Research Projects Ongoing

Future Health Systems: Research Programme Consortium on Effective Health Service Delivery (FHS)

Agency     :   DFID, UK and Johns Hopkins University, USA

Team          :   Barun Kanjilal, Debjani Barman, Shibaji Bose (Consultant), Upasona Ghosh, Arnab Mandal, Lalitha Swathi Vadrevu, Rittika Brahmachari, Rohit Jain

The Future Health System (FHS) research project in India was initiated by IIHMR in 2006 as a part of a Research Program Consortium led by the Bloomberg School of Public Health, the Johns Hopkins University and in partnership with six other institutions across the world. The primary objective of this project was to prepare a knowledge base on which an appropriate strategy for a more equitable health system would be developed. In India, the FHS research is implemented by IIHMR with the primary focus on the health care delivery system in the Indian part of the Sundarbans. The main focus of this research is to generate knowledge on the barriers to delivery and access of health care services for children and find out the ways by which they can be made more effective in the Sundarbans. It tries to understand the multidimensional nature of the crisis in health care access in the Sundarbans to plan effective service delivery mechanism. The generation of knowledge primarily relates to the what, where, and how of an effective service delivery system.

The research is currently in its second phase (2011-16). During the year (2014-15), several studies were conducted on Rural Medical Practitioners, Innovative public health programmes in the Sundarbans region of West Bengal. Based on the survey results, a series of research products (briefs, journal article, blogs, etc.) on child health issues and their solutions were published and disseminated. The project is currently in its sixth year. Two studies were completed in 2014-15. They were: health system innovations in Sundarbans and Social networking of RMPS. The evidence from these studies will be disseminated to a wide range of stakeholders working for child health through a state level consultation meet in June 2016.

Comprehensive National Nutritional Survey Zone-1

• To organize and supervise the data entry and sample report of the subject in coordination with the regional agencies and laboratory institution of India
• To prepare a draft report for state and national level
• To advocacy and dissemination of the report.

The methodology of the study isto estimates for the nutrition status among the three age groups: pre-school children (0-5 years), school- age children (6-14 years), and adolescents (15-19 years) in 30 states of India.

Performance Monitoring and Accountability 2020 (PMA-2020)

Agency       :   Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA.

Team          :   Dhirendra Kumar, Danish Ahmad, Kshitiz Sisodia, Gargee Gopesh, Rajnish Chordia, Sandeep Kumar, Narendra Singh Shekhawat, Punit Soni

Performance Monitoring and Accountability 2020 (PMA2020) project uses innovative mobile technology to routinely gather data on family planning and water, sanitation and hygiene. Data are collected at household and facility levels via mobile phones through a network of female Resident Enumerators stationed throughout the country. Resident Enumerators (REs), transfer data by phone to a central server via the mobile data network. In real-time, data are validated, aggregated and prepared into tables and graphs, making results more quickly available to stakeholders as compared to a paper-and-pencil survey. PMA2020 can be integrated into national monitoring and evaluation systems by offering a low-cost, rapid-turnaround survey platform that can be used for various other health data needs. Similar program is also being carried out in 11 different countries of Asia and Africa.

IIHMR University, Jaipur implementing the Performance Monitoring and Accountability 2020 (PMA2020) in Rajasthan, India with the technical and financial support from Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA. IIHMR University has set up a Project Management Unit of central staff and deployed a cadre of female Resident Enumerators and primary data collectors. The overall direction and support of PMA2020 is being provided by the Bill & Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health.

ASHA Motivation Audit

The study will be conducted in the high priority districts of Uttar Pradesh in which RMNCH+A strategy is being facilitated by TSU in Uttar Pradesh. a mixed method (qualitative and quantitative) approach will be used for data collection. The objectives of the study are:

• To identify the key factors of low and high motivation level among the ASHAs.
• To assess the need of training, mentoring and support towards better job satisfaction and quality health provisioning.
• To draw up recommendations on enabling factors for ASHA motivation

National Family Health Survey (NFHS-4) Rajasthan

Agency       :   International Institute for Population Sciences (IIPS), Mumbai, Ministry of Health & Family Welfare, GoI Team          :   Anoop Khanna, BS Singh, RS Rathore, Gowthamghosh B, Mohammed Sherif, Melvin Baxla, Kailash Prajapati

Ministry of Health & Family Welfare, Government of India (MoHFW-GoI) is conducting CAPI based National Family Health Survey-4 (NFHS-4) in all 35 States and Union territories of India. NFHS is being undertaken with the main objective of strengthening India’s demographic and health database by providing information that is both valid and reliable.

In the second round, MoHFW-GoI entrusted IIHMR with the task of conducting field work of NFHS-4 in Rajasthan. IIHMR is conducting district wise household survey in all 33 districts of Rajasthan. As per the estimate, 32680 households will be covered from 1634 PSUs of Rajasthan. The sample spreads in all 33 districts. Each district will have 43-86 Primary Sampling Units (PSUs) covering rural and urban representation as per the percentage of rural and urban population of the state. From each PSU pre-determined 22 households are being surveyed.

One of the components of the household survey is Clinical Anthropometry Biochemical Testing (CAB). The CAB component includes measurements of height, weight, blood pressure, hemoglobin and random blood sugar for men, women and children in the selected households. In a subsection of the households, Dried Blood Spots (DBS) are being taken from men and women for HIV testing.

National Family Health Survey (NFHS-4) Odisha

One of the components of the household survey is Clinical Anthropometry Biochemical Testing (CAB). The CAB component includes measurements of height, weight, blood pressure, hemoglobin and random blood sugar for men, women and children in the selected households. In a subsection of the households, Dried Blood Spots (DBS) are being taken from men and women for HIV testing.

National Family Health Survey (NFHS)-4 Chhattisgarh

Agency       :   International Institute for Population Sciences (IIPS), Mumbai, Ministry of Health & Family Welfare, GoI

Team           :   JP Singh, Arindam Das, Suresh Siwal, Paras Kumar

Ministry of Health & Family Welfare, Government of India (MoHFW-GoI) is conducting CAPI based National Family Health Survey-4 (NFHS-4) in all 35 States and Union territories of India. NFHS is being undertaken with the main objective of strengthening India’s demographic and health database by providing information that is both valid and reliable.

In the second round, MoHFW-GoI entrusted IIHMR with the task of conducting field work of NFHS-4 in Chhattisgarh. IIHMR is conducting district wise household survey in all 18 districts of Chhattisgarh. As per the estimate, 18920 households will be covered from 946 PSUs of Chhattisgarh. The sample spreads in all 18 districts. Each district will have 43-86 Primary Sampling Units (PSUs) covering rural and urban representation as per the percentage of rural and urban population of the state. From each PSU pre-determined 22 households are being surveyed.

One of the components of the household survey is Clinical Anthropometry Biochemical Testing (CAB). The CAB component includes measurements of height, weight, blood pressure, hemoglobin and random blood sugar for men, women and children in the selected households. In a subsection of the households, Dried Blood Spots (DBS) are being taken from men and women for HIV testing.

Khushi Baby (KB): Efficacy and Impact Assessment of Novel Mobile Health Solution for Vaccination Record Keeping in Rural Udaipur, Rajasthan

Agency       :   Future Health Systems, Johns Hopkins University, USA

Team          :   Mohammed Shahnawaz, Ruchit Nagar, Barun Kanjilal

The primary objective of Khushi Baby Inc (KB), a not for profit venture, is to improve monitoring of child vaccination by digitizing individual vaccine records with low-cost technology that does not require high-level connectivity. To achieve this objective, KB has designed an NFC (Near Field Communication)-enabled mobile application which simultaneously stores vaccine records on a physical NFC chip and sends them to a cloud-based database. The chip, costing less than $1, can be encased in any culturally appropriate form factor, a pendant to hang around a baby’s neck. With KB’s Android application, community health workers can read/update vaccine records on the chips in even the remotest rural areas, and the database will be updated as soon as the phone re-enters an area with internet network (2G/3G/Wi-Fi). Thus, each baby with a culturally appropriate wearable chip will have an easily accessible digital vaccine record and contribute to a database which improves understanding of vaccination rates by health care workers, agencies, and governments.

This simple solution uses off-the-shelf technology to keep costs low and offers many advantages to current data collection methods, which rely heavily on manual paper reporting. KB can also standardize reporting functions to make electronic databases easily accessible and allow for sophisticated data analysis and individual record tracking which can inform vaccination interventions.

Bottleneck Analysis of Civil Registration Vital System (CRVS) in Chhattisgarh

Agency     :   UNICEF Chhattisgarh

Team        :   Nutan Jain, Suresh Joshi, Arindam Das, Matadin Sharma, Piyush Mishra, Vidya Bhushan Tripathi

The RBD Act 1969 has made registration of births and deaths compulsory. Civil registration system (CRS) is defined as continuous, compulsory recording of the occurrence and characteristics of vital events. It provides a safe guard to social status and individual benefits. The Act enables the government to regulate the registration and compilation of vital statistics in the state so as to ensure uniformity and comparability leaving enough scope to the states to develop efficient system of registration suited to the regional conditions and needs.

The aim of the bottleneck analysis is to reinforce the provisions of the RBD Act in both letter and spirit to achieve cent percent registration. The objectives of bottleneck analysis are to:

• identify barriers, bottlenecks, and enabling factors which either constrain or advance the achievement of universal registration of births and deaths in the state;
• assess capacity and strategy of CRVS in Chhattisgarh;and
• suggest roadmap for accelerating civil registration with a sharper focus on equity

The results of Bottleneck Analysis (BA) are intended to strengthen the civil registration system and to achieve 100 percent birth, stillbirth and death registration. The BA provides key indicators at the district level. The study was conducted in five districts of Chhattisgarh: Balrampur, Dantewada, Raipur, Sarguja and Sukma.

Strengthening Civil Registration and Vital Statistics System in India to Achieve Vision 2020: Facilitation to Office or Registrar General, India

India after careful analysis has set itself an ambitious vision of achieving Universal Birth Registration and cent percent registration of institutional deaths by 2020. This has been christened as “Vision 2020”. To chalkout the strategies for improvement in Civil Registration System and formulate the plan of action for the States, a team of experts, comprising international and national experiences in the field of Civil Registration and Vital Statistics (CRVS) has been set up with the help of UNICEF through IIHMR University Jaipur. The team will conduct a participatory comprehensive assessment of CRVS and formulate an action plan for achieving the vision. The team is working under the overall guidance/supervision of Registrar General India.

In order to conduct a participatory assessment, an orientation workshop was arranged successfully at Jaipur during January 19-22, 2016 with the coordination of IIHMR, UNICEF and ORGI. The Workshop was attended by the representatives from the Chief Registrars and DCO Offices of selected 6 States namely Assam, Bihar, Rajasthan, Madhya Pradesh, Kerala, Uttar Pradesh, representatives of UNICEF and ORGI also attended the workshop. A comprehensive assessment tool for Chief Registrars, District Registrars, Registrars and Medical institutions was framed and discussed with the participants. The tools framed for Registrars were tested on pilot basis during field visit at Jaipur on 21st January, 2016. In order to evaluate the registration system of the States, it has been decided to organize the field visit in the selected States during February/March, 2016. A strategy along with acceleration plan for the low performing states will be prepared.

Rapid Assessment of ANC, Natal and PNC Services in UNICEF focused Districts in Rajasthan

Agency     :   UNICEF Rajasthan

Team        :   Suresh Joshi, NK Sharma, Rahul Sharma, Vijay Mishra

Coverage Evaluation Survey MNCH interventions in small villages of Dungarpur and Barmer Districts : The IIHMR University undertakes a rapid Coverage Evaluation Survey in the districts of Barmer and Dungarpur to see reach out with MCHN services in small and difficult to reach villages in the UNICEF Focus Districts in Rajasthan. The proposed studies assess the coverage levels of various MCHN indicators and compare it with the earlier survey to see the change due to the intervention. The study also attempts to establish the evidence of effectiveness of the present strategy facilitated by UNICEF State Office. 30 clusters were identified from village with less than 1000 population from each districts and in each identified village 7 children in the age group of 1-2 and 7 women who have delivered in last 12 months were assessed for different MCHN interventions. In addition, information regarding water sanitation, education personal hygiene and nutrition would also be collected from household which have less than 5 children and adolescent girls. The study also focus on assessing the knowledge and skills of service providers including Health workers, Anganwadi worker and ASHA sahyogini in providing MCHN related services in the villages covered under the study. A review of the service inputs would be matched to understand the bottlenecks in making service available and accessible.

Assessment of quality of services provided in 4 UNICEF HPDs (Banswara, Barmer, Dungarpur and Jalore) with special emphasis on Intrapartum and Newborn care: A Rapid Health Facility Assessment (RHFA) to understand the quality of service in the district hospital, CHCs and PHC s in four UNICEF focused districts viz., Banswara, Barmer, Dungarpur and Jalore with a focus on intra-partum and post partum care in the institutions. The labour room and nurseries and sick new born units have been the focus for up-gradation. The inputs focused on capacity building and supplies to improve quality of service to match the NABH accreditation guidelines.

The rapid health facility assessment would be conducted on a randomly selected CHC and PHCs where UNICEF extra inputs have been undertaken. The focus of the rapid assessment would be to find out the current status of the quality parameters adhered while providing maternal and new born care in the identified health institution. It would also make an attempt to identify the good practices undertaken by service provider to maintain quality. Further the assessment would also attempt to identify any bottlenecks encountered in undertaking and maintaining quality parameters in the institution.

Technical Support Unit for Food Fortification in Rajasthan

Agency       :   Global Alliance for Improved Nutrition (GAIN)

Team          :   Dhirendra Kumar, Sudeep Sharma, Ranjeeta Rani

With an aim to improve the food and nutrition security of the people of Rajasthan and improving their nutrition and health status, Government of Rajasthan in its budget declaration of the year 2015-16 announced provisioning of fortified food items like fortified wheat flour, fortified edible oil and double fortified salt through Fair Price Shops under Public Distribution System (PDS). For this, GAIN and IIHMR University has setup a Technical Support Unit (TSU) at IIHMR University, Jaipur in November 2015 for providing technical support to Department of Food and Civil Supplies and Rajasthan State Food and Civil Supplies Corporation Ltd. for supporting in translating the budget announcement into action and facilitating smooth implementation whereby the fortified staple foods are mainstreamed into the PDS. TSU is providing support to the Government under the core areas such as Production, Quality Assurance, Social Marketing and Promotion and Monitoring and Evaluation.

Gender Rights in Adolescent Friendly Health Services (AFHS): Policy and Practice in a Government Programme in West Bengal State of India

Agency     :   World Health Organization, Geneva

Team        :   Manasee Mishra, Nutan Jain, Saheli Manish Kumar

The study aims to develop a case study on the Adolescent Friendly Health Services (AFHS) in West Bengal state of India. It critically analyses the state mandated AFHS intervention using human rights principles and a gender sensitive approach. Nine human rights principles have been used for the purpose. These are: non-discrimination, availability, accessibility, acceptability, quality of health services, informed decision making about own health, privacy and confidentiality, participation in health policy and service decision making, transparency and accountability. Qualitative research methodology has been adopted for the study. Both secondary and primary data shall be used. A sample of urban and rural sites in the state shall be visited. The study is among a group of case studies from across the world expected to inform programme strategies of the WHO in the future.

Climate Change, Uncertainty and Transformation

Agency     :   Norwegian University of Life Sciences, Norway

Team        :   Upasona Ghosh, Manasee Mishra, Shibaji Bose (Consultant), Sabyasachi Mandal (Research Assistant)

The study uses qualitative methodology to explore how different actors from above (e.g. policy makers), middle (e.g. media)and below (e.g. local communities) conceptualize climate change related uncertainties in the Sundarbans in West Bengal. It explores how and to what extent climatic uncertainties are impacting the major drivers in the lives of the ‘below’ of Sundarbans, and how people are living with such uncertainties. Further, it explores whether and to what extent climatic uncertainties are leading towards transformation in the socio- ecological system of the Sundarbans. The study is expected to contribute to an understanding of the following in the Sundarbans in West Bengal: contextual and social changes due to the changing climate; coping and adaptation mechanisms of the people of the Sundarbans due to climatic threats; policy paradigms and implementation with specific reference to changing climate; and future alternative pathways for sustainable development for the people of the Sundarbans.

Linkages of Parallel Health Providers and Impact on Health System: A Social Network Analysis from Indian Sundarbans

Agency     :   IIHMR In-House Research Grant

Team        :   Rittika Brahmachari, Sabyasachi Mandal (Research Assistant)

Social network theory informs the study. Using qualitative methodology, the study explores the following: the presence and functioning of the network of rural medical practitioners with health system actors in the Sundarbans in West Bengal; the extent of influence of the healthcare market on the rural medical practitioners and vice versa; and how to make use of these networks for effective service delivery for the people of the Sundarbans in West Bengal. The study found three types of significant linkages in the social network of the rural medical practitioners: formal healthcare actors, private healthcare market actors, and community based actors. The network comprises of strong and weak social ties which act as safety nets for the rural medical practitioners. The resilience of these groups of community based informal healthcare providers has the potential to complement the formal healthcare providers, both in normal times and during climate shocks. The strengthening of the weak ties with formal healthcare providers can lead to building resilient and responsive health systems.

Are Women of Indian Sundarbans Living in Dark: A Gender Analysis of Eye Health Problem

Agency   :   Cross Research Programme Consortia Partnership on Gender, Ethics and Health Systems (RinGS)

Team      :   Debjani Barman, Arnab Mandal, Manasee Mishra, Barun Kanjilal

The study is located in the Indian Sundarbans. It follows context embeddedness and intersectional approach, and uses mixed methods. It seeks to answer the following: assess differences in perception of visual impairment by gender and other social determinants; assess the differences in detection of visual impairment by gender and other social determinants; explore the differences in health care seeking and financing for visual impairment by gender and other social determinants; and explore the difference in dependencies following visual impairment by gender and other social determinants.Gender, age and education are important determinants of visual impairment and care seeking for eye health.

In the Sundarbans in West Bengal, elderly females are less likely to seek care despite being more likely to develop eye problems. Elderly educated males are less likely to suffer from eye problems. Preliminary findings of in-depth interviews reveal a low perceived severity of eye problems and low importance to eye care seeking among females. This may be due to women’s activities being primarily restricted to the household. Elderly women with male partners or sons were found to have less decision making power than single women or widows. Male relatives often take decisions related to eye health on behalf of the women.

Participatory Action Research on Interventions to Support Deaf Young People in West Bengal and Karnataka

Such a participatory action research would benefit them in the immediate and long term contexts. Deaf young people would be empowered during their engagement in the process. Activities such as reflections of life experiences, articulation of aspirations, interaction with peers, or the enabling environment created through the action research intervention would positively affect them as the action research project is underway.

The long term benefits of the action research project are that, it would offer a set of interventions that has been designed, implemented and tested for its effectiveness. Future programming of DCW for deaf young people in India and other countries across the world will be actively informed by the set of interventions tested in the action research project.

Strengthening Convergent Action for Reducing Child under Nutrition

Agency    :    ICICI Foundation, Mumbai

Team       :    Sunita Nigam, Abhishek Dadich, Rajeev Dhakad, Abhishek Kumar

Strengthening Convergent Action for reducing Child under nutrition is a three-year pilot project being implemented by ICICI Foundation for inclusive Growth in partnership with Department of Women and Child Development, Government of Rajasthan. This intervention is aimed at improving nutritional status, prevention, reference, management and treatment at MTC.

The project seeks to improve the nutritional status of 0-6-year-old through a three pronged, comprehensive approach of preventing and managing under nutrition and the treatment of severe under nutrition. In the first phase, the project implemented in 250 anganwadi centres in two blocks viz Kishanganj and Shahbad of Baran District of Rajasthan State. In second phase the other 244 anganwadi centres were covered for scaling up.

The key objective of the project is to measure key outcome indicators to assess the impact of the project vis-à-vis its objective and shares the successful practices among the key stakeholders.

The assessment of nutritional status will be carried out based on the indices of weight-for-age, height-for-age, weight-for- height and MUAC. These three indices of nutritional status will be expressed in standard deviation units (z-scores) from the median for the international reference population. Children who are more than two standard deviations below the reference median on any of the indices will be considered as undernourished, and children who falls more than three standard deviations below the reference median will be severely under-nourished.