9.
Northern Ireland and the Bill & Melinda Gates Foundation of 10. Merten S, Dratva J, Ackermann-Liebrich U. Do baby-friendly hospitals
the United States of America, with UNFPA and other partners, influence breastfeeding duration on a national level? Pediatrics.
2005;116(5):e702–8.
hosted the London Summit on Family Planning on 11 July
2012.16 More than 150 leaders from low- and middle-income 11. Abolyan LV. The breastfeeding support and promotion in baby-friendly
maternity hospitals and not-as-yet baby-friendly hospitals in Russia.
and donor countries, international agencies, civil society, Breastfeed Med. 2006;1(2):71–8.
foundations and the private sector united to launch Family 12. Atchan M, Davis D, Foureur M. The impact of the Baby Friendly Health
Planning 2020 (FP2020) – a global commitment to provide an Initiative in the Australian health care system: a critical narrative review
additional 120 million women and girls in low- and middle- of the evidence. Breastfeed Rev. 2013;21(2):15–22.
income countries access to voluntary family planning services, 13. Philipp B, Radford A. Baby-Friendly: snappy slogan or standard of care?
information and supplies by 2020.16 Arch Dis Child Fetal Neonatal Ed. 2006;91:145–9. http://www.bmc.org/
breastfeeding/documents/ukbfbobbi.pdf - accessed 25 April 2015.
With renewed interest in family planning, support for the 14. Walker M. International breastfeeding initiatives and their relevance
to the current state of breastfeeding in the United States. J Midwifery
FPFHCI and its effective institutionalization in family planning Women’s Health. 2007;52:549–555. http://www.breastbabyproducts.
practices should be considered. The authors hope the results com/pdf/12_breastfeeding_iniatives.pdf - accessed 25 April 2015.
of this initiative will put family planning/contraception on a 15. World Health Organization. WHO’s strategic vision in sexual and
more visible and higher political agenda, and will make policy- reproductive health and rights – business plan 2010–2015. Geneva:
makers and health professionals aware of the importance and WHO; 2010 [Document No. WHO/RHR/10.10]. http://whqlibdoc.who.
potential of this strategy, in line with the objectives laid out at int/hq/2010/WHO_RHR_10.10_eng.pdf - accessed 25April 2015.
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http://www.familyplanning2020.org/- accessed 25April 2015.
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expand and improve the quality of family planning services,
thus contributing to the goals set by the FP2020 initiative. How to cite this article: Ali M, Sharma V, Mathur A,
Temmerman M. Family Planning – friendly Health facility
Initiative to promote contraceptive utilization. WHO South-East
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REFERENCES
Source of Support: Nil. Conflict of Interest: None declared. This report
1. World Health Organization, UNICEF, UNFPA, World Bank. Trends in
contains the collective views of an international group of experts, and does
maternal mortality: 1990 to 2010. Geneva: WHO; 2012. http://www.
who.int/reproductivehealth/publications/monitoring/9789241503631/ not necessarily represent the decisions or the stated policy of the World
en/ - accessed 25 April 2015. Health Organization. Contributorship: MA, VS and AM were involved
2. Singh S, Darroch JE, Ashford LS. Adding it up: the costs and benefits of in conception of the paper, MA did literature review and prepared the draft;
investing in sexual and reproductive health 2014. New York: Guttmacher MA, VS, AM, and MT reviewed the analysed content; MA, VS, AM, and
Institute; 2014. MT contributed in revising it critically for substantial intellectual content.
3. Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive All authors read and approved the final manuscript.
use: an analysis of 172 countries. Lancet. 2012;380:111–25.

Review Website: www.searo.who.int/

A review of the Sri Lankan health-
sector response to intimate partner
violence: looking back, moving forward
Sepali Guruge1, Vathsala Jayasuriya-Illesinghe1, Nalika Gunawardena2
ABSTRACT 1
Daphne Cockwell School of
Intimate partner violence (IPV) is a major health concern for women worldwide. Nursing, Ryerson University,
Prevalence rates for IPV are high in the World Health Organization South-East Asia Toronto, Canada,
Region, but little is known about health-sector responses in this area. Health-care 2
Faculty of Medicine, University
professionals can play an important role in supporting women who are seeking of Colombo, Sri Lanka
recourse from IPV. A comprehensive search was conducted to identify relevant
published and grey literature over the last 35 years that focused on IPV, partner/ Address for correspondence:
spousal violence, wife beating/abuse/battering, domestic violence, and Sri Lanka. Professor Sepali Guruge, Ryerson
University, 350 Victoria Street,
Much of the information about current health-sector response to IPV in Sri Lanka
Toronto, Ontario, Canada M5B 2K3
was not reported in published and grey literature. Therefore, key personnel from Email: sguruge@ryerson.ca
the Ministry of Health, hospitals, universities and nongovernmental organizations
were also interviewed to gain additional, accurate and timely information. It
was found that the health-sector response to IPV in Sri Lanka is evolving, and
consists of two models of service provision: (i) gender based violence desks,
which integrate selective services at the provider/facility level; and (ii) Mithuru
Piyasa (Friendly Abode) service points, which integrate comprehensive services
at the provider/facility level and some at the system level. This paper presents
each model’s strengths and limitations in providing comprehensive and integrated
health services for women who experience IPV in the Sri Lankan context.
Key words: Intimate partner violence, health-sector response, models of service
integration, Sri Lanka
INTRODUCTION the needs of women experiencing it. However, because the

experience of IPV is unique to each woman and her specific
Intimate partner violence (IPV) refers to behaviours by a sociocultural-economic context,2 it is less clear how best to
current or former intimate partner that cause physical, sexual support women’s efforts to seek recourse from IPV. Moreover,
or psychological harm, including physical aggression, sexual some practices that were formerly considered effective have
coercion, psychological abuse and controlling behaviours.1 been called into question. For example, in the past, evidence
IPV is a global public health issue, with one in three women supported universal, opportunistic or at-risk screening to
worldwide at risk.2,3 Based on global estimates published in identify and offer services to women experiencing IPV.4
2013, the lifetime prevalence of physical and/or sexual IPV However, more recent evidence has shown that screening for
among ever-partnered women in the WHO South-East Asia IPV does little to improve a woman’s quality of life.5
Region was 37%, slightly higher than the estimated global
average.3 Early discussions about health-sector responses to IPV were
often guided by studies from North America and Europe,6,7 but
A substantial body of literature highlights not only the emerging evidence from other regions has begun to contribute
magnitude of the IPV problem, but also its short- and long- to this discourse. The WHO multicountry study on domestic
term health consequences for women, and the significant role violence has identified the need for context-specific data
that can be played by the health-care sector in responding to related to IPV.1

Guruge et al.: Sri Lankan health-sector response to intimate partner violence
Sri Lanka is home to more than 20 million people. It is emerging and middle-income settings was used in this paper.10 They
from a 30-year civil war, which ended in 2009, and provides identified several models of service integration that have
a unique context to examine a health-sector response to IPV. been replicated in a number of settings, and classified them,
This paper presents the results of a review that examined the based on the range of options provided and the level and
Sri Lankan health-sector response to IPV, in light of service- type of integration within and across health-care settings. At
integration models used in other low- and middle-income the lowest level of integration (Level 1), one or two services
settings. are offered in one health-care setting. For example, Family
Counselling Centres in India provide immediate medical
care and counselling to women seeking services.11 Because
METHODOLOGY selective services are provided by one or more care providers
at a single institution, Level 1 is categorized as selective
A comprehensive search of published and grey literature provider/facility-level integration. At the next level (Level 2),
was conducted using the key words IPV, partner/spousal a wider range of services is offered by one or more health-
violence, wife beating/abuse/battering, domestic violence care staff within the same site/setting. The aim is to provide
and Sri Lanka, published from 1980 to 2015. The search comprehensive services in one setting within one health-care
included electronic bibliographic databases, websites, peer- institution. Colombini et al. offer the One-Stop Crisis Centre
reviewed journals and reference lists of articles and reports, as an example of a Level 2 service-integration model.10 This
as well as repositories and archives at universities and model was developed in Canada, and later implemented in a
libraries in Sri Lanka. A preliminary search identified journal number of settings worldwide, including Malaysia, Thailand,
articles, reports, published and unpublished dissertations and India and Bangladesh in the WHO South-East Asia Region.11
theses, conference proceedings and media reports. Although The highest level of integration, Level 3, offers the widest
Sinhala and Tamil are Sri Lanka’s official languages, an range of services at multiple sites/settings. A system of referral
initial review of collected material revealed that almost all and back-referrals across multiple sites/settings provides for
of the relevant work was published in English. The few peer- an extensive range of services with system-wide, seamless
reviewed journals published in Sri Lanka are in English. The integration between different institutions. For example, the
Sri Lankan Government – including the Ministry of Health – Woman Friendly Hospital Initiative in Bangladesh provides
and nongovernmental organizations (NGOs) working with the integrated services for women at multiple levels and different
health sector also produce most of their reports in English. institutions, to provide comprehensive maternal and child care
Based on the preliminary search and review, the authors also and management of violence against women, while ensuring
realized that much of the information about current health- quality of care and gender equity for women.12 The common
sector response mentioned in agency reports, newspapers classification system and identification of services with
and electronic media was not captured in published and grey potential for scaling-up in low- and middle-income contexts
literature in a very timely manner. Therefore, several key make Colombini et al.’s service integration framework useful
personnel from the Ministry of Health, hospitals, universities for the present review of the Sri Lankan health-sector response
and NGOs were also interviewed, to gain additional, accurate to IPV.
and timely information. After reviewing more than 230
abstracts and articles, 23 relevant publications were selected RESULTS
for detailed review. Findings from these publications, and
information gathered through interviews, were reviewed and In 1978, the Sri Lankan Government took the first step to
compared with service-delivery models in other settings. The formally address violence against women (VAW) through
findings are summarized in this paper, in light of the historical the establishment of the Women’s Bureau of the Ministry of
and current context of the health-sector response to IPV in Women’s Affairs. Since that time, successive governments in Sri
Sri Lanka. Lanka have ratified five international gender focused policies:13
the Universal Declaration of Human Rights (in 1980),14 the
Convention on the Elimination of All forms of Discrimination
A framework for service integration Against Women (CEDAW) (in 1981),15 the Vienna Declaration
on the Elimination of Violence against Women (DEVAW) (in
Research about various health-sector responses to IPV reveals 1993),16 the Beijing Declaration and Platform for Action (in
the complexities of designing, implementing and evaluating 1995)17 and the Optional Protocol to the Convention on the
them.8 These complexities are evident in the lack of consensus Elimination of All Forms of Discrimination Against Women
about how to provide effective services to women in health-care (in 2002), pledging to protect women and girls from all forms
settings. There is general agreement, however, that services of violence directed against them. A number of mechanisms
need to be integrated into existing health-care programmes or have also been instituted to support the implementation of
systems, to ensure sustainability, uptake and effectiveness.9 these policies including: The Women’s Charter of 1993, which
However, there is debate about the most suitable entry points affirms the country’s commitment to CEDAW and DEVAW;
and about the most appropriate methods for integrating services the National Committee on Women, established in 1994 to
into health-care systems. address advocacy and policy issues related to VAW, gender
discrimination and other breaches of women’s rights; and
An integration framework identified by Colombini et al.[10]
the National Plan of Action for Women, adopted in 1996 to
in their review of health-sector responses to IPV in low-
identify and set action goals for the government.19,20

Early research on VAW in Sri Lanka focused on ‘wife abuse/ international and local NGOs’ access to war-affected areas.30
battering’. The first study was published in 1982,21 and has been Third, a tendency by government officials to label all NGOs’
followed by other studies.22,23 These studies report a wide range work as anti-government or pro-separatist, affected their ability
of prevalence rates (from 18% to 72%) for IPV against women to work in Sri Lanka.24 NGOs allege that the government and
in various regions and of various ethnocultural and religious state institutions have failed to ensure women’s rights and, as
backgrounds. It is difficult to interpret these prevalence a result, failed both to recognize the need for IPV services, and
estimates because these studies spanned over 30 years, used to provide support for IPV service delivery in the country.30
different enquiry methods (quantitative, qualitative and mixed-
methods), had wide variations in sample sizes (ranging from The earliest documented health-sector response to IPV in
24 to 2311), focused on a variety of subpopulations (urban, Sri Lanka was in 2002, when a short-term, pilot project was
rural, tea-estate populations, low-middle social classes) and implemented in the North Central province.31 This initiative
geographical locations (predominantly in Western, Central, was mainly an awareness-raising programme in the form of
North Central, Southern and Northern provinces), and a two-day training for doctors, nurses and midwives from
employed different definitions/terms related to IPV.22,23 With local hospitals and the community. A specific service point
respect to the latter, terms such as ‘violence against women’, was not established, and although the training was supported
‘domestic violence’, ‘intimate partner violence’ and ‘gender by hospital administration, there was limited commitment by
based violence’ were often used interchangeably to refer to staff and administration for continued IPV service provision.31
violence against women by marital or cohabiting male partners Alongside this training, all women attending the antenatal
(even though traditionally some of these terms include non- and gynaecological clinics of participating hospitals were
partner violence). Most studies focused on Sinhalese women; screened for IPV and referred to a centre managed by an
only a handful of research included Tamil and/or Muslim NGO (Sarvodaya) for counselling services. Building on the
women. The situation of women in the north and east of the experience gained from this pilot programme, two service
country, areas that were predominantly affected by a civil war models were developed – Gender based violence (GBV) desks
(from 1983 to 2009), is less well documented. Even though and Mithuru Piyasa (Friendly Abode) service points.
the war ended in 2009, reports suggest that women in the
previously conflict-affected regions are more vulnerable to
IPV,24,25 similar to women in other war-torn countries.26 Overall, Gender-based violence desks
information about IPV in Sri Lanka is limited, and even less is
documented about the nature and quality of services available One of the earliest health-sector initiatives to provide in-
for women. hospital services for women experiencing IPV was the GBV
desk.29,31 GBV desks are service points for IPV-related care
Sri Lanka has both publicly and privately funded health care.27 and counselling that make use of easily accessible first contact
The Ministry of Health is responsible for overall health-policy points for women in the hospitals, including outpatient and
formulation and governance, and public health-care funding at emergency departments, health education units and clinics.
the national and provincial levels. The Family Health Bureau Dedicated spaces were identified in these locations to provide
oversees maternity and child health programmes and has a private space to talk to women. Nurses and doctors from the
created a gender focal point. All formal IPV services provided hospital provide a limited range of services at GBV desks,
through the state health system fall under the purview of the including befriending (supportive listening), and referral to
Family Health Bureau. The National Policy on Maternal other in-hospital clinics/services. Because the number of
and Child Health outlines the strategies for prevention and hospital-based counsellors is generally quite limited, most GBV
management of gender based violence issues and includes in desks have had to rely on staff from local NGOs to provide
its mandate capacity-building for health-care professionals and services within the hospital.29,32 NGO staff have also been able
establishment of related services.28 to use their own networks and resources to offer women a wide
range of services, including access to safe homes, legal aid and
Historically, counselling services for women experiencing IPV social services that are located outside the hospital setting.29,32
in Sri Lanka were led by faith-based organizations, women’s In fact, in some locations, NGO staff have identified the need
rights groups, NGOs and civil society organizations.29 The for IPV-related services and worked with the local hospital
Good Shepherd Sisters, Salvation Army and Family Planning administrators to establish GBV desks.32
Association were pioneers of such services in Sri Lanka,
dating back to 1924.29 Currently, Women in Need, Sevelanka, GBV desks played a key role in the north and east of the country
Women’s Sarvodaya Collective and Women’s Development during the civil war and after the Indian Ocean tsunami in
Centres are some of the better-known NGOs providing 2004, when health-care services, in general, were disrupted.30
counselling, shelters, legal aid and financial support to women The large influx of foreign aid and funding for NGOs during
experiencing IPV.29 Despite their long history of service the war and after the tsunami helped strengthen their resources
provision, especially among marginalized communities across and efforts. According to published reports, about 3000 women
the county, several barriers have made it hard for these agencies visited GBV desks across the country in 2009, but because
to provide consistent levels of service. First, civil society the number of women seeking services was not available
organizations in Sri Lanka have not received any substantial from all GBV desks in Sri Lanka,29 this is likely to be an
state support and have to rely on financial contributions from underestimation of actual service utilization. Currently, there
international NGOs and donors.20 Second, since the end of are 27 GBV desks in different parts of the country (personal
the civil war in 2009 the government placed restrictions on communication, N Mapitigama) and they continue to play a

vital role in identifying women’s needs and referring women In-hospital referral may include counselling services from a
to appropriate services within and outside hospitals. However, psychiatrist, reproductive health care from a gynaecologist,
a formal process for institutionalizing GBV desks was not or trauma care from a surgeon, etc. Out-of-hospital referrals
established and, as a result, they continue to be perceived as may include those to local NGOs providing short-term
an NGO-led initiative, even though government resources and housing, counselling, legal aid or financial aid.31 As part of this
funds are provided for them. initiative, awareness-raising and capacity-building activities
have also been implemented, including training for hospital
According to the service-integration model described earlier,10 staff and public health staff working in the community, and
GBV desks fit with Level 1 selective provider/facility-level posters and flyers about IPV that are targeted towards health-
services because of the limited range of services offered to care professionals and the public.31,33
women by one or more service providers. In other countries,
Level 1 integrations tend not to provide referrals to outside Alongside the Mithuru Piyasa initiative, the Ministry of Health
service providers;31 however, because the GBV desks are also implemented a health-promotion programme using a range
regularly staffed by NGOs, a wider, multisite integration of information, education and communication (IEC) strategies,
of services has been possible (albeit in an ad hoc manner). including posters, a manual and a short film. These strategies
Although no efforts have been made to carefully evaluate the aim to address community misperceptions about gender roles
effectiveness of GBV desks in Sri Lanka, available information and promote healthy relationships among marital partners, for
suggests that they have faced several challenges. For example, primary prevention of IPV.
the sustainability of some GBV desks has depended on
NGO support because hospital resources available for these The Mithuru Piyasa programme was led and funded by the
additional services have been limited. In addition, NGO staff Ministry of Health, as part of the state response towards
collaborating in service provision at GBV desks have reported addressing GBV.28 The United Nations Population Fund
a lack of support from hospital staff and marginalization by (UNFPA) and other international NGOs supported this
doctors at their hospital.32 At some GBV desks, care provision initiative, providing resources and funding for staff training
has been affected because hospital staff lacked knowledge and capacity-building. There are currently 33 Mithuru Piyasa
about and/or held negative attitudes towards IPV.32 service points throughout the country and efforts are being
made to set up additional centres countrywide (N Mapitigama,
GBV desks have the potential to be scaled up to a multilevel personal communication).
integration model, Level 2 or Level 3 service integration.
The strength of the GBV desk model relates to its low The Mithuru Piyasa model shares some characteristics with
resource utilization, which imposes little burden on already One-Stop Crisis Centres in other settings such as Malaysia,
constrained human resources within hospitals. Similar NGO- Thailand and India, in that it provides a comprehensive range
led, hospital-based initiatives have been scaled up to national- of services for women at one setting.10,31 However, unlike the
level programmes in India and Bangladesh.31 However, in Sri original One-Stop Crisis Centre model, the Mithuru Piyasa
Lanka, this service is being scaled down and in some cases model allows for a much wider range of services and integration
replaced altogether by the second type of service provision at multiple sites and levels. For example, hospital staff are able
(Mithuru Piyasa) described next. A detailed evaluation of to refer women to out-of-hospital services because the training
GBV desks as a service-integration model could have proven and capacity-building they receive through this programme
useful for resource-poor settings that are seeking to introduce enables them to identify local resources, create networks
and/or integrate IPV-related services. Unfortunately, the lack and formalize referral mechanisms with a range of service
of a formal evaluation of GBV desks means that, in the case providers, including the police, NGOs and social services.
of Sri Lanka, this opportunity may already have been missed. This has allowed Mithuru Piyasa staff to provide shared,
integrated services that are beyond the scope of a traditional
One-Stop Crisis Centre. The awareness-building components
Mithuru Piyasa (Friendly Abode) service points of the programme for hospital staff and public health staff
(for example, training workshops for doctors and nurses and
The Ministry of Health commenced a formal process of introduction of relevant education content into public health
institutionalization of hospital-based services in 2007, with the midwives’ curricula) have also helped shift health-care
establishment of a service point at a government hospital in professionals’ negative attitudes towards IPV care provision.
the Southern province.31,33 Similar to the GBV desks, Mithuru
Piyasa centres are also located in easily accessible outpatient Service integration using the One-Stop Crisis Centre model
and emergency care settings within hospitals. Women may has faced some challenges in other countries, including
self-identify as needing services and visit a Mithuru Piyasa lack of collaboration within and between institutions, lack
centre, or may be referred by health-care staff from clinics/ of commitment from health-care professionals, and low
wards within the hospital. Nurses and/or doctors greet women institutional capacity to provide supportive services.10
and take on the role of a befriender, helping women to feel Although a formal evaluation of Mithuru Piyasa services has
comfortable about discussing their concerns related to IPV. A not been undertaken, they seem to face similar challenges. For
detailed history is taken, to assess women’s health status and example, some reports indicate lack of interprofessional and
to identify their immediate care and service needs. Following intersectoral collaboration.22,23,32 The Mithuru Piyasa model
this, they may be offered in-hospital and/or out-of-hospital requires a high degree of collaboration between stakeholders,
services, through an already established system of referrals. as it aims for multisite referral and seamless service integration,

beyond the provider/facility-level service integration achieved existing legislative and administrative barriers. Lengthy court
in the traditional One-Stop Crisis Centre model. Additionally, proceedings and lack of support for women going through
societal and cultural beliefs, in general, and gaps in health-care the legal process become barriers for agencies trying to help
professionals’ knowledge and skills, in particular, negatively women seek legal remedies to address IPV.30
influence their responses to women experiencing IPV in the
Sri Lankan context.34
CONCLUSION
DISCUSSION The GBV desks and Mithuru Piyasa service points have
integrated IPV services into the health sector in Sri Lanka at
Health-sector responses to support women experiencing IPV in the provider/facility and system-wide levels, respectively.
Sri Lanka are evolving, and currently consist of two models of GBV desks showcase an NGO-led initiative utilizing
integration: GBV desks, with facility-level selected integration; community capacity and resources without much dependence
and Mithuru Piyasa, a modified version of the One-Stop Crisis on government resources. Mithuru Piyasa, in contrast, is a
Centre model, with some system-wide integration. state-led institutionalization of services, which is being scaled
up to a national-level programme replacing the GBV desks. In
GBV desks are the longest-standing service model within the moving forward from an NGO-led model to a government-led
health sector, offering services for women experiencing IPV service, opportunities for building on the existing partnerships
in Sri Lanka. They are an example of an NGO-led initiative with NGOs have not been fully utilized. NGOs that continue to
to introduce hospital-based services for IPV, similar to the provide vital, out-of-hospital services to Mithuru Piyasa service
early IPV services in the Maldives, Nepal, Papua New Guinea points should receive the necessary programme and policy
and Timor-Leste.31 Although limited in the range of services supports to continue such work. Expanding and strengthening
provided at one site, GBV desks have been supported by well- partnerships with NGOs, and sharing information and resources
established local NGOs, allowing for system-wide integration with them, will facilitate better collaboration and coordination.
of services beyond their individual settings. This service
model does not place a heavy resource burden on already Evaluating existing services in terms of women’s access,
limited hospital resources, and has proven to be a well-utilized utilization and outcome of services, as well as health-care
service, especially in conflict-affected areas.34 However, professionals’ perceptions of and attitudes towards IPV, and
because they are widely perceived as an NGO-led initiative, their capacity and readiness to provide services, will help
hospital staff have generally failed to recognize their relevance develop evidence-informed interventions to address these
and potential as an effective hospital-based service for IPV. A concerns. While considerable efforts are being put into
formal evaluation of the GBV model before the GBV desks are establishing countrywide services for women experiencing IPV
replaced could prove useful for resource-poor settings seeking in Sri Lanka, parallel efforts are needed to address economic,
to introduce and/or integrate IPV services into health-care political, social, cultural and other systemic factors that create
systems. and sustain gender inequality and oppression of women in
general and the perpetration of IPV in particular.
The more recent Mithuru Piyasa initiative aims to provide
comprehensive services, with some opportunities for system-
wide service integration. Mithuru Piyasa is supported by ACKNOWLEDGEMENTS
Sri Lanka’s federal and provincial health systems, and is
formalized using standard protocols and manuals. Parallel We acknowledge the contribution made by Melanie Selvadurai
programmes of awareness-raising (staff training, capacity- (research assistant) in conducting online searches and gathering
building and development of IEC material) aim to create a literature for this review.
supportive environment to increase uptake of these services.
Similar to the One-Stop Crisis Centre model in other countries, REFERENCES

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manuscript.


National nursing and midwifery legislation
in countries of
South-East Asia with high HIV burdens
Nila K Elison1, Andre R Verani2, Carey McCarthy2
ABSTRACT 1
School of Public Health, Georgia
This paper analyses nursing and midwifery legislation in high HIV-burden State University,
countries of the World Health Organization (WHO) South-East Asia Region, with 2
Division of Global HIV/AIDS,
respect to global standards, and suggests areas that could be further examined US Centers for Disease Control
to strengthen the nursing and midwifery professions and HIV service delivery. To and Prevention (CDC), Atlanta,
provide universal access to HIV/AIDS prevention, care and treatment, sufficient Georgia, United States of America
numbers of competent human resources for health are required. Competence in
this context means possession and use of requisite knowledge and skills to fulfil Address for correspondence: Mrs
Nila K Elison, 1600 Clifton Road
the role delineated in scopes of practice. Traditionally, the purpose of professional
MS E-41Atlanta, GA 30329,
regulation has been to set standards that ensure the competence of practising United States of America
health workers, such as nurses and midwives. One particularly powerful form of Email: nilakusumawatielison1@
professional regulation is assessed here: national legislation in the form of nursing gmail.com
and midwifery acts. Five countries of the WHO South-East Asia Region account
for more than 99% of the region’s HIV burden: India, Indonesia, Myanmar, Nepal
and Thailand. Online legislative archives were searched to obtain the most recent
national nursing and midwifery legislation from these five countries. Indonesia was
the only country included in this review without a national nursing and midwifery
act. The national nursing and midwifery acts of India, Myanmar, Nepal and Thailand
were all fairly comprehensive, containing between 15 and 20 of the 21 elements in
the International Council of Nurses Model Nursing Act. Legislation in Myanmar and
Thailand partially delineates nursing scopes of practice, thereby providing greater
clarity concerning professional expectations. Continuing education was the only
element not included in any of these four countries’ legislation. Countries without
a nursing and midwifery act may consider developing one, in order to facilitate
professional regulation of training and practice. Countries considering reform to
their existing nursing acts may benefit from comparing their legislation with that of
other similarly situated countries and with global standards. Countries interested in
improving the sustainability of scale-up for HIV services may benefit from a greater
understanding of the manner in which nursing and midwifery is regulated, be it
through continuing education, scopes of practice or other relevant requirements
for training, registration and licensing.
Key words: HIV/AIDS, India, Indonesia, legislation, Myanmar, Nepal, nurses’ act,
nursing, South-East Asia, Thailand
INTRODUCTION of deaths due to AIDS.3 With the exception of Thailand, which

at 78% coverage has nearly achieved the target of universal
HIV/AIDS remains a serious global health issue, as evidenced HIV treatment access, overall coverage of antiretroviral
by its contribution to the global burden of disease and by global treatment (ART) in the WHO South-East Asia Region is still
commitments to expand access to prevention and treatment far below the target of 80%.4,5 Coverage rates for prevention
services.1,2 The World Health Organization (WHO) South- of mother-to-child transmission of HIV in the region are low
East Asia Region is second only to the African Region in the and slow to improve.5 However, Member States of this Region
number of people of all ages living with HIV and the number

Elison et al.: National nursing legislation in South-East Asia
have committed to expand ART access and eliminate new HIV The ICN Model Nursing Act outlines 21 standard elements
infections in women and children.6 (seven structural and 14 functional) that are encouraged
for inclusion in national nursing acts.21 Thus, international
To provide universal access to HIV/AIDS prevention, care and guidance can be used as a benchmark to evaluate the content of
treatment, sufficient numbers of competent human resources national nursing acts. WHO urges countries to regularly review
for health are required.4,5 In this context, competence means and strengthen their legislation governing health professionals
that health workers, particularly nurses, who form the majority and to ensure that nurses and midwives give their optimum
of professional health workers in the countries reviewed, have contribution to the community.23 The contribution of nurses and
and utilize the requisite knowledge and skill to fulfil their midwives need not be limited to delivering health services. For
roles as delineated in scopes of practice. In all five countries example, to promote community outreach, they may be called
included in this review, the density of nurses is greater than that upon to supervise other nurses, midwives and community
of physicians, suggesting that nurses are probably providing a health workers.
larger portion of health-care services – especially in countries
such as Indonesia and Thailand, which have the highest Although nurses are the largest health professional group in
densities of nurses and lowest densities of physicians in the the WHO South-East Asia Region,3 to date there has not been
Region. The importance of nurse-initiated and -managed ART an examination of the nursing and the midwifery legislation in
education, policy, regulation and practice for scaling up HIV Member States of this Region. In light of global and regional
treatment in east, central and southern Africa has already been commitments to increase access to life-saving HIV services,
discussed in the literature.7 Additional research suggests that, to and the previously cited clinical weaknesses in the nursing and
provide ART to 1000 patients, between one and two physicians midwifery professions in the Region, a review of nursing and
and between two and seven nurses are required.8 However, in midwifery legislation and its alignment with global normative
the WHO South-East Asia Region, there is a severe shortage guidance would add to existing knowledge concerning health
of physicians and nurses (the latter averaging fewer than 2 per professional regulation. The purpose of this paper is to analyse
1000 patients); the distribution of these professionals within nursing acts in high HIV-burden countries of the Region with
countries is skewed towards urban areas; and many nurses respect to global standards, and to suggest areas that could be
and midwives lack the clinical skills to adequately respond to further examined to strengthen the nursing profession and the
health-care demands.9–13 Legislation can establish mandates; critical role it plays in addressing HIV specifically, and primary
authorize issue of regulations; and allocate resources to health care more broadly.
address deficiencies in the numbers of health workers, their
distribution and clinical capacity. In many low- and middle-
income countries, nurses are in greater supply than physicians METHODOLOGY
and a growing body of evidence suggests that the quality of
nurse-led ART initiation and management services is not Countries were selected for inclusion in this review according
inferior to that provided by physicians.14–16 These studies have to a 2010 global report on HIV-related disability-adjusted life
noted the importance of high-quality training and supervision years (DALYs), a common measure used to quantify disease
to ensure quality of care,14–16 and professional regulation can burden.1 Five countries of the WHO South-East Asia Region
facilitate both. account for more than 99% of the Region’s HIV burden:
India, Indonesia, Myanmar, Nepal and Thailand.5 The rank
Traditionally, the purpose of professional regulation has of HIV/AIDS DALYs and statistics on nurse and physician
been to set standards (such as pre-service and continuing densities for each of the five countries are presented in Table
education requirements, and scopes of practice) that ensure the 1.24 DALYs are a measure of both morbidity and mortality
competence of practising health workers, such as nurses and due to a particular cause and are, therefore, widely used to
midwives.17 In countries around the world, health professionals quantify disease burden for comparative purposes. India has
are regulated through national or subnational legislation the highest number of HIV/AIDS DALYs in the Region by far
(such as a nursing act) that establishes a regulatory body or (more than eight times the second highest country), in part due
council and authorizes it to issue regulations pertaining to to the substantially greater national population of India. The
education and practice. Common regulatory functions of contribution of HIV to total DALYs varies by country, with
nursing and midwifery councils include accreditation of HIV contributing three times more in Thailand (5.6%) than
training institutions, registration and licensing of qualified in India (1.8%). All countries have a combined workforce
nurses and midwives, implementation of continuing density below the WHO-recommended minimum of 2.3 health
education requirements, delineation of scopes of practice, professionals per 1000 people.25 Available data from each of the
and enforcement of professional codes of conduct.18,19 Thus, five countries indicate their population density of nurses and
nursing and midwifery acts aim to ensure the quality of nursing midwives is greater than the density of physicians. Thailand
and midwifery services, to protect the public from harm, and to and Indonesia have the highest densities of nurses and also the
advance the professions. lowest densities of physicians.
While health professional legislation varies from country to The most recent nursing and midwifery legislation from these
country, international nongovernmental organizations such as five countries was obtained by searching the online legislative
the International Council of Nurses (ICN) and the International archives of ICN, the International Labour Organization,
Confederation of Midwives (ICM) have issued global standards national regulatory bodies and governments, from May to
for nursing and midwifery legislation and regulation.20–22 October 2013. Advanced search terms used were “nurses’ act”,

Table 1: HIV burden and health workforce in select countries of the WHO South-East Asia Region
Nurses and
HIV/AIDS DALYs in Physicians per Nursing
National population midwives per
Country thousands in 2010 1000 people in legislation
in 201225 1000 people in
(rank in Region)1 2005–20123 enacted?
2005–20123
India 1 236 686 732 9265.13 (1) 0.65 1.00 Yes
Thailand 66 785 001 1123.30 (2) 0.30 1.52 Yes
Myanmar 52 797 319 1098.67 (3) 0.50 0.86 Yes
Indonesia 246 864 191 650.61 (4) 0.20 1.38 No
Nepal 27 474 377 217.74 (5) 0.21 N/A Yes
N/A: data not available.
“nursing act”, “nurses and midwives”, “health professions council, often from the ministry of health. The councils include
act” and “legislation”. As necessary, the regulatory body or representation from multiple sectors. However, only Thailand’s
the national nurses’ association was contacted via email, to act calls for a private non-profit member to be represented on
request the latest national nursing legislation.26 Other countries the council; India’s act is the only one to explicitly include a
of the Region not selected for this review, owing to lower medical representative; and Nepal’s is the only one to include
HIV burdens, are Bangladesh, Bhutan, Democratic People’s a representative from the consumers’ group. Nepal’s council is
Republic of Korea, Maldives, Sri Lanka and Timor-Leste. the only one of the four that does not include a representative
from the midwifery sector. All councils have authority granted
The national nursing and midwifery acts of India, Nepal and by the legislative acts to establish committees, as needed, to
Thailand were retrieved from online sources.27–29 The legislation implement their mandates. Professions regulated by the acts
from Myanmar was obtained from the Nurse and Midwife include nurses and midwives of various types, including
Council in June 2013;30,31 Indonesia does not have national auxiliaries, assistants and aids.
nursing legislation.32 The four nursing acts were reviewed to
understand how each of the councils was established and the The acts from India, Thailand, Myanmar and Nepal were
extent to which the 21 elements recommended by the ICN reviewed to determine whether or not they addressed each
Model Nursing Act21 were included in the acts. Additionally, of the 21 elements included in ICN’s global standard (see
the acts were reviewed in greater depth to understand the Table 3).21
professional scopes of practice of regulated nurses and
midwives. The purpose of the review was not only to explore
what actions and procedures nurses and midwives were legally Structural elements
permitted to perform, but also to reveal whether performance
of HIV/AIDS-related tasks in these countries was addressed in Each act included the title of legislation and the most recent
their respective legislation. year of amendment, and defined key terms. India was the
first country to enact its nursing legislation (1947) and Nepal
was the most recent (1996). All acts have been amended; the
RESULTS least recent was in 1996 (India) and the most recent were in
2002 (Myanmar and Nepal). The purpose and composition
The national nursing and midwifery acts of India, Thailand, of the council was described in each act. Similarly, all acts
Myanmar and Nepal were reviewed to understand how their established specific committees or authorized the councils to
councils and council memberships were established (see establish them.
Table 2). In each case, the act created the council as the entity
mandated to regulate nurses and midwives. Each council
was established as a new, regulatory entity; the number of Functional elements
members on each council ranged from 11 to 33. In broad terms,
council membership across these countries is structured to Registration of nursing and midwifery professionals was
enable participation from government, the health professions comprehensively addressed in each act, including creation of the
themselves and the private sector. Thailand’s act created a position of registrar, requiring the establishment and maintenance
Council Committee of 33 members to function as the council’s of registers, and setting specific criteria for registration. Two
decision-making body while extending council membership to of the three recommended elements for pre-service education
all nurses and midwives regulated by the act. In the acts of India, and training were present in each act: educational standards
Thailand and Nepal, a mix of election and appointment is used and authority to approve training institutions. However, a
to select council members, in contrast to Myanmar where all requirement for continuing education after registration was not
members are appointed. Respective appointments are made by included in any act. Elements pertaining to fitness to practise
the Central Government of India, Thailand’s Minister of Public were present in each act except for India’s. Neither India’s nor
Health, Myanmar’s Minister of Health and the Government Thailand’s act established an appeals process for disciplinary
of Nepal. All acts call for government representation on the procedures. The Indian Nursing Council was the only council

Table 2: Composition of the councils established by the national acts

Composition or membership
India Thailand Myanmar Nepal
of nursing councils
Council members appointed Yes Yes Yes Yes
Council members elected Yes Yes No Yes

Number of council members 11 33 on Council 11 15
established Committee
Council members appointed or Yes Yes Yes Yes
elected from various sectors
Ministry of health or equivalent Yes Yes Yes Yes
Private non-profit No Yes No No
Nursing Yes Yes Yes Yes
Midwifery Yes Yes Yes No
Medical Yes No No No
The public No No No Yes
Training institutions Yes No No Yes
Criteria set out to select Yes Yes Yes Yes
chairperson or president of
council
Council is created as a new, Yes Yes Yes Yes
separate entity
Committees of council are No Yes (Council No No
established Committee)
Council is authorized to Yes (executive Yes (ethics and Yes (as needed) Yes (as needed)
establish its own committees committee and others, others, as needed)
as needed)
Professions regulated Nurses; midwives; Nurses (first and Nurses; midwives; Nurses; midwives;
auxiliary nurse- second class); nurse-midwives; assistant nurse midwives
midwives; health visitors; midwives (first and nurse-aids
public health nurses second class);
nurse-midwives (first
and second class)
with full autonomy to make and approve rules and regulations; of practice, such as “diagnosis”, “care” and “treatment”, may
other acts allocated rule-making authority among the councils make a significant difference to the involvement of nurses
and one or more governmental entities. All acts included in HIV service delivery and other health tasks. This further
provisions to recognize foreign-trained nurses, and all acts delineation or interpretation of scopes of practice may occur
regulated the midwifery profession in addition to nursing. Three when councils and ministries of health issue rules, regulations
acts (all but India’s) addressed funding of the councils. Overall, or other policies to implement their legislative mandates as set
of the 21 structural and functional elements, Myanmar’s and out in the acts.
Nepal’s acts each addressed 20; Thailand’s addressed 19; and
India’s addressed 15.
DISCUSSION
The review of scopes of practice provision revealed that brief
definitions of the terms “nurse”, “midwife”, “nursing”, and This study compared existing national nursing and midwifery
“midwifery” exist in Thailand’s and Myanmar’s acts (see acts in the countries of the WHO South-East Asia Region with the
Table 4). Similarly, only those two acts provided general highest HIV burden to the ICN global standard,21 and reviewed
scopes of practice, elaborating on the brief definitions. Since the scopes of practice in each act. India, Thailand, Myanmar
none of the acts included a more detailed, task-oriented scope and Nepal each had over 70% of the 21 elements recommended
of practice for the nurse or midwife, it was unclear whether by ICN; Indonesia was the only country in the review without a
specific HIV-related tasks, such as initiating HIV treatment, national nurses’ and midwives’ act. Since enacted, all acts have
were encompassed in the more general scope of practice. been amended, albeit not recently (between 13 and 19 years
Thus, the interpretation of terms from these general scopes ago). This suggests that countries may benefit from reviewing

Table 3: Comparison of national nursing acts with the ICN Model Nursing Act21
ICN Model Nursing Act elements India Thailand Myanmar Nepal
Structural elements
Part I. General
Title of legislation Indian Nursing Professional Nursing Law relating to the Nepal Nursing
Council Act and Midwifery Act Nurse and Midwife Council Act
(1947) (1985) (1990) (1996)
Most recent year of amendment 1996 1997 2002 2002
Key terms defined Yes Yes Yes Yes
Part II. Council and committees
Name of council Indian Nursing Nursing and Midwifery Myanmar Nurse and Nepal Nursing
Council Council Midwife Council Council
Purpose of council set out Yes Yes Yes Yes
Composition of council specified Yes Yes Yes Yes
Committees established or authorized Yes Yes Yes Yes
for establishment
Functional elements
Part III. Registration
Registrar position Yes Yes Yes Yes
Establishment and maintenance of Yes Yes Yes Yes
register
Criteria for registration Yes Yes Yes Yes
Part IV. Education and training
Education standards specified (curricula) Yes Yes Yes Yes
Authority to approve training institutions Yes Yes Yes Yes
Continuing training required No No No No
Part V. Fitness to practise
Code or standards of conduct/ethics No Yes Yes Yes
Disciplinary procedures No Yes Yes Yes
Part VI. Appeals
Established process No No Yes Yes
Part VII. Regional harmonization
Recognition of foreign-trained Yes Yes Yes Yes
professionals
Part VIII. Midwifery
Encompasses midwifery Yes Yes Yes Yes
Part IX. Offences
Offences/penalties listed No Yes Yes Yes
Part X. Miscellaneous
Making and approval of rules or Yes (Council) Yes (Minister of Yes (Ministry of Yes (Council and
regulations Health and Council Health, Government Government)
Committee) and Council)
Funding of council No Yes (fees and other Yes (fees) Yes (fees and
sources) other sources)
Total number of elements addressed 15 19 20 20

Table 4: Scopes of practice provisions in the nursing acts

Provisions India Thailand Myanmar Nepal
Nurse defined No Yes Yes Yes
Nursing defined No Yes Yes No
Midwife defined No Yes Yes Yes
Midwifery defined No Yes Yes No
General scope of practice No Yes a
Yes b
No
Specific scope of practice No No No No
(tasks)
a
“Professional Practice of Nursing means practice of nursing to individual, family and the community in the following actions: (1) to provide
education, advice, counseling, as well as solving health problems; (2) to act and assist individuals physically and mentally, including their
environment, in order to solve problems of illness, alleviate symptoms, prevent dissemination of diseases and provide rehabilitation; (3) to
provide treatment, as mentioned in primary medical care and immunization; (4) to assist physicians to perform treatments. These actions shall
be based on scientific principles and the art of nursing in performing health assessment, nursing diagnosis, planning, nursing intervention and
evaluation.”29
“Professional Practice of Midwifery means practice of midwifery to pregnant women, postdelivery women, their newborns and families in the
following actions: (1) to provide education, advice, counselling, as well as solving health problems; (2) to act and assist pregnant women,
postdelivery women, and their newborns physically and mentally, in order to prevent complications during pregnancy, delivery, and postdelivery;
(3) to provide physical examinations, delivery of the baby and family planning services; (4) to assist physicians to preform treatments. These
actions shall be based on scientific principles and the art of midwifery in performing health assessment, diagnosis, planning, intervention and
evaluation.”29
b
“Nursing Profession means a profession capable of rendering physical, mental, social nursing care needed by a sick person and also health
care, mental and social needs of the family and relatives of such sick person. This expression includes rendering services in respect of better
health care and disease preventive measures to the healthy persons.”30–31
“Midwife Profession means rendering pre-natal care to pregnant women before delivery, and rendering safe delivery at the time of birth. This
expression includes rendering care to mother and new born baby.” 30–31
their national nursing acts to take into consideration current general or how specific a scope of practice should be is not a
health-care needs and global guidelines. Revisions to nursing question this study sought to answer, as strong arguments can
and midwifery acts, or permissive interpretation of existing be made for both approaches. General scopes of practice can
legal and regulatory scopes of practice, could expand the provide greater flexibility for health professionals to respond
workforce for health services such as ART. This is particularly to changing needs with new technologies and skills, whereas
relevant because nurses greatly outnumber physicians in the specific scopes of practice can provide greater protection for,
countries profiled, and globally. and direction to, health professionals, as authorized tasks are
explicitly delineated in writing. In the absence of specific scopes
While functional regulatory elements relating to registration of practice, the ways in which Thailand’s and Myanmar’s
and pre-service education were well represented in all acts general scopes of practice are interpreted and implemented
reviewed, none of the acts required continuing education may well make a significant difference to the involvement of
after initial registration. Continuing education or continuing nurses and midwives in HIV service delivery. General scopes
professional development (CPD) ensures that nurses and of practice could be made more specific, to provide further
midwives update their knowledge and skills to maintain guidance to providers and their employers about what tasks
congruence with the rapid evolution of medical research, nurses and midwives are authorized to undertake. Specific
science and technology.33 Continuing education also helps to scopes of practice could include HIV-related tasks, such
ensure that health workers sustainably provide high-quality as nurse-initiated and -managed ART, as recommended by
health-care services.34 Thus, the absence of a CPD requirement WHO to include prescriptive authority for nurses.15 Means of
in all of the acts reviewed is noteworthy. reform could include legislative amendment or issue of rules
or regulations. Further delineation or interpretation of scopes
Only two acts (Thailand and Myanmar) included a general scope of practice may occur when councils and ministries of health
of practice, which elaborated on the brief definitions provided. issue rules, regulations or other policies to implement their
However, none of the acts included a detailed, task-oriented legislative mandates as set out in the acts. However, assessing
scope of practice for nurses or midwives, making it difficult to whether these countries have issued such rules or regulations
interpret how the terms in the general scope of practice, such or other policies is outside the scope of this review.
as “diagnosis”, “care” and “treatment”, might relate to HIV-
specific tasks, such as diagnosing HIV and initiating ART. How

All the acts created councils as new entities, but with clear The second limitation lies in the nature of the review carried
influence from the countries’ governments. For example, all out. National acts are a primary, but by no means the only,
councils had government representatives as members that form of regulation of nursing and midwifery. Therefore, this
were either appointed or elected by government: some council type of review provides important though limited information
members in India are appointed by its central government; in on how nations regulate nursing and midwifery. For example,
Thailand, the minister of public health appoints the council state or territorial level health legislation may also play an
members and is the special president; in Nepal, the government important role, as in India.35 Future research should explore
appoints the chairperson and some council members; and in the implications of nursing acts and their implementation on
Myanmar, the minister of health appoints all council members, nursing professionals and the public, such as whether the lack
including its chairman. of legislative provisions requiring continuing education affects
the quality of services delivered.
In terms of financing, both Thailand’s and Nepal’s acts
explicitly allowed councils to receive funds from sources
beyond fees charged for services, such as registration. Such CONCLUSION
funding provisions create opportunity for those councils
to receive funds from external sources, including domestic The national nursing acts of India, Thailand, Myanmar and
government support and, potentially, external donor funding. Nepal were all fairly comprehensive, containing 15–20
elements of the 21 elements in the ICN Model Nursing Act.21
Comparing nursing acts in countries of the WHO South- Continuing education was the only element not included in any
East Asia Region to the ICN Model Nursing Act21 can assist act. Given the importance of continuing education to quality
national governments and regulatory bodies to identify areas of practice in HIV care and other areas, this is a problematic
of regulation to review and strengthen in order to improve the finding; however, the study did not assess whether continuing
nursing profession and its contribution to the national health education is required through means other than the act (such as
system. Though the connection between national law and local regulations). Requirements for continuing education can help
health-care practice is not a direct one, it is certainly plausible health workers maintain and improve upon training received
that national legislation may have a major impact on both the prior to entry to service, thus facilitating quality patient care.
quantity and quality of nursing and midwifery services for None of the acts included a scope of practice specifically listing
HIV prevention, care and treatment, and for primary health HIV-related tasks. Without explicit and specific directions
care in general. The intent of nursing and midwifery acts is to concerning which tasks a nurse or midwife may undertake
set standards for these professions, thereby facilitating quality within their scope of practice, some nurses and midwives may
of care. Furthermore, as noted earlier, evidence suggests that hesitate to practise to their full scope, for fear of exceeding
health workers undergoing continuing education are able to it. However, general language in scopes of practice may
provide higher-quality health-care services. For example, potentially be interpreted by domestic authorities to include
strengthening health policies for continuing education on HIV such tasks, without necessarily listing each one. Thus, the lack
care and treatment may lead to improvement in the quality of specific scopes of practice is not necessarily a barrier to
of HIV service delivery. Additionally, better delineation of task sharing of HIV services. Indonesia was the only country
scopes of practice to align with WHO guidance (for example in this review without a national nursing and midwifery act.
ART initiation including prescribing authority for nurses) may Countries without a nursing and midwifery act may consider
facilitate sustainable scale-up of health services, including developing one, in order to facilitate professional regulation
ART coverage. The role of nurses and midwives in HIV/AIDS of training and practice for HIV specifically, and for primary
care is paramount in South-East Asia and elsewhere. This is health care more broadly. Countries considering reform to
due to the greater density of nurses and midwives compared their existing nursing and midwifery acts may benefit from
with physicians, and to their placement on the front lines of comparing their legislation with that of other similarly situated
health care, often in facilities lacking physicians. In short, countries and with global standards. This review may assist
nurses and midwives are critical to HIV/AIDS care. Therefore, countries in the WHO South-East Asia Region, and beyond, to
those interested in improving the sustainability of scale-up evaluate and improve their nursing and midwifery legislation
for HIV services may benefit from a greater understanding of and regulations as part of efforts to strengthen their national
the manner in which nursing and midwifery is regulated, be health systems and increase coverage of HIV and other primary
it through continuing education, scopes of practice or other health-care services.
relevant requirements for training, registration and licensing.
Indonesia, which lacks a nursing and midwifery act, may
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2013 Aug;63(4):125–32. East Asia with high HIV burdens. WHO South-East Asia J
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manuscript. All authors read and approved the final manuscript.


Mosquito-borne diseases in
Assam, north-east India: current
status and key challenges
V Dev1, VP Sharma2, K Barman3
ABSTRACT 1
National Institute of Malaria
Mosquito-borne diseases, including malaria, Japanese encephalitis (JE), lymphatic Research (Field Station), Guwahati,
filariasis and dengue, are major public health concerns in the north-eastern Assam,
state of Assam, deterring equitable socioeconomic and industrial development. 2
Centre for Rural Development
Among these, malaria and JE are the predominant infections and are spread and Technology, Indian Institute of
across the state. The incidence of malaria is, however, gradually receding, with Technology, New Delhi,
a consistent decline in cases over the past few years, although entry and spread 3
National Vector Borne Disease
of artemisinin-resistant Plasmodium falciparum remains a real threat in the Control Programme, National
country. JE, formerly endemic in upper Assam, is currently spreading fast across Health Mission, Government of
the state, with confirmed cases and a high case-fatality rate affecting all ages. Assam, Guwahati, Assam, India
Lymphatic filariasisis is prevalent but its distribution is confined to a few districts Address for correspondence:
and disease transmission is steadily declining. Dengue has recently invaded the Dr V Dev, National Institute of
state, with a large concentration of cases in Guwahati city that are spreading to Malaria Research (Field Station),
suburban areas. Control of these diseases requires robust disease surveillance Guwahati – 781 022, Assam, India
and integrated vector management on a sustained basis, ensuring universal Email: mrcassam@hotmail.com
coverage of evidence-based key interventions based on sound epidemiological
data. This paper aims to present a comprehensive review of the status of vector-
borne diseases in Assam and to address the key challenges.
Key words: Assam, dengue, Japanese encephalitis, lymphatic filariasis, malaria,
north-east India, vector-borne diseases
INTRODUCTION Apart from tea plantations (the cash crop), paddy cultivation,
livestock and sericulture are the major occupations for
Vector-borne diseases, including malaria, Japanese encephalitis subsistence. The climate is typically subtropical, with hot
(JE), lymphatic filariasis and dengue/chikungunya, continue and humid summers and severe monsoons followed by mild
to plague tropical countries globally.1 These diseases cause winters. The region receives heavy rainfall (2–3 m annually), on
considerable illness and mortality in India, where over account of extended monsoons, beginning with pre-monsoon
1 billion people are living at risk of infection, contributing the activity during March/April and maximum precipitation
majority of cases in the World Health Organization (WHO) during May to September/October. During this period (wet
South-East Asia Region.2–4 North-eastern states of India, season), temperatures range from 23 °C to 34 °C and many
representing ~4% of the country’s population, are home to all parts of the state are affected by waves of flash floods each
these infectious diseases with indigenous transmission. Among year. Monsoons start to retreat in October, with a concomitant
these states, Assam (24°44’ to 27°45’N latitude; 89°41’ to fall in temperatures, and minimum temperatures of 9 °C to
96°2’E longitude) alone constitutes 70% of the total population 10 °C are recorded during December/January (winter season).
of north-east India (~43 million), and is a major industrial state The high relative humidity (60–80%) throughout the year is
endowed with a huge rain forest reserve and natural resources. conducive to proliferation and longevity of disease vectors,
The state is split into 27 administrative districts, which can permitting active transmission of the causative parasites.
broadly be classified into three groups of districts, namely
upper Assam, lower Assam and south Assam, marked by major Despite accumulated knowledge on disease epidemiology
river systems and valleys supporting diverse fauna and flora. and additional inputs under the Global Fund to Fight AIDS,
A vast majority of the population is rural (>80%) and an Tuberculosis and Malaria (GFATM), these communicable
estimated 36% of the population lives below the poverty line.5 diseases continue to inflict ill health and deter equitable

Dev et al.: Mosquito-borne diseases in Assam, India
socioeconomic development across India.6 Assam is currently (70%), and the threat of resurgence looms large, on account
witnessing rapid ecological changes, owing to unprecedented of parasite diversity and evolution of drug resistance over
population growth on account of human migration, urbanization time and space.11 Ever since detection of chloroquine-resistant
and environmental degradation; this creates opportunities for malaria in the Karbi Anglong district of Assam in 1973, drug-
vector proliferation and increased receptivity. Given the health resistant foci have multiplied and the parasite has become
infrastructure and interventions for disease management, mono- to multi-resistant.12 The distribution range is rapidly
malaria, JE and lymphatic filariasis continue to persist, while expanding, and the north-east region of India is considered the
dengue is a relatively recent introduction and emerging as a corridor for spread in the country and beyond. Consequently,
public health concern in Assam, with imminent threat to the there has been steady increase nationally in the proportion of
other north-eastern states of India. This review aims to present P. falciparum over the past few decades, to a current level of
a comprehensive overview of the present status of vector- about 50% of the total number of cases in the country.13
borne diseases, with major emphasis on malaria, JE, lymphatic
filariasis and dengue/chikungunya, using unpublished data Mosquito fauna are rich and breeding sites are diverse and
from the State Disease Surveillance Programme. numerous. Of the six dominant vector species in India,
Anopheles minimus s.s. and An. baimaii have been repeatedly
incriminated and are widely prevalent.14 Both these mosquito
MALARIA species have a strong predilection for human blood and
have been unequivocally proven, by many independent
Malaria is a major public health illness in Assam.7 All districts investigators, to be efficient vectors. Of these, An. minimus
are co-endemic for Plasmodium falciparum and P. vivax. The is the most predominant and widespread across the state in
transmission intensities vary across districts and are estimated the valley areas, breeding in the foothill perennial seepage
to be low to moderate.8 P. falciparum is the predominant water streams. An. baimaii, on the other hand, has restricted
infection and is solely responsible for a high proportion of distribution, with predominance in districts sharing either an
cases and attributable deaths (see Table 1). However, the interstate or international border with adjacent vast stretches
disease is unevenly distributed, with a large concentration of of deep forest reserve (State Entomologist, Integrated Disease
cases in marginalized population groups of a few districts.9 For Surveillance Project, Assam, unpublished).
data based on 2011–2013, most districts reported <1 annual
parasite incidence (API), apart from five districts, namely two Even though both An. minimus s.s. and An. baimaii remain
autonomous hill districts of Karbi Anglong and North Cachar highly susceptible to DDT (the residual insecticide currently
Hills (Dima Hasao), and three districts of Chirang, Kokrajhar used in the programme), malaria transmission continues
Udalguri that share an international border with Bhutan; in large parts of the state. This is due to high refusal rates
these districts are all categorized high risk for consistently by communities for spraying indoors (>50%), inadequate
reporting an annual case incidence >2 per 1000 population coverage in scheduled times and places, and behavioural
(see Figure 1). All five districts have large concentrations of characteristics of mosquito species for outdoor resting
indigenous ethnic tribes (>30%) and vast forest cover (>40% populations.15 However, the population densities of both
of land area), and have scattered population settlements (<100 these mosquito species are reportedly depleting, owing to
per km2) living under impoverished conditions and lacking deforestation and urbanization, correlated to reducing levels
awareness of disease prevention and treatment. Furthermore, of malaria transmission.16 The ecological niche thus vacated
these districts share either an interstate or international border, is being occupied by An. culicifacies,17 an important vector
and population groups living close to the border/forest fringe in the plains of India. To circumvent these issues, the advent
continue to have poor access to health-care services. of long-lasting insecticidal nets (LLINs) has proven a boon
as an alternative intervention against malaria transmission
Transmission of the causative parasites is typically perennial, that is accepted as being community based and particularly
with a high rise in cases during April to September, appropriate in north-east India.18
corresponding to the wet season/months of heavy rainfall.
Cases were also recorded in other months of the year (dry Today, elimination of malaria is feasible with scientific
season) but the intensity of transmission was less marked approaches as envisaged by WHO.19 The main components
(see Figure 2). This transmission pattern was quite consistent of the strategy comprise case surveillance; ensuring early
but trends showed a clear and steady decline each year, diagnosis using rapid diagnostic kits and/or microscopy;
evidenced by a substantial reduction in the number of cases. vector control by indoor residual spraying and LLINs; and
However, the number of reported cases may be minuscule treatment with evidence-based artemisinin-based combination
in comparison to the actual disease burden, which includes therapy. There are other supportive elements of community
many more unreported/undiagnosed/misdiagnosed cases and participation and awareness programmes that use information,
those treated in the private/public sector, which are normally education and communication to prevent creation of
not captured by the state surveillance. Furthermore, there is habitats for vector proliferation; strengthening public health
a huge asymptomatic reservoir (estimated to be 8–33% of services for improved access to treatment and monitoring of
ethnic communities), for which there is no mechanism for case artemisinin resistance; prevention of malaria invasion from
detection and treatment.10 the neighbouring states/countries; and resource mobilization,
which should all be applied in keeping with the global plan for
Despite the case-management and chemotherapeutic options in an artemisinin-resistance containment programme, to prevent
place, P. falciparum continues to be the predominant infection the spread of drug-resistant parasites.20

22
Table 1: Malaria-attributable morbidity and vector-control interventions in Assam, north-east India, 2009–2013a
Annual Target population in

Blood smears parasite millions for DDT spray
% of positive coverage (% coverage)
incidence
blood-
Population (number of Number
Year smears with
in millions Positive confirmed of deaths
Examined, n (% Positive for Plasmodium
for malaria cases First Second
of population Plasmodium falciparum
parasite, n per 1000 spray spray
checked) falciparum, n (%) population)
(%)
2009 31.27 302 1915 (9.66) 91 413 (3.03) 66 557 (2.20) 73 2.92 8.54 (71) 7.48 (55) 63
2010 31.35 430 9267 (13.75) 66 716 (1.55) 48 330 (1.12) 72 2.13 6.66 (81) 7.72 (68) 36
2011 32.03 4 130 216 (12.89) 47 397 (1.15) 34 807 (0.84) 73 1.48 5.55 (65) 5.61 (70) 45
2012 32.45 397 3341 (12.24) 29 999 (0.76) 20 579 (0.52) 69 0.92 5.13 (67) 5.02 (70) 13
2013 32.91 3 895 330 (11.83) 19 542 (0.50) 14 969 (0.38) 77 0.59 4.28 (70) 3.62 (73) 7
a
Data source: State Health Directorate of Assam (unpublished).
WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

Figure 1: District map of Assam stratified by annual parasite incidence (API) for data based on 2011–2013. High-risk districts reporting >2 cases
per thousand population are colour coded with red (data source: State Health Directorate of Assam, unpublished). API denotes the number of
cases per 1000 population/year (data source, State Health Directorate of Assam). Inset is the map of India, showing the geographical location of
Assam in the north-east region
16 000
14 000
Number of malaria cases
12 000
10 000
8 000
6 000
4 000
2 000
0
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Month
2010 2011 2012 2013
Figure 2: Monthly distribution of malaria cases in Assam, north-east India, 2010–2013 (data source: State Health Directorate of Assam,
unpublished)

JAPANESE ENCEPHALITIS However, unlike other JE-endemic Indian states, there is now
a paradigm shift in Assam for case prevalence by age, with
The earliest record of an outbreak of JE in Assam dates back a significantly higher number of cases in the age group >15
to 1978 in Lakhimpur district; since then, cases and deaths years than in the age group <15 years (see Figure 3). Assam is
have been reported in each consecutive year.21,22 From reports currently witnessing an upsurge of JE/AES cases with spread
based on data in 1991, 2004 and 2014, it was apparent that from upper Assam to all other districts and reports of confirmed
the case incidence was significantly higher in the age group cases and deaths across the state (data source: State Health
<15 years compared with >15 years, generally in the ratio of Directorate of Assam, unpublished). It is a disease largely of
2:1 in males to females.23 Districts of upper Assam, including the rural areas and most cases were recorded during June to
Dhemaji, Dibrugarh, Golaghat, Jorhat, Lakhimpur, Sibsagar August, corresponding with the months of heavy rainfall and
and Tinsukhia, were high risk with a history of repeated JE paddy cultivation (see Figure 4).
outbreaks and deaths. The clinical presentation of patients with
high fever and neurological complications closely mimics JE The implicated disease vectors, Culex vishnui group
but recent serological investigations have revealed that a group (C. tritaeniorhynchus, C. vishnui and C. pseudovishnui), are
of arboviruses other than JE are also prevalent and circulating widely prevalent, breeding predominantly in paddy fields.
in the region, for example, West Nile virus.24,25 All patients For data based on 2013, these mosquito species were proven
presenting with neuropathy are thus broadly categorized as susceptible to pyrethroid and malathion adulticides used in
acute encephalitis syndrome (AES), unless confirmed for JE the control programme.26 The disease is a serious illness with
by detection of immunoglobulin M (IgM) antibodies in serum, lifelong neuropsychiatric sequelae, and the risk of infection
using IgM antibody capture enzyme-linked immunosorbent is assessed to be high for geographical locations of human
assay (MAC ELISA). Analysis of available data based on the habitation near paddy fields/water bodies (the breeding habitat
State Disease Surveillance Programme (data source: State of JE vectors), with the presence of pigs (the amplification
Health Directorate of Assam, unpublished) revealed that host) in close vicinity, and low socioeconomic population
<50% of AES cases were confirmed as JE (see Table 2). The groups facilitating disease transmission. The menace of JE is
cumulative case-fatality rate inclusive of both AES and JE for growing and spreading in areas hitherto free from the disease,
2008–2013 varied from 17% to 31% across all age groups. with increased morbidity and mortality.
Table 2: Morbidity due to acute encephalitis syndrome (AES) and Japanese encephalitis (JE) in Assam,
north-east Indiaa
Year (number of Number of AES and
Number of deaths Case-fatality rate (%)
reporting districts) JE casesb
2008 (9)
AES 319 100 31
JE 157 (49%) 33 21
2009 (13)
AES 643 109 17
JE 218 (34%) 46 21
2010 (21)
AES 495 117 24
JE 154 (31%) 41 27
2011 (24)
AES 1491 281 19
JE 533 (36%) 114 21
2012 (23)
AES 1439 267 19
JE 486 (34%) 107 22
2013 (27)
AES 1396 276 20
JE 496 (36%) 134 27
a
b
Figures in parenthesis denote JE as a percentage of total AES cases.

450
Number of JE cases 400
350
300
250
200
150
100
50
0
2010 2011 2012 2013
Year
<15 years >15 years
Figure 3: Distribution of Japanese encephalitis (JE) cases in Assam, north-east India, by age group, 2010–2013 (data source: State Health
Directorate of Assam, unpublished)
500
450
Number of JE cases
400
350
300
250
200
150
100
50
0
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Month
2010 2011 2012 2013
Figure 4: Monthly distribution of Japanese encephalitis (JE) cases in Assam, north-east India, 2010– 2013 (data source: State Health Directorate
of Assam, unpublished)

To reduce morbidity and case-fatality, the state has taken up source: State Health Directorate of Assam, unpublished). This
bold initiatives under the National Health Mission, including reporting is based on indigenous transmission evidenced by
establishing (i) paediatric intensive care units; (ii) physical clinical cases and microfilariae carriers in the communities
medical rehabilitation departments; (iii) additional sentinel (see Table 3). The mosquito vector, Culex quinquefasciatus is
sites for strengthening disease surveillance (13 sites across the a common household mosquito and constitutes a major source
state); and (iv) capacity-building for training of trainers and of nuisance throughout the rural/urban areas of the region.
recruitment of additional medical professionals, in order to It has been repeatedly incriminated with a high rate of infection
strengthen health-care services. For containment of JE spread, (6.1%) and infectivity (4.6%) of the L3 parasite of W. bancrofti
provisions are made for thermal malathion fogging in high- in disease-endemic districts, and recorded breeding in a variety
risk areas and impregnation of community-owned mosquito of polluted water bodies, for example, open drainage, sewage
nets for proven efficacy;27 application of larvivorous fish for water collections and ditches, often in close proximity to
control of mosquito breeding; and health-education/awareness human habitations.28–30 Surveys of the prevalence of filariasis in
programmes for community action. In addition, vaccination these districts have revealed a significantly higher microfilaria
campaigns are routinely conducted in the endemic districts for rate (4.7–10.3%) in tea garden tribes (descendants of migrated
protection of vulnerable population groups, achieving >70% tribes from West Bengal, Bihar, Madhya Pradesh, Odisha and
coverage of the target population for immunization; provisions Uttar Pradesh), as against the indigenous populations living
have also been made for special rounds of immunization in in close vicinity to a tea garden, which could be attributed to
high-risk districts; and, beginning in 2013, a pilot project variation in sociocultural living conditions and host–parasite
study for a JE vaccination programme for adults (for the first response.29 The microfilaria rates, however, were consistently
time in the country) was taken up in select districts for mass higher in males than females.28 In these communities, cases of
protection and to avert disease outbreaks (data source: State chronic filariasis with involvement of the genitals were more
Health Directorate of Assam, unpublished). common than those involving the lower extremities.28
For control of filariasis, beginning in 2005, seven endemic
LYMPHATIC FILARIASIS districts were subjected to annual rounds of mass drug
administration (MDA) of diethylcarbamazine + albendazole in
Bancroftian filariasis (Wuchereria bancrofti) is prevalent in eligible population groups, that is, excluding children aged <2
Assam but disease has been recorded in only seven districts, years, pregnant women and seriously ill persons.31 Additional
namely Darrang/Udalguri, Dhemaji, Dhubri, Dibrugarh, measures included home-based management of lymphoedema
Kamrup/Kamrup (Metro) and Nalbari/Baksa Sibsagar (data cases and scaling up of hydrocele operations in the identified
Table 3: Districts in Assam, north-east India, with recorded clinical cases of lymphoedema or hydrocele, or
microfilaria carriers, 2010 and 2012a
Number of
Population (% coverage Number of Microfilariae rate
District Year lymphatic filariasis
under MDA) hydrocele cases (%)
cases
Dibrugarh 2010 1 345 751 (77) 438 430 1.69
2012 1 349 624 (84) 494 603 1.46
Dhemaji b
2010 677 875 (93) 18 0 0
2012 692 004 (94) 31 0 0
Dhubri b
2010 1 755 760 (90) 142 317 0
2012 1 843 768 (86) 128 292 0
Kamrup/Kamrup (Metro)b 2010 2 980 089 (85) 44 16 0
2012 3 316 179 (81) 44 16 0
Nalbari/Baksa b
2010 1 833 738 (82) 28 142 0
2012 1 870 635 (73) 28 142 0
Sibsagar 2010 1 148 572 (82) 129 170 3.01
2012 1 163 655 (90) 282 334 0.67
Darrang/Udalgurib 2010 1 815 448 (81) 280 397 0
2012 1 863 755 (77) 120 132 0
MDA: mass drug administration.

a
b
Districts excluded from MDA round in 2013 and targeted for transmission assessment surveys in 2014.

community health centres/district hospitals/medical colleges. antibody assays and other AES viruses.34 Studies on seasonal
With more than five consecutive MDA rounds with >70% infectivity and co-circulation of these viruses are warranted, to
coverage in target districts, there has been substantial progress enable better understanding of transmission dynamics, thereby
in depleting the asymptomatic reservoir, with a state average helping the state control programme to prepare mitigating
microfilaria rate of 0.15%, as against a national average of plans to respond to these imminent threats.
0.27% in 2013.31 Consequently, out of the total of seven
endemic districts, five were excluded from MDA in 2013 and Both these mosquito vector species are reported to be
were scheduled for transmission assessment surveys (TASs) susceptible to malathion, the insecticide of choice for fogging
in 2014, using an immunochromatographic test (ICT) for operations.32–34 For data based on disease prevalence and records
the presence of circulating antigen in children born after the of mosquito breeding, it is imperative that the disease has an
initiation of MDA. In these surveys, filarial antigen positivity established foothold in the state, with indigenous transmission
was observed to be zero in Darrang/Udalguri and Dhemaji corroborated by listing of cases without any travel history.
districts, and varied from 0.12% to 0.64% of the total subjects
screened in Dhubri, Kamrup and Nalbari/Baksa districts With the continued phenomenon of urbanization and prevailing
(K Nath, Directorate of Health Services, Assam, personal climatic conditions, it is projected that dengue will emerge as
communication). The remaining two districts of Dibrugarh a major public health concern in north-east India. For disease
and Sibsagar were assessed to be eligible for another round containment, besides malathion thermal fogging operations,
of MDA, as they reported a microfilaria rate of >1% of the source reduction and promoting personal protection measures,
population surveyed, and they were scheduled for TAS in 2015. the state control programme has embarked upon an intensive
health-awareness campaign for enhanced community-level
Filarial endemicity is steadily declining to meet the national action for prevention and control of mosquito breeding, in
goal of filarial elimination by 2015. The state health department collaboration with the local civic bodies.
is continuously strengthening health-care services for better
case management, coupled with mass awareness campaigns
for disease prevention. For control of disease vectors, DISCUSSION
interventions are applied by recurrent anti-larval measures Among vector-borne diseases, malaria and JE are the major
in urban areas, combined with sanitary measures including public health problems in Assam. However, the threat of
filling ditches, pits and low-lying areas, de-weeding, de-silting, malaria is gradually receding, with a consistent decline in cases
application of larvivorous fish, and, for control of the adult over the past few years, owing to implementation of newer
mosquito population, thermal fogging operations carried out interventions in the control programmme since 2008, assisted
on a continuing basis. under GFATM, namely LLINs/impregnation of community-
owned mosquito nets for vector control, and artemisinin-based
DENGUE/CHIKUNGUNYA combination therapy for treatment, and, above all, making
provisions for induction of accredited social health activists,
Dengue arbovirus has recently emerged as a major public health to ensure early diagnosis at the local and individual level. The
concern with increased morbidity in Assam.32 In 2010, for the existing health-care infrastructure is being further augmented
first time, 237 dengue cases were reported, followed by 1058 under the National Health Mission in the state, for a quality
and 4526 cases in 2012 and 2013, respectively (data source: health-care and outreach programme.
State Health Directorate of Assam, unpublished). Most dengue
cases (>70%) were recorded in Guwahati metropolitan area However, there are many more challenges that remain
during the post-monsoon months in September to December. to be addressed to qualify for pre-elimination specific to
Among these, patients comprised all age groups of both sexes Assam/north-east India. To enumerate a few, the problem of
but there was a higher concentration of cases in adult males asymptomatic malaria (parasite reservoir in the community)
aged 26–60 years. Dengue is currently spreading to semi-urban remains unattended, leaving many cases untreated and
areas and adjoining districts/states of north-east India. inadequate vector-control interventions along international/
interstate borders; this requires priority action to achieve a
Aedes aegypti and Ae. albopictus are implicated as disease substantial reduction of transmission.10 In addition, Assam is
vectors for the spread of dengue and chikungunya, and breed the major contributor for P. falciparum malaria that has become
in a variety of containers.33 Among these, Ae. aegypti has been multi-resistant, and treatment of this remains a continuing
incriminated for the circulating serotype of dengue virus 2, in challenge.35 There are already confirmed reports of declining
both males and females, establishing transovarial transmission response to ACT (artesunate + sulfadoxine–pyrimethamine)
in the region (P Dutta, Regional Medical Research Centre, in the north-east of India, resulting in a shift of drug policy
Dibrugarh, personal communication). It is a common species to AL (artemether + lumefantrine).36 Nevertheless, although
in city premises and recorded breeding is predominantly in there is no evidence for resistance to artemisinin in Assam/
discarded tyres and solid waste containers. Ae. albopictus, north-east India, the threat of import of artemisinin resistance
on the other hand, is commonly encountered in semi-urban/ across borders from neighbouring countries, where it has
rural areas, breeding in tin/plastic containers, flower vases, already surfaced, looms large.37,38 To contain the entry of
cut-bamboo stumps, etc. Along with dengue, few cases of artemisinin resistance, there is an imperative need for robust
chikungunya were recorded in 2012 (five cases) and 2013 disease surveillance, periodic monitoring of the therapeutic
(78 cases); these cases were negative for dengue antigen efficacy of the drug regimen in force for effective radical cure

and intercountry collaboration for coordinated vector control interventions to check the spread of disease. The authors
to prevent its spread. Equally important would be to step up strongly believe that programme ownership and leadership,
pharmacovigilance, preventing circulation of counterfeit drugs innovation in tools and implementation approaches, improved
and enforcing application of a uniform drug policy among disease surveillance, monitoring and evaluation, judicious
private practitioners and discontinuing monotherapies. It is application of a combination of technologies, human resource
strongly advocated to universalize interventions for prevention development, and equity in access to services would help
and access to treatment, prioritizing high-risk areas for keeping accelerate progress in achieving the ultimate goal of freedom
malaria at bay. The authors strongly advocate community- from vector-borne disease.48,49
driven actions for increased awareness of disease and its
prevention, with political commitment for sustained allocation
of resources for uninterrupted supply of logistic requirements.20 ACKNOWLEDGEMENTS
With Bhutan and Sri Lanka heading for malaria elimination
in the WHO South-East Asia Region, it is time for India to The authors wish to thank the State Programme Officer, Vector
re-strategize to achieve a pre-elimination stage, with the focus Borne Disease Control Programme, the State Entomologist,
of attention on the north-east sector, by greater allocation for Integrated Disease Surveillance Project (IDSP), Dr K Nath,
scaling up interventions and health-delivery mechanisms in Assistant Director of Health Services (Filaria), Government
hard-to-reach population groups at high risk of malaria, thereby of Assam and Dr P Dutta, Regional Medical Research Centre,
preventing the spread of drug-resistant malaria.39–42 Dibrugarh, for data access and discussions on the subject. This
manuscript has been approved by the Institute Publication
Cases of JE are emerging in all districts across the state, with Screening Committee and bears the publication number
increased morbidity and case-fatality. There is no breakthrough 049/2014.
for control, apart from immunization to prevent JE cases. The
future priority area of research should include understanding
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Original research Website: www.searo.who.int/

Association between household air pollution
and neonatal mortality: an analysis of
Annual Health Survey results, India
Sutapa Bandyopadhyay Neogi1, Shivam Pandey1, Jyoti Sharma1, Maulik
Chokshi1, Monika Chauhan1, Sanjay Zodpey1, Vinod K Paul2
ABSTRACT 1
Indian Institute of Public Health,
Public Health Foundation of India,
Background: In India, household air pollution (HAP) is one of the leading risk Gurgaon, India;
factors contributing to the national burden of disease. Estimates indicate that 7.6% 2
Department of Pediatrics,
of all deaths in children aged under 5 years in the country can be attributed to HAP. All India Institute of Medical
This analysis attempts to establish the association between HAP and neonatal Sciences (AIIMS), Ansari
mortality rate (NMR). Nagar, New Delhi, India
Methods: Secondary data from the Annual Health Survey, conducted in 284 Address for correspondence:
districts of nine large states covering 1 404 337 live births, were analysed. The Dr Sutapa B Neogi, Indian Institute
survey was carried out from July 2010 to March 2011 (reference period: January of Public Health-Delhi, Public
2007 to December 2009). The primary outcome was NMR. The key exposure Health Foundation of India, Plot
was the use of firewood/crop residues/cow dung as fuel. The covariates were: number 47, sector 44,
sociodemographic factors (place of residence, literacy status of mothers, Gurgaon - 122002, India
Email: sutapa.bneogi@iiphd.org
proportion of women aged less than 18 years who were married, wealth index);
health-system factors (three or more antenatal care visits made during pregnancy;
institutional deliveries; proportion of neonates with a stay in the institution for
less than 24 h; percentage of neonates who received a check-up within 24 h of
birth); and behavioural factors (initiation of breast feeding within 1 h). Descriptive
analysis, with district as the unit of analysis, was performed for rural and urban
areas. Bivariate and multivariable linear regression analysis was carried out to
investigate the association between HAP and NMR.
Results: The mean rural NMR was 42.4/1000 live births (standard deviation [SD]
= 11.4/1000) and urban NMR was 33.1/1000 live births (SD=12.6/1000). The
proportion of households with HAP was 92.2% in rural areas, compared to 40.8%
in urban areas, and the difference was statistically significant (P < 0.001). HAP
was found to be strongly associated with NMR after adjustment (β = 0.22; 95%
confidence interval [CI] = 0.09 to 0.35) for urban and rural areas combined. For
rural areas separately, the association was significant (β = 0.30; 95% CI = 0.13 to
0.45) after adjustment. In univariable analysis, the analysis showed a significant
association in urban areas (β = 0.23; 95% CI = 0.12 to 2.34) but failed to demonstrate
an association in multivariable analysis (β = 0.001; 95% CI = –0.15 to 0.15).
Conclusion: Secondary data from district level indicate that HAP is associated
with NMR in rural areas, but not in urban areas in India.
Key words: developing countries, indoor air pollution, low birth weight, neonatal
mortality

Neogi et al.: Household air pollution and neonatal mortality in India
BACKGROUND The analysis presented in this paper attempts to explore the

possible association of HAP with neonatal mortality. Type
Globally, household air pollution (HAP) is the second-biggest of fuel use has remained unchanged over a period of almost
environmental contributor to the burden of diseases, after two decades. With more than 80% of households relying on
unsafe water and sanitation. Around 2.7% of the global– crop residues/wood or dung as their primary source of fuel,
burden of diseases (in disability-adjusted life-years [DALYs]) the attributable risk could be substantial.23 The objective of
was attributed to HAP in 2004.1 In India, it is estimated to the study was to determine the association between HAP and
be the leading risk factor contributing to the national burden neonatal mortality rate (NMR), based on an analysis of Annual
of disease.2–5 It has become the second-largest risk factor for Health Survey (AHS) data.
disease burden in India.6 It is estimated that 7.6% of all deaths
in children aged under 5 years in the country can be attributed
to HAP.7 METHODS
HAP is associated with increased risk for several acute
and chronic health conditions, including acute respiratory
Study setting
infections, pneumonia, tuberculosis, chronic lung disease, India is a union of 29 states and 7 union territories, with a
cardiovascular disease, cataracts and cancers.8–16 Exposure is huge range of socioeconomic characteristics. States are further
higher among women and children, since they spend more time divided into districts, each with a population of 1–2 million,
near the domestic hearth.17 There is emerging evidence that HAP which are further subdivided into blocks.
also increases the risk of adverse pregnancy outcomes; fetal
mortality; low birth weight (LBW); preterm birth; small for The study includes 284 districts of nine large states – Assam,
gestational age; intrauterine growth retardation; and congenital Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha,
anomalies.12,14,18,19 A study in rural Guatemala has shown that Rajasthan, Uttarakhand and Uttar Pradesh. These states
babies born to women using wood fuel were 63 g lighter (after constitute about 48% of the country’s population, 70% of
adjustment for confounding) than those born to women using infant deaths, 75% of deaths in children aged under 5 years
gas or electricity.20 An association between exposure to HAP and 62% of maternal deaths.25 The Government of India has
and perinatal mortality (odds ratio (OR) = 1.5, after adjusting classified these states as high-focus states, to receive focused
for other factors), has also been established.21 Exposure of attention and greater resource allocation in the health sector.
infants of normal birth weight to HAP has been associated
with respiratory mortality (OR = 1.40) and sudden infant death
syndrome (OR = 1.26).22 Study design
Many studies from India have explored the relationship The study is an analysis of secondary data from a large
between HAP and LBW and/or stillbirth. However, very few population-based survey, the Annual Health Survey (AHS).25
studies have attempted to establish the relationship of HAP
with neonatal mortality. In a large representative sample from
India, it was shown that mortality among 1–4 year olds was Data source
50% higher among those exposed to HAP.23 Among neonates,
the mortality rate was found to be almost eight times higher, The AHS is the largest sample survey in the world. This is the
according to an analysis of data from India’s National Family first survey that records the district-level health outcomes in
Health Survey (NHFS-3), collected in 2005–2006. The analysis high-focus states, to provide critical inputs for public health
revolved primarily around sociodemographic factors that can programmes. The data are available in the public domain.25
influence neonatal health.24
The AHS adopted one-stage stratified random sampling without
Since 2005, multiple interventions have been added to the replacement, except in the case of larger villages in rural areas,
national programme (National Rural Health Mission [NRHM]) to select 20 694 villages and urban blocks. It surveyed about
to increase access to skilled care for pregnant women and 18 million populations, 3.6 million households and 1 404 337
neonates. Implementation of integrated management of live births. The survey was carried out in all nine AHS states
neonatal and childhood illnesses and home-based newborn care between July 2010 and March 2011 (reference period; January
aims to increase the contact of neonates with the health system 2007 to December 2009). A total of 284 districts were covered
during this critical period of life. In addition, the Government in rural areas. In order to avoid unusual sampling fluctuations,
schemes, Janani Suraksha Yojana and Janani Shishu Suraksha estimates for urban areas were not available when the number
Karyakram, facilitate institutional deliveries and also influence of urban sampling units was less than six. Therefore, for most
neonatal health. At the same time, facility-based care has of the variables, data were available from 239 districts. All the
also been improved to take care of sick neonates. These variables were elicited during interviews of family members as
programmatic interventions have a role in improving neonatal part of the large survey. A brief description of the variables is
survival. given in Box 1.25

Box 1. Case definitions, measurements and calculations used in the AHS survey25
• Neonatal mortality rate (NMR): The proportion of neonates who died within 28 days of birth out of 1000 live births in a
district.
• Low birth weight (LBW): Birth weight below 2.5 kg. The information on birth weight was collected for all living children
(for the last two outcomes of pregnancy resulting in live births) during the reference period. The percentage of children
whose birth weight was taken and was less than 2.5 kg was considered.
• Household air pollution (HAP): The proportion of households using firewood/crop residues/cow dung as the main source
of fuel was considered.
• Households using kerosene: The proportion of households using kerosene as the main source of fuel was considered.
• Wealth quintile: In the absence of income and expenditure measures of economic status, household wealth index has been
constructed at state level for each of the states, using the assets possessed (structure of the house and the facilities available
for use by the household). The households were ranked according to their individual Household Asset Score and then
divided into five quintiles, with the same number of households in each quintile. For the present study, the proportion of
households in the lowest 20% and highest 20% income quintile in each district, based on assets possessed, was calculated.
• Effective literacy rate: The proportion of the population in a district with the ability to read and write in any language,
expressed as a percentage.
• Marriage below 18 years: This is the proportion of marriages among women taking place below the legal age, that is
18 years. These proportions were also based on marriages of the members of household (usual residents as in January
2010) taking place during 2007–2009. In addition, the percentage of currently married women aged 20–24 years who were
married before the legal age was calculated.
• Three or more antenatal care (ANC) visits: This was elicited through a series of responses to questions from every married
woman aged 15–49 years. The indicator, the percentage of mothers who received three or more ANC check-ups, is with
reference to the last live/still birth during the reference period.
• Institutional delivery: Details were requested from every married woman aged 15–49 years. This indicator reflects the
percentage of deliveries that took place in institutions (government or private) for the last live/still birth during the reference
period.
• Breastfeeding within 1 h: This was assessed by asking mothers of all living children (for the last two outcomes of pregnancy
resulting in live births during the reference period). The percentage of children breastfed within 1 h was calculated.
• Less than 24 h stay after delivery: This was elicited from every married woman aged 15–49 years for the last live/still birth
during the reference period. This indicator reflects the percentage of women who stayed for less than 24 h in institutions
after delivery. This has a direct bearing on the health of the mother and neonate.
• Neonates checked within 24 h of birth: This was elicited from mothers whose last outcome of pregnancy resulted in live
birth during the reference period. The percentage of neonates who received a check-up within 24 h has been worked out.
For institutional deliveries, if the baby remained in the institution for at least 24 h, it was presumed that the first check-up
was done within 24 h.
• Proportion of people who smoke: This information was collected from usual residents aged 15 years and above. This
reflects the proportion of habitual smokers (who smoke at least once every day).
Study variables The following maternal and delivery care factors were
considered as covariates: sociodemographic factors (place of
The key outcome variable was district-level NMR. residence, literacy status of mothers, proportion of women aged
less than 18 years who were married, wealth index); health-
The key exposure was the use of firewood/crop residues/ system factors (three or more antenatal care [ANC] visits
cow dung as fuel. In the absence of individual-level data, made during pregnancy, institutional deliveries, proportion
the proportion of households using firewood/crop residues/ of neonates with a stay in the institution of less than 24 h,
cow dung as fuel was considered as a surrogate marker of percentage of neonates who received a check-up within 24 h
the proportion of households with HAP. Data on households of birth); and behavioural factors (initiation of breastfeeding
primarily using kerosene as their fuel, and the proportion of within 1 h).
women who smoke were also available but since the values
were very small, these were not considered as exposures.
Instead, data on the proportion of the population, who smoke
was used to indicate exposure to second-hand smoke.

Ethical issues the proportion of households using kerosene and LPG/PNG,

these were excluded because the proportions were very low.
The study is based on the data available in the public domain.
HAP was found to be strongly associated in both unadjusted
and adjusted analysis for total (β = 0.22; 95% confidence
Statistical analysis interval [CI] = 0.09 to 0.35) and rural areas (β = 0.30;
CI = 0.13 to 0.45) (see Table 2). The difference was greater
The analysis was performed by considering all districts for those households where neonates were checked within 24 h
combined, and also stratified by place of residence (that is rural of delivery. The analysis showed a significant association in
and urban). For the district-level analysis, the main outcome urban areas in univariable analysis (β = 0.23; 95% CI = 0.12 to
variable was district-level NMR. The analysis focused on 0.34) but failed to demonstrate an association in multivariable
exploring the relationship between district-level NMR and analysis (β = 0.001; 95% CI = –0.15 to 0.15).
HAP in the nine high-focus states in India. Sociodemographic
characteristics of the districts for both rural (284) and urban
(239) areas have been presented. A simple linear regression
DISCUSSION
analysis was used to study the relationship between the number The analysis from 284 districts indicates that a strong
of households using cooking fuel in rural areas, which is association exists between HAP and NMR, after adjusting for
used as a proxy for HAP, and neonatal mortality. Correlation the proportion of households in the lowest and highest 20%
analysis was performed using Pearson’s correlation, and wealth quintiles; the proportion of neonates checked within
Spearman’s rank correlation, as appropriate. Subsequently, 24 h of birth; those who initiated breastfeeding after 1 h; the
multiple regression models were developed to assess the effect proportion of women who went for three or more ANC check-
of change in the district-level HAP on NMR when adjusting ups; the proportion of babies who stayed for less than 24 h in
for sociodemographic variables. Multiple regression models hospitals; and effective literacy rate. Adjusted analysis suggests
were run for the total sample, as well as for urban and rural that an association between HAP and NMR exists in rural areas
areas separately. Variables that had a strong correlation in but fails to demonstrate an association in urban areas.
bivariate analysis and seemed to be a plausible explanation for
high NMR were considered in the models. All analyses were There is limited evidence on the association of HAP and infant
performed in STATA version 12 (StataCorp, College Station, or neonatal mortality rates. Bassani et al. reported that child
Texas) and SPSS version 21. mortality (age 1–4 years) increased by 50% with exposure to
HAP.23 In their analysis using data from NFHS-3, Epstein et al.
concluded that exposure to HAP increased the risk of NMR by
RESULTS 7.5 times.24 The risk of death of neonates born in households
The mean total NMR was 40.5/1000 live births (standard using coal was more than 18 times higher than that for neonates
deviation [SD] = 11.28/1000), while that of rural and urban areas in households primarily using gas.24
was 42.4/1000 (SD = 11.4/1000) and 33.1 (SD = 12.6/1000) live The strength of the evidence between the use of biomass as
births, respectively. The proportion of LBW in rural areas was cooking fuel and neonatal mortality was found to be weak in a
28.1% (SD = 11.5%) compared to 25.5% (SD = 9.9%) in urban population-based cohort of more than 10 000 neonates in south
areas. The proportion of households with HAP was 92.2% India.26 However, the study documented a 21% increased risk
(SD = 8.3%) in rural areas compared to 40.8% (SD = 15.9%) of dying in the first 6 months of life.26
in urban areas, and the difference was statistically significant
(P < 0.001). Other variables that varied greatly between urban The present results are contrary to the findings provided on the
and rural areas were the proportion of households using basis of death estimates given by a United Nations report that
liquid petroleum gas/piped natural gas (LPG/PNG) as fuel; stated that no neonatal or post-neonatal deaths were attributed
the proportion of households in the lowest 20% and highest to solid-fuel use.23 The present results show that neonatal
20% wealth quintiles; marriage below 18 years of age; the rate mortality as a result of exposure to solid fuel is 4.2% in rural
of institutional deliveries; and the effective literacy rate (see areas, 2.3% in urban areas and 3.0% in total.
Table 1).
The association between solid fuel combustion and LBW
The bivariate analysis (table not shown) indicated that significant is established.4,20,26–28 The reported association (OR) was
correlation exists between HAP and total NMR (r = 0.37, from 1.23 in a hospital-based study to as high as 18.54, as
P < 0.001), as well as for rural (r = 0.36, P < 0.001) and urban represented from an analysis of NFHS-3 data.24,29 There is also
areas (r = 0.29, P < 0.001) separately. Other variables that were strong evidence that HAP is associated with stillbirths.3,4,21,26,30,31
significantly associated with total NMR include initiation of Exposure to HAP has 50% more risk of stillbirths as reported
breast feeding within 1 h of delivery (r = –0.18); the proportion in various studies from India.21,26,30 The current dataset did
of households in the lowest 20% (r = 0.22) and highest 20% not report stillbirths. Low birth weight was reported for every
wealth quintile (r = –0.31); neonates checked within 24 h district. This, too, was based on the records that were made
of birth (r = 0.24); three or more ANC check-ups during available to the survey team. There was no report on the
pregnancy (r = –0.13); and effective literacy rate (r = –0.21). completeness of these data and hence this study did not attempt
Despite there being a significant correlation between NMR and to establish an association between HAP and LBW.

Table 1: Baseline characteristics of the study districtsa

Rural Urban Total
District
characteristics Number of Number of Mean ± SD Number of
districts Mean ± SD (range) districts (range) districts Mean ± SD (range)
Neonatal mortality 284 42.4 ± 11.4 201 33.1 ± 12.6 284 40.51 ± 11.3
rate (per 1000 live (11.0 to 76.0) (8.0 to 73.0) (11.0 to 75.0)
births)
Low birth weight (%) 284 28.1 ± 11.5 239 25.5 ± 9.9 284 25.0
(9.1 to 78.8) (8.5 to 76.7) (19.6 to 32.3)b
(9.4 to 78.2)
Institutional delivery 284 53.6 ± 19.0 239 73.1 ± 15.0 284 56.2 ± 18.6
(%) (15.9 to 92.3) (32.0 to 97.8) (16.8 to 92.5)
Less than 24 h 284 50.4 ± 20.5 239 42.9 ± 20.6 284 49.0 ± 20.2
hospital stay (%) (1.4 to 96.4) (4.2 to 92.8) (4.1 to 85.2)
Neonates checked 284 62.0 ± 16.6 239 77.7 ± 11.9 284 64.3 ± 16.0
within 24 h after (22.1 to 92.3) (39.9 to 98.3) (24.2 to 92.9)
delivery (%)
Breastfeeding within 284 50.0 ± 21.1 239 52.2 ± 19.9 284 50.1 ± 20.6
1 h after delivery (%) (9.4 to 90.5) (8.7 to 99.0) (9.9 to 90.0)
Household air 284 92.2 ± 8.3 239 40.8 ± 15.9 284 85.9
pollution (%) (41 to 99.4) (1.9 to 83.9) (77.2 to 90.7)b
(18.4 to 97.3)
Household use of 284 3.8 239 52.1 ± 15.7 284 9.8
LPG/PNG as fuel (%) (15.0 to 95.3) (5.8 to 17.4)b
(2.1 to 6.3)b (0.0 to 71.8)
(0.2 to 51.8)
Lowest wealth quintile 284 24.6 ± 11.9 284 3.7 284 21.37 ± 11.1
(20%) (1.3 to 66.8) (1.8 to 6.5)b (1.0 to 63.50)
(0 to 28.3)
Marriage below 18 284 12.7 284 3.9 284 11.2
years (%) (7.2 to 22.8)b (1.5 to 7.9)b (6.0 to 20.6)b
(0.5 to 62.7) (0.0 to 47.6) (5 to 53.9)
Three or more 284 46.1 ± 20.7 284 53.9 ± 30.1 283 48.88 ± 20.7
antenatal care visits (7.1 to 94.8) (0.0 to 97.3) (8.0 to 95.2)
(%)
Household use of 284 0.1 284 1.4 284 0.4
kerosene as fuel (%) (0.1 to 0.3)b (0.6 to 2.7)b (0.2 to 0.7)b
(0 to 1.7) (0.0 to 11.5) (0 to 9.1)
Highest wealth 284 9.7 284 50.8 ± 13.2 284 15.7
quintile (20%) (6 to 14.8)b (14.9 to 88.2) (11.0 to 22.1)b
(1.7 to 43.9) (4.3 to 58.6)
Effective literacy rate 284 58.1 ± 9.6 284 77.6 ± 7.3 284 61.9 ± 9.6
(%) (36.1 to 81.3) (48 to 95.2) (36.9 to 84.9)
Population who 284 11.4 ± 4.9 239 6.9 ± 3.3 284 10.4 ± 4.4
smoke (%) (0.6 to 27.5) (0.5 to 19.6) (0.7 to 26.0)
LPG: liquid petroleum gas. PNG: piped natural gas. SD: standard deviation.
a
Data pertain to the indicators of urban and rural population in 284 districts. Indicators for urban population were not available for a few districts.
b
Median and interquartile range are presented.

Table 2: Association of neonatal mortality rate and explanatory variables: results of multivariable analysis
Regression coefficient (P value )
Rural Urban Total
Explanatory Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted
variables (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)
Household air 0.42 0.30 0.23 0.001 0.30 0.22
pollution (0.26 to 0.57) (0.13 to 0.45)** (0.12 to 0.34) (–0.15 to 0.15) (0.21 to 0.39) (0.09 to 0.35)*
Lowest wealth 0.15 0.18 0.89 0.74 0.22 0.21
quintile (20%) (0.04 to 0.26) (0.04 to 0.33)* (0.47 to 1.3) (0.20,1.3)* (0.10 to 0.33) (0.06 to 0.36)*
Highest wealth –0.34 –0.18 –0.27 –0.15 –0.33 –0.15
quintile (20%) (–0.52 to –0.15) (–0.44 to 0.08) (–0.40 to –0.14 ) (–0.32 to 0.03) (–0.45 to –0.21) (–0.36– 0.05)
Neonates 0.20 0.29 — — 0.17 0.33
checked within (0.12 to 0.28) (0.22 to 0.37)** (0.09 to 0.25) (0.25 to 0.41)**
24 h after
delivery
Breastfeeding –0.08 –0.10 — — –0.09 –0.13
within 1 h after (–0.14 to –0.02) (–0.16 to –0.05)** (–0.16 to –0.03) (–0.19 to –0.06)**
delivery
Three or more — — –0.13 –0.09 –0.07 –0.05
antenatal care (–0.19 to –0.07) (–0.19 to (–0.13 to –0.01) (–0.12 to 0.02)
visits –0.007)*
Effective — — –0.56 –0.23 –0.24 0.09
literacy rate (–0.80 to –0.31) (–0.55 to 0.09) (–0.37 to –0.19) (–0.05 to 0.24)
Institutional — — –0.16 –0.06 — —
delivery (–0.27 to –0.04) (–0.18 to 0.05)
Less than 24 h — — — — 0.07 –0.05
hospital stay (0.00 to 0.13) (–0.12 to 0.02)
CI: confidence interval.

*P < 0.05, **P < 0.001.
In a meta-analysis of five studies, Pope et al. concluded that NMR, yet a degree of consistency with other studies that have
exposure to HAP is associated with 1.38 times higher risk focused on smoking, use of biomass as fuel, and urban air
of LBW and 51% higher risk of stillbirth.11 Assuming a 70% pollution is appreciable.
prevalence of solid fuel use, population-attributable risk
for LBW and stillbirth were found to be 21% and 26.3% Temporality is also established, since it can be presumed that
respectively. A more recent analysis from India, using district- exposure to HAP was present during pregnancy. Boy et al.
level data, indicated that around 12% of stillbirths in India could reported a possibility that some women change fuel during the
be prevented by providing access to cleaner fuel, assuming a later part of pregnancy, which could result in a bias.20 This is
causal association.31 unlikely in Indian settings where affordability of cleaner fuel
is a challenge.
There are certain inherent limitations in the analysis of
secondary data and also with a study design that is ecological An attempt was made to control confounding by a variety of
in nature. There is a possibility of selection bias, uncontrolled factors – sociodemographic, health systems and behavioural
confounding and misclassification of exposure and outcome.24,32 factors unlike other studies where only sociodemographic
Neonatal deaths are hard outcomes and may not be biased. factors were adjusted for. However, it is likely that residual
confounders (such as maternal nutrition and anaemia) affected
Errors could be introduced by variations in settings, type of the results.
exposure, study design, sampling techniques and factors
such as random errors. Controlling for confounding factors Moreover, the studies reported were based on data collected
in ecological studies is more difficult than in individual- before 2006. After this period, with the advent of the NRHM,
based studies because of extra potential sources of bias due strengthening of health systems has been the focus and there
to aggregation of subjects into groups.13 Another limitation have been dramatic improvements. Measures were instituted
is that the present analysis is based on the data aggregated at to improve the contact of neonates with community health
the district level, since the researchers did not have access to workers within the first 24 h – the most critical period of
individual-level data. It is, therefore, not possible to comment life – and to promote deliveries in hospitals, to ensure skilled
on the individual-level association between these variables. personnel are involved. These factors, which are known to
It may be unfair to over-interpret the magnitude of effect on influence NMR directly, were controlled during the analysis.

Sociodemographic factors take time to change and hence little intervention to reduce exposure to HAP, while meeting
difference was expected between the previous and the present domestic energy and cultural needs and improving safety, fuel
analysis. Nevertheless, the fact that, despite these adjustments, efficiency and environmental protection, along with economic
HAP still continues to be predictive of neonatal mortality is a affordability.
concern.
Other sources of environmental smoke and outdoor air ACKNOWLEDGEMENTS

pollution were not considered in the present analysis. Studies
from developing countries have reported a decline in birth We acknowledge the contribution of Dr Ranjana Singh,
weight with exposure to second-hand smoke.26 Smoking Associate Professor, Indian Institute of Public Health-Delhi,
was not considered as an exposure because, in India, active Public Health Foundation of India, for providing suggestions
smoking is relatively rare in pregnancy as compared to tobacco on statistical analysis.
chewing. Information on chewing tobacco was unavailable in
the data captured. In the present study, the proportion of the
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The validity of self-reported helmet
use among motorcyclists in India
Shirin Wadhwaniya1, Shivam Gupta1, Shailaja Tetali2, Lakshmi
K Josyula2, Gopalkrishna Gururaj3, Adnan A Hyder1
ABSTRACT
Background: Motorcyclists are the most vulnerable vehicle users in India. No 1
Johns Hopkins International Injury
published study has assessed the validity of self-reported estimates of helmet Research Unit, Department of
use in India. The objectives of this study were to assess helmet use by comparing International Health, Johns Hopkins
observed and self-reported use and to identify factors influencing use among Bloomberg School of Public
motorcyclists in Hyderabad, India. Health, Baltimore, United States of
America,
Methods: Population-based observations were recorded for 68 229 motorcyclists 2
Indian Institute of Public Health,
and 21 777 pillion riders (co-passengers). Concurrent roadside observations and Hyderabad, India,
interviews were conducted with 606 motorcyclists, who were asked whether they 3
National Institute of Mental
“always wear a helmet”. Multivariate logistic regression analyses were conducted Health and Neuro Sciences,
to determine factors influencing helmet use. Bengaluru, India
Results: In the population-based study, 22.6% (n = 15,426) of motorcyclists and Address for correspondence:
1.1% (n = 240) of pillion riders (co-passengers) were observed wearing helmets. In Dr Shivam Gupta, Johns Hopkins
roadside interviews, 64.7% (n = 392) of the respondents reported always wearing International Injury Research Unit,
a helmet, 2.2 times higher than the observed helmet use (29.4%, n = 178) in Department of International Health,
the same group. Compared with riders aged ≥40 years, riders in the age groups Johns Hopkins Bloomberg School
30–39 years and 18–29 years had respectively 40% (95% confidence interval of Public Health, 615 N Wolfe
Street Suite E 8010, Baltimore, MD
[CI]: 0.4 to 1.0, P < 0.05) and 70% (95% CI: 0.2 to 0.5, P < 0.001) lower odds of
21205, USA
wearing a helmet after controlling for other covariates. Riders with postgraduate Email: sgupta23@jhu.edu
or higher education had higher odds of wearing a helmet (adjusted odds ratio
[OR]: 4.1, 95% CI: 2.5 to 6.9, P < 0.001) than those with fewer than 12 grades of
schooling. After adjusting for other covariates, younger riders also had 40% (95%
CI: 0.3 to 0.9, P < 0.05) lower odds of self-reporting helmet use, while those with
postgraduate or higher education had 2.1 times higher odds (95% CI: 1.3 to 3.3,
P < 0.01) of reporting that they always wear a helmet. Police had stopped only
2.3% of respondents to check helmet use in the three months prior to the interview.
Conclusion: Observed helmet use is low in Hyderabad, yet a larger proportion of
motorcyclists claim to always wear a helmet, which suggests that observational
studies can provide more valid estimates of helmet use. Interview findings suggest
that a combination of increased enforcement, targeted social marketing and
increased supply of standard helmets could be a strategy to increase helmet use
in Hyderabad.
Key words: India, helmet, motorcycle, road safety, road traffic injury
INTRODUCTION group of vulnerable road users, representing 23% of the global

RTI burden.1
It is estimated that, worldwide each year, 1.24 million deaths
and 20 to 50 million injuries are caused by road traffic crashes In India, 136 834 persons reportedly died due to RTI in 2011
(RTCs).1 The burden of road traffic injuries (RTIs) is increasing and an estimated 2 million people have disabilities as a result
and, unless addressed, is projected to become the fifth-leading of RTCs.3,4 India has also experienced increased motorization,
cause of death by the year 2030.2 Low- and middle-income with the total number of registered vehicles increasing by
countries account for 92% of global RTI deaths, although as much as 161% between 2000 and 2010.5 Motorcyclists
their share of global vehicles is only 53%.1 Motorcyclists are a constitute the largest proportion (71%) of vehicle users in

Wadhwaniya et al.: Validity of self-reported motorcycle helmet use in India
India and, compared with other vehicle users, this group has reported helmet use; and (iii) to identify factors influencing
a higher proportion of RTIs (22.5%).3,5–7 Like the country as a helmet use.
whole, Andhra Pradesh (now bifurcated into Andhra Pradesh
and Telangana states) state in India, with a population of 85 The present study was part of an ongoing evaluation of
million, has observed a substantial increase in the number of Bloomberg Philanthropies Global Road Safety Program,
vehicles, and motorized two-wheelers constituted 73.2% of all implemented in 10 countries that account for nearly half of
vehicles in 2010.8,9 Previous studies conducted in the capital, the global burden of fatal RTIs.28,29 The overall goal of the
Hyderabad city, have estimated an annual incidence of 1919 programme was to reduce the burden of RTIs and fatal RTIs
per 100 000 for RTCs and 14.4 per 100 000 for fatal RTIs in selected countries, by “focusing on proven preventive and
among motorcyclists, indicating their vulnerability.10 Helmet care interventions, identifying high-performing, experienced
use is mandatory for both motorcycle drivers and pillion partners for implementation, and rigorously evaluating
riders (co-passengers) in Andhra Pradesh, with a penalty of outcomes”.28,29 The city of Hyderabad was one of the
`100 (US$ 1.80) for the first offence and `300 (US$ 5.40) for programme sites in India, with a population of 7.7 million and
subsequent offences.11 Compared with the average monthly 11.8 million registered vehicles.8,9
income of `5357 in India in 2010, this fine is very low.12 Also,
the enforcement of helmet law in Hyderabad has been sporadic
and an issue of much political debate.13–16 METHODS
Among motorcyclists, injury to the head and neck is often the The local study team and traffic police of the city selected eight
main cause of death and disability, and helmet use can reduce sites for the study. The criteria considered in selecting sites
this risk substantially.17,18 Non-use of helmets is associated included: (i) the location was safe for the observer/interviewer;
with injuries and disabilities that result in higher treatment (ii) the location was a site where the observer is at a level that is
costs in the event of a crash.17 Also, enforcement of helmet equal to or higher than the height of a motorcycle; and (iii) the
laws has demonstrated a decrease in rates of head injuries and location was where local residents rather than tourists are
deaths, while repealing these laws has shown an increase in likely to be observed. In addition, it was ensured that at least
these rates.17 one site was selected from each of the six administrative zones
in Hyderabad. To ensure representativeness, an additional site
Data on helmet use can help assess enforcement, develop was selected from the two larger zones. In each zone, the site
programmes and establish baseline rates for monitoring and or sites selected was the one or ones with the highest average
evaluation of interventions to increase helmet use.17 Two traffic volume, estimated from monthly data available from
methods are commonly used for gathering data on helmet traffic police.
use – population-based observations and roadside interviews/
surveys.17 Both these methods have their strengths and During July 2011, data were collected from these eight sites,
demerits. using two methods: (i) population-based observation to
assess helmet use; and (ii) roadside interview to understand
There are limited risk-factor-specific data on RTIs in India and knowledge, attitudes and practices related to helmet use among
there is also limited published research on evaluation of RTI motorcyclists and to identify factors influencing helmet use. The
interventions.19,20 Some hospital-based studies from India have data-collection procedures for these methods is described next.
estimated helmet use among RTI victims.21–24 However, there
are fewer population-based studies on helmet use from India.
A recent study conducted in New Delhi used video recording Population-based observational study
to determine helmet use among pillion riders and found 99%
of female pillion riders were not wearing a helmet and they At each site, observations were recorded on one weekday
accounted for 81% of all pillion riders who were not wearing (Monday to Friday) and one weekend day (Saturday to
a helmet.25 In a previous study conducted in Hyderabad, 70% Sunday). Two data collectors (one recording observations for
of motorcyclists self-reported that they do not always wear motorcyclists and the other for pillion riders) took position on
a helmet and some of the predictors for not always wearing the side of the road close to a traffic signal and observed all
a helmet included driving a borrowed motorcycle, driving a motorized two-wheelers moving in one direction, continuously
lower-capacity motorcycle, older age, lower education and for 90 minutes at three different times of the day, that is, morning
male sex.26 Another study conducted in New Delhi with female (10:00 to 11:30), afternoon (13:30 to 15:00) and evening
pillion riders, using an interview method, found religion to be (17:00 to 18:30). Observations were recorded if motorcyclists
a significant predictor for agreeing with mandatory helmet law and pillion riders were wearing helmets correctly (strapped),
without exemptions.27 wearing helmets incorrectly (unstrapped) or not wearing
helmets. If more than one pillion rider was on the motorcycle,
Previous studies from India have used either an observation observations were recorded for all of them. If more than one
method or roadside interviews/surveys to study helmet use. To motorcycle was passing at the same time, observations were
the authors’ knowledge, no study in India has directly compared recorded for the motorcycle that was closest to the kerb/side of
observed and self-reported helmet use among motorcyclists. the road. In this study, “motorcyclists” refers to riders of any
Such a comparison allows for cross-validation of findings. The motorized two-wheeler, that is, motorcycle, scooter or moped.
specific objectives of this study are: (i) to assess helmet use “Pillion rider” refers to any rider (adult or child) riding on a
in Hyderabad city, India; (ii) to compare observed and self- seat behind the rider of a motorized two-wheeler. Observations
were recorded on paper forms developed for this study.

Data collectors received classroom-based, followed by in- and observed and self-reported helmet use were compared.31
field, training. Frequent refresher training was also organized Descriptive analysis of roadside interviews was conducted to
for data collectors. During these training sessions, inter-rater understand the knowledge, attitude and practices related to
reliability was assessed and was found to be high (>85%). helmet use. Bivariate and multiple regression analyses were
However, no reliability or validity checks were made during conducted to understand the factors associated with observed
data collection. and self-reported helmet use.31 Based on the results of previous
studies conducted in India, age group, sex, education, type
of motorcycle, ownership of motorcycle and purpose of trip
Roadside interview were selected as explanatory variables.26,32 Chi-square tests
were used to determine an association between helmet use
Trained interviewers conducted interviews at the same sites and explanatory variables.31 This study was approved by the
and at the same (three) times of day as the population-based Institutional Review Board of Johns Hopkins Bloomberg
observational study. While one group of data collectors was School of Public Health, United States of America, and the
recording helmet observations, the other group conducted Institutional Ethics Committee of the Indian Institute of Public
roadside interviews, using a questionnaire consisting of 33 Health, Hyderabad, India.
items developed for this study. At each site, the local traffic
police stopped motorcyclists and directed them to the study
team. The interviewers informed the motorcyclists of the RESULTS
purpose of the study and obtained verbal consent. In the
interview, no personal identifiers were collected and each Population-based observational study
interview took about 5–10 minutes. The interview included
14 points to be observed and 19 questions to be administered. In the population-based observational study, helmet
Observations were recorded for helmet use, helmet certification observations were recorded for 68 229 motorcyclists and
marking/sticker, type of road, type of motorcycle and site. 21 777 pillion riders. About 22.6% of motorcycle drivers
The questions administered focused on knowledge, attitudes and only 1.1% of pillion riders were found to be wearing
and practices related to helmet use. The respondents were helmets. A statistically significant difference was noted in the
asked whether they “always wear a helmet”, why they always proportion of motorcyclists and pillion riders wearing helmets
wear (or do not wear) a helmet, factors considered important (P < 0.001; see Table 1). Also, among those who were observed
when purchasing a helmet, the amount spent on a helmet, and wearing a helmet, only 4% were wearing helmets incorrectly
enforcement of helmet use by police. All questions in the survey (unstrapped).
were closed. The interviewers were trained in asking questions
and recording the responses. The interviewers selected the
response that most closely related with the response that was Roadside interview
provided by the respondent. When in doubt, the interviewer
asked the respondent to clarify their response. If the response Using roadside interviews, a total of 718 motorcyclists were
was not listed as an option, then the interviewer could mark it contacted, of whom 606 motorcyclists agreed to participate
as “other” and specify the exact response that was provided by (response rate 84.3%); reasons for refusal were not collected.
the respondent. The majority of the respondents were male (94.7%), between
18 and 44 years of age (91.8%) and had some school/college
Data from both the population-based observational study education (97.2%). Most of the respondents (96.5%) owned
and the roadside interview were entered into MS Excel and their motorcycle and the main purpose of their trips was to
analysed using STATA 12.30 The data from the population- commute to or from work or school (89.1%; see Table 2).
based observational study were analysed to determine the
prevalence of helmet use. Using the test of proportions, the In roadside interviews (n = 606), a statistically significant
observed helmet use among motorcyclists and pillion riders, difference was noted between self-reported and observed
Table 1: Comparison of observed and self-reported helmet use among motorcycle drivers in Hyderabad city, India
Self-reported
Observed helmet use P value for test of difference in proportions
helmet use
Helmet use Helmet use Helmet use
observed in observed observed in
Population-based Roadside Roadside
population-based in roadside population-based
observational study interview interview
observational interview versus observational
(n = 90 006a), (n = 606), (n = 606),
study versus self-reported study drivers
n (%) n (%) n (%)
self-reported in in roadside versus pillion
roadside interview interview riders
Among
15 426 (22.6) 178 (29.4) 392 (64.7) 0.000*** 0.000*** 0.000***
motorcyclists
Among pillion
240 (1.1) — —- — —
riders
***P < 0.001.
a
Observations for 68 229 motorcyclists and 21 777 pillion riders combined.

Table 2: Characteristics of the roadside interview respondents and factors associated with observed and self-
reported helmet use in Hyderabad, India (n = 606)
Variable Total Observed helmet use Self-reported helmet use
n (%) Yes, n (%) No, n (%) χ2 P value Yes, n (%) No, n (%) χ2 P value
Sex
Male 574 (94.7) 167 (29.1) 407 (70.9) 0.523 372 (64.8) 202 (35.2) 0.790
Female 32 (5.3) 11 (34.4) 21 (65.6) 20 (62.5) 12 (37.5)
Age group, years
18–29 298 (49.2) 68 (22.8) 230 (77.2) 0.001** 183 (61.4) 115 (38.6) 0.142
30–39 195 (32.2) 63 (32.3) 132 (67.7) 128 (65.6) 67 (34.4)
≥40 113 (18.6) 47 (41.6) 66 (58.4) 81 (71.7) 32 (28.3)
Education
Schooling (less 179 (29.5) 36 (20.1) 143 (79.9) 0.000*** 105 (58.7) 74 (41.3) 0.016**
than grade 12)
Graduate 253 (41.8) 63 (24.9) 190 (75.1) 160 (63.2) 93 (36.8)
(bachelor’s
degree)
Postgraduate 174 (28.7) 79 (45.4) 95 (54.6) 127 (73.0) 47 (27.0)
(professional
degree, master’s
degree and
above)
Type of motorcycle
<100 cc 43 (7.1) 7 (16.3) 36 (83.7) 0.050 22 (51.2) 21 (48.8) 0.054
>100 cc 563 (92.9) 171 (30.4) 392 (69.6) 370 (65.7) 193 (34.3)
Owns motorcycle
No 21 (3.5) 1 (4.8) 20 (95.2) 0.012* 11 (52.4) 10 (47.6) 0.230
Yes 585 (96.5) 177 (30.3) 408 (69.7) 381 (65.1) 204 (34.9)
Purpose of trip
Travelling to/from 540 (89.1) 170 (31.5) 370 (68.5) 0.002** 349 (64.6) 191 (35.4) 0.449
work or school
Travelling to/from 27 (4.5) 6 (22.2) 21 (77.8) 20 (74.1) 7 (25.9)
leisure activity or
for pleasure
Commercial 39 (6.4) 2 (5.1) 37 (94.9) 23 (59.0) 16 (41.0)
activity
***P < 0.001, **P < 0.01, *P < 0.05.
helmet use: 64.7% of the respondents claimed to always wear In roadside interviews, among those who were observed
a helmet, which was 2.2 times higher than the observed helmet wearing a helmet, a majority (94.2%) had standard helmets
use of 29.4% in the same group (P < 0.001; see Table 1). (standards set forth by the Bureau of Indian Standards),
When the self-reported helmet use from roadside interviews determined by observing authentic certification/sticker (ISI
was compared with the helmet use in the population-based mark). The average amount spent on a helmet was `800
observational study, the former was 2.9 times higher than (US$ 16) and 18.3% of respondents had spent less than `500
observed helmet use and the difference was statistically (US$ 10). In purchasing a helmet, respondents gave importance
significant (P < 0.001; see Table 1). to high quality (66.0%) and certification (15.2%), over price
(4.6%) or style/look (2.6%).
Respondents who claimed to always wear helmets cited “it
can save my life” (99.2%) as the most common reason. Major In bivariate analysis, a statistically significant association was
reasons for not wearing helmet included: (i) lack of helmet found between observed helmet use and explanatory variables
(27.4%); (ii) decision to wear a helmet was dependent on the – age, education, ownership of motorcycle and purpose of
location of the trip, that is highway or local road (25.1%); and trip – whereas for self-reported helmet use, a statistically
(iii) forgetting to wear one (23.7%). In the three months prior significant association was found for education (see Table
to the interview, only 2.3% of the respondents reported being 2). In multiple logistic regression after controlling for other
stopped by the police to check for helmet use. covariates, age was a significant predictor of observed helmet

use; compared with those in the age group ≥40 years, those in Cambodia also found self-reported helmet use to be higher than
the age groups 30–39 and 18–29 years had respectively 40% observed use.37,38 Similarly, differences have been reported for
and 70% lower odds of wearing a helmet (see Table 3). After studies assessing seat-belt use in Turkey, where self-reported
controlling for other covariates, riders with postgraduate or rates were found to be greater than observed rates.33 This
higher education also had 4.1 times higher odds of wearing a suggests that in countries such as India with low rates of helmet
helmet than those with fewer than 12 grades of schooling (see use, observational studies can provide more valid estimates of
Table 3). Age and education were also found to be significant utilization.
predictors of self-reported helmet use after adjusting for other
factors (see Table 3). Compared with those in the age group This discrepancy between observed and self-reported helmet
≥40 years, those in the age group 18–29 years had 40% lower use could be because respondents do not want to report their
odds of self-reporting helmet use, while compared with those so-called incorrect road behaviour, or they do not consider
with no/some schooling, respondents with postgraduate or themselves to be so-called irresponsible drivers and so give
higher education had 2.1 times higher odds of self-reporting a socially desirable answer.26,39,40 Social desirability bias is to
helmet use (see Table 3). respond in a way “that makes the respondent look good” and
a respondent may, therefore, either exaggerate or understate a
behaviour, which is a common source of self-reported bias.40
DISCUSSION
This study also indicates that people tend to overestimate their
The prevalences of observed helmet use from two different helmet use, and highlights two different categories of helmet
methods – population-based observational study and roadside non-users – (i) those who do not wear a helmet and do not
interview – are similar to those reported in earlier studies claim to wear one (32.7%); and (ii) those that do not wear a
conducted in Hyderabad city.22,26 The present study also found helmet but claim to always wear (38.0%) (see Table 4). This
self-reported helmet use to be more than twice the observed has implications for potential behaviour-change interventions,
use. To the best of the authors’ knowledge, this is the first study since these two categories of non-users may have different
from India to compare observed and self-reported helmet use. sets of attitudes and beliefs, and so-called a one-size fits all
The wide difference between observed and self-reported use approach of social marketing campaigns may not work for both
is similar to that in other studies conducted in settings with these groups. For example, those who do not wear and do not
low utilization of road-safety interventions.33–36 A study from claim to wear a helmet may consider helmet use unimportant,
while those who do not wear a helmet but claim to wear one
Table 3: Multivariate analyses of factors associated may be aware of the importance of helmet use, though giving a
with observed and self-reported helmet use in roadside socially desirable answer. The social marketing strategy for the
interviews, Hyderabad, India former group could focus on increasing awareness – benefits of
Variable Adjusted odds Adjusted odds helmet use and consequences of non-use – while for the latter
ratio for observed ratio for self- group, the focus could be on overcoming barriers, increasing
helmet use (95% reported helmet self-efficacy and maintaining helmet-wearing behaviour.41
confidence use (95% In contrast, strong and consistent enforcement of helmet law
interval) confidence
interval) may increase helmet use in both groups. Further research with
Sex
a larger set of variables is required to identify predictors of
discrepancy between observed and self-reported helmet use
Male 1.00 1.00 among respondents.
Female 1.4 (0.6 to 3.0) 0.9 (0.4 to 1.9)
Age group, years The findings from roadside interviews provide insights into
≥40 1.00 1.00 the some of the reasons behind low helmet use in Hyderabad.
30–39 0.6 (0.4 to 1.0)* 0.7 (0.4 to 1.2) Interview findings indicate that the police stopped only 2.3% of
18–29 0.3 (0.2 to 0.5)*** 0.6 (0.3 to 0.9)* motorcyclists to check for helmet use. India has a national law
Education that makes helmet wearing compulsory for both motorcycle
drivers and pillion riders, but its enforcement is generally
Schooling (less 1.00 1.00
than grade 12) weak.1 This is because the enforcement of traffic laws is a state
Graduate 1.5 (0.9 to 2.4) 1.3 (0.9 to 1.9)
responsibility and enforcement levels vary even within a state.
(bachelor’s degree) Enforcement of helmet law in Hyderabad has been weak and
Postgraduate 4.1 (2.5 to 6.9)*** 2.1 (1.3 to 3.3)** this can explain the low compliance in the city.13–16 Previous
(professional studies in India have indicated low helmet use; similar findings
degree, master’s were noted in an observational study conducted in Bengaluru
degree and above) city, where most of the motorcyclists were wearing helmets
Type of motorcycle but pillion riders were not, as the state law did not specify
<100 cc 1.00 1.00 mandatory use among these riders.22–24,26,32,42,43 Thus, if there
>100 cc 2.0 (0.8 to 4.8) 1.8 (0.9 to 3.4) is no enforcement, people are less likely to wear helmets and
Owns motorcycle enhanced enforcement can increase helmet use. In addition,
No 1.00 1.00 targeted social marketing campaigns, emphasizing penalties
Yes 4.5 (0.6 to 35.0) 1.1 (0.5 to 2.8) for not wearing helmets, can also complement enhanced
enforcement efforts.1
***P < 0.001, **P < 0.01, *P < 0.05.

Table 4: Observed and self-reported helmet use for respondents of roadside interview, Hyderabad, India (n = 606)
Observed helmet use
Yes No Total
Yes 162 (26.7%) 230 (38.0%) 392 (64.7%)
Self-reported helmet use
No 16 (2.6%) 198 (32.7%) 214 (35.3%)
Total 178 (29.3%) 428 (70.7%) 606 (100%)
Findings in the present study were similar to those of Dandona safety data. The study has some limitations. Firstly, helmet
and colleagues who reported that safety was a major reason observations were not conducted at night and helmet use may
cited for always wearing a helmet, whereas lack of a helmet be different at night. Secondly, compared with the population
was a major reason for not always wearing a helmet.26 A smaller of 7.7 million in Hyderabad city, with 11.8 million vehicles, the
proportion of respondents also reported that their helmet was sample size of 606 for roadside interview is small and general
broken (not in usable condition). This highlights the need for application of the responses collected to the total population
increasing the accessibility and availability of good quality is difficult. Also, because of sociocultural and environmental
helmets. The decision to wear a helmet was also based on the differences, the results of this study might not be generalizable
location where the respondents were driving. In other studies, to other sites in India. The presence of police may also have
distance, location, time-related factors and day of the week influenced helmets observations, as some riders may have put
were noted as factors influencing helmet use.26,43 Studies their helmet on because they saw the police. Fourthly, any
have also reported aesthetic and physical reasons, such as gender differences in helmet use cannot be determined, as the
obstruction of vision, neck pain, hearing problems, headache, number of female respondents in the roadside interview was
heat and heaviness, as reasons for not wearing a helmet.26,44,45 very small because the traffic personnel (mostly male) were
In the present study, unlike previous ones, relatively fewer less likely to stop women riders for interviews. In addition,
respondents reported inconvenience or discomfort as a reason in the population-based observational study, the gender of the
for non use. This could be because of the time of year and motorcyclists was not recorded. Lastly, in the population-based
differing weather conditions when interviews were conducted; observational study, helmet use could not be observed for some
the present study was conducted in July, which is monsoon motorcyclists, because of high traffic volume.
season in India and a relatively cooler time of the year.
This study highlights low helmet use among motorcyclists and
Some of the factors associated with helmet non-use reported pillion riders in Hyderabad. The discrepancy between observed
in other Indian studies included older age, lower education, and self-reported helmet use suggests that population-based
driving a motorized two-wheeler other than a motorcycle, and observational studies can provide more valid information on
driving a borrowed vehicle.26 In the present study, a significant helmet use. There is also a need for further study with a larger
relation was found between age and helmet use; those in sample size, to determine predictors of discrepancy between
an older age group were more likely to wear helmets. This observed and self-reported helmet use. The study also brings to
highlights the need to focus enforcement and social marketing light the different groups of helmet non-users and the need for
campaigns to target young motorcyclists. a strategy that targets both demand- and supply-side factors to
increase helmet use. The demand for standard helmets can be
This study found that nearly all (94.2%) of those who had increased through enhanced enforcement and targeted social
helmets were wearing standard helmets and respondents also marketing, while supply and availability of standard helmets
gave importance to quality and certification when purchasing also need to be increased.
a helmet. A multicentre study conducted in nine low- and
middle-income countries found a strong association between
the cost of a helmet (those spending less than US$ 10) and use ACKNOWLEDGEMENTS
of a non-standard helmet.46 In the present study, about 18.3%
had spent less than US$ 10 and may be using a non-standard The authors would like to thank the Indian Institute of Public
helmet. A multicentre helmet study also found that only 46% of Health, Hyderabad, and the Traffic Police Department,
helmets had certification markers/stickers and, of these, 19% Hyderabad, for their assistance with the study.
were not authentic.46 Enforcement of helmet law may increase
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Safety Programme in India, funded by the Bloomberg Philanthropies.
25. Swaroop M, Marie Siddiqui S, Sagar S, Crandall ML. The problem of
the pillion rider: India’s helmet law and New Delhi’s exemption. J Surg Conflict of Interest: None declared. Contributorship: SW and SG
Res. 2014;188:64–8. analysed and interpreted data and wrote the first draft; ST and JK oversaw
26. Dandona R, Kumar GA, Dandona L. Risky behavior of drivers of data collection and helped in revising the manuscript; GG and AAH
motorized two wheeled vehicles in India. J Safety Res. 2006;37:149–58. contributed to data interpretation, helped in developing and revising the
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of helmet influences of female pillions in New Delhi. J Surg Res. the final version of the manuscript.
2013;184:404–10.


A cross-sectional study of exposure
to mercury in schoolchildren
living near the eastern seaboard
industrial estate of Thailand
Punthip Teeyapant, Siriwan Leudang, Sittiporn Parnmen
Toxicology Centre, National

ABSTRACT Institute of Health, Department
of Medical Sciences, Ministry
Background: Industrial activity in Thailand’s coastal areas has significantly of Public Health, Thailand
increased mercury concentrations in seawater, causing accumulation through the
food chain. Continuous exposure to mercury has been linked to bioaccumulation Address for correspondence:
in living organisms and potential adverse health effects in children. Dr Sittiporn Parnmen, Toxicology
Centre, National Institute of
Methods: Blood samples were collected from 873 schoolchildren aged 6–13 Health, Department of Medical
years living in four sites near the eastern seaboard industrial estates of the Gulf Sciences, Ministry of Public Health,
of Thailand in 2011. Total mercury level in whole blood (Hg-B) was compared with Nonthaburi, 11000 Thailand
standard reference values. Email: sittiporn.p@dmsc.mail.go.th
Results: Mean (± standard deviation) concentrations of Hg-B from schoolgirls
(2.19 ± 0.5 μg/L; n = 405) and schoolboys (2.29 ± 0.3 μg/L; n = 468) did not
exceed the regulatory limits of the United States Environmental Protection Agency
(US EPA), the German Commission on Human Biological Monitoring (HBM I, II)
or Clarke’s analysis of drugs and poisons reference values. Nevertheless, 67
children (34 girls and 33 boys) had individual values that exceeded the lowest of
these standards (4 μg/L).
Conclusion: The relatively low concentrations of Hg-B detected in this study
suggested a relatively low risk for schoolchildren. However, 67 children had
elevated mean total Hg-B concentrations, especially in the two sites located
nearest the industrial area. This information may serve as an early warning of
the potential for pollution to affect children living around industrial areas. Further
regular monitoring, including studies assessing the health impact of mercury
pollution in this region of Thailand, is to be encouraged.
Key words: blood levels, eastern seaboard industrial estate, Environmental
Protection Agency, German Commission on Human Biological Monitoring,
mercury, schoolchildren, Thailand
INTRODUCTION established in 1989 by state enterprises, under the management

of the Industrial Estate Authority of Thailand.2 It serves
The eastern seaboard development programme was introduced as a heavy industrial zone, with a gas separation plant, oil
during Thailand’s fifth National Economic and Social refineries, petrochemical industries and chemical plants.1,3 As
Development Plan (1981–1984).1 The programme plays an a result of these industrial activities, increasing mercury levels
important role in Thailand’s economy and covers an area have been recorded in the coastal areas by the heavy metal
of four provinces: Chon Buri, Chachoengsao, Rayong and monitoring scheme, which was started in 1974.2 During the
Samut Prakan. Economic activities in the coastal area of these period of 1995 to 1998, high mercury levels were detected in
provinces include agriculture, fisheries and tourism, as well MTPIE, especially in the area around the natural gas platform
as heavy industry, and the area is also populated with urban and the inner Gulf zone, owing to the release of mercury
communities. Map Ta Phut Industrial Estate (MTPIE) is a from discharged water produced from oil and gas activities.2,4
large industrial park located in Rayong province, which was The Pollution Control Department of the Ministry of Natural

Teeyapant et al.: Mercury exposure in schoolchildren in Thailand
Resources and Environment monitors the environmental METHODS

quality in MTPIE on a yearly basis. Overall results obtained
from the Pollution Control Department indicate that mercury
concentrations in seawater, sediment, marine organisms and Subjects
wastewater are within acceptable standards.1,2 However, to The study was carried out in four senior schools at four sites (S1
the authors’ knowledge, there has been no risk assessment of to S4) near the MTPIEs in the Rayong province of Thailand.
mercury exposure in children living near the industrial estates Sites S1 and S2 are located closer to the petrochemical and
area. chemical industrial plants than sites S3 and S4 (see Figure 1).
Mercury pollution has become an issue of public concern in The schools were selected because their pupils were in the
Thailand. Chronic toxicity from continuous exposure to this appropriate age group and because they had large numbers
element is linked to its bioaccumulation in living bodies and of pupils. Kindergarten and elementary schools in these areas
to its biomagnification along the food chain.5–8 Mercury exists were excluded because of their small populations and more
in different chemical forms, including elemental (metallic), limited age ranges.
inorganic and organic. Organic mercury, such as methylmercury, Consent to participation was sought from the parents/legal
which accumulates in the food chain, is the most hazardous guardians of a total of 961 children at the four schools; 88
form of mercury to human health.9 A high dose of mercury declined to consent. The study population, therefore, comprised
can cause adverse effects during any period of development, 873 schoolchildren (405 boys and 468 girls) aged 6–13 years
including neurodevelopmental toxicity, nephrotoxicity, (grades 1 to 6). The participants were divided into two different
teratogenicity, cardiovascular toxicity, carcinogenicity, age groups, with 327 children in the younger age group (6–9
mutagenesis, reproductive toxicity and immunotoxicity.9,10 years) and 546 children in the older age group (10–13 years).
The objective of this study was to determine the total mercury The study was approved by the Ethical Review Committee
levels in blood samples from schoolchildren aged 6 to 13 for Research in Human Subjects of Thammasat University,
years living around the industrial zone of MTPIE, and to Thailand (Project No. 031/2010). Written informed consent
assess the health risks, by comparing the levels with a range of was obtained from the legal guardians of children and from the
international standard reference values. children themselves. Additionally, the study was conducted in
Figure 1: Map of the study area of the four sites situated around Map Ta Phut Industrial Estate, Thailand
Source: Adapted from Wikipedia, The Free Encyclopedia. Rayong province (http://en.wikipedia.org/wiki/Rayong_Province, accessed 10 June 2015).

accordance with the principles of the Declaration of Helsinki, RESULTS

as amended by the 59th General Assembly of the General
Medical Association in Seoul, Republic of Korea, October Blood mercury concentrations (Hg-B) of 873 schoolchildren
2008. aged 6–13 years, living around MTPIE are summarized in
Table 1. Their mean total blood mercury concentrations ranged
from 1.5 to 3.0 μg/L; most values were below the LOQ.
Blood mercury measurements Comparisons of total Hg-B concentration according to age
and sex between different sites were performed (see Table 2).
For each subject, a blood sample of 4 mL was obtained by There was no statistically significant difference in total
venepuncture, collected in a Vacuette® silicone tube with an Hg-B for all sites combined by sex, when age group was not
EDTA anticoagulant agent, and mixed thoroughly by inverting accounted for, but older children had a higher total Hg-B than
the tube several times. Total mercury was measured in whole younger children when sex was not accounted for (P = 0.001).
blood, using flow-injection cold-vapour atomic absorption Statistically significant differences were observed for boys
spectrometry.11 Blood samples were digested by microwave and for girls when comparing the age groups 6–9 years and
digester, with a mixture of 2:1 (v/v) nitric acid/hydrogen 10–13 years for all sites combined (boys: P = 0.005; girls:
peroxide, and determined by a PerkinElmer® Model 4100 with P = 0.001). There was a significant difference between boys
flow-injection atomic spectrometry 200 for measurements of and girls in the age group 6–9 years (P = 0.035) but not in the
total mercury (PerkinElmer Instruments, Shelton, CT, United age group 10–13 years (P = 0.203).
States of America [USA]). The limit of quantification (LOQ)
for blood analysis was 1.5 μg/L (for data-analysis purposes, Analysis of total Hg-B according to age and sex within each
values below the LOQ were substituted with half this limit, site were also performed (see Table 2). Relating to sex within
that is, 0.75 μg/L). The recovery of mercury varied from 70% sites, there were statistically significant differences in mean
to 135%, obtained by the addition of three concentrations of Hg-B concentration in sites S1 (girls’ levels higher than boys;
standard solutions (1.97–17.7 μg/L) to the blood samples of P = 0.018) and S3 (boys’ levels higher than girls; P = 0.038).
the non-exposure group prior to the digestion. The average Relating to age within sites, older (10–13 years) children had
coefficient of variation between duplicate assay samples was higher mean Hg-B concentrations than younger (6–9 years)
less than 10%. children in sites S2 (P = 0.038), S3 (P = 0.001) and S4
(P = 0.001), respectively.
Statistical methods The older age group had significantly higher mean total
mercury levels than younger children in boys in all sites and in
Differences in the amount of mercury between or across groups girls in sites S3 (P = 0.001) and S4 (P = 0.007).
were assessed by Kruskal–Wallis H test, Student’s t test or
analysis of variance (ANOVA), as appropriate. The statistical The standard reference Hg-B values of HBM I (5 μg/L), HBM
analyses were done by use of SigmaPlot for Windows (version II (15 μg/L), US EPA (5.8 μg/L) and Clarke’s analysis of drugs
11.0, Systat Software, Chicago, IL, USA). and poisons (4 μg/L)14 were exceeded by 20 (4.9%), 1 (0.2%),
14 (3.5%) and 33 (8.1%) boys respectively. Similarly for girls,
16 (3.4%), 0 (0%), 7 (1.5%) and 34 (7.3%) girls exceeded
Reference values standard reference Hg-B values of HBM I, HBM II, US EPA
and Clarke’s analysis of drugs and poisons, respectively (see
Mercury uptake by humans occurs mainly via consumption Table 3).
of fish and shellfish (methylmercury), inhalation of vaporous
mercury released from industrial activities, and leakage from Sixty-seven children had levels of total Hg-B that exceeded
dental amalgams.12,13 Various reference values for blood the limit set in Clarke’s analysis of drugs and poisons.14 Their
mercury exist; this study used reference values published by mean Hg-B ranged from 5.2 to 7.9 μg/L (Table 4) and one
the German Commission on Human Biological Monitoring 13-year-old boy had a total Hg-B of 20.6 μg/L – the maximum
(HBM), the United States Environmental Protection Agency value recorded in this study (see Figure 2). The higher
(US EPA) and Clarke’s analysis of drugs and poisons.14 HBM concentrations were observed in sites S1 and S2, which are
recommended two different reference values for mercury located closer to the petrochemical and chemical industrial
in blood for the general population, based on toxicology plants than sites S3 and S4. When comparisons were made by
and epidemiology studies, HBM I and HBM II.15,16 Toxin age and sex groups within these 67 schoolchildren, statistically
concentrations below the lower HBM I level (5 μg/L; alert significant differences were found in the higher total Hg-B in
level) are not considered to be a risk for the general population, older than younger boys (P = 0.001) and higher values in boys
while concentrations above HBM II (15 μg/L; action than girls aged 10–13 years. (P = 0.005).
level) indicate an increased risk of adverse health effects in
susceptible individuals of the general population.16,17 The US
EPA reference dose for total mercury level in whole blood DISCUSSION
(Hg-B) corresponds to the estimated concentration assumed The rapid expansion of industrialization and urbanization that
to be without appreciable harm (below 5.8 μg/L).18,19 Clarke’s is taking place around the eastern seaboard industrial estates in
analysis of drugs and poisons reports a Hg-B reference value Thailand has led to an increase in heavy metal pollution, with
of less than 4 μg/L in a non-exposed population.14

Table 1: Whole blood total mercury levels (Hg-B) from schoolchildren living around Map Ta Phut Industrial Estate,
Thailand
Site, sex and age n Mean ± SD (μg/L) 95% CI Mediana (IQR) <LOQb,c (n)
S1
Boys
6–9 years 39 1.5 ± 0.9 1.17 to 1.75 0.75 (0.75 to 2.17) 22
10–13 years 61 2.3 ± 2.0 1.76 to 2.92 1.80 (0.75 to 2.80) 21
Girls
6–9 years 36 2.7 ± 2.6 1.79 to 3.57 2.05 (1.55 to 2.65) 8
10–13 years 82 2.5 ± 1.2 2.17 to 2.73 2.20 (1.80 to 3.00) 11
S2
Boys
6–9 years 30 1.9 ± 1.3 1.47 to 2.41 1.80 (0.75 to 2.50) 11
10–13 years 59 2.7 ± 2.9 1.96 to 3.46 2.30 (1.60 to 3.00) 8
Girls
6–9 years 32 2.0 ± 1.0 1.66 to 2.35 1.95 (1.50 to 2.55) 7
10–13 years 72 2.3 ± 1.0 2.04 to 2.53 2.20 (1.65 to 2.80) 8
S3
Boys
6–9 years 37 2.1 ± 1.4 1.66 to 2.61 1.80 (0.75 to 3.12) 14
10–13 years 53 3.0 ± 1.6 2.57 to 3.47 2.60 (1.80 to 3.92) 5
Girls
6–9 years 45 1.9 ± 1.0 1.63 to 2.23 2.00 (0.75 to 2.70) 13
10–13 years 50 2.6 ± 1.2 2.27 to 2.96 2.55 (1.70 to 3.60) 6
S4
Boys
6–9 years 53 1.7 ± 1.1 1.48 to 2.09 1.70 (0.75 to 2.70) 22
10–13 years 73 2.3 ± 1.6 1.88 to 2.63 2.00 (1.50 to 2.62) 17
Girls
6–9 years 55 1.9 ± 1.2 1.58 to 2.22 1.70 (0.75 to 2.40) 19
10–13 years 96 2.4 ± 1.4 2.14 to 2.69 2.20 (1.60 to 3.10) 17
CI: confidence interval. IQR: interquartile range. LOQ: limit of quantification. SD: standard deviation.
a
IQR indicates the interquartile range of Hg-B in each age group. There is a statistically significant difference in the median value between the
different groups (Kruskal–Wallis H = 58.62, P < 0.001).
b
Number of schoolchildren whose blood total mercury levels were below the limit of quantification (LOQ).
c
Limit of quantification (LOQ); the smallest concentration of Hg detectable by the method used) was 1.5 μg/L.
Values below the LOQ were substituted with half of this limit (0.75 μg/L), for the purpose of analysis.
potentially serious health consequences. There are numerous in seawater and sediments, as well as in marine organisms
industries located along the coastline that release their wastes in the coastal zones.1,2,4 Their analyses have recently shown
into the Gulf, thereby continuing to aggravate water pollution. that mercury contamination did not exceed the normal
MTPIE is well known for problems linked to heavy metals, standards.1,2,4 However, biological monitoring of exposure to
such as mercury, zinc and manganese, discharged by industrial mercury of people residing near industrial facilities has yet to
communities.1,2 As a consequence of environmental concerns be investigated.
of water pollution linked to the petrochemical activities of
MTPIE, the Pollution Control Department has extensively The present study evaluated total mercury concentration in
monitored the levels of heavy metals, especially total mercury, whole blood of schoolchildren, as a biomonitoring-based

Table 2: Whole blood total mercury levels (Hg-B) from Site and
Mean ± SD (μg/L) t-test P value
schoolchildren according to age and sex between and characteristic
within sites S2
Site and Sex
Mean ± SD (μg/L) t-test P value
characteristic
Boys 2.5 ± 2.5 0.175
All sites combined
Girls 2.2 ± 1.0
Sex
Age
Boys 2.29 ± 0.3 0.366
6–9 years 2.0 ± 1.1 0.038
Girls 2.19 ± 0.5
10–13 years 2.5 ± 2.1
Age
Boys
6–9 years 2.0 ± 1.4 0.001
6–9 years 1.9 ± 1.3 0.042
10–13 years 2.5 ± 1.7
10–13 years 2.7 ± 2.9
Boys
Girls
6–9 years 2.1 ± 1.6 0.005
6–9 years 2.0 ± 1.0 0.092
10–13 years 2.4 ± 1.2
10–13 years 2.3 ± 1.0
Girls
Age 6–9 years
6–9 years 1.8 ± 1.2 0.001
Boys 1.9 ± 1.3 0.189
10–13 years 2.6 ± 2.2
Girls 2.0 ± 1.0
Age 6–9 years
Age 10–13 years
Boys 1.8 ± 1.2 0.035
Boys 2.7 ± 1.9 0.145
Girls 2.1 ± 1.6
Girls 2.3 ± 1.0
Age 10–13 years
S3
Boys 2.6 ± 2.2 0.203
Sex
Girls 2.4 ± 1.2
Boys 2.8 ± 1.5 0.038
S1
Girls 2.7 ± 1.6
Sex
Age
Boys 2.0 ± 1.9 0.018
6–9 years 2.0 ± 1.2 0.001
Girls 2.5 ± 1.8
10–13 years 2.8 ± 1.5
Age
Boys
6–9 years 2.0 ± 2.0 0.087
6–9 years 2.1 ± 1.4 0.003
10–13 years 2.4 ± 1.8
10–13 years 3.0 ± 1.6
Boys
Girls
6–9 years 1.5 ± 0.9 0.003
6–9 years 1.9 ± 1.0 0.001
10–13 years 2.3 ± 2.0
10–13 years 2.6 ± 2.2
Girls
Age 6–9 years
6–9 years 2.7 ± 2.6 0.309
Boys 2.1 ± 1.4 0.232
10–13 years 2.5 ± 1.2
Girls 1.9 ± 1.0
Age 6–9 years
Age 10–13 years
Boys 1.5 ± 0.9 0.005
Boys 3.0 ± 1.6 0.078
Girls 2.7 ± 2.6
Girls 2.6 ± 1.2
Age 10–13 years
Boys 2.3 ± 2.0 0.370
Girls 2.2 ± 1.0

Site and indicator of exposure to mercury. Normally, mercury uptake

Mean ± SD (μg/L) t-test P value occurs mainly in two ways in humans, namely by eating fish
characteristic
and shellfish (methylmercury) and by breathing mercury vapour
S4
released from industrial activities and dental amalgams.12,13
Sex Mercury discharged into the environment by industrial
Boys 2.1 ± 1.4 0.155 activities may affect human health, and children living near
the industrial estates are particularly at risk. The criteria for
Girls 2.2 ± 1.3
biological monitoring of population exposure were applied by
Age evaluating the magnitude of exposure in comparison with the
6–9 years 1.8 ± 1.1 0.001 reference values, and then comparing the levels of exposure in
different countries.17 The reference values used in the present
10–13 years 2.4 ± 1.5
study were HBM I, HBM II, US EPA and Clarke’s analysis of
Boys drugs and poisons.14
6–9 years 1.7 ± 1.1 0.028
HBM recommended two different reference values for mercury
10–13 years 2.3 ± 1.6 in blood for the general population, based on toxicology
Girls and epidemiology studies, HBM I and HBM II.15,16 Toxin
6–9 years 1.9 ± 1.2 0.007 concentrations below the lower HBM I level (or alert level)
are not considered to be a risk for the general population,
10–13 years 2.4 ± 1.4 while concentrations above HBM II (or action level) indicate
Age 6–9 years an increased risk of adverse health effects in susceptible
Boys 1.7 ± 1.1 0.309 individuals of the general population.16,17 Among the total of
405 boys, 20 (0.05%) and 1 (0.002%) exceeded the HBM I
Girls 1.9 ± 1.2 and HBM II guidelines for Hg-B respectively, whereas only
Age 10–13 years 16 girls exceeded HBM I (0.03%) and none exceeded HBM II.
Boys 2.3 ± 1.6 0.247 One boy from the 13-year-old group from the S2 area had the
highest total Hg-B (20.6 μg/L). All the children of the S1, S3
Girls 2.4 ± 1.4 and S4 areas had Hg-B values below the HBM II guideline. The
SD: standard deviation. US EPA reference dose for Hg-B corresponds to the estimated
Table 3: Guideline values for total mercury in whole blood (Hg-B) and number of children with Hg-B above the given
standards
Number (%) higher than reference
Site and sample Number in sample
HBM I (5 μg/L) HBM II (15 μg/L) US EPA (5.8 μg/L) Clarke (4 μg/L)
S1
Boys 100 4 (0.04) 0 (0) 3 (0.03) 6 (0.06)
Girls 118 8 (0.07) 0 (0) 5 (0.04) 11 (0.09)
S2
Boys 89 4 (0.04) 1 (0.01) 4 (0.04) 6 (0.07)
Girls 104 0(0) 0 (0) 0 (0) 2 (0.02)
S3
Boys 90 9 (0.1) 0 (0) 4 (0.04) 16 (0.18)
Girls 95 2 (0.02) 0 (0) 0 (0) 6 (0.06)
S4
Boys 126 3 (0.02) 0 (0) 3 (0.02) 5 (0.04)
Girls 151 6 (0.04) 0 (0) 2 (0.01) 15 (0.1)
Total
Boys 405 20 (0.05) 1 (0.002) 14 (0.03) 33 (0.08)
Girls 468 16 (0.03) 0(0) 7 (0.02) 34 (0.07)
HBM: German Commission on Human Biological Monitoring. US EPA: United States Environmental
Protection Agency. Clarke: Clarke’s analysis of drugs and poisons.14

Figure 2: Blood mercury (Hg) levels of 873 schoolchildren residing near Map Ta Phut Industrial Estate, Thailand
S1 to S4: study sites 1 to 4; a: 6–9-year-old boys; b: 10–13-year-old boys; c: 6–9-year-old girls; d: 10–13-year-old girls.
concentration assumed to be without appreciable harm (below CONCLUSION

5.8 μg/L).18,19 A total of 14 boys (0.03%) and seven girls (0.02%)
exceeded the US EPA guideline value. Clarke’s analysis of The findings of this study indicate that most of the 873
drugs and poisons was used by the authors’ laboratory as a schoolchildren residing in four different areas around
reference value for Hg-B in non-exposed populations.14 The the industrial zone of MTPIE did not exceed the Hg-B
number of children whose Hg-B was above Clarke’s handbook recommended reference values of HBM I and II, US EPA and
reference value ranged from 0.02% to 0.1% in the various sites Clarke’s analysis of drugs and poisons.14 However, 67 subjects
and among the different boys and girls. exceeding the lowest standard were observed in this study. The
two sites close to the industrial zone of MTPIE showed highest
Mean total Hg-B in this study was 2.19 ± 0.5 μg/L in girls and total Hg-B concentrations in schoolchildren.
2.29 ± 0.3 μg/L in boys. A study performed in the USA in 1250
children in 1999 to 2000 reported a much lower mean Hg-B Previously there was no information available on mercury
value of 0.34 μg/L.20 Total Hg-B from 162 schoolchildren exposure in Thai schoolchildren who live near industrial
in the Philippines aged 5–17 years ranged from 0.757 μg/L communities. Hence, we suggest that these baseline data could
to 56.88 μg/L.21 A study performed from 2003 to 2006 in be used as an early warning of the threat of pollution, to protect
schoolchildren aged 6–14 years in Germany measured a Hg-B children, especially in the areas at risk. Moreover, continuous
of 0.24 μg/L.22 A recent study from the Republic of Korea monitoring of children’s levels of mercury in children’s blood
revealed that mean Hg-B from 1974 schoolchildren (7–13 should be done to protect against harmful exposure to this
years) was 2.42 ± 1.02 μg/L.10 Therefore, although mean total heavy metal.
Hg-B from schoolchildren living near MTPIE did not exceed
the reference values, the values were high relative to data
obtained from the USA and Germany.20,21 ACKNOWLEDGEMENTS
The authors wish to sincerely thank Associate Professor
Dr Nuntavarn Vichit-Vadakan at the Faculty of Public Health,
Thammasat University, Thailand, for her valuable guidance
and suggestions.

Table 4: Details of 67 children with levels of mercury above the recommended standard
Characteristic Frequency, n (%) Mean ± SD Hg-B (μg/L) ANOVA or t-test P value
Site
S1 17 (25%) 7.1 ± 2.9 0.023a
S2 8 (12%) 7.9 ± 5.6
S3 22 (33%) 5.2 ± 0.9
S4 20 (30%) 5.5 ± 1.7
Sex
Boys 33 (49%) 6.7 ± 3.3 0.056b
Girls 34 (51%) 5.6 ± 1.9
Age
6–9 years 17 (25%) 5.4 ± 1.8 0.241b
10–13 years 50 (75%) 5.2 ± 2.9
Boys
6–9 years 8 (12%) 4.9 ± 0.8 0.001b
10–13 years 25 (37%) 7.3 ± 3.7
Girls
6–9 years 9 (13%) 5.6 ± 2.1 0.122b
10–13 years 25 (37%) 5.2 ± 1.1
Age 6–9 years
Boys 8 (12%) 4.9 ± 0.8 0.069b
Girls 9 (13%) 5.6 ± 2.1
Age 10–13 years
Boys 25 (37%) 7.3 ± 3.7 0.005b
Girls 25 (37%) 5.2 ± 1.1
ANOVA: analysis of variance. Hg-B: total mercury in whole blood. SD: standard deviation.
a
Analysis of variance.
b
t-test
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Inequality in maternal health-care services
and safe delivery in eastern India
Arabinda Ghosh
ABSTRACT
Background: The target for Millennium Development Goal 5 (MDG-5) is to reduce
the maternal mortality ratio by three quarters between 1990 and 2015. The United Food and Supplies Department,
Nations 2014 report on MDG-5 concluded that little progress had been made in Government of West Bengal,
the South Asian countries, including India, which accounts for 17% of all maternal West Bengal, India
deaths globally. In resource-poor economies with widespread disparities even
within the same country, it is very important to explore inequalities in safe delivery
Dr Arabinda Ghosh, IAS, S-10/4,
during childbirth by key socioeconomic factors in order to provide insights for future Srabani Abasan, FC Block,
programming and policy actions. Sector III, Salt Lake,
Methods: Data from the Indian District Level Household and Facility Survey 3 Kolkata 700106,
were analysed to examine inequalities in safe delivery in eastern India. Univariate West Bengal, India
and multivariate logistic regression models were used. Email: ghosharabinda@hotmail.com
Results: There were substantial inequalities in safe delivery by asset quintile,

education of the woman and her husband, area of residence (rural or urban), religion
and age at marriage (<18 years or ≥18 years); however, not all inequalities were
the same. After adjusting for education levels of both parents, area of residence,
religion and mother’s age at marriage, the odds of having a safe delivery were
almost eightfold higher for those in the highest asset quintiles compared with
those in the lowest quintiles. The odds for a safe pregnancy were three times
higher for educated women compared with a base case of no education. The
chances of having a safe delivery were twofold higher for women living in urban
areas compared with those in rural areas (odds ratio 2.04, 95% confidence interval
1.91–2.17).
Conclusion: Addressing inequalities in maternal health should be viewed as a
central policy goal together with the achievement of MDG-5 targets. In addition
to following the indirect route of improving maternal health via poverty alleviation,
direct interventions are needed urgently. Women’s education has a strong potential
to improve access for poor pregnant women to safe delivery services and to reduce
disparities in maternal health outcomes in resource-poor economies.
Key words: India, inequality, maternal mortality ratio, Millennium Development
Goal 5, safe delivery
INTRODUCTION Bank and the World Health Organization launched the Safe
Motherhood Initiative to raise awareness about the number of
Over half a million women die each year due to complications women dying each year from complications of pregnancy and
during pregnancy and childbirth. The majority of these deaths childbirth, and to challenge the world to reduce this mortality
are preventable.1 Maternal mortality – the death of women burden.3 The 1994 International Conference on Population
during pregnancy or childbirth, or in the 42 days after delivery, and Development strengthened international commitment
from any cause related to or aggravated by the pregnancy or to reproductive health. The importance of maternal survival
its management but not from accidental or incidental causes was reinforced in 2000, when it was included as one of the
– remains a major challenge to health systems worldwide.2 In eight Millennium Development Goals (MDGs).4 The target for
1987, the United Nations Population Fund (UNFPA), the World MDG-5 is to reduce the maternal mortality ratio (MMR) by

Ghosh: Maternal health-care services in eastern India
three quarters between 1990 and 2015.5 For India, the target India will achieve MDG-5 by reducing the MMR level to 109
is to achieve an MMR of 109 per 100 000 live births by 20156 by 2015. India is among the 51 nations with slow progress in
versus the MMR of 178 recorded for 2010–2012.7 maternal and child care.11
Despite these efforts, maternal mortality remains unacceptably Safe delivery is defined as either institutional delivery or home
high across much of the developing world. Globally it decreased delivery assisted by a skilled person, such as a doctor, nurse or
by less than 1% per year between 1990 and 2005 – far below the a midwife with experience and proficiency in uncomplicated
5.5% annual improvement needed to reach the MDG targets. deliveries. The objective of this study is to explore inequalities
During the 2009 World Health Assembly, Mr Ban Ki-moon, in safe delivery by key socioeconomic factors in the eastern
Secretary-General of the United Nations (UN), stated that, part of India to provide insights for future programming and
“Today, maternal mortality is the slowest moving target of all policy actions.
the Millennium Development Goals – and that is an outrage.
Together, let us make maternal health the priority it must be.
In the twenty-first century, no woman should have to give her METHODS
life to give life”.8
Indian District Level Household
Though admittedly some progress has been made in reducing
maternal mortality since 1990, the rate of decline is far from and Facility Survey 3
adequate for achieving the goal. An estimated 289 000 maternal The current study uses data from Indian District Level
deaths occurred in 2013, giving a global MMR of 210 maternal Household and Facility Survey 3 (DLHS-3). The Ministry of
deaths per 100 000 live births.9 Many of these deaths could Health and Family Welfare, Government of India, initiated
have been prevented if the women had been attended by skilled District Level Household and Facility Surveys in 1997 to
health personnel during pregnancy and childbirth.10 provide district-level estimates of health indicators to assist
Preventable maternal deaths indicate gross violation of the policy-makers and programme administrators in decentralized
basic human right of survival and highlight the gross failure of planning, monitoring and evaluation. The surveys were
the health services on almost all fronts, particularly in terms of initiated in 1997 with a view to assessing the utilization of
choice of strategic interventions and their extent of coverage services provided by government health-care facilities and
in the population.11 The progress in maternal health has been people’s perceptions of the quality of services. DLHS-3 is the
uneven, inequitable and unsatisfactory.12 The UN report card third in the series of district surveys, preceded by DLHS-1 in
on MDG-5 concluded that little progress had been made in sub- 1998–1999 and DLHS-2 in 2002–2004. DLHS-3, like the two
Saharan Africa, where half of all maternal deaths take place. earlier rounds, is designed to provide estimates of important
Sub-Saharan Africa had the highest MMR among developing indicators of maternal and child health, family planning and
regions, with 510 deaths per 100 000 live births, followed by other reproductive health services. This survey provides
South Asia. Almost one third of all global maternal deaths district-level estimates on maternal and child health, family
are concentrated in two populous countries: India, with an planning and other reproductive health services to assist
estimated 50 000 maternal deaths (17%), and Nigeria, with an policy-makers and programme administrators in decentralized
estimated 40 000 maternal deaths (14%).13 planning, monitoring and evaluation. DLHS-3 adopted a
multistage stratified probability proportional to size sampling
Inequalities in the use and coverage of skilled maternity design. Fieldwork was conducted between December 2007
care persist within poor countries alongside maternal health and December 2008, and information was gathered from
outcomes. Overall, women from the wealthiest income or most 720 320 households from 34 states and union territories in
educated groups are much more likely than the poorest or least India (excluding Nagaland). From these households, 643 944
educated women to use skilled care during pregnancy, delivery ever-married women aged 15–49 years and 166 260 unmarried
and the postpartum period.14–18 women aged 15–24 years were interviewed. Sampling weights
for households, ever-married women and unmarried women
A reasonable number of inequalities in health determinants are were generated for each district. DLHS-3 combined household
due to the failure of publicly financed health care reaching the amenities, assets and durable goods to compute a wealth index
poor in almost all developing countries.19 Disparity in income at the national level and this was divided into five quintiles.
is perhaps the most important factor leading to inequality in Households were categorized from the poorest to the richest
health.20 Education in general and female literacy in particular groups corresponding to the lowest to the highest quintiles at
may play an important role in accessing maternal health-care the national level.
services. Equality in maternal health outcomes and access to
maternal health interventions have been on top of the equity
agenda, as maternal health is an important component of the Determinants of safe delivery
MDGs.21 in states of eastern India
In India, the MMR declined from 301 per 100 000 live births in The present study focuses on socioeconomic inequalities in safe
2001–2003, to 178 in 2010–2012.The MMR ranged from 328 delivery in eastern India, which comprises 11 states: Arunachal
in Assam to 66 in Kerala during 2010–2012.7 Keeping in view Pradesh, Assam, Bihar, Jharkhand, Manipur, Meghalaya,
the overall pace of decline in the MMR, it seems unlikely that Mizoram, Orissa, Sikkim, Tripura and West Bengal; 25.9%

of the Indian population live in these states. Information was Table 1: Sociodemographic characteristics of 201 522
gathered from 237 425 households in these states using DLHS- ever-married women aged 15–49 years
3, and 201 522 ever-married women aged 15–49 years were
Characteristic %
interviewed.
Place of residence
To look for determinants of safe delivery in these selected Rural 85.5
states of eastern India, a multivariate logistic regression
model was used to calculate odds ratios (ORs), a measure of Urban 14.5
association between an outcome and an exposure variable. Household characteristics
The independent variables in the regression models included Electricity supply connected 47.6
asset quintile, education of the woman and her husband, area
of residence (rural or urban), religion and age at marriage Latrine facility 48.3
(<18 years or ≥18 years). Kachha house a
57.9
Semi-pucca housea 29.3
The household wealth status information provided by DLHS-
3 was used as a socioeconomic indicator. Other variables Pucca house a
12.8
used to measure inequality were area of residence (rural or Wood as main fuel for cooking 55.5
urban), educational status of women and their husbands (none,
Religion
1–4 years, 5–9 years and ≥10 years of schooling), religion
(Hindu, Muslim, Christian or other) and age at marriage Hindu 64.8
(<18 years or ≥18 years). Muslim 11.1
The concentration index (Ci) is one of the commonly used Christian 15.2
measures of inequality in the field of economics. In recent Other 8.9
years, it has become a fairly standard measurement tool in the
Education
health economics literature on equality and inequality in health
and health care. It allows the measurement of health inequality Never attended school 46.6
while taking into consideration the distribution of the health Husband never attended school 28.4
variable across all categories of the health stratifier.22
Age at marriage under 18 years 49.0
Formally, the Ci in case of discrete social categories is defined Mobile phone possession 24.5
as: µ
, where hi is the health sector variable, a
Pucca, semi-pucca and kachha are the highest (e.g. cement,
steel) to lowest (e.g. mud, wood) qualities of housing.
µ is its mean, and ri = i/N is the fractional rank of individual i

in the living standards distribution, with i = 1 for the poorest
and/or sanitary latrines, while 57.9% of the households lived in
and i = N for the richest. For computation, a more convenient
a kachha house (short-lived structure made with inexpensive
formula for the Ci defines it in terms of the covariance between building materials), 24.5% had mobile phones and 46.6% of
the health variable and the fractional rank in the living standards the respondents had never attended school, while the rate was
distribution: . 28.4% among their husbands.
We used the concentration index, which varies between −1 and In our study area, only 39.6% of the respondents had a safe
+1, to measure wealth-related and education-related inequality delivery against an all-India average of 52.7%. Table 2 shows
in safe delivery. A Ci of 0 indicates a lack of inequality while the the inequalities in safe delivery in the eastern Indian states
more the index deviates from zero, the greater the magnitude of by area of residence, asset quintile, age at marriage, religion
the inequality. A negative Ci indicates that a given favourable and education. The wealth inequality in safe delivery was
condition or practice (that is, safe delivery) is found more widespread (Ci 0.28). Safe delivery was as low as 20.4% for
often among the economically poor or less educated, while a the poorest respondents against 87.9% for the richest.
positive index suggests that a favourable condition or practice
is found less often among the poorer than among the wealthier Regarding the relationship between safe delivery and level of
or educationally advanced social strata.22,23 education (Ci 0.25710), safe delivery was as low as 22.6% for
women having no education, and as high as 76.9% for women
who had had schooling for 10 years or more. With reference
RESULTS to the rural/urban inequality in safe delivery, safe delivery was
74.0% in urban areas and less than half of that in rural areas.
Sociodemographic characteristics Religion was also a determining factor in these areas in ensuring
safe delivery. The Hindu and Christian populations had a very
Table 1 provides the descriptive statistics of sociodemographic
similar level of safe delivery but the level for Muslim women
characteristics of the respondents in percentages. Most of the
was less than two thirds of this level.
households lived in rural areas (85.5%), and 64.8% of them
were Hindu. Only about half of the households had electricity

Table 2: Safe delivery in the states of eastern India by area of residence, asset quintile, age at marriage, religion and education in 2007–2008
Bihar Sikkim Arunachal Manipur Mizoram Tripura Meghalaya Assam West Bengal Jharkhand Orissa Eastern India
Pradesh
% SD % SD % SD % SD % SD % SD % SD % SD % SD % SD % SD % SD
Rural 29.8 0.46 54.8 0.50 43.1 0.50 48.2 0.50 50.8 0.50 42.3 0.49 25.2 0.43 37.0 0.48 45.9 0.50 20.9 0.41 47.4 0.50 35.2 0.48
Urban 59.9 0.49 89.9 0.30 67.8 0.47 90.3 0.30 89.3 0.31 92.3 0.27 65.7 0.48 71.3 0.45 82.6 0.38 64.2 0.48 78.0 0.41 74.0 0.44
Poorest 19.7 0.40 10.5 0.32 20.0 0.40 22.3 0.42 5.4 0.23 13.6 0.34 11.2 0.32 20.1 0.40 31.5 0.46 11.4 0.32 30.1 0.46 20.4 0.40
quintile
Richest 83.2 0.37 88.0 0.33 76.7 0.42 96.7 0.18 92.0 0.27 93.1 0.25 81.5 0.39 85.2 0.36 95.0 0.22 86.8 0.34 92.0 0.27 87.9 0.33
quintile
<18 years 28.1 0.45 46.8 0.50 43.9 0.50 36.5 0.48 46.8 0.50 38.3 0.49 22.8 0.42 29.0 0.45 42.9 0.49 22.1 0.41 35.1 0.48 30.2 0.46
≥18 years 43.6 0.50 60.1 0.49 50.2 0.50 60.1 0.49 68.1 0.47 53.0 0.50 32.3 0.47 46.5 0.50 62.0 0.49 28.5 0.45 59.9 0.49 49.1 0.50
Hindu 33.7 0.47 56.6 0.50 57.1 0.50 86.9 0.34 40.5 0.50 51.9 0.50 46.7 0.50 50.3 0.50 58.8 0.49 28.9 0.45 51.4 0.50 42.8 0.49
Muslim 22.6 0.42 55.6 0.51 51.7 0.50 50.4 0.50 53.8 0.51 21.7 0.41 25.0 0.44 22.8 0.42 35.7 0.48 25.1 0.43 68.4 0.47 26.5 0.44
Christian 39.1 0.50 59.6 0.49 46.3 0.50 33.4 0.47 66.8 0.47 45.7 0.50 28.7 0.45 32.7 0.47 48.3 0.51 15.7 0.36 26.6 0.44 41.4 0.49
Respondent: 23.0 0.42 34.7 0.48 30.5 0.46 35.8 0.48 17.9 0.38 19.3 0.39 16.8 0.37 22.3 0.42 31.9 0.47 14.9 0.36 27.5 0.45 22.6 0.42
no education
Respondent: 69.6 0.46 93.0 0.26 75.1 0.43 80.7 0.40 88.3 0.32 87.2 0.33 69.8 0.46 70.6 0.46 88.8 0.32 67.8 0.47 88.4 0.32 76.9 0.42
education for
≥10 years
Husband: no 20.3 0.40 33.7 0.47 28.4 0.45 31.0 0.46 25.9 0.44 17.9 0.38 20.2 0.40 20.5 0.40 32.9 0.47 11.7 0.32 25.9 0.44 20.9 0.41
education
Husband: 50.5 0.50 87.0 0.34 65.6 0.48 73.5 0.44 81.5 0.39 78.8 0.41 54.8 0.50 64.6 0.48 79.4 0.40 48.6 0.50 81.4 0.39 62.3 0.48
education for
≥10 years
%: Number of women having a safe delivery divided by the total population of women who delivered in that location; SD: standard deviation.
WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

57
Finally, age at marriage also played an important role in Table 4 provides the multivariate logistic regression results
ensuring safe delivery in the states of eastern India. It was for the determinants of safe delivery in eastern India. The
found that for mothers who were married when they were ORs in Table 4 show the impact of an independent variable
under 18 years, the safe delivery rate was as low as 30.2% after adjusting for all other variables included in this model.
compared with 49.1% for those married at 18 years and older. It was found that wealth, education of mother, education of
husband, area of residence, religion and age at marriage all
Of women living in urban areas of eastern India who had had played important roles in determining safe delivery in eastern
secondary education and were in the highest asset quintile, India. Women belonging to the highest economic strata were
94.6% had a safe delivery compared with 16.9% of rural, more likely (OR 7.69, P <0.001) than those in the poorest
uneducated women in the lowest asset quintile. category to deliver in an institution or at home assisted by a
skilled person (assuming constant values for education, area
of residence, religion and age at marriage). Women who had
Education and inequality in maternal had an opportunity to attend primary education (1–4 years
health outcomes of schooling) were almost one and a half times more likely
to have a safe delivery (OR 1.44, P <0.001) than those with
Women in urban and rural areas who had attended school had no education. As compared with women with no education,
greater access to safe delivery. For example, among urban women those who had received a secondary education (5–9 years of
without any education and in the highest asset quintile, access to schooling) were two times (OR 2.05, P <0.001) more likely to
safe delivery was 63.1%. In contrast, for urban women with 10 have a safe delivery. Finally, women who had had schooling
years and more schooling, safe delivery was 94.6%. Similarly, for 10 years and more were three times (OR 3.24, P <0.001)
among rural women without any education in the lowest asset more likely to have a safe delivery. It was further found that
quintile, access to safe delivery was 16.9%. On the other hand, a woman’s own educational status was more important than
for rural women with 10 years or more of schooling and in the that of her husband in ensuring a safe delivery. Although the
lowest asset quintile, access to safe delivery was 39.8%. father’s years of schooling also contributed to safe delivery,
the ORs were lower than those for the mother at each level of
Ci values presented in Table 3 and Figure 1 provide schooling. Regarding religion, Muslim, Christian and women
information on the degree of inequality. Table 3 shows that Ci of other religions were less likely to have a safe delivery in
indicates significant inequality in favour of richer households comparison with Hindu women. The likelihood of a safe
for safe delivery. Mizoram had the lowest inequality (wealth) delivery for Muslim and Christian women was 48% (OR 0.52)
for safe delivery (Ci 0.18) and highest level of safe delivery and 43% (OR 0.57) less than for Hindu women, respectively.
(coverage 64.24%) among the states of eastern India. On the Age at marriage also played an important role in having a safe
other hand, Jharkhand had highest level of inequality (Ci 0.36) delivery. The likelihood of having a safe delivery increased
and lowest level of safe delivery (coverage 24.93%). With by 27% (OR 1.27) among women who married at ≥18 years
respondents ranked by level of education, the inequality was of age, compared with those who married at younger than 18
relatively lower for safe delivery. Inequality in safe delivery years of age.
was considerably lower by place of residence. It was found
that higher coverage was associated with lower values of the Ci
(r = –0.739; P <0.01).
Table 3: Equality results for safe delivery according to asset quintile, and respondent’s education and place of
residence
Safe delivery, Asset quintile Education Place of residence
State
% Ci SE Ci SE Ci SE
Bihar 31.93 0.23 0.01 0.21 0.01 0.06 0.00
Sikkim 56.48 0.19 0.01 0.17 0.01 0.03 0.00
Arunachal Pradesh 48.59 0.22 0.01 0.19 0.01 0.09 0.01

Manipur 55.88 0.27 0.01 0.17 0.01 0.11 0.01
Mizoram 64.24 0.18 0.01 0.15 0.01 0.14 0.01
Tripura 46.88 0.28 0.01 0.24 0.01 0.09 0.01
Meghalaya 29.35 0.28 0.01 0.25 0.01 0.13 0.01
Assam 40.24 0.26 0.01 0.23 0.01 0.07 0.00
West Bengal 51.41 0.22 0.01 0.20 0.01 0.09 0.00
Jharkhand 24.93 0.36 0.01 0.30 0.01 0.15 0.01
Orissa 50.87 0.24 0.01 0.24 0.01 0.06 0.00
Eastern India 39.26 0.28 0.00 0.26 0.00 0.10 0.00
Ci: concentration index; SE: standard error of the mean.

Figure 1: Safe-delivery coverage and equality in states of eastern India
DISCUSSION There is a need to adopt strategies for economically underserved

people to ensure equality in having a safe delivery. In the
In developing countries such as India, addressing inequalities absence of a concerted effort to guarantee that health systems
in maternal health should be viewed as a central policy goal reach disadvantaged groups more effectively, such inequalities
together with achievement of MDG-5 targets. The huge are likely to continue. Yet these inequalities need not be
inequalities in maternity care underline the need for effective accepted as inevitable, for there are many promising measures
provision of services. Over the past decades, countries have that can be pursued, such as establishing goals for improved
introduced various strategies to increase the demand for and coverage among the poor, rather than in entire populations, and
improve the availability, accessibility and affordability of use of the goals to direct planning towards the needs of the
professional delivery attendants.24 disadvantaged.25 There is a need to adopt strategies for poor
people to establish equality in terms of access to, and use of,
Although governments may claim that they provide services to maternal health-care services. To safeguard the interest of poor
ensure that the poor are reached, their health service subsidies people, direct interventions are needed. Many demand-side
tend to provide considerably greater benefits to the well-off. financing schemes have been proposed globally. Interventions
The situation in 21 countries (or areas within countries) was recently tried include: improved means of identifying poor
covered in a 2003 review (Argentina, Armenia, Bangladesh, individuals (Colombia and Mexico), cash payments for use
Bulgaria, Colombia, Costa Rica, Côte d’Ivoire, Ecuador, of services (Mexico), services provided by nongovernmental
Ghana, Guinea, Honduras, India, the state of Uttar Pradesh in organizations working under contracts with carefully specified
India, Indonesia, rural Kenya, Madagascar, Nicaragua, South performance indicators (Cambodia), mass campaigns (Ghana
Africa, Sri Lanka, United Republic Tanzania and Viet Nam). and Zambia), and social marketing (United Republic of
The top 20% of the population obtained on average over 26% Tanzania). But the effectiveness of such interventions has not
of the total financial subsidies provided through government been adequately assessed in different contexts.27
health expenditure, compared with less than 16% in the lowest
20% of the population.25 In India, the top 20% of the population Despite the increasing emphasis on institutional deliveries, the
obtained 32% of the financial subsidies against 10% for the use of such services in general and among the poor in particular
lowest 20% of the population.26 remains low. In addition to economic reasons, cultural and
societal factors, and the availability of quality health services

Table 4: Determinants of safe delivery in eastern India

Number of Univariate
% safe Multivariate
Predictor respondents (%) logistic 95% CI 95% CI
delivery model (OR)
(N = 73 439) regression
Asset quintile
Lowest 22 006 (30.0) 20.35 1.00 - - 1.00 - -
Second 20 135 (27.4) 29.47 1.63 1.56 1.71 1.37 1.31 1.44
Middle 14 375 (19.6) 43.60 3.03 2.89 3.17 1.90 1.81 2.00
Fourth 10 760 (14.6) 65.08 7.29 6.93 7.68 3.24 3.05 3.44
Richest 6 160 (8.4) 87.86 28.31 26.05 30.77 7.69 6.98 8.47
Respondent’s education
None 34 460 (46.9) 22.56 1.00 - - 1.00 - -
1–4 years 8 550 (11.6) 34.47 1.82 1.73 1.92 1.44 1.36 1.53
5–9 years 20 480 (27.9) 52.44 3.79 3.65 3.93 2.05 1.96 2.15
≥10 years 9 919 (13.6) 76.92 11.44 10.85 12.07 3.24 3.02 3.48
Husband’s education
None 21 155 (28.9) 20.88 1.00 - - 1.00 - -
1–4 years 9 345 (12.8) 31.08 1.73 1.63 1.83 1.20 1.13 1.28
5–9 years 24 072 (32.9) 42.07 2.75 2.64 2.87 1.32 1.26 1.39
≥10 years 18 524 (25.4) 62.33 6.27 6.00 6.56 1.44 1.36 1.53
Area of residence
Rural 65 064 (88.6) 35.19 1.00 - - 1.00 - -
Urban 8 375 (11.4) 74.04 5.22 4.99 5.53 2.04 1.91 2.17
Religion
Hindu 47 951 (65.3) 42.82 1.00 - - 1.00 - -
Muslim 10 809 (14.7) 26.51 0.48 0.46 0.50 0.52 0.50 0.55
Christian 9 737 (13.3) 41.41 0.94 0.90 0.99 0.57 0.54 0.60
Others 4 942 ( 6.7) 33.58 0.68 0.64 0.72 0.55 0.51 0.59
Age at marriage
<18 years 36 706 (50.0) 30.15 1.00 - - 1.00 - -
≥18 years 36 733 (50.0) 49.08 2.23 2.17 2.30 1.27 1.22 1.32
CI: confidence interval; OR: odds ratio.

In multivariate model: all P values <0.001.
Pseudo R2 = 0.1852.
affect medical assistance at delivery in a country.28 However, maternal health via poverty alleviation. Although the findings
the Government of India has recently started an ambitious of the present study show that asset quintiles exert a significant
conditional cash transfer scheme: the Janani Suraksha Yojana impact on safe delivery, changing the distribution of asset
(JSY), a 100% centrally sponsored scheme under the umbrella quintiles through poverty eradication methods would take
of the National Rural Health Mission, to promote institutional time. In the present situation, emphasis on direct interventions
delivery, particularly among pregnant women above the age is needed urgently.
of 19 years belonging to below-poverty-line families, in both
rural and urban areas.29 A recent evaluation of the JSY suggests It was found in this study that apart from wealth inequality,
that the poorest and least educated women did not always have differences in the educational levels of parents, particularly
the highest odds of receiving JSY payments. However, findings those of the mothers, are crucial determinants for access to safe
emphasize the need for targeting poor women.30 delivery. Though there is seemingly multicollinearity among
some of the independent variables such as asset quintile and
Policy-makers in resource-poor economies prefer to give education, this study found that each individual variable affects
emphasis to poverty eradication rather than improving safe delivery, even after adjusting for values of seemingly
maternal health, and they follow the indirect route of improving correlated exogenous variables.

Nothing can be changed about area of residence and religion. 13. United Nations. The Millennium Development Goals report 2014. New
However, public interventions may target rural areas and York: UN; 2014. http://www.un.org/millenniumgoals/reports.shtml -
accessed 5 May 2015.
religious minorities. Education has the advantage of improving
14. Louise H, Susan M, Deborah T. The evidence towards MDG 5: a working
the wealth/income position and warding off marriage at an paper. London; 2010. https://www.gov.uk/government/uploads/system/
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15. Saxena D, Vangani R, Mavalankar DV, Thomsen S. Inequity in maternal
Empowering women through education should be one of the health care service utilization in Gujarat: analyses of district-level health
most fundamental strategies to promote health and reduce survey data. Global Health Action. 2013;6:1-9.
inequalities. The findings from this study indicate that education 16. Say L, Raine R. A systematic review of inequalities in the use of
maternal health care in developing countries: examining the scale of the
in general and women’s education in particular have a strong problem and the importance of context. Bulletin of the World Health
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and Population (HNP) Discussion Paper. The International Bank for
ACKNOWLEDGEMENT Reconstruction and Development / The World Bank; 2004.
18. UNFPA. Rich mother, poor mother: the social determinants of maternal
The author acknowledges the guidance provided by Dr Sajal death and disability. 2012. http://www.unfpa.org/sites/default/files/
resource-pdf/EN-SRH%20fact%20sheet-Poormother.pdf - accessed 5
Chattopadhyay, Economic Advisor, Centers for Disease May 2015.
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this paper. Organ. 2002;80(2):97-105.
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in health and its determinants: evidence from China. Health Policy.
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Prevalence of household drinking-
water contamination and of acute
diarrhoeal illness in a periurban
community in Myanmar
Su Latt Tun Myint, Thuzar Myint, Wah Wah Aung, Khin Thet Wai
Department of Medical
ABSTRACT Research, Yangon, Myanmar
Background: A major health consequence of rapid population growth in urban Address for correspondence:
areas is the increased pressure on existing overstretched water and sanitation Dr Su Latt Tun Myint, Department
services. This study of an expanding periurban neighbourhood of Yangon Region, of Medical Research, No. 5 Ziwaka
Myanmar, aimed to ascertain the prevalence of acute diarrhoea in children under Road, Dagon Township, Yangon
5 years; to identify household sources of drinking-water; to describe purification 11191, Myanmar
and storage practices; and to assess drinking-water contamination at point-of-use. Email: sltm06@gmail.com
Methods: A survey of the prevalence of acute diarrhoea in children under 5

years was done in 211 households in February 2013; demographic data were
also collected, along with data and details of sources of drinking water, water
purification, storage practices and waste disposal. During March–August, a subset
of 112 households was revisited to collect drinking water samples. The samples
were analysed by the multiple tube fermentation method to count thermotolerant
(faecal) coliforms and there was a qualitative determination of the presence of
Escherichia coli.
Results: Acute diarrhoea in children under 5 years was reported in 4.74%
(10/211, 95% CI: 3.0–9.0) of households within the past two weeks. More than
half of the households used insanitary pit latrines and 36% disposed of their waste
into nearby streams and ponds. Improved sources of drinking water were used,
mainly the unchlorinated ward reservoir, a chlorinated tube well or purified bottled
water. Nearly a quarter of households never used any method for drinking-water
purification. Ninety-four per cent (105/112) of water samples were contaminated
with thermotolerant (faecal) coliforms, ranging from 2.2 colony-forming units
(CFU)/100 mL (21.4%) to more than 1000 CFU/100 mL (60.7%). Of faecal
(thermotolerant)-coliform-positive water samples, 70% (47/68) grew E. coli.
Conclusion: The prevalence of acute diarrhoea reported for children under 5 years
was high and a high level of drinking-water contamination was detected, though
it was unclear whether this was due to contamination at source or at point-of-use.
Maintenance of drinking-water quality in study households is complex. Further
research is crucial to prove the cost effectiveness in quality improvement of drinking
water at point-of-use in resource-limited settings. In addition, empowerment of
householders to use measures of treating water by boiling, filtration or chlorination,
and safe storage with proper handling is essential.
Key words: Acute diarrhoea, drinking-water quality, periurban neighbourhood,
children under 5 years, water purification

Myint et al.: Drinking-water contamination and diarrhoea in Myanmar
INTRODUCTION METHODS
The Millennium Development Goal target 7C was to “Halve, The setting for this study was North Dagon Township, an
by 2015, the proportion of the population without sustainable expanding periurban neighbourhood of the Yangon Region,
access to safe drinking water and basic sanitation”. By 2010, Myanmar. North Dagon comprises 27 wards; two of these
the world had met the target of halving the proportion of people wards were purposely selected for this study since our previous
without access to improved sources of water, five years ahead survey had identified high levels of acute diarrhoea in children
of schedule. Nevertheless, in 2011, an estimated 768 million aged 5 years or younger.8 These wards have a higher proportion
people did not use an improved source for drinking water and of lower-income households than other wards in the township.
2.5 billion lacked access to an improved sanitation facility.1
This study comprised a household survey to collect recall
Population density, climate change and water scarcity situations data on diarrhoea in children under 5 years, followed by
are the main factors influencing sources of drinking water and analysis of drinking water from a subset of households. The
likely contamination. The WHO/UNICEF Joint Monitoring first survey was carried out during February–March 2013, at
Programme for Water Supply and Sanitation drinking-water the beginning of the hot, dry season, which is a period when
ladder defines the continuum of sources of drinking-water the area typically experiences water shortages. In the previous
from unimproved to improved (that is protected from outside study done in 2012, we surveyed 575 households that included
contamination) (See Box 1).1 Globally, consumers from poor children younger than 5 years. The sample size for the current
households rarely use household water-treatment products survey was calculated as 211, based on an estimated diarrhoea
such as chlorine or a water filter on a sustained basis,2,3 and prevalence of 10% in the hot, dry season, with an acceptable
a better understanding of the factors that promote or inhibit accuracy of 5% at the 95% confidence level inclusive of 5%
use of these products is needed.4 Along with poor sanitation nonresponse rate, assuming a design effect of 1.5.
and hand hygiene, drinking-water contamination is one of the
routes by which there can be transmission of the bacterial, viral A total of 211 of the 575 households were selected at random.
or protozoal pathogens responsible for diarrhoea.5,6 Every second household in the list was included. All selected
households who were approached by the survey team
There is a need to examine three interrelated factors that participated in the study and none refused. At each selected
contribute to the sources of microbiological risk among household, after obtaining written informed consent, trained
households with access to improved water sources: water interviewers administered a pretested, structured questionnaire
storage, risks specific to piped water supplies and household to the mothers or carers of children under 5 years. Issues of
water management practices. It is essential to focus on the privacy, anonymity and confidentiality were observed. This
provision of microbiologically safe water at both community study was approved by the Ethics Review Committee of the
and household levels. Even when water sources are improved, Department of Medical Research. The structured questionnaire
water-quality risks may still exist at the point of consumption, allowed collection of household demographic data and details
and this has implications in the use of international targets for of sources of drinking-water, water purification and storage
safe drinking-water access.7 practices, and waste disposal. Interviewers recorded mothers’/
carers’ recall of diarrhoea in their children during the past two
Low-income countries such as Myanmar are particularly weeks, past month and past year. For the purpose of this study,
affected by deficient water systems and services, and poor acute diarrhoea was defined as: passage of three or more loose
sanitation and hygiene. The objectives of this study were: (i) to watery motions, more than usual loose watery motion, a single
ascertain the two-week and one-year prevalences of acute large watery motion in a day, or a mother’s assessment that her
diarrhoea in children under 5 years; (ii) to identify the sources child passed more-frequent liquid stools.
of drinking water, water purification and storage practices; and
(iii) to assess the bacteriological contamination of household
drinking water at point-of-use.
Box 1:
Drinking-water ladder
Unimproved drinking water Improved drinking water
Surface drinking-water Unimproved drinking-water Other improved drinking- Piped water on premises:
sources: river, dam, sources: unprotected dug water sources: public taps piped household water
lake, pond, stream, canal, well, unprotected spring, cart or standpipes, tube wells or connection located inside the
irrigation channels with small tank/drum, bottled boreholes, protected dug user’s dwelling, plot or yard
water wells, protected springs,
rainwater collection
Source: World Health Organization and United Nations Children’s Emergency Fund.1

The second survey of drinking water was done between March RESULTS
and August 2013. Owing to funding constraints, it was not
possible to revisit all of the 211 households, thus a subsample In this study, 25% (53/211) of the household heads had primary
of 112 was purposely selected by prioritizing households with school level education. The age of the respondents ranged
poor sanitation facilities. The number was based on feasible from 18 to 74 years (mean age 37.5 ± 12.6 years) and 83%
laboratory facilities to analyse water quality. No household (175/211) were women. Around 63% (133/211) of the study
refused to have their drinking-water examined. Samples population were families of five or more members and the total
were taken from a cup used by the family to drink water, and number of children under 5 years was 262 (mean age 1.2 ± 0.5
collected in sterile glass bottles and transported in ice-cooler years) ranging from age 1 to 3 years. There were no children
boxes to the laboratory of the Bacteriology Research Division, older than 3 years of age or younger than 1 year of age in the
Department of Medical Research, for processing within six surveyed households. Nearly half of the households (102/211)
hours of collection. were made of bamboo. About half of households had insanitary
pit latrines (111/211); other households used sanitary fly-proof
For microbial water quality, verification is usually based on latrines. There were no community block toilets and 36%
the analysis of faecal indicator microorganisms, with the (77/211) of householders disposed of their waste in nearby
organism of choice being Escherichia coli or, alternatively, surface water-bodies (for example, stream and ponds).
thermotolerant (faecal) coliforms.9 Guideline values for
verification of microbial quality according to the WHO
guidelines for drinking-water quality are shown in Table 1. Reported acute diarrhoea in children under 5 years
Water samples were analysed by the multiple tube fermentation
method to detect total faecal coliforms and E. coli. Quantitative Ten of the 211 (4.74%; CI: 3.0–9.0%) households reported
assessment to detect faecal coliforms was by enumeration of acute diarrhoea in children under 5 years within the past two
CFU and this was classified into five categories of <1 CFU/100 weeks. Further, within the past four weeks, 18 households
mL, 1–10 CFU/100 mL, 11–100 CFU/100 mL, 101–1000 (8.53%; CI: 5.0–13.0%) had reported acute diarrhoea, and 33
CFU/100 mL and >1000 CFU/100 mL. E.coli was detected households (15.64%; CI: 1.0–21.0%) cumulatively reported
qualitatively. acute diarrhoea in children under 5 years within a one-year
period.
Quantitative data were entered into the EpiData software
application after thorough checks. Episodes of acute diarrhoea
at different periods within the past two-week period, and Sources of domestic water and drinking-
over the past two weeks within a one-year follow-up period water, storage and purification
were computed, along with the 95% confidence interval (CI).
Frequency distributions were carried out for variables of Nearly 42% (88/211) of households obtained their water for
interest. SPSS version 17.0 was used for univariate analysis, domestic use from the improved-source ward reservoir. Of
and the chi-squared test was used to determine associations. these, approximately 77% (68/88) of households had a piped-
Spearman’s rank correlation coefficient was computed to in supply and the remaining households carried the water
identify the relation between faecal coliform contamination manually from the reservoir. In 74/211 (35.1%) households,
and the presence of E.coli in drinking-water samples. the nonchlorinated ward reservoir was also used for drinking
Table 1: Guideline values for verification of microbial qualitya

Organisms Guideline value
All water directly intended for drinking: Must not be detectable in any 100 mL sample
E. coli or thermotolerant coliform bacteriab,c
Treated water entering the distribution system: Must not be detectable in any 100 mL sample
E. coli or thermotolerant coliform bacteriab
Treated water in the distribution system: Must not be detectable in any 100 mL sample
E. coli or thermotolerant coliform bacteriab
a
Immediate investigative action must be taken if E. coli are detected.
b
Although E. coli is the more precise indicator of faecal pollution, the count of thermotolerant coliform bacteria is an acceptable alternative.
If necessary, proper confirmatory tests must be carried out. Total coliform bacteria are not acceptable as an indicator of the sanitary quality
of water supplies, particularly in tropical areas, where many bacteria of no sanitary significance occur in almost all untreated supplies.
c
It is recognized that in the great majority of rural water supplies, especially in developing countries, faecal contamination is widespread.
Especially under these conditions, medium-term targets for the progressive improvement of water supplies should be set.
Source: World Health Organization.9

water; most households (137/211; 64.9%), sourced drinking previously been filled with purified water (93/211, 44.1%),
water from improved sources other than the reservoir, that is, and ceramic jars (50/211, 23.7%); (See Table 2). Only 20% of
from a chlorinated tube well or purified bottled drinking-water drinking-water containers were fully covered.
(See Table 2).
As shown in Table 3, 2.7% of households (2/74) with drinking-
Nearly a quarter of households (52/211; 24.6%) used no water sourced from the reservoir reported acute diarrhoea in
method of drinking-water purification. Among households children under 5 years within past two weeks compared with
using drinking-water purification, 82% (131/159) reported 5.8% (8/137) of households using other improved drinking-
use of a cloth filter (which could easily be contaminated), and water sources. Likewise, reported acute diarrhoea within a
33.3% reported boiling the water (53/159). Use of chlorine 1-year period was lower in households using the reservoir for
tablets and liquid chlorine for drinking-water purification was drinking-water than in those using other improved sources.
rare (2.5%; 4/159) (See Table 2). The differences were not statistically significant.
Observations revealed the storage of drinking-water in clay

pots (59/211, 28%), plastic bottles of 20-litre capacity that had
Table 2: Drinking-water management in study households

Characteristic Number Percentage
Source of drinking water (n = 211)
Reservoir 74 35
Tube well only 58 27.5
Purified bottled water only 78 37.0
Tube well and bottled water 1 0.5
Storage of drinking water a
(n = 211)
Clay pots 59 28.0
Large plastic bottles (20 litre) 93 44.1
Ceramic jars 50 23.7
Small plastic bottles (1 litre) 17 8.1
Steel pots 2 0.9
Drinking-water purification (n = 211)
No 52 24.6
Yes 159 75.4
Households with drinking-water purification (n = 159)
Cloth filter 131 82.4
Boiling 53 33.3
Ceramic filter 24 15.0
Sedimentation 26 16.4
Chlorine products 4 2.5
a
Some households used more than one type of storage vessel.
Table 3: Relationship between source of drinking water and reported acute diarrhoea in children under 5 years
Reported acute diarrhoea in children under 5 years (per household)
Household source of drinking water Never Within past two weeks Within one year Total
n % n % n % n %
Reservoir 61 82.4 2 2.7 11 14.9 74 100.0
Tube well and/or bottled water 107 78.1 8 5.8 22 16.1 137 100.0
Statistical significance Chi squared = 1.2; P = 0.56

Table 4: Relationship between presence of faecal coliform bacteria and E.coli in drinking-water samples
E. coli detection Total number with
Thermotolerant (faecal) coliform counta No Yes faecal coliforms
n % N % n %
<1 7 11.9 0 0.0 7 6.2
1–10 23 39.0 1 1.9 24 21.4
11–100 8 13.6 5 9.4 13 11.6
101–1000 0.0 0.0 0.0 0.0 0.0 0.0
>1000 21 35.6 47 88.7 68 60.7
Total count 59 100.0 53 100.0 112 100.0
a
Colony-forming units per 100 mL (CFU/100 mL).
Bacteriological contamination of is an attempt by the local municipal service to increase the

household drinking water coverage of piped water from the public reservoir, with central
chlorination in the area in 2016.
When analysing water samples obtained from serving cups,
94% (105/112) were contaminated with thermotolerant (faecal) Rapid population growth in urban areas puts increased pressure
coliforms, that is, had a coliform count of one or more. The on existing overstretched essential services such as water
range varied from 2.2 CFU/100 mL to over >1000 CFU/100 mL supplies, sewage and sanitation and collection, and disposal
(See Table 4). Of faecal-coliform-positive water samples, 50% of solid waste. This is consistent with the findings of the
(53/105) grew E. coli, indicating faecal contamination probably present study, which was conducted in low-income households
from hands, drinking cups or storage vessels. In addition, one of an expanding periurban settlement with unsatisfactory
could not rule out postsource contamination. As expected, environmental conditions. A report from India also supported
the presence or absence of E. coli was a fairly good marker, the argument that high population density, coupled with poor
indicating that about 70% (47/68) of water samples had gross sanitation facilities, were found to worsen living conditions
contamination (>1000 CFU/100 mL) with faecal coliforms. and affect the quality of water.13 There is a growing body of
The rank correlation value of 0.6 was highly significant (P = evidence that safe, clean, accessible and affordable drinking-
0.0005) indicating a high level of contamination that required water and sanitation is linked to reduction of childhood
attention. (See Table 4) diarrhoea. In study households, people were able to obtain
drinking-water from improved sources, but this study and
others are a reminder that use of an improved water source
DISCUSSION does not mean that the water is safe.14
Vulnerability to diarrhoea in children increases in the presence Water with an initially acceptable microbial quality often
of environmental contaminants and is a significant challenge becomes contaminated with pathogens during transport and
in a resource-limited context. Acute diarrhoea in children storage.15 Especially during storage, contamination can occur
under 5 years reported within the past two-week period in if the water containers are not fully covered, as found in this
this study is higher than that reported in the previous study study. Safe storage and household water treatment interventions
conducted in the same area at the end of rainy season (4.74% may improve water quality in slums. Simple reports of water
vs 1%).8 This might be due to the effect of seasonality. In the purification practices are unreliable metrics for understanding
study area, the hot season is usually linked to water shortages, the complexities of purification practices. People might report
intermittent pipe water supply, increased storage and increased that they treat their water, but may not do so in reality.
likelihood of contamination of drinking water from an
unsanitary environment, which may all cause acute diarrhoea For drinking-water purification, very few study households
in children under 5 years. Approximately 88% of diarrhoeal reported boiling and use of chlorine products (2.5%); most
diseases are attributable to unsafe drinking-water apart from used cloth filters. This finding is similar to an Indian study
poor environmental conditions including household-water in which 568 (59.2%) households in a slum did not use any
insecurity10 and there is recent evidence that the incidence method of water purification, 25.8% used a cloth filter and
of acute diarrhoea in children under 5 years is reduced 17.2% boiled their drinking-water prior to consumption.16
by expanding access to household-water chlorination.11 A Boiling fails to ensure drinking water safety at the point of
modelling study estimated that the proportion of the population consumption because of contamination during subsequent
using drinking water sourced from protected groundwater in storage and poor domestic hygiene.17 In this study, there was an
2012 was only 11.9% of the urban population and 12.6% of inconsistency of reported acute diarrhoea between households
the rural population of South-East Asia.12 In the present study, with either an improved or an unimproved water supply. This
only 32% of households had a piped-in unchlorinated water finding indicated that water was likely to be contaminated at
supply from the private reservoir in the ward. However, there point-of-use, in addition to at source, and this may contribute
towards the acute diarrhoea burden in this environment.

There are complex microbiological processes occurring within research is crucial to capture the composite index of water-
the transport and storage vessels, indicating the interaction of quality risks in vulnerable sites as a signal of outbreaks.
the biota in the collected water with biofilms in the containers
and/or recontamination through dipping hands and cups into This study confirms that improved water sources are not
water-holding containers at point-of-use.18 Bacteriological always safe, as there are many factors that can change the
parameters, especially E.coli, have been found to be the most quality of water between the point of source and the home.
specific indicator of faecal contamination in drinking water.19 Unless water source and distribution systems are intact, with
In study households, the concentration levels of total and faecal no chance of contamination, additional measures at home
coliforms and E. coli in collected water samples were above the are essential, such as treating water by boiling, filtration or
permissible limits of the WHO guidelines for drinking-water chlorination, and safe storage with proper handling. Therefore,
quality, which note that, “immediate investigative action must a key factor is empowering household members to employ
be taken if E. coli are detected”.9 Inadequate water quality is these interventions.
associated with outbreaks and endemic disease. Dirty hands
contaminate drinking water at point-of-use, adding to microbial
contamination.20–22 In this study it was unclear whether the very ACKNOWLEDGEMENT
high prevalence of faecal coliform contamination (more than The authors are indebted to Dr Kyaw Zin Thant, Director
1000 CFU/100 mL) in drinking water was due to contamination General, Department of Medical Research (DMR), Yangon,
at source or at point-of-use. Myanmar, for funding support; the Department of Health
Further attempts to differentiate between contamination of and the township health authorities concerned for their full
drinking water at source or at point-of-use are essential. support during the survey; the survey team members from
Epidemiological surveillance of household drinking water the Epidemiology Research Division and the Bacteriology
quality plays a pivotal role in minimizing health risks Research Division (DMR) for conducting the survey; and
caused by contamination from an insanitary environment. last, but not the least, the participating households for their
This requires capacity building in the community and close enthusiasm.
monitoring of drinking-water quality at the local service level
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contributed equally to this work.


Innovative social protection mechanism
for alleviating catastrophic expenses
on multidrug-resistant tuberculosis
patients in Chhattisgarh, India
Debashish Kundu,1 Vijendra Katre,2,3 Kamalpreet Singh,2,3
Madhav Deshpande,3 Priyakanta Nayak,1 Kshitij Khaparde,1
Arindam Moitra,1 Sreenivas A Nair,1 Malik Parmar1 1
World Health Organization
Country Office for India,
New Delhi, India,
ABSTRACT 2
Rashtriya Swasthya Bima Yojna
and Mukhyamantri Swasthya
Background: Patients with multidrug-resistant tuberculosis (MDR-TB) incur huge Bima Yojana, State Nodal Agency,
expenditures for diagnosis and treatment; these costs can be reduced through a Directorate of Health Services,
well-designed and implemented social health insurance mechanism. The State of Raipur, India,
Chhattisgarh in India successfully established a partnership between the Revised 3
Directorate of Health
National TB Control Programme (RNTCP) and the Health Insurance Programme, Services, State Government of
to form a universal health insurance scheme for all, by establishing Rashtriya Chhattisgarh, Raipur, India
Swasthya Bima Yojna (RSBY) and Mukhyamantri Swasthya Bima Yojana
(MSBY) MDR-TB packages. The objective of this partnership was to absorb Dr Debashish Kundu, D-776,
the catastrophic expenses incurred by patients with MDR-TB, from diagnosis to First Floor, C R Park,
treatment completion, in the public and private sector. This paper documents the New Delhi – 110019, India
initial experience of a tailor-made health insurance programme, linked to covering Email: debashishkundu@yahoo.com,
catastrophic health expenditure for patients with MDR-TB. kundud@rntcp.org
Methods: In this descriptive study, data on uptake of insurance claims through
innovative MDR-TB packages from January 2013 to April 2014 were collected.
A simple survey of costs for clinical investigation and inpatient care was conducted
across two major urban districts in Chhattisgarh. In these selected districts, three
health facilities from the private sector and one medical college from the public
sector with a functional drug-resistant tuberculosis (DR-TB) centre were chosen
by the RSBY and MSBY State Nodal Agency to complete a simple, structured
questionnaire on existing market rates. The mean costs for clinical investigations
and hospital stay were calculated for an individual patient with MDR-TB who would
seek services from the private or public sector.
Results: A total of 207 insurance claims for RSBY and MSBY MDR-TB packages
were processed, of which 20 were from private and 187 from public health
establishments, covered under the health insurance programme, free of charge.
An estimated catastrophic expenditure, of approximately US$ 20 000, was saved
through the RSBY and MSBY health insurance mechanism during the study period.
Conclusion: The innovative RSBY and MSBY MDR-TB insurance package is a
step towards reducing catastrophic expenses associated with treatment for MDR-
TB.
Key words: catastrophic expenditure, health insurance, MSBY, multi-drug-
resistant tuberculosis, public–private partnership, RNTCP, RSBY, social protection

Kundu et al.: Catastrophic expenditure on MDR tuberculosis in Chhattisgarh, India
INTRODUCTION Mukhyamantri Swasthya Bima Yojna (MSBY), for those who

are not included in RSBY (see Tables 1 and 2). The poverty
Tuberculosis (TB) is primarily a disease of poverty. In India line is defined as the level of expected income that allows an
currently, there are 1 million so-called missed TB cases, as individual to consume enough food to maintain capacity for
the majority of these patients are probably seeking care in the labour intact.11 The RSBY and MSBY already had a Respiratory
private sector and so are missed from public-sector notification. Medical TB insurance package to cover the expenses of seriously
In many high-burden countries such as India, TB patients incur ill TB patients (confirmed bacteriologically or histologically
catastrophic expenditure, directly and indirectly, for diagnosis for TB), but this only applies during medical hospitalization
and treatment of their disease.2 The direct and indirect cost of (inpatient care basis) for a maximum period of 10 days (see
disease to India is estimated to be US$ 23.7 billion annually.3 Table 3). However, they did not have insurance packages
In India, 62 000 multidrug-resistant TB (MDR-TB) cases are specifically designed for patients with MDR-TB to cover their
estimated to emerge annually among notified pulmonary TB medical expenses with RNTCP linkages. Also, mechanisms to
cases,1 while a similar volume of cases are expected to be cover catastrophic expenses for all pre-treatment evaluations,
managed by the private sector but remain unnotified. These admissions, travel costs, follow-up investigations, ancillary
complex cases are more likely to be fatal and unnotified are drugs and nutritional support for patients with MDR-TB are
as much as 100 times more costly to treat,4 compared with not well established within and outside the programme.
drug-sensitive TB cases.5 The estimated market for annual
TB diagnostics in India is US$ 222 million (in both the public Countries in the lower middle income range, such as Brazil,
and private sector), of which the non-Revised National TB Cambodia, China, Rwanda, Mexico, South Africa and
Control Programme (non-RNTCP; private) sector accounts for Thailand have adopted national health insurance as models for
at least 62%.6 In the action framework of the World Health universal health coverage and a few case-studies demonstrate
Organization (WHO) End TB Strategy, one of the key targets set that integration of TB services with national health insurance
for 2035 is that there should be no TB-affected families facing has a positive effect on access to services and their quality.12
catastrophic costs due to TB.7,8 Removal of financial barriers to
health-care access is vital to achievement of universal health This study discusses the initial experience of linking RSBY
coverage9 and prevention of catastrophic expenditures. and MSBY provision, tailor-made to cover catastrophic health
expenditure for patients with MDR-TB; the potential of such
A number of social protection schemes are being implemented linkages for universal health coverage; and challenges and
by the central and state governments of India for improving future scope for the national TB control programme. The
TB patients’ access to and affordability of health care.10 The primary objective of this study is to ascertain (i) the proportion
Universal Health Insurance Scheme (UHIS) is one such of patients with MDR-TB who are diagnosed from a recognized
scheme in the State of Chhattisgarh in India, which provides laboratory in the state, who benefited from the innovative
health insurance coverage and protection to all people to RSBY and MSBY MDR-TB insurance claim packages;
fund medical treatment. UHIS is managed by the National and (ii) the number of claims made in both the private and
Health Insurance Programme, known as Rashtriya Swasthya public sector. The study also aimed to estimate the amount of
Bima Yojna (RSBY) for people below the poverty line and catastrophic expenditure possibly saved due to this innovative
the Chief Minister’s Health Insurance Scheme, known as social protection mechanism.
Table 1: Details of the Rashtriya Swasthya Bima Yojna (RSBY) and Mukhyamantri Swasthya Bima Yojna (MSBY)
package for poor and non-poor households
RSBY and MSBY – what is the scheme? Coverage amount Financing
RSBY is a cashless, paperless and Total insurance coverage amount is up to Beneficiaries need to pay only US$ 0.42
portable social health insurance scheme to `30 000 (US$ 500a) per annum as a registration fee, while the central and
that operates through smart cards. RSBY state government pay the premium to the
and MSBY, the Chief Minister’s Health insurer selected by the state government
Insurance Scheme in Chhattisgarh, on the basis of a competitive bidding.
also managed by RSBY, provide health Every beneficiary family is issued a
insurance coverage and protection to biometric-enabled smart card containing
people below and above the poverty line their fingerprints and photographs
to fund medical treatment for packages
covered in Round IV of the RSBY and
MSBY disease list in Chhattisgarh state:
●● on admission basis;
●● for five enrolled members in a family; US$ 17 (~US$ 2 per visit)
●● covering transportation expenses in
a year across all RSBY-empanelled
network hospitals (both private and
public) in the state
a
US$ 1 = `60.

Table 2: Details of the innovative Rashtriya Swasthya Bima Yojna (RSBY) and Mukhyamantri Swasthya Bima Yojna
(MSBY) MDR-TB package in Round IV
Number of times/
Medical/ MDR-TB package Package
Package details days claims can be
surgical name cost
processed
Medical Pre-treatment Chest X-ray, relevant haematological and `4000 Once
conditions evaluations biochemical tests: complete blood count (CBC), (US$ 67a)
liver function tests (LFT), thyroid function tests
(TFT), blood urea nitrogen (BUN), creatinine, urine
(routine & microscopic), urinary pregnancy tests
(UPT)
Medical Follow-up Chest X-ray, relevant haematological and `3300 Maximum five times
conditions evaluations biochemical tests: CBC, LFT, BUN, creatinine, (US$ 55) for creatinine and
urine (routine & microscopic) all other tests for
maximum of twice
Medical Hospital stay Bed charges, doctors’ consultation fees and any `5600 Maximum 7 days’ stay
conditions other additional/ancillary drugs (US$ 93 @ on pro-rota basis
US$ 13/day)
MDR-TB: multidrug-resistant tuberculosis.

a
US$ 1 = `60.
Table 3: Details of the RSBY and MSBY Respiratory Medical TB package

Number of days
Package
Medical Package name Package details claims can be
cost
processed
Fixed medical Respiratory TB Respiratory TB, bacteriologically and histologically US$ 158 10
package confirmed (seriously ill TB patients)
TB: tuberculosis.
METHODS to treat MDR-TB are toxic and expensive compared with those
used in the treatment of basic TB. While a course of standard
TB drugs costs approximately `765 (~US$ 13), MDR-TB
Setting drugs can cost `103 920 (~US$ 1732) based on the National
Programme’s drugs procurement cost.
The State of Chhattisgarh in central India (population 26
million) has 80% of the population living in rural areas,
of whom 30% are considered “tribal” (as notified by the Intervention
Government of India). Chhattisgarh is one of the pioneer states
in implementation of various information and communication A policy decision was taken in early 2012 by the Chhattisgarh
technology (ICT)-enabled schemes, which includes RSBY, the State Government to include packages under RSBY and MSBY
Centralised Online Real-time Electronic Public Distribution in various national health programmes, where hospitalization
System (Core PDS), and e-Kosh for e-transfer of salaries to is necessary. Leveraging this opportunity, the State TB Control
government staff. Programme in Chhattisgarh facilitated RNTCP partnership
with RSBY and MSBY through creation of innovative MDR-
Under the RNTCP in India, most patients diagnosed with TB packages (see Tables 1 and 2) under the UHIS, integrating
MDR-TB are initially hospitalized for a week or two at drug- it in a list of other disease packages in Chhattisgarh by
resistant TB (DR-TB) centres, established mostly at the medical December 2012.14 These packages are applicable for MDR-TB
colleges by the programme, for pre-treatment evaluations, patients, above and below the poverty line, who are diagnosed
initiation of treatment and monitoring early events of adverse as having MDR-TB, by a RNTCP-certified or any other
drug reactions.13 There were two functional DR-TB centres recognized laboratory. Beneficiaries are provided with RSBY
in Chhattisgarh, one each at the public sector medical college and MSBY smart cards for using the integrated schemes,
located in the districts of Raipur and Bilaspur, respectively, which are ICT enabled and also linked with the Core PDS
until early 2014. Expenditures for diagnosis (culture and drug- for nutrition support. Operational guidance on the RSBY and
sensitivity tests) and treatment of MDR-TB (second-line anti- MSBY MDR-TB packages was issued by the State TB Officer
TB drugs) are, as per policy, provided free of charge to the of Chhattisgarh to all concerned, in early 2013, to establish
patients registered for treatment under the public sector. Drugs close linkages with the RNTCP.

Study period and data collection per individual MDR-TB patient. A structured questionnaire
was completed by a field representative of the RSBY and
This is a descriptive study in which initial data on the uptake MSBY State Nodal Agency and mean costs on pre-treatment
of packages was collected from the RSBY server, accessible at investigations, hospital stay and follow-up investigations were
the RSBY and MSBY State Nodal Agency of the Directorate calculated for each patient with MDR-TB seeking services
of Health Services, Raipur, from January 2013 to April 2014 from either the private and public sector (see Table 4).
(for the Round IV period15 of the health insurance programme
in the state). This information was shared electronically for the
purpose of the study. A simple survey was conducted in public Data variables, data entry and analysis
health facilities (medical colleges where DR-TB centres are
located) and private health facilities, by the RSBY and MSBY The predefined data variables on hospital code, hospital
State Nodal Agency in the districts of Raipur and Bilaspur, name, package code, package name and claim status were
Chhattisgarh, to estimate the direct expenditure a patient with collected from the electronic server and then directly exported
MDR-TB incurs in the public and private sector, from diagnosis to Microsoft Excel for further analysis. Data were tabulated
to treatment completion. Estimates of indirect costs, such as and the following were calculated: the proportion of uptake of
daily wages lost and nutritional costs, were excluded, as the insurance claims of the RSBY and MSBY MDR-TB package by
study was based on record review of claims data and a simple patients with MDR-TB; the number of claims processed in the
estimate of direct costs incurred. A structured questionnaire public and private sector for both MDR-TB and TB packages;
was used to ascertain the cost for laboratory investigations and the amount of catastrophic expenditure estimated to be
(including the cost for X-rays) and a hospital stay in these saved by the UHIS.
health facilities.
The two districts of Raipur and Bilaspur were selected Ethical considerations
purposively, because they have an urban population and both
private-sector health facilities and a public-sector medical Since this study was a review of reports and did not involve
college with a functional DR-TB centre. From the selected patient interaction, individual patient consent was deemed
districts, three well-functioning private health facilities, unnecessary. The protocol was reviewed and permission to
identified by the RSBY and MSBY State Nodal Agency, and conduct the study was granted by the RSBY and MSBY State
a public-sector medical college with a functional DR-TB Nodal Agency, Directorate of Health Services, Government of
centre, were enrolled to enable estimation of the market cost Chhattisgarh.
Table 4: Estimated costs of laboratory investigation and hospital stay based on a simple market survey conducted in
Raipur and Bilaspur districts of Chhattisgarh
Private Public (medical colleges with DR-TB centres)
Items PTE, average FE, average HS, `800/ PTE, average FE average HS, `10/
cost, ` cost, ` bed × 7 days cost, ` cost, ` bed × 7 days
X-ray 263 525 55 110
Electrocardiogram 210 0 35 0
Laboratory analysis
Complete blood count 270 540 33 65
Liver function tests 525 1050 130 260
Creatinine 100 500 45 225
Blood urea nitrogen 100 200 25 50
Urine (routine & 85 170 8 15
microscopic)
Thyroid function tests 578 0 175 0
Urinary pregnancy 190 0 25 0
tests
HIV 315 0 400 0
Biopsy 488 0 105 0
OPD card 10 0 5 0
Total 3134 2985 5600 1041 725 70
DR-TB: drug-resistant tuberculosis; FE: follow-up evaluations; HS: hospital stay (including doctors’ fees, nutritional
support and ancillary drugs); OPD: outpatient department; PTE: pre-treatment evaluations.

RESULTS Considering that a patient with MDR-TB spends, on average,

`120 238 (~US$ 2000) in the private sector (without free
A total of 206 patients with MDR-TB were diagnosed from diagnosis and drugs) and `3636 (US$ 61) in the public sector
1 January 2013 to 30 April 2014, from recognized laboratories (with free diagnosis and drugs) from diagnosis to treatment
(especially from the intermediate reference laboratory) in the completion (see Table 6), the total catastrophic expenditure
state. Of these, 113 (55%; 7 from private and 106 from public estimated to be saved as a result of uptake of 207 health
health facilities); underwent one pre-treatment evaluation (see insurance claims by the MDR-TB patients (see Table 7) from
Table 5) before initiating treatment for DR-TB, as the MDR- this intervention during the study period was approximately
TB package on pre-treatment evaluation could only be claimed `1 169 709 (~US$ 20 000).
for once by a patient with MDR-TB (see Tables 4 and 5);
these patients benefited from the RSBY and MSBY MDR-TB
insurance packages. DISCUSSION
A total of 207 total health insurance claims under three For the first time in India, national health insurance was
different MDR-TB health insurance packages were processed successfully linked with the national TB control programme
in RSBY and MSBY empanelled private and public hospitals through creation of special packages for patients with MDR-
(see Table 5). Of these, 20 claims were from the private and TB. This is the first study that describes collaboration between
187 from the public hospitals (see Table 5). In the pre-existing RSBY and the RNTCP, and early findings of implementation
RSBY and MSBY Respiratory Medical TB Package, 196 of the RSBY and MSBY MDR-TB packages shows that this
claims were processed from the private hospitals and 137 from innovative mechanism is working. The possible implications
the public hospitals (see Table 5). of RSBY linkage with the RNTCP on policy and practice are
discussed next.
Table 5: Status of uptake of insurance claims by TB patients in RSBY (1 January 2013 to 30 April 2014)
Hospital type RSBY and MSBY
TB/MDR-TB Insurance claims
(public or private) package name
MDR-TB Private (private/NGO hospital) Pre-treatment evaluation (MDR-TB): 7
X-ray, laboratory analysis, CBC,
LFT, creatinine, BUN, urine (R&M),
TFT, UPT (only MDR-TB diagnosed
patient from recognized laboratory)
MDR-TB hospital stay (only 13
MDR-TB diagnosed patient from
recognized laboratory)
MDR-TB follow-up examination 0
(only MDR-TB diagnosed patient
from recognized Laboratory)
Public (district hospital/ Pre-treatment evaluation (MDR-TB): 106
community health centre/ X-ray, laboratory analysis, CBC,
primary health centre/medical LFT, creatinine, BUN, urine (R&M),
college) TFT, UPT (only MDR-TB diagnosed
patient from recognized laboratory)
MDR-TB hospital stay (only 68
MDR-TB diagnosed patient from
recognized Laboratory)
MDR-TB follow-up examination 13
(only MDR-TB diagnosed patient
from recognized laboratory)
Total claims in MDR-TB package 207
Public (district hospital/ Respiratory TB, bacteriologically 137
community health centre/ and histologically confirmed
primary health centre/medical
college)
Private (private/NGO hospital) Respiratory TB, bacteriologically 196
and histologically confirmed
Total claims in TB package 333
BUN: blood urea nitrogen; CBC: complete blood count; LFT: liver function tests; MDR-TB: multidrug-resistant tuberculosis; NGO: nongovernmental
organization; R&M: routine and microscopic; RSBY: Rashtriya Swasthya Bima Yojna; TFT: thyroid function tests; UPT: urine pregnancy tests.

Table 6: Estimated expenditure an MDR-TB patient incurs in the private and public sectora from diagnosis to treatment
completion
Private-sector expenditure, ` Public-sector expenditure, `
Average laboratory investigations cost (pre-treatment 3 134 1 041
evaluations – see Table 4)
Hospital stay including nutritional support, ancillary 5 600 70
drugs and doctors’ fees (for 7 days’ stay @ `800/
day in private and @ `10/bed per day in government
medical college hospital)
Average cost of laboratory investigations cost 2 985 725
(follow-up evaluations – see Table 4)
Travel costb 1 800 1 800
Drugs 103 920 c
Freee
Diagnosis 2 800d Freee
Total 120 238 (~US$ 2 000)f 3 636 (~US$ 61)f
MDR-TB: multidrug-resistant tuberculosis.

a
Costs were estimated considering the cost of drugs and diagnosis is absorbed by the Government in the public sector and is based on simple
market survey conducted in the districts of Bilaspur and Raipur, Chhattisgarh.
b
Travel cost of an MDR-TB patient is calculated based on expected 12 visits to a diagnostic laboratory @ INR 100 INR during follow-up visits and
minimum three visits with an attendant to the DR-TB centres @ `200.
c
Expected cost in the private sector, as similar cost is absorbed by the Revised National TB Control Programme (RNTCP) in the public sector.
Costing is based on personal communication received from Central Tuberculosis Division (CTD) on cost of first- and second-line anti-TB drugs
per patient on 17 July 2014.
d
Expected diagnosis cost in the private sector is based on culture and drug susceptibility testing scheme in RNTCP guidelines on revised
schemes for NGOs and private providers.
e
Cost of diagnosis and drugs is absorbed by RNTCP in government health facilities.
f
US$ 1 = `60.
Firstly, synergy with RSBY and MSBY to cover MDR-TB under the health insurance schemes, with improvement in the
broadens the scope of uptake of standardized services from the quality of care. However, as indicated by the simple market
public and private sector, free of charge, reducing catastrophic survey in Raipur and Bilaspur districts of Chhattisgarh, the
expenditure (~US$ 20 000 was estimated to be saved through availability of Programmatic Management of Drug Resistant
the RSBY and MSBY insurance mechanism), which was Tuberculosis (PMDT) services in the public sector is mostly
earlier untapped by the RNTCP. RSBY and MSBY makes the free of charge (especially the component of MDR-TB drugs
participating poor (below poverty line) and non-poor (above and diagnosis); this contrasts with the private sector in the state,
poverty line) household a potential client worth attracting, on where the cost is substantial. Therefore, without proper social-
account of the significant revenues that hospitals, in both the protection linkages such as the RSBY and MSBY MDR-TB
public and private sector, stand to earn through the scheme. health insurance packages, a greater number of patients may
The scheme has been designed as a business model for a not be able to afford private care for MDR-TB. Coincidentally,
social-sector scheme with incentives built for each stakeholder, this study also found that a total of 333 claims of the pre-
namely, insurers, hospitals and government. Even public- existing Respiratory Medical TB insurance package, without
sector hospitals have an incentive to treat beneficiaries under RNTCP linkages, were processed for TB patients requiring
RSBY, as the money from the insurer will come directly to inpatient care from RSBY- and MSBY-empanelled hospitals.
the concerned public hospital, where it can be used for their This could be indicative of increasing demand for affordable
own development. This will lead to healthy competition treatment services by the patients, both below and above the
between public and private hospitals, which, in turn, will poverty line, in these health facilities under health insurance
improve the functioning of public-sector hospitals. The RSBY cover, and requires further investigation.
and MSBY MDR-TB packages could empower patients with
DR-TB to avail cashless, paperless and portable transactions Initial acceptance of these integrated schemes by the providers
as per their choice, by increasing their access to any RSBY- and the beneficiaries clearly shows this model is able to fulfil
and MSBY-empanelled hospitals providing quality care its objectives to provide social protection to poor (below
across Chhattisgarh, thereby encouraging them to adhere to poverty line) and non-poor (above poverty line) households
treatment and achieve treatment success with better survival from catastrophic expenditures related to MDR-TB treatment.
probabilities. These integrated health insurance schemes have RSBY is a government-sponsored scheme especially for
triggered an increase in the number of providers involved, as the population of India living below the poverty line, and
many private hospitals have started treating MDR-TB cases the majority of the financing, about 75%, is provided by the

Table 7: Total catastrophic expenditure estimated to be saved due to uptake of insurance claims of RSBY and MSBY
MDR-TB packages
Number of claims processed/beneficiary costing
Unit cost Total expenses
Private sector Unit cost Public sector
(with free to be incurred
(number RSBY-MSBY (applicable (number
diagnosis by MDR-
RSBY-MSBY package name/ of claims MDR-TB cost per of claims
and TB patients
item processed package patient in processed
drugs in without any
or number of rate, ` private or number of
public insurance
beneficiaries) sector)b beneficiaries)
sector), ` cover, `
a b c d e f=
(a × c) + (d × e)
Claims processed in MDR- 7 4 000 3 134 106 1 041 132 284
TB pre-treatment evaluation
package (laboratory
investigations)
Claims processed in MDR-TB 13 5 600 5 600 68 70 77 560
hospital stay package
(up to 7 days’ stay)
Claims processed in MDR-TB 0 3 300 2 985 13 725 9 425
follow-up evaluation package
(laboratory investigations)
MDR-TB drugs 7 Linked with 103 920 106 Free 727 440
RNTCP
MDR-TB diagnosis 7 Linked with 2 800 106 Free 19 600
RNTCP
Total travel cost for MDR-TB 7 1000/year 1 800 106 1 800 203 400
patient and one attendant in 2
years of treatment
Total catastrophic expenditure 1 169 709
saved due to uptake of RSBY- (~US$ 20 000)a
MSBY MDR-TB health insurance
packages
MDR-TB: multidrug-resistant tuberculosis; MSBY: Mukhyamantri Swasthya Bima Yojna; RNTCP: Revised National Tuberculosis Control
Programme; RSBY: Rashtriya Swasthya Bima Yojna.
a
US$ 1 = INR60.
b
see table 4.
Government of India, while the rest is paid by the respective state drugs with RSBY and MSBY. There are 3 820 000 families
government. However, in the case of MSBY, the Government enrolled under the scheme and each year 8% of these families
of Chhattisgarh is financing 100% in implementation of its utilize RSBY and MSBY services in Chhattisgarh. RSBY and
schemes for households both below and above the poverty line, MSBY cover most of the diseases that require hospitalization,
with assurance of full financial support. RSBY and MSBY including pre-authorization, apart from immunization,
have provision for secondary care treatment up to US$ 500 alcohol-induced disease and war-related injuries. A third-
(`30 000) in a year. The cost for each procedure has been fixed party evaluation of RSBY implementation in Chhattisgarh has
and a household can only avail only up to US$ 500, even if a indicated that 80% of people rated their satisfaction from the
single procedure absorbs the entire amount. However, it has schemes as “good” (34%), “very good” (28%) or “excellent”
been observed over the years by the RSBY and MSBY State (18%).15
Nodal Agency that the mean hospitalization cost per patient in
Chhattisgarh is around US$ 133 (`8000) through RSBY, and Secondly, hospitals empanelled under RSBY are ICT enabled
so the integrated packages for MDR-TB patients can be well and connected to the server at the district and state level,
absorbed in the health coverage ceiling of US$ 500. In this ensuring smooth data flow regarding service utilization; this
integration model, MDR-TB drugs should be provided free can be an opportunity to improve TB notification in the private
of cost from the programme when a patient seeks treatment sector through the existing ICT platform in the RSBY health
services from the RSBY- and MSBY-empanelled hospital in insurance scheme, by bridging it with NIKSHAY, the national
the private sector. An initial guidance document was issued online case-based notification and patient tracking system in
by the State TB Officer of Chhattisgarh for linking MDR- India.
TB treatment initiation by national government-approved TB

Thirdly, the claims were processed after the launch of by the MDR-TB patient, with or without HIV co-infection, and
the RSBY and MSBY MDR-TB packages in early 2013– the social-protection strategy adopted by the states to mitigate
2014, with minimum advocacy communication and social this expenditure for impacting MDR-TB outcomes, could also
mobilization (ACSM) activities such as media publicity, be a topic for further research.
sensitization meetings etc., carried out by the RSBY State
Nodal Agency. Whenever a new, innovative and integrated
scheme is introduced in the system, an awareness campaign CONCLUSION
is an important component for the success of the scheme.
Therefore, proper planning, coordination, awareness (ACSM) Initiation of decentralized treatment of DR-TB patients in
activities and sensitization of the RNTCP and RSBY staff RSBY and MSBY empanelled health facilities (both public and
are essential to improve uptake of the claims and resolve private) due to RSBY and MSBY MDR-TB packages, indicates
any operational challenges towards its implementation in that initiation of treatment for MDR-TB is not only limited to
Chhattisgarh. The RSBY and MSBY MDR-TB insurance DR-TB centres in the medical colleges of the state. This is an
package model in Chhattisgarh can also be scaled up across the innovative step towards making systems more efficient for the
country through proper ACSM activities. There is a pertinent management of patients with MDR-TB, with the possibility of
need for further systems to be built up jointly by RNTCP and reducing the time between diagnosis of MDR-TB to initiation
RSBY, to operationalize successful implementation of these of treatment for MDR-TB. Coverage through RSBY insurance
innovative and integrated schemes in the state with adequate schemes is primarily based on hospitalization, to make
awareness campaigns. use of the packaged services and not outpatient treatment.
Considering that treatment for both drug-resistant and drug-
This study had certain limitations. Firstly, it was expected sensitive TB is ambulatory and takes a long time to complete,
that each patient with MDR-TB would undergo pre-treatment outpatient care needs to be included in the mainstream health
evaluations once under hospitalization, before initiating the insurance. RNTCP collaboration with RSBY and MSBY can
DR-TB treatment. However, it was found that, in the public ensure financial protection to patients with TB, and, in order to
sector, fewer claims (68) were processed for hospital stays address the social-protection component of the post-2015 End
than for pre-treatment evaluations (106), while in the private TB strategy,7, 8 mechanisms emphasizing collaboration with
sector, more claims for hospital stays (13) than for pre- existing social health insurance schemes need attention in the
treatment evaluations (7) were processed. It is possible that a national policy framework for TB control.
greater preference for pre-treatment evaluations for MDR-TB
patients, followed by decentralized outpatient treatment and
care (not limited to the DR-TB centres) has started in RSBY- ACKNOWLEDGMENTS
and MSBY-empanelled hospitals in the public sector, in an The authors acknowledge the assistance provided by the
attempt to optimize convenience for patients with MDR-TB. staff of the Rashtriya Swasthya Bima Yojna (RSBY) and
On the other hand, it is observed that, in the private sector, Mukhyamantri Swasthya Bima Yojana (MSBY) State Nodal
more emphasis is placed on inpatient care for patients with Agency, Directorate of Health Services, Government of
MDR-TB. MDR-TB patient admissions to hospital in the Chhattisgarh. The State TB Officer of Chhattisgarh provided
private sector resulting from adverse drug reactions also cannot initial guidance to operationalize integration of RSBY and
be ruled out. These new patterns of seeking pre-treatment MSBY multidrug-resistant tuberculosis (MDR-TB) health
investigation for MDR-TB patients in public and private sector insurance packages with the Revised National TB Control
health establishments, emerging since the launch of MDR-TB Programme. The cost estimate of first- and second-line anti-
insurance packages, need to be further explored. There is scope TB drugs per patient in India was communicated by Strategic
for separate research in this area to establish the relationship Alliance Management Services, Central TB Division,
between treatment seeking and the new insurance packages, Ministry of Health and Family Welfare, Government of India.
and implications for treatment outcomes of MDR-TB patients A workshop was convened in Delhi, India, for the purpose of
in the two years since introduction of the integrated MDR-TB building capacity in writing scientific papers. The workshop
packages in January 2013. was run by the World Health Organization Country Office for
Secondly, the study’s estimation of the cost a patient with India, New Delhi, India.
MDR-TB incurs for pre-treatment investigations, admissions,
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A cross-sectional survey of the models
in Bihar and Tamil Nadu, India for
pooled procurement of medicines
Maulik Chokshi1, Habib Hasan Farooqui1, Sakthivel Selvaraj2, Preeti Kumar2
ABSTRACT 1
Indian Institute of Public Health –
Background: In India, access to medicine in the public sector is significantly Delhi, Public Health Foundation of
affected by the efficiency of the drug procurement system and allied processes India, New Delhi,
and policies. This study was conducted in two socioeconomically different states: 2
Public Health Foundation
Bihar and Tamil Nadu. Both have a pooled procurement system for drugs but of India, New Delhi
follow different models. In Bihar, the volumes of medicines required are pooled
at the state level and rate contracted (an open tender process invites bidders Address for correspondence:
to quote for the lowest rate for the list of medicines), while actual invoicing and Dr Habib Hasan, Associate
Professor, Indian Institute of
payment are done at district level. In Tamil Nadu, medicine quantities are also
Public Health – Delhi, Plot No
pooled at state level but payments are also processed at state level upon receipt 47, Sector 44, Institutional Area,
of laboratory quality-assurance reports on the medicines. Gurgaon-122002, Haryana, India
Methods: In this cross-sectional survey, a range of financial and non-financial data Email: drhabibhasan@gmail.com
related to procurement and distribution of medicine, such as budget documents,
annual reports, tender documents, details of orders issued, passbook details and
policy and guidelines for procurement were analysed. In addition, a so-called ABC
analysis of the procurement data was done to to identify high-value medicines.
Results: It was observed that Tamil Nadu had suppliers for 100% of the drugs
on their procurement list at the end of the procurement processes in 2006, 2007
and 2008, whereas Bihar’s procurement agency was only able to get suppliers
for 56%, 59% and 38% of drugs during the same period. Further, it was observed
that Bihar’s system was fuelling irrational procurement; for example, fluconazole
(antifungal) alone was consuming 23.4% of the state’s drug budget and was being
procured by around 34% of the districts during 2008–2009. Also, the ratios of
procurement prices for Bihar compared with Tamil Nadu were in the range of 1.01
to 22.50. For 50% of the analysed drugs, the price ratio was more than 2, that is,
Bihar’s procurement system was procuring the same medicines at more than twice
the prices paid by Tamil Nadu.
Conclusion: Centralized, automated pooled procurement models like that of
Tamil Nadu are key to achieving the best procurement prices and highest possible
access to medicines.
Key words: Access to medicines, medicine availability, medicine prices, pooled
procurement
INTRODUCTION systems and medicines policy. Around 90% of the global burden
of disease is in low- and middle-income countries,2 whereas
The World Health Report 2000 defines three intrinsic goals of their global share in health-care expenditure is only 10%.3
the health system – to improve health, to be responsive to the Furthermore, the pattern of expenditure on pharmaceuticals
legitimate demands of the population, and to ensure that no is skewed towards high-income countries; they account for
one is at risk of serious financial losses because of ill health.1 78.5% of global pharmaceutical expenditure, whereas low-
Inequities in access to medicines reflect failures in health and middle-income countries account for only 11.3%. In 2011,

Chokshi et al.: Pooled procurement of medicines in Bihar and Tamil Nadu, India
the per capita pharmaceutical expenditure in high-income METHODS

countries was US$ 431.6 compared with US$ 7.61 in low-
and middle-income countries. Pharmaceutical expenditure The selection of states in this study was purposively determined,
has been reported to be positively correlated with health-care based on need to capture the availability of essential medicines
utilization.5–7 in different models of procurement as well as geographical,
socioeconomic and cultural diversity. The study was conducted
One of the key barriers to access to medicines is price, which in two socioeconomically diverse states: Bihar and Tamil
is an outcome of competition in the pharmaceutical industry, Nadu. Both states have a pooled procurement system but
innovation and brand loyalty.8–10 Other factors include the follow different models. Bihar uses a so-called cash and carry
disease profile of the country, the systems of delivery of health- model, where the volumes of medicines required are pooled at
care services, and consumer-related factors.11 In addition, an the state level and rate-contracted, while actual invoicing and
inefficient procurement system and suboptimal processes payment is done at the district level. In Tamil Nadu, medicine
and policies, such as lack of a standard bidding document, quantities are pooled at the state level, as in Bihar, but payments
delays in awarding contracts, irregularity in supplier selection, are processed at state level upon receipt of laboratory quality-
procurement at higher rates, delay in supply, non-utilization assurance reports on the medicines. The drug distribution is
of products, poor quality of products and underutilization of then carried out through a value-based passbook issued to
funds,12 also lead to poor access to medicines. India ranks third each health facility. A comparative assessment was conducted
globally in terms of production of medicines, and 38% of the between the models in Tamil Nadu and Bihar.
global population with no access to medicine lives in India.4
To capture the diversity at the district level, 17 districts
In India, procurement of medicines and medical supplies in from Bihar and 18 districts from Tamil Nadu were selected.
the health system takes place at various levels, namely the Districts were selected using a combination of economic and
national/federal level, state level, local government level and geographical criteria. Data from the Economic Survey 2008–
by autonomous bodies. In addition, medicines for national 200914 and the Department of Economics and Statistics, 2006–
disease-control programmes, such as the Revised National 2007,15 for Bihar and Tamil Nadu, respectively, were used for
Tuberculosis Control Programme, National AIDS Control ranking the districts as economically rich, moderate or poor.
Programme and others, are procured through a national This selection was also adjusted to geographical criteria by
procurement agency. Indian states procure medicines for mapping the districts on a political map to capture the specific
their health systems through their own procurement agencies, geographical representation from each state.
although they may also receive funding from the national
government. States such as Tamil Nadu, Kerala and now Thirty health facilities were selected from the study districts of
Rajasthan follow a so-called centralized procurement and each state for primary data collection. In Bihar, the 30 health
decentralized distribution system, whereas several other states facilities were located in 17 of the 38 districts; in Tamil Nadu,
follow a decentralized procurement and distribution process, the facilities were in 18 of the 32 districts. The selected health
with an annual so-called rate contract, where bidders are invited facilities are first-level referral units (called referral hospitals
to quote for the lowest rate for the list of medicines, through in Bihar and upgraded primary health care [PHC] facilites in
an open tender process. In some states, a central medical Tamil Nadu) that are essentially 30-bed hospitals catering for
stores department procures medicines for the health system a population of about 100 000. First-level referral units were
through an annual rate contract. The Chief Medical Officers chosen for the survey since a substantial volume of drugs is
or Medical Superintendents at the district level are empowered dispensed from these facilities. Furthermore, the selection
to place orders for required medicines with the rate-contracted of health facilities in each district was based on the size of
supplier, for health facilities in their jurisdiction. They are also the district and distance from district headquarters; at least
empowered to make payments through the general treasury one health facility located closest to the district headquarters
within the limit of their budget, which is mostly on a pro rata was selected from each district and more than one facility
basis. These models that have been adopted by the national was selected from larger districts. The proportion of selected
and state governments are based on their requirements and facilities across Tamil Nadu and Bihar was 14% and 43%,
administrative convenience. respectively. The significantly higher number of upgraded
PHCs in Tamil Nadu than in Bihar resulted in selection of a
However, these procurement agencies differ in many ways, lower proportion of facilities in Tamil Nadu.
such as in their governance structure, financial management,
tender guidelines, distribution of drugs, preference for In addition, a range of financial and non-financial data related to
manufacturers. Also, there is limited evidence on the efficiency procurement and distribution of medicine were obtained from
of pooled procurement at national level,13 especially in terms state government authorities, in the form of budget documents,
of the impact of the procurement model on procurement annual reports, tender documents, orders, issue details,
prices and medicine availability at the facility level. In this passbook details, policy and guidelines for procurement.
context, this study was undertaken to measure the impact of Another set of data used for the purpose of financial analysis
two different procurement models on procurement prices and is state-level budget documents providing details on financial
medicine availability at the facility level, and competition allocation for medicine. In addition, published literature on the
among the medicine suppliers.

official website of the medicine procurement department of Table 1: Health systems in the states of Bihar and
the respective state governments was downloaded, to collect Tamil Nadu
information relating to tender documents, prices, procurement
Demographic indicators18 Bihar Tamil Nadu
policy and guidelines.
Total population (Census 2001),
828.8 624.1
Furthermore, a so-called ABC analysis was undertaken to millions
identify high-value medicines in the procurement systems. Maternal mortality rate per 100 000
ABC analysis reveals which drug items account for the greatest 312 111
live births
proportion of the budget. The monetary value of consumption
Infant mortality rate per 1000 live
is calculated by multiplying the unit cost by the number of 56 31
births
units consumed for all drugs, from which the percentage of
total consumption for each medicine is calculated. This is Crude birth rate per 1000
28.9 16.0
compared with the cumulative percentage value of the total population
value for each medicine. Medicines are then categorized as Crude death rate per 1000
8.8 7.4
A: the few medicines that account for 75–80% of the total population
value; B: the medicines that account for the next 15–20% Health infrastructure19
of value; and C: the bulk of medicines that only account for
the remaining 5–10% of value.16 The common medicines Subcentres 8858 8706
were further analysed for prices and competitiveness of the Primary health centres 1641 1215
procurement model. Price comparison was also done between Community health centres 70 206
the prices of the medical service corporations and the lowest
and highest market prices for individual drugs, using the 2008 Doctors at primary health centres 1565 2260
Monthly Index of Medical Specialities.17 The same data set was Pharmacists 439 1349
also used to estimate the number of bidders in medical service
corporations, as compared to private retail market suppliers.
Landscaping of procurement models
The primary survey across health facilities in Tamil Nadu and
Bihar was conducted between August 2009 and March 2010. The pooled procurement models of both Tamil Nadu and Bihar
The study protocol was approved by the ethics committee of follow a two-bid system (technical bid and commercial bid) for
the Public Health Foundation of India. tendering once a year, but their governance and organizational
structures are significantly different. The Tamil Nadu
procurement agency is known as the Tamil Nadu Medical
RESULTS Services Corporation (TNMSC), which is an autonomous
agency that functions through the Tamil Nadu Transparency
India’s health system is characterized by significant diversity,
in Tenders Act, 1998.22 The Act and associated rules provide
as states within the country are constitutionally provided with
details on the methods of tendering, the publicity requirements,
the mandate of delivering health-care services. However, there
technical specifications (information on the product quality,
are wide variations between the states and its health systems,
packaging and manufacturing practices), commercial
as seen from Table 1, which compares Tamil Nadu and Bihar,
conditions (information on product prices, inclusive of taxes,
the two states in this study.
logistics and material cost), evaluation criteria, place and time
In terms of health indicators and health outcomes, Tamil Nadu for receipt of tenders, minimum time for submission of bids,
is one of the best-performing states in India, largely due to a time/place of opening of bids, time to be taken for evaluation
well-developed health system, whereas Bihar’s performance and extension of tender validity, determination of the lowest
has been relatively poor. The Human Development Index evaluated price, and preparation of the evaluation report and
(HDI) is a composite indicator of literacy, life expectancy and award of tenders.
per capita income; the Government of India’s National Human
In Bihar, the State Health Society, a state-level agency guided
Development Report of 2002 reported that HDI had increased
by the principles of the centrally-funded National Rural Health
for Bihar, as for the rest of India, but at 0.367 was still lower
Mission (NRHM), functions as the procurement agency.
than the Indian average of 0.472.20 By contrast, Tamil Nadu
Under the State Health Society, the Directorate of Health
was among the top few states in terms of the HDI, with 0.531
Services oversees the entire procurement process and follows
points in 2001.20 The stark contrasts between these two states
procedures laid down in the Bihar Finance (Amendment)
are visible in every available indicator. In 2007, institutional
Rules 2005.23 These rules clearly define the entire procurement
deliveries in Bihar were low at 22% compared to 90% for
process. However, the tender lacks information on criteria for
Tamil Nadu.21 Similarly, immunization rates in Tamil Nadu
technical and commercial bids, especially on the quantity to be
were around 80%, against Bihar’s 33%.21 The other health
supplied, transportation cost, order period and schedule.
outcome indicators, namely infant and maternal mortality,
point to similar trends.21

Both Tamil Nadu and Bihar follow a two-bid system – advance payment is made to the winning bidders for procuring
technical tenders and commercial tenders are separate. drugs and they are required to to establish depots/warehouses in
However, the processes followed for bid opening and supplier the state capital city, Patna, and other district headquarters for
finalization differ. In Tamil Nadu, the committee of state ensuring supplies across the state. The District Health Society,
representatives first opens the technical bid; if the technical which receives funds from the State Health Society, makes
bid is successful, the commercial bid is then opened, but the advance payments for the medicine procurement. However,
rest are not considered. The entire process is transparent, the payments have to be approved by the district magistrate
as all the successful bidders are invited to participate in the and medical officer, resulting in delays that lead to shortages at
tender-opening process, to share their price information and to facilities level. In addition, it was noticed that, in Bihar, there
identify the lowest bidder (L1). The L1 rates are announced on were multiple mechanisms for drug procurement at the district
the day of bid opening, physically as well as electronically. In level, apart from cash and carry, which include buying drugs
Bihar, on the other hand, there is a special committee called the without quotations, instruction from the State Health Society
Project Appraisal Committee, which includes a representative for drug procurement, three quotations and open tender within
from each pharmaceutical company with a successful technical thresholds defined by the Bihar Finance (Amendment) Rules,
bid and undertakes a process similar to Tamil Nadu for supplier 2005,23 or through order passed by the District Collector.
finalization, but L1 rates are not announced on the same day.
In the event of the lowest bidder being unable to provide an
adequate supply of medicines for some reason, in Tamil Nadu, Efficiency of the centralized
price negotiation takes place with the second-lowest supplier procurement model
to supply at L1 rates, whereas in Bihar, price negotiations are
conducted to secure a better price for tendered drugs. As shown in Table 2, in terms of competitiveness, the TNMSC
model is quite successful and is able to attract more suppliers
The financing and distribution systems are also quite than the Bihar model. The competitiveness is defined as the
different for each state. In Tamil Nadu, TNMSC operates in number of supplier’s applications, successful tenders and
an integrated manner, where the funds for drug procurement products supplied to the facilities. The numbers of firms
are deposited into a public account of TNMSC by each health submitting bids in Bihar was low at 29, 25 and 31 tender
facility. The health facility receives a passbook in return for applications for 89, 91 and 369 medicines during 2006, 2007
the amount deposited, which is generally 90% of the facility and 2008 respectively. However, during the same period in
drug budget. This allows the facility to pick up the drugs from Tamil Nadu, the numbers of bidders were 135, 124 and 100
the district warehouses every quarter without any financial for 270, 271 and 252 drugs respectively, although it should be
transaction. Further, automation of the processes is a key noted that in both states the numbers of bidders reduced for
attribute of TNMSC. For example, in automation of financial each year but the number of drugs per bidder increased.
management, once the reports on receipt of a consignment and
approved quality are received by TNMSC, electronic transfer It should also be noted that in Bihar, the number of products
of funds to the suppliers takes place by default. In addition, in for which tender was invited increased between 2006 and
Tamil Nadu, all financial transactions take place at the state 2008, from 89 to 369, an increase of over 300%. Similarly,
level, including payment to the suppliers, whereas in Bihar, the percentage of successful technical bids for year 2007–
the drug-distribution system functions through a so-called 2008 in Bihar was 87%, compared with 65% in Tamil Nadu,
push and pull mechanism. The pull mechanism is based on but the percentage of successful commercial bids was only
an innovative so-called cash and carry approach, where an 70%, as compared to 100% for Tamil Nadu. Hence, in terms
Table 2: Competitiveness in the procurement system, Bihar and Tamil Nadu models
Bihar Tamil Nadu
Variable
2005–2006 2006–2007 2007–2008 2005–2006 2006–2007 2007–2008
Number of drugs tendered 89 91 369 270 271 252
Number of drugs with no bidder 39 37 NA 0 0 0
Number of firms submitting bids 29 25 31 135 124 100
Number of drugs per bidder 3.0 3.6 12 2 2.1 2.5
Number of successful technical bids 14 19 27 76 77 65
% of successful technical bids 48.2 76.0 87.1 56.3 62.1 65.0
Number of successful commercial bids 9 13 22 76 77 65
% of successful commercial bids 31.0 52.0 70.0 100 a
100 a
100 a
Number of products selected 50 54 141 270 271 252
% of products selected 56.1 59.3 38.2 100 a
100 a
100 a
a
All payments are processed on receipt of a laboratory quality-assurance report, thus the figure is 100%.
NA – Not available

of competitiveness, this cannot be attributed as healthy budget was spent on the procurement of non-rate-contracted
competition because many products/drugs found no supplier drugs, which were not on the state’s Essential Drug List.24 These
in Bihar by the end of the procurement process. In the context inefficiencies can be largely attributed to the decentralized
of efficiency, TNMSC is very successful, as 100% of drugs on procurement and distribution system followed in Bihar. It was
their procurement list had a supplier at the end of procurement not possible to perform similar district-wise analysis for Tamil
process, while in Bihar only 56%, 59% and 38% of drugs on Nadu, as the pooled procurement takes place at state level.
their list had a supplier by the end of procurement process in However, ABC analysis of Tamil Nadu pooled-procurement
2006, 2007 and 2008 respectively (see Table 2). data for 2007 highlighted that, of 20 drugs that accounted for
around 80% of the state drug expenditure, 11 were antibiotics.
Inefficiencies of the decentralized cash In terms of prices, both procurement systems, TNMSC and
and carry procurement model Bihar, were able to procure medicines at prices that were
significantly lower that the retail market prices, with some
As shown in Table 3, decentralization of financial autonomy exceptions. However, the prices at which TNMSC procured
might fuel inefficiency in the procurement system. An ABC were significantly lower than the Bihar procurement prices.
analysis16 was performed and it was observed that 17 drugs The prices of 15 medicines with comparable formula, pack
accounted for 71% of state drug expenditure. Of these 17 size and strength across Tamil Nadu and Bihar were selected
drugs, nine were antibiotics, two were cough syrups and from a so-called basket of drugs list containing 22 drugs. It was
two were multivitamins. In 2008–2009, an antifungal drug observed that the ratio of prices in Bihar compared with Tamil
fluconazole consumed 23.4% of the state drug expenditure and Nadu was in range of 1.01 to 22.50. For example, the unit price
was procured by approximately 34% (13/38) of the districts. of paracetamol syrup (60 mL bottle) was almost same for Bihar
Similarly, the antibiotic azithromycin accounted for 5.6% of and Tamil Nadu (see Table 4). However, chlorpheniramine
state drug expenditure and was procured by only two districts, tablets (4 mg) had the highest price ratio of 22.50 per unit
norfloxacin consumed 1.4% of expenditure and was procured purchase for Bihar (` 0.45), as compared to Tamil Nadu
by four districts. In addition, around 57% of Bihar’s drug (` 0.02). For seven out of 14 medicines, the price ratio was more
Table 3: Drug expenditure on various medicines, Bihar, 2008–2009

Number of
% of the overall
Serial Therapeutic districts
Name Specification Quantity procurement
number category purchasing
budget
(n = 38)
1 Fluconazole Tablet 150 mg Antifungal 741 000 23.44 13
2 Anti-rabies vaccine Vial 0.5 mL Vaccine 465 342 14.95 38
3 Azithromycin Tablet 250 mg Antibiotic 706 000 5.57 2
4 Cough expectorant 100 mL pack Respiratory 2 835 606 4.38 36
system
5 Vitamin B complex Syrupa Vitamins 1 529 129 4.00 34
6 Ciprofloxacin (E) – tablet Tablet 500 mg Antibiotic 18 711 999 3.78 31
7 B complex Tableta Vitamins 33 155 490 1.88 38
8 Ciprofloxacin + tinidazole Tablet Antibiotic 6 401 935 1.86 22
500 mg + 600 mg
9 Ciprofloxacin Tablet 250 mg Antibiotic 12 238 590 1.62 27
10 Norfloxacin Tablet 800 mg Antibiotic 240 000 1.41 4
11 Amoxicillin Capsule 250 mg Antibiotic 5 029 796 1.35 26
12 Cough sedative Syrup 100 mL Respiratory 761 602 1.27 17
system
13 Oral rehydration salt (ORS) 20.5 g Alimentary 3 282 900 1.15 26
system
14 Erythromycin Tablet 500 mg Antibiotic 3 186 700 1.14 19
15 Pantoprazole Tablet 40 mg Antiemetic 177 387 1.10 3
16 Ampicillin Capsule 500 mg Antibiotic 2 141 700 1.08 6
17 Metronidazole Tablet 400 mg Antibiotic 17 093 320 1.06 37
a
Data not provided on pack size/dose.

Table 4: Price per unit of drug procurement in Tamil Nadu, Bihar and retail market, 2008–2009
Tamil Nadu Retail market prices
Name of drug Bihar (`) Ratio
(`) range17 (`)
Albendazole tablet (400 mg) 0.94 0.49 1.91 0.75–1.48
Amoxicillin capsule (250 mg) 1.59 0.71 2.24 3.1–4.5
Chlorpheniramine maleate tablet (4 mg) 0.45 0.02 22.50 NAa
Ciprofloxacin tablet (500 mg) 1.20 0.97 1.24 3.9–9.5
Cough syrup (50 mL bottle) 9.16 3.36 2.73 NAa
Diclofenac sodium tablet (500 mg) 0.21 0.12 1.75 1–2.3
Gentamicin eye/ear drops (5 mL) 4.02 0.02 1.61 NAa
Metronidazole tablet (400 mg)b 0.19 0.14 1.36 0.35–3.6
Paracetamol syrup 125 mg/5 mL (60 mL bottle) 4.65 4.59 1.01 NAa
Ranitidine tablet (150 mg) 0.37 0.18 2.06 0.42–0.57
Salbutamol tablet (4 mg) 0.18 0.04 4.50 0.16–0.28
Erythromycin stearate tablet (250 mg) 1.09 0.66 1.65 2.3–3.5
Co-trimoxazole tablet (80 mg trimethoprim + 400 mg 0.80 0.18 4.44 0.59–0.89
sulfamethoxazole)
Calcium lactate tablet (300 mg) 0.40 0.06 6.67 NAa
a
NA reflects non-availability of similar formulation in the retail market.
b
200 mg tab in Tamil Nadu.
than 2, that is, the Bihar procurement system was purchasing In addition, it was observed that the TNMSC tender documents
the same medicines at twice the prices paid by TNMSC. Also, were explicit and detailed, running into hundreds of pages
in some instances, Bihar procured medicines at a price that was itemizing each step of the procurement processes, which has
higher than the lowest retail price. For example, albendezole resulted in efficient implementation and has significant bearing
tablets and salbutamol tablets were procured at higher prices on attracting bidders. Further, this positive effect of attracting
than the lowest retail prices that is, (` 0.94 and ` 0.18 per unit a high number of bidders has positive effects in terms of
procurement prices compared with a retail price of ` 0.75 and enhancing competition and efficiency. It was further observed
` 0.16 for albendazole and salbutamol, respectively). that the integrated nature of the procurement and financing
function in TNMSC has also contributed to lower prices. Since
the suppliers are aware of the entire process, responsibilities
DISCUSSION and expected timelines, including supply costs and payment
schedules, there is a high number of bidders, with the benefit
It is pertinent to point out that the efficiency of any procurement that lower prices are quoted.
system depends on how well the individual functions of
financing, regulation, tendering and stakeholder involvement This observation is also reinforced by the fact that
are performed. This study observed that the TNMSC model multistakeholders’ engagement in the TNMSC procurement
is a good example of how clear rules and regulations, system strengthens its implementation and builds confidence
along with clearly outlined processes for implementation, in the process. One of the key features of TNMSC is that
can help in attainment of a high level of transparency and the opening of the bids for rate finalization takes place in
accountability.25,26 In terms of governance, TNMSC has been the presence of all the successful tender applicants. This has
established as an autonomous agency, through the Tamil Nadu significantly increased the transparency of and confidence in
Transparency in Tenders Act, 1998,22 which has resulted in the system. This confidence in the system, along with assured
seamless implementation of policy guidance and trust between timeliness of payments, has positively influenced the behaviour
the state and the procurement agency. However, the Bihar of suppliers, which has resulted in regular supply of drugs at the
procurement agency follows the guiding principles laid down facilities, hence increasing the availability of drugs to the end
by the federal government, as it receives funding from the users. It also is evident from the analysis of tender documents
federal government to procure medicines through its flagship (see Table 2) that transparency in the process results in high
programme, National Rural Health Mission (NRHM). The levels of competition and does have an effect on the prices
implementation of NRHM is largely decentralized through the and availability of drugs.16 It is also reported that although
State and District Health Societies, which sometimes results the TNMSC system may not always provide a level playing
in inefficiencies in procurement, resulting from an absence of field to all the suppliers, the competition among suppliers has
economies of scale and lack of regulatory control. brought down the procurement prices of the drugs.8

However, in Bihar’s cash and carry model, because of pooled procurement and decentralized distribution system
decentralized payment structures and uncertainty in payment such as TNMSC can ensure efficient utilization of the financial
schedules, the bidders tend to quote higher prices for drugs resources available for procurement, through ensuring a
on tender. Similar observations have emerged from analysis of transparency and accountability in the procurement system.
private-sector drug prices, where assumed delays in payments A procurement system like TNMSC also helps in achieving
have contributed to higher drug prices.27 Further, as observed in good value for money for the government. In addition, through
the Bihar model, rate contracting and decentralized financing multistakeholder engagement and a transparent process, it
were fuelling inefficient procurement for certain classes of ensures trust and confidence in the system, which ultimately
drugs in specific districts, leading to high expenditure (see Table translates into an increased number of bidders, increased
3). Further, it is important to understand that the procurement competition among suppliers and lower purchase prices for
models and processes may need some time to mature and medicines for the government.
generate desired results. As seen in the Bihar model, the
procurement system and processes have refined significantly
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Policy and practice Website: www.searo.who.int/

Barriers and facilitators to development
of standard treatment guidelines in India
Sangeeta Sharma,1,2 Gulshan R Sethi,3
Usha Gupta,2,4,5 Ranjit Roy Chaudhury2,6,7
ABSTRACT
1
Department of
This paper describes 15 years’ experience of the development process of the Neuropsychopharmacology, Institute of
first set of comprehensive standard treatment guidelines (STGs) for India and Human Behaviour and Allied Sciences,
their adoption or adaptation by various state governments. The aim is to shorten Shahdara, Delhi, India, 2Delhi Society
the learning curve for those embarking on a similar exercise, given the key role for Promotion of Rational Use of
of high-quality STGs that are accepted by the clinical community in furthering Drugs (DSPRUD), New Delhi, India,
universal health coverage. The main overall obstacles to STG development are: 3
Department of Paediatrics, Maulana Azad
(i) weak understanding of the concept; (ii) lack of time, enthusiasm and availability of Medical College and L N Hospital, New
local expertise; and (iii) managing consensus between specialists and generalists. Delhi, India, 4Nodal Corporate Resource,
Major concerns to prescribers are: encroachment on professional autonomy, loss Fortis Healthcare Ltd, Delhi, India,
of treating the patient as an individual and applying the same standards at all
5
Department of Pharmacology, Maulana
Azad Medical College, New Delhi, India,
levels of health care. Processes to address these challenges are described. At the 6
National Academy of Medical Sciences,
policy level, major threats to successful completion and focused implementation
New Delhi, India
are: frequent changes in governance, shifts in priorities and discontinuity. In the 7
Advisor, Health, Government of
authors’ experience, compared with each state developing their own STGs afresh, National Capital Territory of Delhi,
adaptation of pre-existing valid guidelines after an active adaptation process Delhi and Chairman, Task Force for
involving local clinical leaders is not only simpler and quicker but also establishes Research, Apollo Hospitals Educational
local ownership and facilitates acceptance of a quality document. Executive orders and Research Foundation (AHERF)
and in-service sensitization programmes to introduce STGs further enhance their
adoption in clinical practice. Address for correspondence:
Sangeeta Sharma, Department of
Key words: Evidence-based guidelines, essential medicines, standard treatment Neuropsychopharmacology, Institute of
guidelines (STGs), rational use of medicines Human Behaviour and Allied Sciences
(IHBAS), Delhi 110095, India
Email: sharmasangeeta2003@gmail.com
INTRODUCTION governments to introduce STGs to address this challenge.

Delhi was the first Indian state to adopt a comprehensive
The provision of quality health care for all has been a recent rational drug policy in 1994.3 The various components of
key challenge for the Government of India. The health this policy were implemented through the Delhi Society
sector in India is disorganized to a large extent and reliant for the Promotion of Rational Use of Drugs (DSPRUD), a
on inequitable, regressive financing by way of out-of-pocket nongovernmental organization (NGO), during 1996–2004.
expenditure, which can reduce household spending on basic The programme considerably improved the availability of
necessities.1 In order to provide assured and equitable access to medicines in public hospitals.4–6
health-care services, the Steering Committee of the 12th Five
Year Plan (2012–2017) proposed universal health care (UHC).2 Rising health-care costs, variations in clinical practice among
However, entitlement-based UHC arrangements covering providers and hospitals, and difficulties faced by prescribers
outpatient, inpatient and emergency treatment for every citizen in keeping up to date with the overwhelming and fast-growing
may result in cost escalation unless measures such as routine volume of new scientific evidence, especially in resource-
application of standard treatment guidelines (STGs) and use of poor settings, have increased interest in STGs.7 Irrational
generic medicines are rigorously implemented. medicine use is responsible not only for escalating health-care
costs but also for adverse health outcomes; thus, successful
There has been a concerted effort by the Ministry of Health, implementation of STGs reduces inappropriate variation in
Government of India, and some more proactive state practice and also improves patient safety and quality of care.8–12

Sharma et al.: Developing standard treatment guidelines in India
However, the large number of sometimes conflicting or

Box 1. Key features of Standard Treatment Guidelines – a
poor-quality clinical practice guidelines being produced
manual for medical therapeutics
by individuals, professional organizations, insurers and
others has led to concerns about quality,13 although some Contains about 20 chapters covering all major specialties.
successful approaches to developing STGs have been well More than 325 priority diseases covered. Key features of
documented.14–17 The development of STGs is complex and content for each disease include:
lengthy, and writing guidelines is not without risk; there is
always the threat of nonacceptance by the clinicians. Due • Salient features and diagnostic tests
to considerable differences of opinion among prescribers, • Nonpharmacological and pharmacological treatment
managing consensus is difficult and time consuming. Hence the
production of successful guidelines needs strong development, • Drugs referred to by generic names in order of preference
editorial and project-management processes, together with a • Drug selection based on criteria of efficacy, safety,
keen eye for detail.18 suitability and cost
As part of the comprehensive rational drug policy described • Treatment goals, step-up/step-down therapy or criteria
above, DSPRUD developed the first set of comprehensive for referral, key assessment indicators and monitoring
STGs for India. Standard Treatment Guidelines – a manual for intervals
medical therapeutics was first published in 2002 with financial
support from the World Health Organization (WHO), via the • Patient-education section – nature, duration of illness,
WHO-INDIA Essential Drugs Programme. The second and prognosis, preventive measures, duration of therapy,
third editions were published in 2005 and 2009, respectively. follow-up, drug precautions and side-effects
The current, fourth, edition was published in 2015 and • Key references
provides guidance on treatment approach for more than 320
priority diseases, from primary to tertiary care.19 These STGs
have now been extensively reviewed and adopted by several delivery to the Department of Health and Family Welfare. The
state governments. medicines included in the STGs were matched with those on
the Delhi Essential Medicines List (EML),20 and medicines
This paper describes 15 years of first-hand experience of that were recommended in the STGs were included in the EML
development, dissemination, implementation and evaluation (that is, medicines listed in the EML but not in the STGs were
of the guidelines; sharing this experience may shorten the deleted from the EML). The revised EML was then used as a
learning curve for those embarking on a similar exercise. The basis for procurement and supply of essential medicines in the
aim is to discuss barriers, facilitators, issues and concerns state of Delhi.
crucial to acceptance among prescribers during development
and adaptation in other states, and implementation issues for Application of lessons learnt and use of a structured approach
policy-makers and managers. meant that subsequent revisions took only around six months.
To date, the guidelines have been peer reviewed by more than
150 experts in a range of states.
Process of development of the STGs
The successive editions of the STGs have been widely
Figure 1 summarizes the development of the STGs. The accepted, since: (i) they have been developed by a
process was a great challenge, particularly in a state such as representative multidisciplinary group and extensively peer
Delhi, which has several academic centres of excellence and reviewed; (ii) recommendations are based on evidence or, if
a diverse health-care infrastructure ranging from quaternary evidence at the required level is not available, a consensus
care to periurban dispensaries in the public sector, in addition of expert opinion; (iii) they identify problem areas in daily
to nonqualified private practitioners. Work was formally care; and (iv) clinicians are alerted to ineffective, dangerous
initiated in 2000 with the selection of priority diseases on the and wasteful practices. The recommendations are made on the
basis of morbidity patterns and national programmes, as well basis of capacity appropriate to the level of the health facility.
as diseases with high potential for inappropriate treatment. Where appropriate capacity in terms of adequately trained
A core group was mandated to develop treatment protocols personnel or infrastructure is not available, the guidance
and referral guidance starting with first aid and progressing provides advice to the treating physician to stabilize the patient
through the continuum of primary, secondary and tertiary care. and take timely action for referral to a higher-level facility. The
Development of the first edition took two years. Key features guidelines also clearly identify situations where immediate
of the STGs are shown in Box 1. referral to a tertiary care centre is required. The regularity
with which the guidelines have been updated to reflect current
During the two years following the launch, the publication was recommendations and actual experience have further added to
distributed, work on linking and matching with drug supplies their credibility and acceptance. Although the first edition was
was done and feedback was collected. The scepticism that developed with assistance from WHO, subsequent editions
this project would never be completed or reach the intended have been produced in association with a publishing house
users was dispelled by ensuring time-bound completion and and nominally priced to cover incidental costs and ensure
providing a personal copy of the guidelines to each doctor a nationwide network for distribution, thereby ensuring
registered with Delhi Medical Council instead of via bulk sustainability and widespread availability.

The experience of working on this series of STGs has provided were: (i) one publication for all levels serving as a complete
a wealth of insight into the barriers and facilitating factors to reference; (ii) precision, simplicity and flexibility; (iii) step-
successful development and acceptance among prescribers; up/step-down treatment according to level of the facility
these are summarized below. from primary to tertiary care, along with referral criteria; (iv)
treatment goals; (v) assessment criteria; and (vi) frequency of
the updates and credibility of the contributors.
Barriers and facilitating factors to STG
development and acceptance About 68% of doctors found that guidelines matched their own
prescribing but some consultants had residual concerns that,
Allaying practitioners’ concerns about the role of guidelines with STGs, their professional autonomy was lost and, since
not all cases have a typical presentation, the concept of patient
Contributors and critics raised several concerns during the individuality is lost. However, such concerns among doctors
development process. The chief concerns were: (i) misuse by are common and most can be resolved if due care is taken to
nonqualified practitioners; (ii) the legal liabilities or protections provide flexibility of drug choices and to conduct in-service
offered by this type of document; (iii) the danger that STGs programmes to introduce STGs.21
would lead to so-called cookbook medicine; and (iv) doctors’
loss of prescribing autonomy. The concerns were allayed by Our own experience further endorses that the development
interactive rounds of discussions with experienced, respected process is important for acceptance of the end-product. The most
clinicians using examples from real-life settings. common reason for lack of credibility and nonimplementation
of STGs is an a priori failure to involve a wide range of experts
As non-qualified practitioners were beyond our jurisdiction, and established institutions in the development process.
it was decided that guidelines should clearly provide details
of the first aid and red-flag signs so that, at the least, timely Writing process and precision of language used in guidelines
referral to a proper health facility may be arranged by these
practitioners. Regarding so-called cookbook medicine, it was Flexibility was needed when setting deadlines for contributors
emphasized that the role of the STGs is not to order or direct who, although motivated, had difficulty combining work on
patient management. Rather, STGs minimize the chances of the guidelines with their busy schedules. Several contributors
variation in treatment such that the clinician can concentrate found that the best approach to adhering to the schedule was to
on the diagnosis itself without expending time and energy allocate a time and place away from routine work.
identifying the best treatment approach. Clinical behaviour is more likely to change if guidelines are
Concerns about legal liability were allayed by explaining precise, simple and reader friendly.18 To ensure uniformity
that they are guidelines, not law, and clinicians should be in throughout the STGs, certain rules were framed, and standard
a position to explain why STGs were not followed in a given abbreviations and definitive recommendations were given.
situation. A major debate was on how there could be a same Words such as “may” were avoided as were instructions
standard of treatment at all health-care levels; this notion was that could be interpreted in different ways. For example an
especially unacceptable to specialists as they felt they were instruction such as “give slowly” was made more precise
offering an added level of expertise to the management of to, for example, “give over 5 minutes”. Similar clarity was
a patient who had already been seen by a doctor at a lower used to describe factors such as length of treatment or the
level. Through repeated dialogue, they were convinced that recommended interval between two tests.
it is referral criteria that differ rather than the first-choice A patient-education section was included to empower both
treatment for a patient, since choice of medicines depends on patient and doctor, as time constraints can limit clinicians’
the patient’s diagnosis and condition, and not on the seniority ability to provide brief, relevant information about the course
of the prescriber or level of the health facility. of an illness, prognosis, early identification of red-flag signs
Target audience for the guidelines and follow-up. Details, such as the incidence of different
conditions, which may be of general interest but are not
Another concern raised was whether the intended STG users required for decision-making, were omitted. Condensing
would be doctors from only public hospitals, or private all relevant information into a brief format was difficult for
practitioners as well. The proposal to address particularly junior contributors and writing the patient-education sections was the
doctors and private practitioners was more than welcomed by most challenging.
all; however, consultants/specialists were averse to the idea
that they were also expected to follow guidelines. Despite
these reservations, a post-release survey revealed that 90% of Participatory and consensus-building
respondents – including senior doctors – appreciated attributes approaches to guideline development
of the guidance and stated that, if used sensibly, STGs would
improve quality of care. Junior doctors commented that STGs The strengths of the STG development process were the
gave them additional confidence, whereas senior doctors participatory approach involving end-users and a sufficiently
mostly found the guidelines of help in areas other than their large group of doctors from different disciplines and various
own specialty. The most-appreciated attributes of the STGs levels of health care. The large number of experts involved also

made consensus management and time-scheduling difficult. Observations on adoption

Since team coordinators themselves co-opted contributors, this or adaptation of STGs
helped to establish good communication among the groups
and also facilitated consensus building. Furthermore, the time When considering developing STGs, policy-makers have the
spent in repeated meetings and consultations with a large opportunity to develop their own new guidance or use existing
number of experts and professional associations did a great guidance, either by adopting it as a whole or adapting it to their
deal to promote the team approach by resolving queries/doubts needs. New, locally produced STGs that involve end-users
and difference of opinion, particularly when the desired level may have better potential acceptability than so-called imported
of evidence was not available. guidance, but developing STGs afresh for each location may
be an expensive waste of time, effort and money, particularly if
Arriving at a consensus is difficult to manage and time they are not developed correctly.23 In addition, in cases where
consuming. There is also a danger of introducing inaccurate individual institutional departments have developed guidelines,
guidelines by including treatment choices that reflect common they often have idiosyncrasies, inconsistent formats, lack
existing practices rather than best practice, thus providing an evidence base and are not regularly reviewed.18 More
wrong information to prescribers. The greatest risks are that an importantly, there is a potential danger of noncompletion of
inappropriate action may result from an error in the guideline, projects.
misinterpretation of a guideline or use of a guideline that is
inappropriate for an individual situation.10 Clinical errors may In our experience, there are only a few other initiatives to
occur as a result of ambiguity in the guidelines; hence the need develop STGs in India that have been completed, regularly
for robust editorial processes.7 revised and widely accepted. Lack of awareness of the concept
and availability of expertise locally were major obstacles, as
Time-bound following of a consistent format with a diverse was prescribers’ insistence on inclusion of outdated practices,
range of contributors, not all of whom were sensitized to and or of drugs by brand names of unproven efficacy. Moreover,
requirements of guidelines development, was difficult. A strong it was observed that guideline review groups often lacked
editorial process is a key component to the development of time, enthusiasm, resources and skills to gather and scrutinize
quality guidelines and includes: (i) liaising with authors; every piece of evidence, particularly in relation to editorial
(ii) associated correspondence/documentation with appropriate responsibilities. These difficulties have also been reported by
specialists; (iii) editing and proofreading to ensure that there others.10,24
are no errors; and (iv) liaising with the printer to ensure
adherence to production schedules. Experiences similar to Adoption and adaptation of Standard Treatment Guidelines – a
ours have been reported by Woolf et al. and McMaster et manual for medical therapeutics is summarized in Figure 1.
al.10,18 Our observations also concur with the finding of Woolf The Government of Gujarat adopted the second edition
et al. that use of editors whose area of work is not primarily of these STGs with a message from the State Minister of
in the specialist area being covered is useful to circumvent Health in 2004. The governments of Rajasthan (in 2006),25
assumption of knowledge.10 Uttarakhand (in 2007),26Haryana (in 2013)27and Delhi (in
2014)28 adapted the STGs after peer review by local experts
Guidelines or essential medicines list – which comes first? and provided a personal copy to all practising doctors in the
Policy-makers face the dilemma of deciding whether STGs or public sector. The peer review process was led by the authors
an EML should be developed first. In our experience, having from DSPRUD. Rajasthan published a revised adapted edition
an EML in place first saves time and delivers initial gains by in 2012.29 A few states – Karnataka, Maharashtra, Chhattisgarh,
improving availability and accessibility to essential medicines Himachal Pradesh and Uttar Pradesh – successfully developed
by setting-up/streamlining systems for procurement. In their own independent STGs. However, these publications
parallel, the adaptation process for the STGs can be initiated were either targeted at primary care alone or focused only on
and completed within a short time and matched with EML certain diseases; in addition, the sections on treatment were
without losing momentum caused by extraneous factors such less comprehensive and none has been updated since the
as changes in governance or a shift in priorities. Finally, first edition. One state decided to develop its own guidelines
guidelines cannot be effectively used unless linked with but these were never published for various reasons: lack of
essential medicines supplies. motivation and committed core group, time constraints and,
most importantly, a change in governance and shift of priorities.
Raising awareness of guidelines and measuring impact
In our experience, adoption/adaptation of valid pre-existing
Since dissemination of guidelines alone does not change guidelines not only saves time, effort and money but also
practitioners’ behaviour, we used a multifaceted approach to ensures that there is a good-quality document in place after an
raise awareness of the STGs. The programme of activities active adaptation process. Since adapting/adopting guidelines
included news reports of the official launch in leading daily saved time and money, health systems could focus their efforts
newspapers and The Lancet,22 educating patients, endorsement and resources on effective implementation activities such as
by clinical groups, book reviews and training programmes linking with procurement sources and monitoring prescribing
that focused especially on interns to increase awareness and patterns. Although there are disadvantages to this approach,
acceptance of guidelines. However, to achieve a sustainable such as lack of local resource creation, there are substantial
impact on prescribing practices, in-service training of doctors, advantages in terms of success rate.
supervision and medical audit are required.

• Identification of team leaders

• Co-option of team members by team leaders
• Multidisciplinary group of 70 respected contributors from 11 broad
specialties representing different levels of health care and private
practitioners
• Sensitization workshop followed by three mid-term workshops
• Identification of core group and • Finalization of the list of priority diseases
• collection of morbidity and • Resolution of queries and difficulties encountered in the writing process
mortality data in 2000 • Finalization of format and scope of STGs
• Two rounds of internal reviews by the core group
• External review by 15 experts
• Text finalization and publication of first edition in 2002
• Official launch and preview of STGs in leading newspapers

• Distribution of a personal copy to all the doctors registered with Delhi
Medical Council
• Linking and matching of drug supplies according to STGs
• Development of second
edition (2 years) • Feedback on acceptance of STGs, contents and scope, and collection of
suggestions for future revision
• Government of Gujarat adopted the STGs in 2004

• Governments of Rajasthan (in 2006), Uttarakhand (in 2007), Haryana
(in 2013) and Delhi (in 2014) adapted the STGs after peer review and
provided a personal copy to all practising doctors in the public sector
• Adoption/adaptation by several • To reflect therapeutic advances, Rajasthan published a revised adapted
state governments and development edition in 2012
of third and fourth editions
• Third and fourth editions published in 2009 and 2015, respectively
• Peer reviewed by more than 150 experts in a range of states
Figure 1: Development of Standard Treatment Guidelines – a manual for medical therapeutics

STG: standard treatment guidelines.
With adaptation/adoption, good acceptance among clinicians priority diseases, while only a few changes in the treatment
can be achieved, especially through active participation of protocols were needed. Adaptation also saved money as it
local clinical leaders and allowing local clinical input by covered only the printing and logistics costs, and the editorial
practitioners. Active local participation helped overturn team/contributors were not compensated for their intellectual
the beliefs of doctors accustomed to outdated practices and input; when developing fresh STGs, sufficient resources are
boosted appreciation of the importance of consistency of care needed to reimburse all contributors, in addition to the costs of
and the difference between a textbook and guidelines. Another printing, dissemination and training. The creation of the state’s
advantage of adoption/adaptation is that one need not repeat own STGs, with its own book cover design, created a sense of
the same mistakes again. ownership. An executive order from the government and an
in-service sensitization programme introducing STGs further
The adaptation process in the various states revealed that facilitated adoption of guidelines in clinical practice.
the main changes required were the addition of a few more

CONCLUSION Programme on Essential Drugs, World Health Organization, WHO/

DAP/94.14.
Good–quality STGs are critical to promoting rational use 16. Developing clinical practice guidelines? Australia updates methodology.
of medicines and have great potential to improve patient Essential Drugs Monitor. 2002; 31:28-29.
care. Robust STG development is best undertaken across a 17. Graaff PJ, Forshaw CJ. Developing Standard Treatment Guidelines in
Malawi. Essential Drugs Monitor. 1995; 19.
network of motivated and cooperating contributors. However,
successful guideline development requires dedicated resources 18. McMaster P, Rogers D, Kerr M, Spencer A. Getting guidelines to work
in practice. Arc. Dis. Child. 2007; 92:104-106.
and a well–defined process, along with a strong editorial team.
19. Sharma S, Sethi GR, Gupta Usha (eds). Standard Treatment Guidelines:
Regular updates to reflect current recommendations and actual A Manual for Medical Therapeutics. 4th edition. Published by Delhi
clinical experience add to the credibility and acceptance of the Society for Promotion of Rational Use of Drugs and Wolters Kluwer
guidelines. Local adaptation/adoption of pre-existing valid Health, Delhi; 2015.
guidelines makes the process easier and quicker and fosters 20. The Essential Medicines List. Government of NCT of Delhi 2004.
a good sense of ownership and acceptance among doctors. 21. Grol R, Dalhuijsen J, Thomas S, Veld Cees int, Rutten G, Mokkink
Since adaptation/adoption of pre-existing guidance saves time H. Attributes of clinical guidelines that influence use of guidelines in
general practice: observational study. BMJ. 1999; 318:728–730.
and money, policy-makers can focus resources on activities
to change practitioners’ behaviour, such as pre-service/in- 22. Dinesh C Sharma. US charity donation for HIV/AIDS in India sparks
government row. The Lancet. 16 November 2002; 360 (No.9345):
service sensitization programmes, endorsement by opinion p1576.
leaders/professional organizations, prescription monitoring 23. Quick JD, Hogerzeil H, Rankin JR, Laing RO, Dukes MNG, O’Connor
and feedback. RW, Et al. Managing Drug Supply: Management Science for Health in
collaboration with World Health Organization. Kumarian Press, Second
edition, 1997; 137-149.
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Policy and practice Website: www.searo.who.int/

Demand–supply gaps in human
resources to combat vector-borne
disease in India: capacity-building
measures in medical entomology
Anuja Pandey1, Sanjay Zodpey1, Raj Kumar2
1
Public Health Foundation of India,
ABSTRACT New Delhi, India,
2
Department of Community
Vector-borne diseases account for a significant proportion of the global burden of Medicine, Armed Forces
infectious disease. They are one of the greatest contributors to human mortality Medical College, Pune, India
and morbidity in tropical settings, including India. The World Health Organization
declared vector-borne diseases as theme for the year 2014, and thus called for Address for correspondence:
renewed commitment to their prevention and control. Human resources are critical Dr Anuja Pandey, Assistant
to support public health systems, and medical entomologists play a crucial role in Professor, Public Health Foundation
public health efforts to combat vector-borne diseases. This paper aims to review of India, Institutional Area, Vasant
the capacity-building initiatives in medical entomology in India, to understand Kunj, New Delhi – 110 070, India
the demand and supply of medical entomologists, and to give future direction Email: anuja_2kn@yahoo.com
for the initiation of need-based training in the country. A systematic, predefined
approach, with three parallel strategies, was used to collect and assemble the data
regarding medical entomology training in India and assess the demand-supply
gap in medical entomologists in the country. The findings suggest that, considering
the high burden of vector-borne diseases in the country and the growing need of
health manpower specialized in medical entomology, the availability of specialized
training in medical entomology is insufficient in terms of number and intake
capacity. The demand analysis of medical entomologists in India suggests a wide
gap in demand and supply, which needs to be addressed to cater for the burden of
vector-borne diseases in the country.
Key words: Arthropod vectors, capacity-building, medical entomology, vector-
borne diseases
INTRODUCTION basis, causing considerable morbidity and mortality.3 Apart

from the health impact on humans, vector-borne diseases pose
Vector-borne infectious diseases, such as malaria, dengue, a serious threat to food security, ecosystems and socioeconomic
yellow fever and plague, account for a significant proportion development, by affecting animal and plant populations.
of the global burden of infectious disease; indeed, nearly half
of the world’s population is infected with at least one type of WHO declared “vector-borne diseases” as the theme for 2014.
vector-borne pathogen.1 In the past three decades, there has To advance the agenda of the WHO theme, there is a need to
been dramatic global re-emergence of epidemic vector-borne ensure renewed commitment to the prevention and control
diseases. Many of the diseases that were effectively controlled of vector-borne diseases, by strengthening the capacity of
in the middle part of 20th century have re-emerged and new public health systems to combat them. Systematic evaluation
pathogens have also emerged, both of which are causing major of biological and ecological factors that affect the dynamics
epidemics of disease.2 of transmission of vector-borne disease is necessary, in order
for control programmes to successfully anticipate outbreaks
In recent years, vector-borne diseases have developed as a and intervene with preventive actions. Hence, it is imperative
serious public health problem in countries of the World Health to have a health workforce that is specialized in dealing with
Organization (WHO) South-East Asia Region, including India. vector-borne diseases, for their containment at national, state
Many of these, particularly dengue, Japanese encephalitis (JE) and district levels.
and malaria, now occur in epidemic form almost on an annual

Pandey et al.: Capacity building in medical entomology in India
The discipline of medical entomology is concerned with The search was directed at obtaining data on the following
insects and arthropods that impact human health. It deals with parameters: name and location of the institute offering the
biology, ecology and the application of modern tools in the course, theme and course duration, course structure, and
management of vectors and vector-borne diseases.4 In view eligibility criteria. These parameters were incorporated in
of emerging and re-emerging vector-borne diseases in India, a matrix. The institutional data were entered in this matrix
there is a growing need for entomologists in the field of public and the findings were triangulated wherever possible, using
health. Against this background, this study was undertaken to alternative strategies. Any other salient features of relevance
review the capacity-building initiatives in medical entomology to the courses were also incorporated subjectively into this
in India, to understand the demand–supply gap of medical matrix.
entomologists in the country, and to give future direction for
the establishment of need-based training. To undertake the supply–demand analysis of medical
entomologists in the country, first the supply was calculated,
based on the output from long-term training programmes. The
METHODOLOGY cumulative output from all training was calculated, to estimate
the annual supply of medical entomologists in the country. The
Data regarding capacity-building initiatives in medical demand for medical entomologists was computed by gathering
entomology were collected using three strategies. A systematic, information on the requirement for medical entomologists in
predefined approach was used for obtaining this information. practice, research and education. For this purpose, an Internet
Each step was conducted in a parallel manner, and the search was done to note the requirement and vacancies for
information was entered into an Excel spreadsheet. medical entomologists in various institutions. Based on the
information on long-term training programmes in medical
The first search strategy consisted of using the information entomology, the demand for faculty in these institutions was
available on the Internet during October 2013 to March 2014. calculated. In parallel, information on the demand for medical
The online search was conducted using the Google search entomologists was also gathered by contacting experts in the
engine. The first step in this strategy involved identifying a set field of entomology, to identify programmes/projects where
of key words encompassing various domains related to medical medical entomologists are required.
entomology courses. The key words included were “medical
entomology”, “public health entomology training/courses”,
“vector-borne diseases” and “medical arthropods”. The search RESULTS
was limited to courses offered in India and to collaborations
between Indian and foreign institutes, if any. The websites of Training programmes
the Indian Council of Medical Research, National Centre for
Disease Control and National Institute of Malaria Research The training programmes in medical entomology in India can
were searched from October 2013 to March 2014, using the be broadly classified into three categories, depending on the
key words of the identified subjects and training programmes. type of institutions offering the course and the duration of
The search was not restricted by course duration or the type course:
of degree/certification awarded on successful completion.
Detailed information about the courses was collected from 1. medical entomology as a part of syllabus in medical schools
the respective institutions or from the designated websites of 2. long-term academic programmes in medical entomology
these institutions. The majority of information regarding the
available courses and institutions was gathered using this 3. short-term training in medical entomology.
strategy.
The second strategy involved a detailed review of the literature Training in medical schools
to identify medical entomology courses. Indexed and non-
Undergraduate training in medical entomology is mostly
indexed journals in the field were identified and searched for
provided within the realms of medical colleges, where
notifications and invitations for nominations for educational
medical entomology is taught as a part of community
courses. The search was limited to journals published in
medicine (preventive and social medicine). The course
English language within the last five years, that is from January
curriculum includes theoretical knowledge about arthropod
2009 to December 2013. Key institutes involved in research
vectors and disease transmission through the vectors, as
in medical entomology were identified from the author
well as entomology specimen demonstration. The syllabus is
affiliations. Additional information about short-term training
designed to give medical graduates a broad overview about
in malariology and parasitology could be obtained from this
arthropods and insects of public health importance. Students
strategy.
are taught vector biology in the context of disease transmission
The third strategy involved contacting experts in the field of and vector control. Students are also introduced to various
medical entomology in India. This was done through email and/ vector-management strategies and integrated vector control.
or telephone. The experts were requested to share information At present, undergraduate teaching in medical entomology is
about the courses offered in their institutes and also to suggest imparted to 52 455 medical undergraduates annually, across
the names of other institutes offering courses in the identified 400 medical colleges in India.5
fields. This strategy was useful to gather information on course
curricula and the availability of courses.

Apart from the undergraduate curriculum in medical colleges, country. Specialized courses in medical entomology include
medical entomology is also an integral part of postgraduate diploma, master’s, doctoral and fellowship courses.
courses in preventive and social medicine/community
medicine, which includes Doctor of Medicine (MD; Doctoral courses (PhD) in subjects related to medical
Community Medicine/Preventive and Social Medicine) and entomology (PhD Zoology/PhD Community Medicine/
postgraduate diplomas in public health, namely Diploma in MPH/PhD Biotechnology) are offered by Pune University;
Public Health (DPH) and Diploma in Community Medicine Puducherry University; Madurai Kamaraj University; the
(DCM). MD/DPH/DCM candidates are expected to have National Institute of Malaria Research in collaboration with
knowledge of medical entomology and apply the principles of Goa University; Indraprastha University; Jiwaji University,
medical entomology in prevention and control of vector-borne Gwalior; Kumaun University, Nainital; and Maharshi
illnesses at field level. The postgraduate curriculum includes Dayanand University, Rohtak. The course is usually completed
details of vector biology and transmission and studies these over a period of three to five years. Eligibility requirements
from a public health perspective. The course also includes for enrolling for a PhD programme include either an MD in
international initiatives and national programmes directed community medicine/social and preventive medicine, or an
towards prevention and control of vector-borne diseases. The MSc in zoology/medical entomology. The intake capacity
annual output of MD courses is 786, offered in 229 medical of the candidates depends on the availability of faculty and
colleges; 90 for DPH, offered in 39 medical colleges; and varies accordingly. Other postgraduate courses include a
11 for DCM, offered in six medical colleges. Postgraduate Postgraduate Diploma/MSc in Medical Entomology/Public
programmes in tropical medicine, at the School of Tropical Health Entomology. A Postgraduate Diploma in public health
Medicine, Kolkata, also include medical entomology as an entomology is offered by The Tamil Nadu Dr MGR Medical
important component. The annual intake is seven for MD University at the Institute of Vector Control and Zoonoses,
(Tropical Medicine) and 12 for Diploma in Tropical Medicine Hosur. The postgraduate diploma course takes two years and
Health (DTMH).6 candidates with a BSc in the discipline of zoology botany/
life sciences/medical laboratory technology/microbiology/
biochemistry, or a BVSc or MBBS or BE/BTech degree with
Long-term academic programmes in medical entomology biotechnology qualifications can apply for the course. For in-
(see Table 1) service candidates, lateral entry into the second year of the
diploma course is available at Dr MGR Medical University.
Recognizing the need for specialized graduates in the field
of medical entomology, some institutions are providing A two-year postgraduate degree course in public health
specialized courses in the subject; however, the numbers are entomology (MSc [PHE]) is offered by the Vector Control
low, with most institutes clustered in the southern part of the Research Centre, Puducherry. The programme is designed to
Table 1: Institutions offering courses in medical entomology across India

Institute Course Duration Eligibility criteria
Pune University, Puducherry PhD (Medical Entomology) 3–5 years MD (Community Medicine/Social & Preventive
University; Madurai Kamaraj Medicine/MSc (Medical Entomology)
University
National Institute of Malaria PhD (Medical Entomology) 3–5 years Life science graduation and cleared National
Research in collaboration with Eligibility Test exam conducted for Junior
Goa University; Indraprastha Research Fellowship
University; Jiwaji University;
Kumaun University, Nainital;
Maharshi Dayanand University,
Rohtak
The Tamil Nadu Dr MGR Medical Postgraduate Diploma in 2 years BSc (Zoology)/BSc (Microbiology)/MBBS
University at the Institute Of Public Health Entomology
Vector Control And Zoonoses,
Hosur
Vector Control Research Centre MSc (Public Health 2 years BSc, Zoology, Botany, Life Sciences, Medical
(Indian Council of Medical Entomology) Laboratory Technology, Microbiology,
Research), Puducherry Biochemistry, BVSc, MBBS, BE, and BTech
National Centre for Disease Fellowship training 1 month WHO-nominated candidates
Control programme on Malaria
Entomology and
Parasitology
National Centre for Disease Fellowship training 1 month WHO-nominated candidates
Control programme on Malariology

Table 2: WHO fellowship programmes in India

Institute Course Duration Desired qualification
National Centre for Integrated Integrated pest/vector 4 weeks Health managers/professionals working in the
Pest Management, New Delhi management relevant areas
Armed Forces Medical College, Entomology for those 10 days Medical officers/officers in the vector-borne
Pune working in the vector-borne disease control department
disease control department
address the growing need for entomologists in the field of public Many institutes in the country, including degree colleges,
health, in view of emerging and re-emerging vector-borne medical colleges, universities, defence research and
diseases in India. Apart from these specialized programmes, development establishments, and institutes of the Indian
WHO fellowship programmes are also available at the Vector Council of Medical Research do conduct continuing medical
Control Research Centre, Puducherry, covering various aspects education (CME) or continuing education programmes for
of vector biology and vector-borne diseases and their control. a few days, on various aspects of vectors and vector-borne
diseases, for scientists, administrators, policy-makers and
The National Centre for Disease Control, New Delhi, offers public health professionals. Some agriculture universities,
programmes on malariology and malaria entomology and including Punjab Agriculture University, Ludhiana; CCS
parasitology. These programmes are of one-month’s duration Haryana Agriculture University, Hissar; institutes of the Indian
each and are conducted on a periodic basis for WHO-nominated Council of Agriculture Research; and Acharya NG Ranga
candidates (see Table 2). Agriculture University, Bapatla, Guntur, offer compressed
doctoral programmes that lead to a PhD (Entomology). There
are various universities in India awarding PhD (Zoology) with
Short-term training in medical entomology a dissertation or thesis topic in entomology, which is designed
The National Centre for Disease Control, New Delhi; National to cater for the needs of individuals who wish to practise
Institute of Malaria Research, New Delhi; Vector Control entomology but who do not have a postgraduate degree in
Research Centre, Puducherry; Regional Medical Research public health/community medicine/medical entomology to
Centre, Bhubaneshwar; Centre for Research in Medical orient them in public health entomological concepts and
Entomology, Madurai; and Armed Forces Medical College, practices.
Pune, are some of the premier institutes of the country offering Most universities do not have a specialized entomology
short-term training programmes in medical entomology. department but instead offer courses in entomology. Many
Short-term training is usually a specialized course focusing on entomologists receive a general undergraduate degree in
specific audiences and designed to deliver skill sets specific to biology or zoology and then specialize in entomology at the
their needs. postgraduate level. Research/teaching positions in universities,
the government and industrial organizations require either a
master’s degree or, in most cases, a PhD.
Other capacity-building measures
Medical and public health entomologists work for central, state
WHO has developed and expanded various entomology and local public health departments, and deal with problems
training programmes for vector biology and control of vector- of pest control. Entomologists engaged in public health work
borne diseases and partnered with premier health institutions in different areas of research and in the control of house flies,
of the country to enhance entomology capacity for effective mosquitoes, cockroaches, lice, fleas, sand flies, ticks and many
outbreak response and control. Also, over the last few decades, other pests that pose a health hazard or nuisance problem.
various other initiatives have been undertaken by WHO,
states, nongovernment organizations, and the public–private Public health specialists in military positions work as
partnership sector, but none of these efforts have resolved entomologists for the armed forces and supervise pest-
the need for quality medical entomological capacity that control operations at a large number of military bases in India
is comparable to the standards available in various foreign and abroad (when on deputation). Research work and the
universities. protection of military personnel against insect-borne diseases
and parasites are important aspects pertaining to entomology
Most of the entomology training available in the country is in the armed forces.
modelled on classroom teaching. Some courses are rather
academic in nature, such as the various public health degrees
awarded by different medical universities across the country, The role of professional organizations
including the MD in Preventive and Social Medicine, Social
and Preventive Medicine, Community Medicine or Community in capacity-building in medical
Health Administration. These generally have similar course entomology (see Box 1)
content and style of imparting education and are three-year
degree programmes that qualify for a degree from the Medical The Entomological Society of India encourages and promotes
Council of India. the dissemination of entomological knowledge in the

country. It arranges meetings that provide opportunities to its Role of the National Institute of Malaria Research
members and others interested in the subject to keep in touch
with entomological activities, both in India and abroad. The The National Institute of Malaria Research conducts short-term
Entomology Academy of India has been taking a keen interest and long-term training courses in the field of vector control,
in capacity-building in entomology in the country, including microscopy, entomology, surveillance, quality assurance of
medical entomology. The organization conducts CME and rapid diagnostic tests, insecticide bioassay, bioenvironmental
short-term training and workshops on research and updates control, field applications of biocides, indoor residual
in entomology. The Indian Society for Malaria and other spraying, preparation of blood smears for diagnosis, malaria
Communicable Diseases and the National Academy of Vector in pregnancy, anti-malaria operations, and new tools such as
Borne Diseases are national-level professional organizations remote sensing and geographical information systems in the
that publish journals, organize annual conferences and publish prevention and control of vector-borne diseases. The National
newsletters in the field of medical entomology and vector-borne Institute of Malaria Research also delivers training to national
diseases. The Indian Society for Parasitology, Indian Society and international participants from all levels.9
of Advancement of Insect Sciences, Society of Mosquitoes and
Mosquito Borne Diseases in India, National Environmental
Science Academy and National Academy of Sciences, India, Role of the National Institute of Virology
are national-level professional bodies that have vector-borne The National Institute of Virology, Pune, a premier virology
diseases and medical entomology as one of their major areas institute of the country, also conducts training and projects in
of work. medical entomology. This institute has nurtured a large number
of trained entomologists, PhD students, short-term trainees and
Box 1: arbovirus experts, for more than 60 years. It has contributed
Various national societies related immensely in India’s efforts to combat vector-borne diseases
to entomology in India and its major achievements include from recognition to vaccine
development of vector-borne diseases such as Kyasanur Forest
• National Academy of Vector Borne Diseases
disease (KFD) and Chandipura virus infection. Several new
• Indian Society for Parasitology species of ticks, lice, fleas, sand flies and mosquitoes, together
with a new species of rodent, have been described by the
• Indian Society for Malaria and Other Communicable
scientists of the institute.10
Diseases
• Indian Society of Advancement of Insect Sciences
Demand–supply analysis
• Entomological Society of India
• Entomological Academy of India Based on the results on the specialized training programmes
in medical entomology, it was observed that the annual output
• Society of Mosquitoes and Mosquito Borne Diseases of trained specialists in medical entomology is below 100 and
in India far below the need for medical entomologists in the country.
• National Environmental Science Academy Under the Integrated Disease Surveillance Project, each state
surveillance team needs one medical entomologist at the state
• National Academy of Sciences, India headquarters, amounting to 35 consultants, and there is a need
for entomologists for 643 districts. Apart from this, there
is need for trained medical entomologists for training and
Initiatives under the National Vector education of medical entomologists to meet the growing needs
Borne Disease Control Programme of the country. Medical entomologists are also needed to work
in vector-borne disease programmes and malaria programmes.
The National Vector Borne Disease Control Programme has The demand analysis estimates that there is a need for at least
contributed to the development of human resources in vector- 1000 specialists in medical entomology. This suggests a wide
borne diseases, by providing training to health professionals gap in the demand and supply of these professionals, which
and non-health sector professionals, as well as developing needs to be addressed.
training materials.7
DISCUSSION
Role of the National Centre for Disease Control
Epidemic vector-borne diseases have been among the most
Realizing the limited capacity of the health staff in medical important emerging infectious diseases on a global scale.11
entomology, the National Centre for Disease Control has In India, malaria, dengue, chikungunya, filariasis, JE and
been providing various short-term training courses in medical visceral leishmaniasis are major prevalent vector-borne
entomology, through the Centre for Medical Entomology diseases. Failure to control disease vectors, and the illnesses
and Vector Management located at New Delhi. This centre transmitted by them, has resulted in recurrent outbreaks all
conducts various ad hoc and regular training courses on vector- over the country.12 In order to address this issue, it is imperative
borne diseases and their control. This centre also maintains the
National Reference Entomological Museum.8

to attend to the shortage of medical entomologists and vector- demand for specialists in this field. There is an urgent need
control experts for planning, implementing, monitoring and to bridge the gap between the demand and supply of medical
evaluation of vector-borne disease control programmes, entomologists in the country. Institutional strengthening,
through strengthening capacity in medical entomology and collaboration, and development of a network of training
through various capacity-building initiatives. These include institutes to synergize resources are possible steps that can be
academic programmes, training courses and institutional taken to strengthen the capacity of medical entomologists in
capacity-building. the country on a long-term basis. This involves generation of
innovative ideas on sustainable financing for health promotion,
Training in medical entomology is being delivered as a such as allocation of a percentage of taxation on tobacco and
small part of medical education and through a few dedicated alcohol for the creation of a health-promotion foundation.
programmes in medical entomology. Taking into account
the large population of the country, the number of training
programmes and the enrolment capacity in most programmes REFERENCES
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Considering the large population of India, the supply of medical
entomologists is far from sufficient for the ever-growing

Report from the field Website: www.searo.who.int/

Challenges in conducting community-
based trials of primary prevention of
cardiovascular diseases in resource-
constrained rural settings
Twinkle Agrawal1, Farah Naaz Fathima1, Shailendra Kumar B Hegde2,
Rajnish Joshi3, Nallasamy Srinivasan4, Dominic Misquith1
1
Health, St John’s Medical
ABSTRACT College, Koramangala, Bangalore,
Karnataka, India,
Cardiovascular diseases account for almost half of all deaths from noncommunicable 2
diseases, and almost 80% of these deaths occur in low- and middle-income Medicine, S R M Medical
countries such as India. The PrePAre (Primary pREvention strategies at the College, Potheri, Kattankulathur,
community level to Promote treatment Adherence to pREvent cardiovascular Kanchipuram, Tamil Nadu, India,
disease) trial was a primary prevention trial of community health workers aimed 3
Department of Medicine, All India
at improving adherence to prescribed pharmacological and nonpharmacological Institute of Medical Sciences,
therapies in cardiovascular diseases. It was conducted at three geographically, Bhopal, Madhya Pradesh, India,
culturally and linguistically diverse sites across India, comprising 28 villages and
4
Raja Muthiah Medical College,
5699 households. Planning and implementing large-scale community-based trials Annamalainagar, Chidambaram,
Tamil Nadu, India
is filled with numerous challenges that must be tackled, while keeping in mind the
local community dynamics. Some of the challenges are especially pronounced Address for correspondence:
when the focus of the activities is on promoting health in communities where Dr Twinkle Agrawal, Department
treating disease is considered a priority rather than maintaining health. This report of Community Health, Robert Koch
examines the challenges that were encountered while performing the different Bhavan, St John’s Medical College,
phases of the trial, along with the solutions and strategies used to tackle those St John’s National Academy of
difficulties. We must strive to find feasible and cost-effective solutions to these Health Sciences, Sarjapura Road,
challenges and thereby develop targeted strategies for primary prevention of Koramangala, Bangalore 560 034,
cardiovascular diseases in resource-constrained rural settings. Karnataka, India
Email: doctwinkle@gmail.com
Key words: Cardiovascular diseases, challenges, community-based primary
prevention trials, implementation
INTRODUCTION St John’s Research Institute, Bangalore, was chosen as one

of the 11 centres of excellence. Under this programme, the
Cardiovascular diseases (CVDs) account for almost half of all PrePAre (Primary pREvention strategies at the community level
deaths from noncommunicable diseases, and almost 80% of to Promote treatment Adherence to pREvent cardiovascular
these deaths occur in low- and middle-income countries such disease) trial was designed to test the hypothesis that
as India.1 Effective low-cost methods are needed to prevent households with individuals at risk for a cardiovascular event
CVDs. Design and implementation of large-scale community- would have improved risk factor levels if they were counselled
based trials in low-income rural settings will help to build a and monitored by community health workers (CHWs), when
robust evidence base for methods to prevent CVDs. The authors compared with households not receiving such visits.
have recent experience of such an undertaking, and use this
article to list the challenges faced during the implementation Approval for the trial was obtained from the institutional
of the trial and the strategies that were used to mitigate them. ethics committees of the participating institutes in India (Rajah
Muthiah Medical College, Annamalainagar, Tamil Nadu, India;
In 2008–2009, the United Health Group and the National Heart, St John’s Medical College, Bangalore, India; Mahatma Gandhi
Lung, and Blood Institute collaborated to support a global Institute of Medical Sciences, Sevagram, India) and from the
network of centres of excellence to help reduce the burden ethics committees of the funding institutes (Population Health
of chronic diseases in low- and middle-income countries. Research Institute, Hamilton, Canada; National Heart, Lung,

Agrawal et al.: Challenges in conducting trials of primary prevention of cardiovascular diseases in resource-constrained rural settings
and Blood Institute, Bethesda, United States of America) and House listing, enumeration and baseline survey
the Health Ministry Screening Committee, Government of
India. The study protocol was registered with Clinical Trial Community-level consent was obtained before initiating the
Registry of India (CTRI/2012/09/002981). activities of the trial (see Table 1). Subsequently, individual
consent and family-level consent were also obtained. Some
The PrePAre trial was a multicentre, household-level cluster- individuals and families did not readily consent to participate
randomized trial with 1:1 allocation to intervention and in the study because of the long follow-up period. The
control arms, conducted at three geographically, culturally investigators spoke personally with these individuals to inform
and linguistically diverse sites across India, comprising 5699 them of the benefits of the trial. Some individuals, despite
households from 28 villages: three villages in Cuddalore the best efforts of the CHWs, did not give their consent to
district, Tamil Nadu, 15 villages in Kolar district, Karnataka participate in the study; however, the number of refusals was
and 10 villages in Wardha district. A short summary of the trial negligible.
methodology is presented here, and further details have been
published elsewhere.2 Households in rural India are not prenumbered. All households
had to be identified with serially numbered stickers printed on
CHWs performed door-to-door surveys and helped to organize a 2-inch-square piece of flex-sheet. After seeking permission
village-level preintervention clinics over a period of six months from the household members, the CHWs pasted the stickers
from October 2011. Households were randomized during on the upper right corner of the door of each house. Some
April 2012. Households randomized to the intervention arm household members refused permission to have the stickers
received one household visit by a CHW every two months for pasted on their doors. The CHWs explained to the members
12 months from May 2012 to March 2013. During each visit, of the household the utility of such numbering and the need
CHWs ascertained and reinforced adherence to prescribed for the stickers to remain pasted for at least 18 months
pharmacological and nonpharmacological therapies, and (see Table 1).
measured and ascertained whether blood pressure values met
the preset targets. Households randomized to the standard care Loss of previously pasted stickers made it difficult for CHWs
arm received clinic-based care and did not receive visits from to identify households at subsequent visits. In some cases,
CHWs. stickers peeled off as a result of monsoon rains. This had not
been anticipated. Social maps had been drawn by the CHWs,
To evaluate the study outcomes, independent trained personnel in which the numbers that had been used to identify the
conducted follow-up household surveys at six months households were marked. About 20% of all stickers had to be
(October 2012), 12 months (April 2013) and 18 months repasted as a result of the stickers peeling off.
(October 2013) after the first CHW intervention visit. The
primary outcome measures were systolic blood pressure and Some CHWs found it difficult to effectively engage all the
adherence to medication. Secondary outcome measures were households in a village because of social or political conflicts.
INTERHEART risk score, waist-hip ratio and body mass In certain villages, CHWs belonging to lower castes were not
index. The final follow-up visits were completed between allowed in the higher-caste households. Many such conflicts
October and November 2013. As of today, the trial, including were successfully resolved through dialogue. Where dialogue
data analysis, stands completed. The investigating team is now failed, households were excluded from the study.
in the process of reporting the findings of the trial. However,
the monthly clinics continue to provide care to patients, despite Safety of female CHWs also needed attention. Most of the
the completion of the trial. CHWs in the trial were women for whom this was their first
formal job. On their way around the villages, they occasionally
encountered verbal sexual harassment. Repeated community
CHALLENGES ENCOUNTERED meetings (with village leaders and youth groups) and peer-
group discussions (with other CHWs working in other projects
The challenges encountered and the strategies undertaken to in similar circumstances) were held to share coping strategies.
address these difficulties are described according to the phases Additionally, CHWs were asked to always work in pairs or in
of the trial (identification and training of CHWs, house listing groups, and to avoid working at night.
and baseline survey, clinic visits, intervention and follow-up
visits). Two very critical challenges were locked households and
nonavailability of all individuals over the age of 35 years in
the study villages. The latter was more pronounced in the
Identification and training of community economically productive groups. In order to address these two
health workers issues, the CHWs made at least three visits to those households
at three different times, including evening visits, to make
Community meetings were held in the 28 villages taking part in sure individuals in those houses were included in the baseline
the study to obtain community consent for participation in the survey. In many cases, the CHWs sought a face-to-face meeting
study. Stakeholders in each village were requested to identify with the subject that had been pre-arranged by a phone call. It
persons from the village who had completed matriculation, took multiple visits by CHWs to complete this task because of
were acceptable to the community members and were willing locked households; therefore, this increased the time taken and
to work as CHWs. An objective selection process was used to the cost of the baseline survey.
recruit a total of 18 individuals.

Table 1: Challenges faced and mitigating stategies undertaken during various phases of the PrePAre trial
Phase Challenge Strategy
House listing Locked houses Three visits per household on three different days
at different times, including evening visits
Not allowed to paste stickers Appropriate dialogue with community members;
explaining study objectives: and persuasion
Loss of stickers due to monsoons Social maps were used to identify households
that had lost stickers; hence, a few of those
households that were included in the baseline
survey may have been missed in the trial
Verbal sexual harassment Discussion with elders in the village, and group
discussion with CHWs with field experience
Baseline survey Nonavailability of individuals Three visits per household on three different days
at different times, including evening visits
Nonconsenting individuals Explanation of the study objectives, and
persuasion
Incorrect registrations and duplications Deleting duplicate and wrong entries
Religion and caste Discussion with elders in the village, and house
visits by medical officer to counsel individuals
Travel to remote villages with limited bus Use of auto-rickshaws and personal vehicles
connectivity
Difficulty in eliciting responses for some questions Accepting this as a challenge and as a social
desirability bias
Standard of living index Corroborate answers by asking different members
of the family
Age variations in house listing and in baseline Document the age obtained during baseline
survey survey
People were not willing to give details regarding Explanation of study objectives, and persuasion
tobacco and alcohol consumption
Waist circumference measurements had to be Accepted as a limitation
taken over saris for females
Waist circumference measurements were taken Measurements were taken in the presence of
for males by female CHWs in many cases other female members of the family
Prerandomization clinics Inadequate response to attend clinics especially Explanation of study objectives, and persuasion
by males, those with high blood pressure
Social stigma Counselling
Timing of clinic Early morning clinics
Natural disaster (floods) and political unrest Nothing much could be done except wait patiently,
which led to a delay in the completion of activities
Intervention Nonavailability of people in the intervention Pre-arranged appointments, early morning visits
households
Migration Lost to follow-up
Loss of household stickers Houses were numbered in serial order
Objects demanded by nonintervention households Refusal to give objects, followed by explanation of
study objectives
Contamination Ensuring that only members of the intervention
household were present during the visit
Phase Challenge Strategy

Postrandomization clinics Subcentre level Explanation of study objectives, and persuasion
Change in local governance Meeting with newly elected members
Health of male members in the family is given CHWs counselled female members of the
more importance households during their home visits
Supply of free drugs by nongovernmental People could access care from any provider;
organization importance of adherence to prescribed medicines
and lifestyle changes were stressed
Patients taking herbal medicines and advice from Counselling
unqualified and unlicensed practitioners
Evaluation Loss of household numbers to follow-up CHWs showed the households, care was taken to
ensure that the evaluators were blinded
CHW: community health worker.
Clinic visits
Many individuals had migrated to nearby cities and visited their Only 70% of those identified as being at intermediate or
rural roots only occasionly, but were listed in the administrative high risk for CVD attended the village clinics (see Table 1).
records as residing in the village in order to qualify for benefits The reason given for nonattendance was that the individuals
of state-sponsored schemes. In some instances, this led to perceived themselves to be healthy. Some people accused
incorrect registrations and duplications. Investigators had to the programme of creating fear in the minds of the people
explain to the household members that such individuals could regarding CVDs since they did not have the disease but had
not be included in the trial and that such a non-inclusion would only risk factors. The concept of risk was difficult for them
have no impact on their benefits from state-sponsored schemes. to understand. Most individuals identified as having a high
After clarification, duplicated and wrong entries were deleted. CVD risk were asymptomatic and were in the high-risk
category because of age, behavioural issues (tobacco use) and
Another very important challenge was reaching remote abnormal measurements (waist circumference). Many of these
villages. The investigators personally visited each village, individuals did not believe that they were at risk for CVD.
making a note of the distance and the availability of public
transport or any other form of transport to and from the village. Individuals who were economically productive had to take
time out of their occupation to attend clinics; in order to suit
The investigators discussed this issue with village elders and
their needs, the clinics started functioning very early in the day,
addressed it through different modes of transport in different
as early as 06:00 in some villages, to allow working people
villages. In some villages, private auto-rickshaws were hired; to attend clinics before leaving for work. In some villages,
in others, villagers who owned vehicles agreed to escort the the clinics were held on Sundays. Despite these efforts,
CHWs to and from the village, both at the time of the survey clinic attendance was not 100%. Health was of a much lower
and at the time of intervention. priority when compared with their occupational commitment.
Disease becomes a priority when individuals feel either pain or
Data collection during the baseline survey also threw up some infirmity; since risk factors do not cause any pain or infirmity,
interesting challenges. The standard of living index was difficult occupation and other commitments are more important.
to assess in some families, and the CHWs had to corroborate Disease would have been a priority; prevention was not.
the answers by asking multiple family members. During
the enumeration and house-listing phase, CHWs collected Some people diagnosed with diabetes or hypertension did not
the age of every individual in the household. However, at attend clinics because they did not want other members in the
the time of the baseline survey, age was one variable where village know that they had these diseases. There was a social
discrepancies were found. Hence, the CHWs were directed stigma associated with these diseases. The CHWs and the
to collect documentary evidence regarding the age of an investigators identified such individuals and counselled them.
individual in all such cases during the baseline survey. Some
people who consumed tobacco and alcohol hesitated to give At one of the sites, the clinic schedules were disrupted as a result
details regarding their intake. The CHWs explained to them of torrential rains leading to flooding. On another occasion,
the clinics were disrupted because of political unrest due to
the study objectives, and the harmful effects of tobacco and
impending local elections. On both occasions, the baseline
alcohol, and how this trial would benefit them in avoiding
survey was delayed. These events were totally unanticipated
tobacco and alcohol, thus convincing them to be forthcoming and thus there was a delay in the completion of activities.
and give information on their smoking and alcohol habits.
Measurement of waist and hip circumferences was difficult The public health care system in rural India does not run
and was addressed as explained in Table 1. clinics below the level of a subcentre. In order to replicate this
situation, after randomization had been carried out, regular
monthly clinics were held at subcentre locations, in order to face meeting with the subject that had been pre-arranged by
review the patients’ medical conditions and to provide drug phone calls.
prescriptions. These clinics were called postrandomization
clinics. This resulted in a drop in attendance at existing clinics. Migration was an important problem faced during
Also, most clients in the postrandomization clinics were from interventions. Permanent migration and seasonal migration
the village where the subcentre was located. Despite this due to occupational or social issues were encountered. Effort
limitation, the investigators did not set up village-level clinics, was made to contact such individuals and include them in the
since this would introduce a bias by introducing facilities not study; however some were ultimately lost to follow-up. In
normally available. The postrandomization clinics were held large community-based trials lasting for a long period of time,
at subcentres. There was a change in local governance after losing study subjects due to migration is an important issue
the trial began and hence the investigators had to obtain fresh that needs to be addressed at the time of planning.
approvals from the local bodies to establish the clinics at the
subcentres.
Follow-up
In India generally, the health of male family members is given
more importance, while that of female family members is Randomized households were followed up at six, 12 and 18
neglected. This was also seen in the clinic attendance, since months by a group of independent evaluators who were blinded
more men attended the clinics compared with women. CHWs to the randomization (see Table 1). The evaluators found it
were told to counsel the women appropriately, and reinforce difficult to trace the study participants because of similar
the fact that their health is equally important. names and missing household stickers. Tracing was much
more difficult among the nonintervention households. To help
During the course of the trial, a nongovernmental organization
started distributing free drugs at one of the sites as a part of
their field activity. However, at all sites in this trial, patients Box 1:
were allowed to obtain medicines from any place, provided Lessons learned from conducting the PrePAre trial
they adhered to trials prescriptions for both pharmacological • Engagement or dialogue with community: multiple
management as well as lifestyle modifications. A bigger problems can be solved by engaging with the
problem, however, was patients taking herbal medicines and community leaders, stakeholders and individual
advice from unqualified and unlicensed practitioners. Apart members of the community through a dialogue
from counselling such patients, it was not possible to do any process.
more.
• Collecting contact numbers: collecting the telephone
number of every study subject reduces multiple visits
Intervention and reduces overall costs.
• Correct identification: correct identification of the
Intervention (see Table 1) used in the trial has been explained in households and study subjects in trials lasting for long
detail elsewhere.2 During intervention, 10 simple and focused periods of time is essential.
lifestyle modification messages in local languages (no tobacco,
dietary modification and physical activity domains) were • Timing of the house visits and clinics: house visits and
placed on common household articles (such as mirrors, salt clinics will be successful if they are held at a time when
containers, drug pouches, mobile phone covers, television sets, it is convenient for the study subjects.
key chains etc.).2 These articles were given to the intervention • Using community resources: travelling to remote
households. Some of the nonintervention households as well and difficult-to-access areas and setting up village
as nonstudy households also demanded these articles from clinics will be cost effective if done using community
the CHWs, which could lead to data contamination. The resources.
CHWs explained the design and purpose of the project to such
individuals and gently declined to hand over the objects to • Examination by acceptable people: anthropometric
them. measurements must be taken by individuals belonging
to the same sex or in the presence of an individual of
Also, the CHWs were instructed to educate strictly only those the same sex to improve participation.
individuals who belonged to the intervention households. • Counselling: issues such as social stigma associated
All interested individuals belonging to the nonintervention with noncommunicable diseases must be addressed
households were requested by CHWs to attend the subcentre- through appropriate counselling.
level clinics.
• Adequate buffer time for unforeseen challenges:
In some intervention households, the CHWs were not one has to understand that political conflicts and
able to meet the individuals because of their occupational natural disasters might strike at any time and might
commitments. In such situations, the CHWs fixed a face-to- significantly alter the schedule of activities.
the evaluators, the CHWs who had done the baseline survey CONCLUSIONS
accompanied the new team to locate the study households,
but stayed away from the households during the evaluation, Planning and implementing large-scale community-based
and care was taken to ensure that the evaluators were blinded. programmes is filled with numerous challenges that must be
A short list of the most important lessons learnt from our tackled while keeping in mind the local community dynamics.
experience is presented in Box 1. Some of the challenges are especially pronounced when the
focus of the activities is on promoting health. Health is not
considered a priority, disease is. Despite these challenges,
STRENGTHS AND LIMITATIONS we must strive to find feasible and cost-effective solutions to
address these challenges in the best possible way and thereby
This report lists the various challenges encountered and thwart the threat posed by CVDs.
the strategies used to address them during the course of
implementing a community-based primary prevention
programme. The strengths and limitations of the trial on which REFERENCES
this report is based have not been mentioned here since that is
the subject of discussion in another article. 1. Global status report on noncommunicable diseases 2010. Geneva: World
Health Organization. 2011;21–3 (http://www.who.int/nmh/publications/
ncd_report_full_en.pdf, accessed 28 June 2015).
The strength of this report is that it not only lists the challenges
2. Fathima FN, Joshi R, Agrawal T, Hegde SB, Xavier D, Misquith D,
but also lists the solutions to those challenges. These solutions et al. Rationale and design of the Primary Prevention strategies at
were customized to suit the needs of the local communities and the community level to Promote Adherence of treatments to prevent
hence they have immense practical value. The other strength cardiovascular diseases trial number (CTRI/2012/09/002981). Am Heart
of this article is that it classifies the challenges according to J. 2013;166:4–12.
the sequential phases of the trial. Thus any other investigator
planning to conduct a community-based primary prevention How to cite this article: Agrawal T, Fathima FN, Hegde SKB,
Joshi R, Srinivasan N, Misquith D. Challenges in conducting
trial in a resource-constrained rural setting can relate to this
community-based trials of primary prevention of cardiovascular
article. diseases in resource-constrained rural settings. WHO South-
East Asia J Public Health 2015; 4(1): 98–103.
The major limitation of this article is a lack of quantitative
assessment of the various challenges. The investigators Source of Support: The PrePAre trial was funded by a grant from the
documented the challenges, but not the quantity in terms of UnitedHealth Group and the National Institutes of Health, United States
numbers. For example, it would have been more useful to of America. No additional funding was received for the preparation of this
report the proportion of people that were not available at home report. Conflict of Interest: None declared. Contributorship: TA and FNF
at the time of visit of the CHWs or the additional number of conceived, planned and revised the manuscript. SKBH and NS wrote the
visits made by the CHWs to reach out to the people. first draft and reviewed the manuscript. RJ and DM reviewed and gave final
approval for the manuscript.
Recent WHO Publications
Strategic plan for Measles Elimination and Rubella

and Congenital Rubella Syndrome Control in the
South-East Asia Region: 2014–2020
World Health Organization, Regional Office for South-East Asia. New Delhi: 2015. 77p.
ISBN: 9789290224914
Available from: http://apps.searo.who.int/PDS_DOCS/B5206.pdf
The Sixty-sixth WHO Regional Committee for South-East

Asia in September 2013 resolved to adopt the goal of measles Quick Response Code:
elimination and rubella/CRS control in the South-East Asia
Region by 2020. In response, the WHO Regional Office for
South-East Asia developed this Strategic Plan for Measles Website:
Elimination and Rubella and Congenital Rubella Syndrome www.searo.who.int/publications/journals/seajph
Control in the South-East Asia Region. This strategic document
provides technical support to Member States in their efforts to
develop elimination policy and strategies, while strengthening
their immunization and surveillance systems and improving
their programme performance. In this way, these ambitious
2020 goals can be met.
International public health hazards:

Indian legislative provisions
ISBN: 9789290224761
“International public health hazards: Indian legislative Access this article online
provisions” presents an outline of the provisions in the Indian Quick Response Code:
legal system which may enable the implementation of IHR
in the country. International Health Regulations (2005) are
the international legal instrument designed to help protect all Website:
countries from the international spread of disease, including www.searo.who.int/publications/journals/seajph
public health risks and public health emergencies. The present
document is the result of a study taken up for the regional
workshop on public health legislation for International Health
Regulations, Yangon, Myanmar,” 8–10 April 2013. The
relevant Indian legislation in the various Acts and rules that
may assist in putting early warning systems in place has been
outlined. The document intends to provide a ready reference
on Indian legislation to enable establishing an early warning
system that could assist the Government to provide health care.
Recent WHO Publications
Ten years after the tsunami of 2004:

impact action change future
ISBN: 9789290224907
On 26 December 2004, two extremely rare events occurred Access this article online
close to the southwestern shores of northern Indonesia. The Quick Response Code:
first was a massive earthquake measuring 9.1 to 9.3 on the
Richter scale, and the second was the devastating tsunami it
generated. Travelling at speeds of over 500 km an hour, the Website:
tsunami wrecked the coastal areas of six countries in the www.searo.who.int/publications/journals/seajph
WHO South-East Asia Region – India, Indonesia, Maldives,
Myanmar, Sri Lanka and Thailand, leaving more than 227 000
people dead and 1.7 million displaced. Countries were caught
unawares, devastated, and were unprepared to cope with the
effects of the disaster.
The event led to a chain of reform measures initiated by
WHO, which are ongoing. These were aimed at building the
capacity of countries to prevent, prepare for, and increase their
resilience, absorbing and buffering capacities in the event of a
disaster. Ten years later, the Nepal earthquake on 25 April 2015
proved that the Region has learnt its lessons well. Countries
today are much better prepared.
Today, we live in a world where there is always a possibility of
danger. Newer vulnerabilities, such as unplanned urbanization,
migration and climate change threaten hard-won development
gains. We need to invest actively in pre-emergencies. These
investments will have invaluable dividends for a safer and
healthier future.
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Inside ISSN 2224-3151 Volume 4, Issue 1, January—June 2015, 1–105
Editorial Inequality in maternal health-care services and
safe delivery in eastern India 54
Towards sustainable access to safe drinking water Arabinda Ghosh
in South-East Asia 1
Prevalence of household drinking-water contamination
Perspective and of acute diarrhoeal illness in a periurban
community in Myanmar 62
Family Planning – friendly Health facility Initiative Su Latt Tun Myint, Thuzar Myint, Wah Wah Aung,
to promote contraceptive utilization 3 Khin Thet Wai
Moazzam Ali, Vinit Sharma, Arvind Mathur,
Marleen Temmerman Innovative social protection mechanism for alleviating
catastrophic expenses on multidrug-resistant
tuberculosis patients in Chhattisgarh, India 69
WHO
Review Debashish Kundu, Vijendra Katre,
A review of the Sri Lankan health-sector response Kamalpreet Singh, Madhav Deshpande,
to intimate partner violence: looking back, moving Priyakanta Nayak, Kshitij Khaparde,
forward 6 Arindam Moitra, Sreenivas A Nair, Malik Parmar
Sepali Guruge, Vathsala Jayasuriya-Illesinghe, A cross-sectional survey of the models in Bihar
Nalika Gunawardena and Tamil Nadu, India for pooled procurement of
South-East Asia
National nursing and midwifery legislation in medicines 78
countries of South-East Asia with high HIV burdens 12 Maulik Chokshi, Habib Hasan Farooqui,
Nila K Elison, Andre R Verani, Carey McCarthy Sakthivel Selvaraj, Preeti Kumar
Mosquito-borne diseases in Assam, north-east India:
current status and key challenges 20 Policy and practice
V Dev, VP Sharma, K Barman Barriers and facilitators to development of
Journal of
standard treatment guidelines in India 86
Original research Sangeeta Sharma, Gulshan R Sethi,
Usha Gupta, Ranjit Roy Chaudhury
Association between household air pollution and

neonatal mortality: an analysis of Annual Health Demand–supply gaps in human resources to combat
Survey results, India 30 vector-borne disease in India: capacity-building
Sutapa Bandyopadhyay Neogi, Shivam Pandey, measures in medical entomology 92
Public Health
Jyoti Sharma, Maulik Chokshi, Anuja Pandey, Sanjay Zodpey, Raj Kumar
The validity of self-reported helmet use among Report from the field
motorcyclists in India 38 Challenges in conducting community-based trials
Shirin Wadhwaniya, Shivam Gupta, of primary prevention of cardiovascular diseases in
Shailaja Tetali, Lakshmi K Josyula, resource-constrained rural settings 98
Gopalkrishna Gururaj, Adnan A Hyder Twinkle Agrawal, Farah Naaz Fathima,
A cross-sectional study of exposure to mercury in Shailendra Kumar B Hegde, Rajnish Joshi,
schoolchildren living near the eastern seaboard Nallasamy Srinivasan, Dominic Misquith
industrial estate of Thailand 45
Punthip Teeyapant, Siriwan Leudang, WHO Publications 104
Sittiporn Parnmen
ISSN 2224315-1
World Health House

Indraprastha Estate,
Mahatma Gandhi Marg, www.searo.who.int/
New Delhi-110002, India publications/journals/seajph
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WHO South-East Asia Journal of Public Health

Volume 4, Issue 1, January—June 2015, 1–105

Volume 4, Issue 1, January—June 2014, 1–105

WHO South-East Asia Journal of Public Health

World Health House

ISSN 2224-3151 January-June| Volume 4 | Issue 1

National nursing and midwifery legislation in countries of

The validity of self-reported helmet use among motorcyclists in India........................................38

A cross-sectional study of exposure to mercury in schoolchildren living

Inequality in maternal health-care services and safe delivery in eastern India.............................54

WHO South-East Asia Journal of Public Health | January–June 2015 | 4 (1) i

Innovative social protection mechanism for alleviating catastrophic expenses

A cross-sectional survey of the models in Bihar and Tamil Nadu, India

Policy and practice

Demand–supply gaps in human resources to combat vector-borne disease in India:

Report from the field

Recent WHO Publications..................................................................................... 104

ii WHO South-East Asia Journal of Public Health | January–June 2015 | 4 (1)

Quick Response Code:

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 1

REFERENCES 5. Wolf J, Prüss-Ustün A, Cumming O, Bartram J, Bonjour S, Cairncross S

2 WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

Quick Response Code:

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 3

4 WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 5

Quick Response Code:

INTRODUCTION the needs of women experiencing it. However, because the

6 WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 7

8 WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 9

Similar to the One-Stop Crisis Centre model in other countries, REFERENCES

10 WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 11

Quick Response Code:

INTRODUCTION of deaths due to AIDS.3 With the exception of Thailand, which

12 WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 13

N/A: data not available.

14 WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

Table 2: Composition of the councils established by the national acts

Council members elected Yes Yes No Yes

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 15

16 WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

Table 4: Scopes of practice provisions in the nursing acts

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 17

18 WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 19

Quick Response Code:

20 WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 21

Annual Target population in

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

2010 2011 2012 2013

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 23

24 WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1)

WHO South-East Asia Journal of Public Health | January-June 2015 | 4 (1) 25

MDA: mass drug administration.

P < 0.001, P < 0.01, P < 0.05.