Introduction: Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries. Methods and Findings: Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of ‘‘private sector’’ included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. ‘‘Competitive dynamics’’ for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff. Conclusions: Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients. Please see later in the article for the Editors’ Summary.

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Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review.

Human resources for health in India

The magnitude of and health system responses to the mental health treatment gap in adults in India and China

The overall volume of antibiotic consumption in the community is one of the foremost causes of antimicrobial resistance. There is much ad-hoc information about the inappropriate consumption of antibiotics, over-the-counter availability, and inadequate dosage but there is very little actual evidence of community practices. This study surveyed antibiotic use in the community (December 2007-November 2008) using the established methodology of patient exit interviews at three types of facilities: 20 private retail pharmacies, 10 public sector facilities, and 20 private clinics to obtain a complete picture of community antibiotic use over a year. The Anatomical Therapeutic Chemical (ATC) classification and the Defined Daily Dose (DDD) measurement units were assigned to the data. Antibiotic use was measured as DDD/1000 patients visiting the facility and also as percent of patients receiving an antibiotic. During the data collection period, 17995, 9205, and 5922 patients visiting private retail pharmacies, public facilities and private clinics, respectively, were included in our study. 39% of the patients attending private retail pharmacies and public facilities and 43% of patients visiting private clinics were prescribed at least one antibiotic. Consumption patterns of antibiotics were similar at private retail pharmacies and private clinics where fluoroquinolones, cephalosporins, and extended spectrum penicillins were the three most commonly prescribed groups of antibiotics. At public facilities, there was a more even use of all the major antibiotic groups including penicillins, fluoroquinolones, macrolides, cephalosporins, tetracyclines, and cotrimoxazole. Newer members from each class of antibiotics were prescribed. Not much seasonal variation was seen although slightly higher consumption of some antibiotics in winter and slightly higher consumption of fluoroquinolones during the rainy season were observed. A very high consumption of antibiotics was observed in both public and private sector outpatients. There was a high use of broad spectrum and newer antibiotics in the community. Suitable and sustainable interventions should be implemented to promote rational use of antibiotics that will help in decreasing the menace of antibiotic resistance.

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Trends in antibiotic use among outpatients in New Delhi, India

Received 14 January 2010; Revised 23 June 2010; Accepted 25 June 2010. Background. It is necessary to understand physician’s prescribing behaviour in order to develop interventions that will effectively improve the use of antibiotics. Objective. To explore the factors that influence primary care physicians to prescribe antibiotics and to investigate possible interventions. Methods. Focus group discussions (FGDs) were used to explore the perspectives of primary care physicians in the public and private sectors from five municipal wards (residential localities) of Delhi from where data on antibiotic use and resistance were collected. FGDs (n = 3 with 36 prescribers) were analysed through grounded theory. Results. Three broad themes identified were as follows: behavioural characteristics of doctors and patients; laxity in regulation of prescribing and dispensing antibiotics and intervention strategies to decrease misuse of, and resistance to, antibiotics. Important factors identified for antibiotic prescriptions by doctors were diagnostic uncertainty, perceived demand and expectation from the patients, practice sustainability and financial considerations, influence from medical representatives and inadequate knowledge. For public sector doctors, besides the above, overstocked and near-expiry drugs and lack of time were the factors that promoted antibiotic overuse. Doctors also identified certain patient behaviour characteristics and laxity in regulation for prescribing and dispensing of antibiotics as aggravating the problem of antibiotic misuse. Interventions like Continuing Medical Educations for doctors, awareness raising of patients, shared decision making and stricter rules and regulations were suggested to promote rational use of antibiotics in the community. Conclusion. Exploration of doctors’ antibiotic use practices and possible interventions will be helpful in carrying out interventions to promote appropriate use of antibiotics in the community.

Factors influencing primary care physicians to prescribe antibiotics in Delhi India

BACKGROUND: There is concern regarding the irrational production, prescription and use of drugs in India. This study aimed to describe the quality of prescriptions by medical practitioners, including both the layout of the prescription and the type and number of drugs prescribed. MATERIALS AND METHODS: A survey of all prescriptions dispensed at a busy pharmacy in the state of Goa, India, was carried out over a consecutive seven-day period. Each prescription was rated on the basis of a priori and pilot-tested variable list. The prescriptions by private practitioners were compared with those from practitioners in the public healthcare system. RESULTS: Nine hundred and ninety prescriptions were collected. The majority (83.9%) were from private practitioners. The quality of the layout of the prescriptions was unsatisfactory: information to identify the practitioner was incomplete in more than a third of the prescriptions and information to identify the patient was incomplete in more than half. Clarity of written instructions on how to take the medicines was unsatisfactory in the majority of prescriptions. Polypharmacy was the norm, with more than half (52.7%) the prescriptions containing at least 3 medicines. Forty per cent of prescriptions included a vitamin or tonic preparation and a quarter of the prescriptions included an antibiotic and an analgesic. Over 90% of prescriptions contained only branded medicines. Private practitioners prescribed significantly greater number of medicines and were more likely to prescribe vitamins and antibiotics, and branded medicines. DISCUSSION: This study confirms that the quality of prescriptions, both in terms of layout and the content of the drugs prescribed, is inadequate. There is a need to standardize the format of prescriptions in India so that all essential information is included. There is a need to strengthen an independent mechanism for continuing professional development of practitioners to ensure that patients are always given evidence-based, cost-effective treatments.

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Irrational drug use in India: A prescription survey from Goa

Aims: To determine (i) the prevalence and characteristics of harmful alcohol consumption in general practice attendees; (ii) social and psychological associations with harmful drinking and (iii) recognition of harmful drinking by GPs. Methods: A cross- sectional study of ten general practices in Goa, India. A total of 1567 general practice attendees were recruited. Results: A total of 338 men (41%) and 597 women (81%) reported that they never consumed alcohol. One hundred and twenty-eight people or 8.2% scored >8 on the AUDIT (123 (15%) men and five (0.7%) women) and were classified as harmful or dependent drinkers. The population attributable fraction of harmful drinking in the perpetration of any physical violence by men over 12 months was 0.36. The population attributable fraction of moderate drinking (vs abstention) in the perpetration of any physical violence by women over 12 months was 0.27. Doctors identified almost 60% of problem drinkers but misidentified 5% of moderate drinkers as problem drinkers. Conclusions: The male pattern of drinking in Goa is one of the high rates of abstention coupled with relatively high rates of harmful and dependent drinking in those who consume alcohol. Most women are abstainers. These data provide the first evidence in India on (i) the role of the GP in identification of harmful alcohol use and (ii) the contribution of harmful drinking to the perpetration of physical violence from the perspective of the alcohol user.

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Harmful alcohol use in Goa, India, and its associations with violence: a study in primary care.

Background Little is known about the prevalence of angina in people seen in Indian general practices. The authors assessed the prevalence of angina and its associated risk factors in Goan general practices. Methods Cross-sectional study on consecutive attendees in nine private general practices in Goa, India. All participants completed the Rose Angina Questionnaire, to ascertain the presence of angina. Other demographic, clinical and biochemical data were also collected. Results 1556 (626 men and 930 women) consecutive attendees aged 30 to 75 years. Angina was detected in 37 (5.9%, 95% CI 2.4 to 9.4%) men and 99 (10.6%, 95% CI=7.4 to 11.2%) women. The prevalence of angina increased with age in both sexes but was greater in women between aged 46–60 (OR=4.3 (95% CI 2.0 to 9.2)) when compared with men. When compared with men, the odds of angina in women of all ages was 2.03 (95% CI 1.10 to 3.75) after controlling for confounders. Angina was associated with depressive and/or anxiety symptoms in both sexes (men OR=5.65, 95% CI=2.25 to 14.16; women OR=2.18, 95% CI=1.01 to 4.69) and with hypertension in men (OR=3.82, 95% CI=1.57 to 9.30) and family history of coronary heart disease (OR=1.53, 95% CI 1.05 to 2.24) in women. Borderline/high total cholesterol levels (OR=0.5, 95% CI 0.28 to 0.89) in women were associated with a reduced risk of angina. Conclusion Women attending general practices in Goa, India are at greater risk of angina than men. Depression/anxiety is strongly associated with angina. Greater awareness of the general practitioners to the disparity in angina between the sexes and its association with psychological distress is required.

https://heartasia.bmj.com/content/heartasia/2/1/28.full.pdf

Angina in primary care in Goa, India: sex differences and associated risk factors.





Purpose:  The purpose of this manuscript is to develop and present a gamification framework with eight gamifying mechanics for the business environment and  delineate how these mechanisms are  different in-game and business/workplace considering gamification as an application of games in non-gaming contexts.
 
Theoretical framework:  The gamification mechanics has eight framework elements –meaning, accomplishment, ownership, scarcity, employment, social influence, unpredictability, and avoidance. Each framework element has 4 sub-elements. Every framework element has described in detail where do they appear in the game vs where do they appear in the business/workplace and their relevance.
 
Design/methodology/approach: The eight-element gamification mechanics framework developed considering the business in e-commerce industry. Each and framework element was dissected and developed considering in business/workplace environment in parallel with the gaming environment under non-gaming contexts.
 
Findings:  The study resulted in the development gamification mechanics framework for a business environment which can be applied in any business environment and workplace.
 
Research, Practical & Social implications:  The developed gamification mechanics framework can be used in any business environment/workplace for performance improvement and enhancing employee engagement. We have provided a detailed description of each gamification mechanics framework element, however. The sub-elements may vary from organization to organization and business to business. Before applying this framework the organization should review the framework along with the organization business goals and decide the course of action.
 
Originality/value: The study offers the business and other organization to implement the gamification framework with eight elements for organizational growth, employee engagement





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Gamification Framework With Reference to Business Perspective

In the present study, the researchers reported the results of an empirical study on remote working and occupational stress and their effects on employees’ job satisfaction, motivation, and performance. Remote working has three subscales: self-proficiency, technology, and teamwork. Intrinsic and extrinsic motivation subscales were included to assess employee motivation. A simple random sampling method was used to select the subjects who are employees of the IT-enabled industries in Hyderabad Metro. A total of 513 responses were obtained on the remote working subscales—the effect on the independent variables, namely, employee self-proficiency, technology, teamwork, and occupational stress, on the dependent variables, namely, job satisfaction, intrinsic motivation, extrinsic motivation, and performance. The measured Cronbach’s alpha was in the range of 0.64–0.77, other reliability statistics split-half (odd-even) correlation was in the range of 0.62–0.84, and theSpearman–Brown prophecy was in the range of 0.70–0.91, demonstrating the reliability and internal consistency of the research instrument. The general linear model results indicated that all the independent variables, namely, self-proficiency, teamwork, and Occupational stress, are statistically significant and influence the outcome variables. The general linear model results also indicated statistically significant age differences in the dependent variables; however, there were no statistically significant gender differences. Of the independent variables, self-proficiency influences job satisfaction, intrinsic motivation, and performance (p < 0.01); teamwork influences employee job satisfaction and extrinsic motivation (p < 0.01 and p < 0.05); and Occupational stress influences performance (p < 0.01), which are statistically significant and thus influence the outcome variables. The model predicted a statistically significant influence of age (p < 0.01) on all the dependent factors, namely, job satisfaction, intrinsic motivation, extrinsic motivation, and performance. The study revealed that remote working is one of the major factors causing anxiety and employee stress. The main reasons are the absence of interaction with peers, the absence of routine fun during breaks, and work–family conflicts. Another observation is that the absence of peer–employee interaction demotivates the employees as there is no competition among the employees during remote working. The authors recommend that organizations develop an integrated human resource policy and performance management system that addresses the issues of employee stress, remote working concerns, peer–employee interactions, and pandemic-type situations. As there are several factors such as occupational stress, job satisfaction, motivation, peer interactions, and remote working concerns, employee stress-coping strategies affect the performance of an employee. The multiple mediation analysis indicates no statistically significant influence of the mediator variables, i.e., occupational stress and job satisfaction, on performance through remote working.

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Raj Vaidya

Papers

Irrational drug use in India: A prescription survey from Goa

Harmful alcohol use in Goa, India, and its associations with violence: a study in primary care.

Angina in primary care in Goa, India: sex differences and associated risk factors.

Gamification Framework With Reference to Business Perspective

Remote working and occupational stress: Effects on IT-enabled industry employees in Hyderabad Metro, India