Previous – Research

Project Title:  : Assessing and Explaining the Impact of Community Based Monitoring and Planning (CBMP) across Multiple Contexts in the State of Maharashtra

Project Period: October 2017 to June 2020

 The Community Based Monitoring and Planning (CBMP) initiative in India has been implemented since 2007 as a component of National Rural Health Mission (NRHM) and later through National Health Mission (NHM). This CBMP intervention, which is a significant form of social accountability of health services, has completed eleven years in Maharashtra state in 2018. The study is being undertaken to examine the impact of CBMP, by analysing various aspects of the CBMP process and its influence on the interface between community health system and communities which access healthcare.

Objectives of the Study

• To assess the impact of CBMP processes in intervention areas on improving access, availability, quality of health services for rural communities
• To understand how CBMP has influenced awareness and participation of community-based actors, and responsiveness of the health system to social inputs.
• To understand factors influencing the impact of CBMP process across multiple contexts within Maharashtra.

This study uses a mixed methods approach, utilising a paired comparative case study (CCS) design including quantitative survey. Paired CCS would further use secondary and primary data which would be both qualitative and quantitative in nature. Five pairs of cases are selected from CBMP and non-CBMP areas using most similar type of case selection method. Paired CCS includes- qualitative in-depth interviews of key stakeholders and quantitative survey with women who have delivered in public health facilities during last six months. This component is augmented with quantitative Survey of RKS and VHNSC Members across CBMP and non- CBMP blocks.

Project Title:  Practices, Regulation and Accountability in the Evolving Private Healthcare Sector: Lessons from Maharashtra State, India’

Project Period: July, 2017 to June 2019

Background:

This project is a two-year collaborative study, being conducted by researchers from SATHI Pune and King’s College London, and supported by Wellcome Trust-Medical Research Council/UKAID/ESRC, UK under their Joint Health Systems Research Initiative Foundation Grant 2017.

The Corporatisation and Regulation in the Private Healthcare Sector in India (CRiPS) is concerned with the expansion and transformation of the formal private sector hospital care and related diagnostic services in India, through an organised, and increasingly transnational, healthcare industry; the regulatory and accountability challenges arising from such changes; and how these can be addressed to improve regulation and social accountability. It will do so through a detailed case study of these developments in Maharashtra. This will be used to inform future advocacy for health rights and development of regulatory policy in the move towards universal health coverage. The study is informed by social policy literature on commercialisation and market relationships in production and provision of healthcare; on issues of power and role of special interest groups in processes of regulation; and on social accountability-social regulation-governance approaches to re-invent and democratise regulation. 

The specific research objectives are:

• To document and analyse the key changes in the private hospitals and diagnostics sector in Maharashtra state and in India, in the last two decades and the likely future trend;
• To study the implications of these transformations for medical and institutional practices, for medical practitioners and users;
• To examine the existing regulatory mechanisms in this sector, and what are the regulatory implications of the expansion of the sector and emergence of new industry actors;
• To develop a social accountability approach to regulation of private healthcare based on the above, and
• To derive lessons for India and for low-middle income countries (LMICs) more broadly in order to facilitate universal access to quality health care.

Project Title:  Promotional Practices of Pharmaceutical Industry and Implementation Status of Related Regulatory Codes in India

Project Period: August 2017 to August 2019

Over the past decade, the Medical Council of India, pharmaceutical Companies and the government have constituted regulatory codes to guide the interaction of medical professionals with the pharmaceutical and allied health sector industries, and to curb unethical promotional practices. These are voluntary codes and anecdotal experience reveals that often these codes are not adhered to. To understand this, a detailed documentation of field level promotional practices of the pharma industry was undertaken with the specific objective of studying its promotional and marketing practices in India and the implementation status of the regulatory codes. The study is qualitative in nature, using purposive and snowball sampling method. 50 In-depth interviews have been undertaken with various key informants in six selected cities across the country. The study primarily focuses on interviewing medical representatives because they are the ones who promote the drugs on actual field to health care professionals. Analysis indicates that several unethical promotional practices continue to exist such as incentives in kind, in cash, sponsorships for attending conferences and sponsored entertainment trips too. Along with these new forms such as providing gift cards (Debit Cards), petro cards, e-vouchers, online purchasing on Amazon, Flipkart etc. have emerged as a new phenomenon. It indicates that even though there are regulatory codes such practices continue to exist and there has been no stringent action been taken to curb the unethical practices which prove the ineffectiveness of voluntary codes.

Project Title:  Project-Understanding the Perspective of Medical Practitioners about Commission Practice in Private Healthcare in India (APPI)

Project Period: January 2016 to March 2017

Expansion of private sector has undoubtedly increased availability and physical access to health services; however, the private health sector is also plagued with certain unethical practices. Unethical practices like unnecessary prescriptions, procedures, and diagnostic tests are discussed anecdotally. Weak regulation of private health sector, lack of monitoring mechanisms and absence of standard treatment protocols have been identified as some of the reasons behind the rise in such unethical practices. Commission practice (splitting professional fees) is one of such unethical practices of which Medical Council of India has taken note of. Despite the clear guidelines by Medical Council of India, commission practice has thrived unscrupulously. Given the dearth of research on private health sector in India, it is important to bring on board the views of private practitioners regarding the nature of commission practice in India. In this context, this study attempts to study the perspectives of radiologists and pathologists in Pune city regarding the commission practice, about its impact on health care providers and also the ways to check this practice. It is a qualitative research study which explored the views of doctors from two different specialties, viz., pathology and radiology. These two branches were chosen since these branches are mostly dependent on the patients referred by other doctors. Total 20 In depth interviews were conducted in the study.

This study has proved that the anecdotal experience of many that the commission practice in the branches of Pathology and Radiology in the city of Pune in India is a well-entrenched practice. The commission practice has become a norm and private doctors look at commission practice as a menace but not as a moral dilemma. Nearly everyone agrees that it is difficult for a new entrant in business to survive if s/he refuses to give commission, the declining moral fabric of society has already shaped world views of doctors.

Project Title: Promoting participatory action on local Health budgets and medicine distribution in Maharashtra (IBP)

Project Period: 1st June 2014- 31st July 2016 

Writing research paper on Community-based Monitoring Process in Maharashtra

The objective of the research is to critically analyse community-based monitoring and planning (CBMP) related to health services in Maharashtra as a way to foster ‘publicness’, to evaluate the potential for scaling up such initiatives in India, as well as for transferability on a global scale. The study is based on secondary research to be carried out in Maharashtra state of India. It will focus on CBMP in relation with accountability, improving access to public health services, enhancing responsiveness of services and reducing out-of-pocket expenditures of people accessing public health services.

First, it will provide international context and theory about Community monitoring of public health services, locating CBMP in Maharashtra in this context. Second, it will identify key successes and problems related to CBMP in public health services in Maharashtra, drawing upon external evaluations and SATHI experiences. Finally, it will draw out key lessons from the Maharashtra CBMP experience which might be relevant for similar accountability work in other settings, including health sector in other countries and other social services.

Project Title:  Assessing Usefulness of Participatory Audit and Planning Process on Improving Functioning of Patient Welfare Committees in Select Public Health institutes from Maharashtra

Project Period: 2013-2015

Community empowerment is being increasingly recognised as a critical component towards enhancing accountability of and equitable access to health care. In India, a participatory process termed ‘Social audit’ has emerged as an effective model for ensuring accountability and equity in the Employment Guarantee scheme. In Maharashtra, a group of Civil Society Organizations (CSOs), implementing Community-Based Monitoring and Planning (CBMP) of health services under the National Rural Health Mission (NRHM) since 2007, considered Rogi Kalyan Samities (RKS, Patient Welfare Committees) as an important gateway to ensure effective and equitable utilisation of flexible funds under what is now the Nation Health Mission (NHM), and initiated a Participatory Audit and Planning (PAP) process.
Retaining the core of social audit with appropriate modifications in the context of RKS funds, a PAP was conducted in 9 health facilities from three tribal districts of Maharashtra between December 2014 and March 2015. In a preparatory phase, RKS expenditure data of the year 2013–2014 were analysed and public report cards were prepared. The PAP then involved examination of financial documents, physical verification of purchases and report cards. Multiple stakeholders (RKS members, elected representatives, health providers and CSO actors) were involved in the process. Eventually, in a dialogue among key stakeholders, identified issues would be discussed, decisions taken and future planning done accordingly.

Project Title:  A Study of Supplementary Nutrition For Under 3 Children In Four Districts Of Maharashtra (NSF)

Project Period: 2012-15

Under the ICDS programme, supplementary nutrition in the form of hot cooked meals is provided to children in the age group 3-6 years while ‘Take Home Ration’ (THR) packets are provided to children aged less than 3 years. The present study was carried out with the objective of assessing two different strategies used for providing supplementary nutrition for under-3 children provided through ICDS scheme. These two strategies are giving THR packets vs. giving cooked food to the children. The comparison was done to see the differences in the distribution, consumption, and nutritional value of food provided through THR versus cooked food. Data were gathered through interviews of caretakers of under three children, direct observation of food preparation and records from Anganwadi. It was seen that, only 11% children in the THR districts were frequent users of the packaged food. In the overall analysis cooked food for children below 3 years was found to be better strategy of providing supplementary nutrition than THR packets due to better acceptability, consumption and adequacy of calorie and protein content (actual consumption). The study indicates that the government should make appropriate modifications to improve the efficacy of the Take Home Ration scheme.

Project Title:  Complementary Feeding Practices amongst Children Aged 6-18 Months in Tribal Parts of Maharashtra, India – Requires to be Complemented Aptly (NSF)

Project Period: 2012-15

The link between malnutrition and child feeding practices has been widely recognised. Late introduction of weaning food by Indian mothers is a well-documented fact and is considered to be a major cause of malnutrition. In India, breastfeeding in rural areas appears to be shaped by the beliefs of a community, which are further influenced by social, cultural, and economic factors. Breastfeeding and weaning practices vary among different regions and communities. Hence, continuous vigilance over infant feeding practices in the community is necessary for timely interventions, to ensure optimal growth and development. The present study was carried out to document the complementary feeding practices in the view of understanding reasons of delayed or deficient practices in children aged six-18 months, from tribal regions of Maharashtra. It was a descriptive, cross sectional study conducted during February 2015- October 2015 in selected blocks from three tribal districts of Maharashtra viz: Amravati, Gadchiroli and Nandurbar. The overall picture indicates that although a majority of mothers were unaware regarding appropriate feeding practices for meeting the child’s nutritional requirements. Top feeding practices are found to be deficient in terms of under feeding and lack of nutritionally balanced diet in the studied children.

Project Title:  Developing capacities for using community oriented evidence towards Strengthening District Health Planning in Maharashtra State, India (WHO)

Project Period: April 2010- September 2012

Health sector policy making in India has been highly centralised with little use of community based evidence. In principle, Government is committed to the decentralisation of power and thereby allows people to have greater say in the process of decision making. Since Districts have distinct context and specific needs as far as health care is concerned, District Health Planning is a necessary component of decentralisation. Activities and strategies mentioned in this proposal are to build capacities of key stakeholders who would be involved in the process of decentralised planning by using community based evidence as well evidence from other sources such as Health Management Information System.

Project Title:  Maharashtra Health Equity and Rights Watch & Research and advocacy on aspects of access and rationality of health services and Universal access to health care; Health rights and equity fellowship programme (IDRC)

Project Period: April 2011 – January 2015

The activities in this project are in continuation of the research activities conducted in the first phase. This project uses a three pronged strategy to develop work on health equity in the state. The three complementary approaches are –

• Additional specific research to deepen understanding regarding certain irrational practices by the private health sector (esp. in context of women’s health) as they accentuate the health inequities, this also includes studying the irrational health care expenditures in the private medical sector.
• Concretising models and shaping public opinion and policy towards a regulated system for Universal Access to Health care, as a key strategy for reduction of health inequities and reduction of irrational health care expenditure.
• Capacity building of younger health professionals to create a larger pool of professionals working on Health rights issues with an equity perspective

The activities in the second phase are as follows –

• Analysis of NFHS 3 data pertaining to Maharashtra focusing on increasing numbers of Caesarean sections reflecting irrationality of delivery care.
• Policy proposal paper on strategies for achieving Universal Access to Health Care in Maharashtra.

One of the important activities of the project is a fellowship programme was to help build the capacity of young professionals. The focus of the fellowship programme was on Health rights and equity.

Project Title : A Study of budgetary provisions, procurement and supply system concerning essential medicines in selected districts of Maharashtra (IBP)

Project Period: August 2009 – March 2012

Research Component

Availability of essential medicines in public health facilities is one of the serious concerns regarding the quality of health care services. This is also one of the major reasons for lower utilisation of the public health system. Some amount of evidence is already available to substantiate this fact including preliminary findings of the household survey conducted by SATHI. For example in the 60th round of National Sample Survey (2004), information was sought regarding the medical expenditure for treatment under different heads of treatment during stay at hospitals as an inpatient. Analysis of this data reveals that the range of proportion of total expenditure on medicines was from 57 to 66. The proportion of expenditure on medicines to total expenditure is higher in the public health facilities as compared to private health facilities. This clearly indicates that though the public health facilities are supposed to provide the health care services at minimal costs, due to non availability of essential medicines in these facilities, the actual costs borne by the patients are very high.

Project objectives: To improve the availability of essential medicines in PHCs

Short term objectives

• To understand the procurement and distribution process in the state of Maharashtra
• To develop tools for monitoring the procurement and distribution system

Key research areas in this project are

• To study budgetary allocations- The budgetary allocations for essential medicines in the districts/ PHCs under study.
• Study of procurement of essential medicines in the state of Maharashtra-The procurement and distribution system of selected essential medicines in the state of Maharashtra with a view of understanding key gaps, bottlenecks and reasons for delay
• Study of availability of essential medicines in the selected districts -Actual availability of various essential medicines at select PHCs

 Activities

• To find out the Per capita allocations and expenditures for essential medicines in the districts/ PHCs under study, the following documents would be studied – At the state level- Annual Financial statement of Procurement Cell of Department of Health, Budget and expenditure statement of procurement cell   At the district level- ZP budget and expenditure on medicines,
• Expenditure tracking for the select medicines purchased at the state level, at the district level as well as PHC level.
• To document the process of procurement for select medicines in the state of Maharashtra
• To study the distribution system for the 9 selected medicines
• To understand the systems that is put in place to ensure quality of medicines procured.
• To check availability of selected essential medicines in the two selected PHC`s

To know more about international budget partnership (IBP) and their partnership initiative click on http://www.internationalbudget.org/