India and Tuberculosis GRETCHEN APGAR MARYMOUNT UNIVERSITY SUMMER SEMESTER II

Global Health Target Population  India  Population: billion (World Bank, 2016)  Religion: Hindu (Caste System), Sikh  Industry: Pharmaceuticals, steel, growing information and space technologies  Development: Weak infrastructure both rurally and in urban areas  Healthcare system: Public and private healthcare services, 80% of the population use private services  Growing middle class  Large number of people living in poverty (approximately ¼ of the population) (World Bank, 2016)

Gender Inequality in India  Gender Inequality Index (GII):  This number indicates a high level of gender inequality  GII represents the loss in potential human development due to disparity between female and male. (United Nations, 2015)

Health Issues in India  Malnourishment in infants and children  Maternal mortality (190 per 100,000 births)  Tuberculosis ( approximately 25% of the world’s TB cases)  Non-communicable diseases (United Nations, 2015) LACK OF ACESS TO PROPER HEALTHCARE

(World Health Organization, 2010)

TB Program History in India  Ministry of Health India  World Health Organization’s Direct Observation Short Course (DOTS)  Revised National Tuberculosis Control Program (RNTCP)

Using the PEN-3 Model The model, originally developed as a conceptual model for health promotion and disease prevention in African countries, consists of three domains including cultural empowerment, cultural identity, and relationships and expectations and three components within each domain (Perez and Luquis, 2014).

PEN-3: Cultural Empowerment  The cultural empowerment domain encourages the promotion of the good aspects of culture and those that are unique as to not focus solely on the negative (Perez and Luquis, 2014).  Cultural empowerment can be viewed as positive when it promotes the intended health behavior, seeking publicly provided, free TB screening and receiving treatment.  Existential aspects of the Indian culture may provide for a more holistic approach to healthcare that would be beneficial to the development of the program.

PEN-3: Cultural Identity  The cultural identity domain seeks to assess the person, extended family, and neighborhood (Perez and Luquis, 2014).  People are not merely defined by their gender, race, culture, they have multiple identities that they experience in different cultures.  Religion plays a role in identity in India. The caste system related to the Hindu religion places men and women in society. An Indian woman may identify as Indian, specific to a tribe, related to a specific caste.

PEN-3: Relationships and Expectations  The relationships and expectations domain assess the perceptions, enablers and nurturers of behaviors from a cultural perspective.  In India the perceptions people may have of the health system and TB as a disease can influence screening and healthcare seeking behaviors.  Enablers are the resources, societal factors, support, that hinder or encourage health behaviors.  The government in India has been proactive about TB diagnosis and treatment for decades although the societal structure, division between those who are poor and those who are wealthy, and the desire to seek care from the private sector influence health behaviors and to access care (Perez and Luquis, 2014).

TB Educational Program: Multi-level DOCTORS AND NURSES IN INDIA  Identify all doctors and nurses practicing in the private sector.  Voluntary documentation.  Engage in a 2-week educational program. COMMUNITY MEMBERS  Heath educators and promoters engage with community members  Complete a Needs Assessment  Provide educational programs and materials to support diagnosis and treatment of TB

TB Educational Program Evaluation The goal for evaluation is:  Determine whether the programs are effective  Determine whether they are of interest to the population both doctors and nurses and community members  Determine sustainability

Program Challenges  Database to collect all information on doctors, nurses, and patients; used for documentation and evaluation  Monitoring treatment  Buy-in from the private sector  Government funding

Questions 1. When developing a health program determining scale is important. You will need to determine which portion of the population will you. Do you believe starting with a smaller model and increasing scale over time is more beneficial than scaling down? Why? 2. Private sector healthcare in India is not regulated. How can the Indian government be encouraged to develop and implement regulations within private sector healthcare? Are incentives beneficial to getting government cooperation in regulating the private sector?

References Perez, M. A., & Luquis, R. R. (2014). Cultural competence in health education and health promotion (2nd ed.). San Francisco, CA: Jossey-Bass. ISBN: United Nations (UN). (2015). Human development reports: Gender inequality index. Retrieved 14 July 2016 from World Health Organization. (2010) NCD country profiles, India. Retrieved 01 August 2016 from World Bank. (2016). Overview, India. Retrived 02 August 2016 from