Narayanan Devadasan - Academia.edu (original) (raw)

Papers by Narayanan Devadasan

Authors' original file for figure 3

Observation guide. This was a guide used to provide structure to the non-participant observations... more Observation guide. This was a guide used to provide structure to the non-participant observations. (DOCX 15 kb)

Interview guides. This document includes guides that were used to semi structure the in-depth int... more Interview guides. This document includes guides that were used to semi structure the in-depth interviews with doctors and patients. (DOCX 21 kb)

BMC Health Services Research, 2019

L’Inde contribue de facon significative au fardeau global de la mortalite maternelle. Plus de 20%... more L’Inde contribue de facon significative au fardeau global de la mortalite maternelle. Plus de 20% des deces lies a la maternite ont lieu en Inde. Afin de s’attaquer a ce fleau, et en particulier afin de promouvoir les accouchements institutionnels, le gouvernement indien a lance un programme conditionnel de soutien financier en especes appele Janani Suraksha Yojana (JSY). Dans le cadre de ce programme, les femmes pauvres qui ont eu trois consultations prenatales et qui accouchent dans une formation sanitaire recoivent une indemnite en especes apres l’accouchement pour en couvrir les couts directs et indirects. Nous avons mene des entretiens avec des personnels de sante et des femmes qui viennent d’accoucher dans quatre etats indiens afin de determiner comment le JSY fonctionne sur le terrain et s’il remplit son objectif initial d’accroitre le nombre d’accouchements assistes au centre de sante. Si des elements existent qui incitent a penser qu’il y a eu une augmentation des accouchem...

BMJ Global Health

Management of chronic conditions is a challenge for healthcare delivery systems world over and es... more Management of chronic conditions is a challenge for healthcare delivery systems world over and especially for low/middle-income countries (LMIC). Redesigning primary care to deliver quality care for chronic conditions is a need of the hour. However, much of the literature is from the experience of high-income countries. We conducted a synthesis of qualitative findings regarding care for chronic conditions at primary care facilities in LMICs. The themes identified were used to adapt the existing chronic care model (CCM) for application in an LMIC using the ‘best fit’ framework synthesis methodology. Primary qualitative research studies were systematically searched and coded using themes of the CCM. The results that could not be coded were thematically analysed to generate themes to enrich the model. Search strategy keywords were: primary health care, diabetes mellitus type 2, hypertension, chronic disease, developing countries, low, middle-income countries and LMIC country names as c...

BMC Public Health

Background: India's Revised National Tuberculosis (TB) Control Programme (RNTCP) offers free TB d... more Background: India's Revised National Tuberculosis (TB) Control Programme (RNTCP) offers free TB diagnosis and treatment. But more than 50% of TB patients seek care from private practitioners (PPs), where TB is managed sub-optimally. In India, there is dearth of studies capturing experiences of TB patients when they navigate through health facilities to seek care. Also, there is less information available on how PPs make decisions to refer TB cases to RNTCP. We conducted this study to understand the factors influencing TB patient's therapeutic itineraries to RNTCP and PP's cross referral practices linked to RNTCP. Methods: We conducted in-depth interviews on a purposive sample of 33 TB patients and 38 PPs. Patients were categorised into three groups: those who reached RNTCP directly, those who were referred by PPs to RNTCP and patients who took DOT from PPs. We assessed patient's experiences in each category and documented their journey from initial symptoms until they reached RNTCP, where they were diagnosed and started on treatment. PPs were categorised into three groups based on their TB case referrals to RNTCP: actively-referring, minimally-referring and non-referring. Results: Patients had limited awareness about TB. Patients switched from one provider to the other, since their symptoms were not relieved. A first group of patients, self-medicated by purchasing get rid drugs from private chemists over the counter, before seeking care. A second group sought care from government facilities and had simple itineraries. A third group who sought care from PPs, switched concurrently and/or iteratively from public and private providers in search for relief of symptoms causing important diagnostic delays. Eventually all patients reached RNTCP, diagnosed and started on treatment. PP's cross-referral practices were influenced by patient's paying capacity, familiarity with RNTCP, kickbacks from private labs and chemists, and even to get rid of TB patients. These trade-offs by PPs complicated patient's itineraries to RNTCP. Conclusions: India aims to achieve universal health care for TB. Our study findings help RNTCP to develop initiatives to promote early detection of TB, by involving PPs and private chemists and establish effective referral systems from private sectors to RNTCP.

Global Health Action

Background: Depending on a country's diagnostic infrastructure, patients and providers play diffe... more Background: Depending on a country's diagnostic infrastructure, patients and providers play different roles in ensuring that correct and timely diagnosis is made. However, little is known about the work done by patients in accessing diagnostic services and completing the 'test and treat' loop. Objective: To address this knowledge gap, we traced the diagnostic journeys of patients with tuberculosis, diabetes, hypertension and typhoid, and examined the work they had to do to arrive at a diagnosis. Methods: This paper draws on a qualitative study, which included 78 semi-structured interviews and 13 focus group discussions with patients, public and private healthcare providers, community health workers, test manufacturers, laboratory technicians, program managers and policymakers. Data were collected between January and June 2013 in rural and urban Karnataka, South India, as part of a larger project on barriers to point-of-care testing. We reconstructed patient diagnostic processes retrospectively and analyzed emerging themes and patterns. Results: The journey to access diagnostic services requires a high level of involvement and immense work from patients and/or their caretakers. This process entails overcoming cost and distance, negotiating social relations, continuously making sense of their illness and diagnosis, producing and transporting samples, dealing with the social consequences of diagnosis, and returning results to the treating provider. The quality and content of interactions with providers were crucial for completion of test and treat loops. If the tasks became overwhelming, patients opted out, delayed being tested, switched providers and/or reverted to self-testing or self-treatment practices. Conclusion: Our study demonstrated how difficult it can be for patients to complete diagnostic journeys and how the health system works as far as diagnostics are concerned. If new point-of-care tests are to be implemented successfully, policymakers, program officers and test developers need to find ways to ease patient navigation through diagnostic services.

BMC health services research, Aug 22, 2016

India has the distinction of financing its healthcare mainly through out-of-pocket expenses by in... more India has the distinction of financing its healthcare mainly through out-of-pocket expenses by individual families contributing to catastrophic health expenditure and impoverishment. Nearly 70 % of the expenditure is on medicines purchased at private pharmacies. Patients with chronic ailments are especially affected, as they often need lifelong medicines. Over the past years in India, there have been several efforts to improve drug availability at government primary health centres. In this study, we aim to understand health system factors that affect utilisation and access to generic medicines for people with non-communicable diseases. This study aims to understand if (and how) a package of interventions targeting primary health centres and community participation platforms affect utilisation and access to generic medicines for people with non-communicable diseases in the current district context in India. This study will employ a quasi-experimental design and a qualitative theory-d...

The Journal of Community Health Management, 2016

One of the strategies of the National Rural Health Mission (NRHM) was the appointment of Block Pr... more One of the strategies of the National Rural Health Mission (NRHM) was the appointment of Block Programme Managers (BPMs) to support the management of the rural health system. This descriptive study provides first insights on who BPMs are, what they do, and what they perceive as barriers to their well-functioning. Data were collected through a semi-structured and self-administered questionnaire from 117 BPMs of Karnataka. Seventy four percent of the contacted BPMs responded. Their average age was 30.4 years, 85% was male, 88.8% had a Master in Business Administration. Self-reported performance and perceived ability is high. BPMs report low salary, lack of cooperation from higher level and field staff, lack of training, lack of logistic support and lack of authority as important barriers to their work. This study suggests that the BPMs require capacity building and supportive supervision with regular feedback to improve their performance. We encourage more research on this important element of NRHM.

Background. Tobacco use imposes a huge burden of disease in India. Most studies on the use of tob... more Background. Tobacco use imposes a huge burden of disease in India. Most studies on the use of tobacco among students in India have focused on secondary school students with a few studies investigating younger children and university students. We aimed to ascertain tobacco use among preuniversity college students in Bangalore. Methods. A cross-sectional study was conducted among 300 students of a purposively selected boys-only, pre-university college in Bangalore. All the students from 4 of 10 randomly selected classes were enrolled in the study. An anonymous self-administered questionnaire was used to collect information on the extent and pattern of tobacco consumption, factors associated with use/non-use of tobacco products, and awareness of the harmful effects of tobacco use. Results. The prevalence of 'ever use' of tobacco was 15.7% (95% CI: 11.7-20.3) of which 5.3% (95% CI: 3.1-8.7) were current users of tobacco. The mean (SD) age of initiation of tobacco use was 14.7 (2.05) years; 78.3% of users were aware that tobacco was harmful. The most common reasons by ever users to start using tobacco included peer pressure, having fun/enjoyment, and curiosity. 'Never users' abstained from usage because of awareness of the negative health implications of tobacco use, a dislike for tobacco products, and the negative social implications of tobacco use. Conclusion. Interventions need to be designed to reduce the use of tobacco among students. Such interventions should raise awareness on the social and economic implications of the use of tobacco, equip students to overcome peer influence and provide counselling to quit using tobacco.

Economic and Political Weekly, Jul 10, 2004

... Some of the self-help groups at DHAN purchase insurance for all SHG members (generally 15 to ... more ... Some of the self-help groups at DHAN purchase insurance for all SHG members (generally 15 to 20) out of profits earned by the SHG (ie, certain SHGs have chosen to make the scheme mandatory). ... The Indian private health sector is un-regulated and unaccountable [Bhat 1999 ...

Tm Ih Tropical Medicine International Health, 2010

Global Health Action, 2015

Background: Many efficacious health service interventions to improve diabetes care are known. How... more Background: Many efficacious health service interventions to improve diabetes care are known. However, there is little evidence on whether such interventions are effective while delivered in real-world resourceconstrained settings. Objective: To evaluate an intervention aimed at improving diabetes care using the RE-AIM (reach, efficacy/ effectiveness, adoption, implementation, and maintenance) framework. Design: A quasi-experimental study was conducted in a poor urban neighborhood in South India. Four health facilities delivered the intervention (n 0163 diabetes patients) and the four matched facilities served as control (n 0154). The intervention included provision of culturally appropriate education to diabetes patients, use of generic medications, and standard treatment guidelines for diabetes management. Patients were surveyed before and after the 6-month intervention period. We did field observations and interviews with the doctors at the intervention facilities. Quantitative data were used to assess the reach of the intervention and its effectiveness on patients' knowledge, practice, healthcare expenditure, and glycemic control through a difference-indifferences analysis. Qualitative data were analyzed thematically to understand adoption, implementation, and maintenance of the intervention. Results: Reach: Of those who visited intervention facilities, 52.3% were exposed to the education component and only 7.2% were prescribed generic medications. The doctors rarely used the standard treatment guidelines for diabetes management. Effectiveness: The intervention did not have a statistically and clinically significant impact on the knowledge, healthcare expenditure, or glycemic control of the patients, with marginal reduction in their practice score. Adoption: All the facilities adopted the education component, while all but one facility adopted the prescription of generic medications. Implementation: There was poor implementation of the intervention, particularly with regard to the use of generic medications and the standard treatment guidelines. Doctors' concerns about the efficacy, quality, availability, and acceptability by patients of generic medications explained limited prescriptions of generic medications. The patients' perception that ailments should be treated through medications limited the use of non-medical management by the doctors in early stages of diabetes. The other reason for the limited use of the standard treatment guidelines was that these doctors mainly provided follow-up care to patients who were previously put on a given treatment plan by specialists. Maintenance: The intervention facilities continued using posters and television monitors for health education after the intervention period. The use of generic medications and standard treatment guidelines for diabetes management remained very limited. Conclusions: Implementing efficacious health service intervention in a real-world resource-constrained setting is challenging and may not prove effective in improving patient outcomes. Interventions need to consider patients' and healthcare providers' experiences and perceptions and how macro-level policies translate into practice within local health systems.

This paper attempts to discuss the proposed National Urban Health Mission (NUHM). While doing thi... more This paper attempts to discuss the proposed National Urban Health Mission (NUHM). While doing this the paper also makes attempts to provide comments on the various strategies of the NUHM while suggesting essential and desirable services for improving access and quality of healthcare services to urban poor populations.

l'accouchement. Ceci peut être perçu comme une promotion des accouchements à domicile, ce qui est... more l'accouchement. Ceci peut être perçu comme une promotion des accouchements à domicile, ce qui est une perversion de l'objectif initial du programme. Mots-clés : Inde, ratio de mortalité maternelle, accouchements institutionnels, transferts d'argent conditionnels, Janani Suraksha Yojana.