The George Institute for Global Health, University of New South Wales, Sydney, Australia.
Injury Division, The George Institute for Global Health, New Delhi, India.
BMC Prim Care. 2023 Aug 11;24(1):160. doi: 10.1186/s12875-023-02109-2.
In 2019, the World Health Organization, set a target to halve the burden of snakebite, by 2030, and identified 'health systems strengthening' as a key pillar of action. In India, the country with most snakebite deaths, the Union Government identified (in September 2022) training of health workers as a priority action area. In this policy context, we provide empirical evidence by analysing the most recent nationwide survey data (District Level Household and Facility Survey - 4), to assess structural capacity and continuum of snakebite care in primary health care system in India.
We evaluated structural capacity for snakebite care under six domains: medicines, equipment, infrastructure, human resources, governance and finance, and health management information systems (HMIS). We categorised states (aspirant, performer, front-runner, achiever) based on the proportion of primary health centres (PHC) and community health centres (CHC), attaining highest possible domain score. We assessed continuum of snakebite care, district-wise, under five domains (connectivity to PHC, structural capacity of PHC, referral from PHC to higher facility, structural capacity of CHC, referral from CHC to higher facility) as adequate or not.
No state excelled ( front-runner or achiever) in all six domains of structural capacity in PHCs or CHCs. The broader domains (physical infrastructure, human resources for health, HMIS) were weaker compared to snakebite care medicines in most states/UTs, at both PHC and CHC levels. CHCs faced greater concerns regarding human resources and equipment availability than PHCs in many states. Among PHCs, physical infrastructure and HMIS were aspirational in all 29 assessed states, while medicines, equipment, human resources, and governance and finance were aspirational in 8 (27.6%), 2 (6.9%), 17 (58.6%), and 12 (41.4%) states respectively. For CHCs, physical infrastructure was aspirational in all 30 assessed states/UTs, whereas HMIS, medicines, equipment, human resources, and governance and finance were aspirational in 29 (96.7%), 11 (36.7%), 27 (90%), 26 (86.7%), and 3 (10%) states respectively. No district had adequate continuum of snakebite care in all domains. Except for transport availability from CHC to higher facilities (48% of districts adequate) and transport availability from PHC to higher facilities (11% of districts adequate), fewer than 2% of districts were adequate in all other domains.
Comprehensive strengthening of primary health care, across all domains, and throughout the continuum of care, instead of a piece-meal approach towards health systems strengthening, is necessitated to reduce snakebite burden in India, and possibly other high-burden nations with weak health systems. Health facility surveys are necessitated for this purpose.
2019 年，世界卫生组织设定了到 2030 年将蛇伤负担减半的目标，并将“加强卫生系统”确定为行动的关键支柱。在印度，这个蛇伤死亡人数最多的国家，联邦政府已将卫生工作者培训确定为优先行动领域（2022 年 9 月）。在这一政策背景下，我们通过分析最近的全国调查数据（地区级家庭和设施调查-4）提供了实证证据，以评估印度初级卫生保健系统中蛇伤护理的结构能力和连续体。
我们评估了六个领域的蛇伤护理结构能力：药品、设备、基础设施、人力资源、治理和财务以及卫生管理信息系统（HMIS）。我们根据达到最高可能域得分的初级保健中心（PHC）和社区保健中心（CHC）的比例，将各州（有抱负者、执行者、领跑者、成就者）分为不同类别。我们评估了各地区的蛇伤护理连续性，根据五个领域（与 PHC 的连接、PHC 的结构能力、从 PHC 转诊到更高设施、CHC 的结构能力、从 CHC 转诊到更高设施），确定是否充足。
在 PHC 或 CHC 的结构能力的六个广泛领域中，没有一个州表现出色（领跑者或成就者）。在大多数州/联邦属地中，与蛇伤护理药品相比，更广泛的领域（物理基础设施、卫生人力、HMIS）在 PHC 和 CHC 层面都较弱。与 PHC 相比，在许多州的 CHC 中，人力资源和设备可用性方面存在更大的问题。在所有 29 个评估的州中，PHC 的物理基础设施和 HMIS 是所有州的抱负领域，而药品、设备、人力资源以及治理和财务是 8 个州（27.6%）、2 个州（6.9%）、17 个州（58.6%）和 12 个州（41.4%）的抱负领域。对于 CHC，所有 30 个评估的州/联邦属地的物理基础设施都是抱负领域，而 HMIS、药品、设备、人力资源和治理与财务在 29 个州/联邦属地（96.7%）、11 个州（36.7%）、27 个州（90%）、26 个州（86.7%）和 3 个州（10%）中是抱负领域。没有一个地区在所有领域都有足够的蛇伤护理连续性。除了从 CHC 到更高设施的交通可用性（48%的地区充足）和从 PHC 到更高设施的交通可用性（11%的地区充足）外，其他领域的充足地区不到 2%。
需要全面加强初级卫生保健，涵盖所有领域，并贯穿护理连续体，而不是对卫生系统进行零碎的加强，以减少印度的蛇伤负担，并且可能减少其他卫生系统薄弱的高负担国家的蛇伤负担。为此目的需要进行卫生设施调查。
