Browsing by Author "Varghese, J"

Now showing 1 - 6 of 6
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    Advancing the application of systems thinking in health: understanding the growing complexity governing immunization services in Kerala, India
    (Health Res Policy Syst, 2014-12) Varghese, J; Kutty, VR; Paina, L; Adam, T
    BACKGROUND: Governing immunization services in a way that achieves and maintains desired population coverage levels is complex as it involves interactions of multiple actors and contexts. In one of the Indian states, Kerala, after routine immunization had reached high coverage in the late 1990s, it started to decline in some of the districts. This paper describes an application of complex adaptive systems theory and methods to understand and explain the phenomena underlying unexpected changes in vaccination coverage. METHODS: We used qualitative methods to explore the factors underlying changes in vaccination coverage in two districts in Kerala, one with high and one with low coverage. Content analysis was guided by features inherent to complex adaptive systems such as phase transitions, feedback, path dependence, and self-organization. Causal loop diagrams were developed to depict the interactions among actors and critical events that influenced the changes in vaccination coverage. RESULTS: We identified various complex adaptive system phenomena that influenced the change in vaccination coverage levels in the two districts. Phase transition describes how initial acceptability to vaccination is replaced by a resistance in northern Kerala, which involved new actors; actors attempting to regain acceptability and others who countered it created several feedback loops. We also describe how the authorities have responded to declining immunization coverage and its impact on vaccine acceptability in the context of certain highly connected actors playing disproportionate influence over household vaccination decisions.Theoretical exposition of our findings reveals the important role of trust in health workers and institutions that shape the interactions of actors leading to complex adaptive system phenomena. CONCLUSIONS: As illustrated in this study, a complex adaptive system lens helps to uncover the 'real' drivers for change. This approach assists researchers and decision makers to systematically explore the driving forces and factors in each setting and develop appropriate and timely strategies to address them. The study calls for greater consideration of dynamics of vaccine acceptability while formulating immunization policies and program strategies. The analytical approaches adopted in this study are not only applicable to immunization or Kerala but to all complex interventions, health systems problems, and contexts.
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    The interactions of ethical notions and moral values of immediate stakeholders of immunisation services in two Indian states: a qualitative study
    (BMJ Open, 2013-02) Varghese, J; Raman Kutty, V; Ramanathan, M
    Objectives :- This study examines the existing norms regarding immunisation within the communities and the ethical notions that govern the actions of different health professionals and their collective synergistic or conflicting effects on the governance of the programme. Design :- We used descriptive and analytical qualitative methods as it suited the research question. Setting :- The data were collected from areas under 16 primary health centres in Kerala and Tamil Nadu identified through a three-step sampling process. Participants :- This involved in-depth interviews with stakeholders including providers, beneficiaries and other stakeholders, focus group discussions with mothers of under-five children and participant and non-participant observations of vaccination-related activities. Results :-Unlike most other ethical analyses that look at the ethics of vaccination policies, the interactions of normative principles and notions are analysed in this article. Moral obligation of parents towards their children, beneficence of healthcare providers and the utilitarian aspirations of the state are the key normative principles involved. Our analysis points to the interplay of both synergy and conflict in ethical notions and moral values in the context of immunisation services. Paternalistic interventions like special immunisation campaigns against polio and Japanese encephalitis are a case in point: they generate conflict at the normative level and create mistrust. Conclusions :- Analysis of vaccination policies and programmes needs to go beyond factors that assess monetary benefits or herd immunity. Understanding the interactions of normative notions that shape the social organisation of the providers and the users of vaccination is important in creating a sustainable environment for the programme.
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    Local Factors Influencing Resource Allocation to Health under the Decentralised Planning Process in Kerala
    (Journal of Health and Development, 2007) Varghese, J; Varatharajan, D; Thankappan, KR
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    Resource allocation in decentralized health systems
    (BULLETIN OF THE WORLD HEALTH ORGANIZATION, 2001) Varghese, J