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      Strategic Management and Leadership for Health Professionals — Skills To Leverage Resources To Achieve Health Goals

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          Abstract

          Introduction The recent approach to healthcare considers the broader determinants of health to improve population health. One is able to positively impact health goals only when these are addressed through multi sectorial coordination.(1) Marc Lalonde in 1974(2) was among the firsts to elaborate the need to look beyond health care organizations to impact health. His report paved the way for an international debate on the role of non-medical determinants of health, including individual risk behavior setting the tone for a new public health discourse and practice in the decades to come.(3) Lalonde's framework groups health determinants in four areas [Figure 1]. There are different weightages assigned to contribution of the four areas to population health. Behavior contributes to around 50%, Environment around 20%, Biology around 10% and health care 20%.(4) There is no data from developing countries on contribution to health by these four broad areas but environment with lack of safe water, sanitation, lack of safety standards at work place and home is likely to be a larger contributor to health. Health system is certainly not a major contributor to population health. Figure 1 Four domains of determinants of population health While the traditional patient-health care provider driven approach held the health professional within the realm of health sector where the majority of time was spent to operationalize mechanisms for disease-centered care. Rampant surge of non-communicable diseases requires a boarder action that promotes good health. The current disease scenario seeks the health professional to look beyond the health sector. After achieving the eradication of small pox, polio and elimination of Guinea worm, and substantial reduction in HIV/AIDS, Leprosy etc. in India, it is now required to move ahead and look at health in a comprehensive manner to achieve sustainable and equitable improvement in health. In India, non-communicable diseases (NCD) account for 60% of deaths followed by communicable, maternal, perinatal and nutritional diseases (28%) and injuries (12%).(5) The root causes of all these diseases are - lifestyle and pollution for NCDs; inadequate water and hygiene etc. for communicable diseases; malnutrition, illiteracy and lack of resources to access timely health care for maternal child health conditions; and unsafe vehicles, houses and road conditions for accidents. It is clear that prevention of deaths in all four major groups of diseases can be done only if other sectors are adequately engaged and the health sector is involved in providing excellent medical care. Thus, the new approach requires policy makers across all sectors to be realize the consequences of their decisions on health and be accountable for population health.(6) Similarly, health ministers, policy makers, health systems scientists, program implementers and other health professional should actively engage with other sectors while continuing with efforts in traditional disease control approaches. It demands for a new skill set where the health professional in his new role interacts with key influencers in other sectors to make decisions that do not lead to ill health and improve health. Influencing others, identifying windows of opportunity, art of advocacy, negotiation and networking form the key skills for a health professional to achieve health goals through multi-sectorial efforts. Last thirty years have also seen a global surge to use health promotion approach to improve health. Health Promotion can be used effectively to address both communicable and non-communicable diseases by going beyond boundaries of health sector.(3) Influencing Others As one moves up the ladder of leadership, one's priorities need to shift from doing own work to managing team and spending more time in networking. In public health, the team leader interacts with other health professionals, bureaucrats, politicians within the Ministry of health and other ministries. One is required to influence and convince them to be able to generate interest in health and actions required. This also gains prospects for his team to positively impact policy making or implementation of a program to improve health of the population. This helps in better planning and execution where the team's goals are aligned with the current needs of the society. In addition to technical knowledge and analytical skills, good communication skills and networking help in advocacy. The ability to visualize future scenario, identify windows of opportunity and negotiation skills further drive the leader towards success. Identifying windows of opportunity Identifying windows of opportunity is the key to influence the policy environment and decision makers within and outside the health sector. A leader should identify opportunities, take advantage of these and engage in activities involved to achieve goals. Some examples of such opportunities in India are presented below: The New health and education policies are being drafted. These present several opportunities to engage people from various organizations/capacities to provide inputs, especially on the role and responsibilities of other sectors in improving health. Like education Policy should include healthy life style education in school children. Pre-service and In-service training of bureaucrats, public health professionals, social sciences and related sectors. New legislations: New Public Health Act being drafted Outbreaks: Any outbreak of disease gets more attention of politician, bureaucrats and media for example, water borne diseases such as Polio, Dengue, Jaundice, Cholera can be used to leverage action in water supply and sanitation; Flu to promote hygiene and dengue to mobilize municipalities, corporations and local self-governments for health starting with elimination of mosquito breeding within and outside households etc. Professional bodies of health and related professions: The potential of these professional bodies is underutilized. They hold regular conferences and bring out journals where these aspects can be highlighted especially in the sessions attended by politicians and bureaucrats. Political agenda: ‘Swachh Bharat Abhiyan’, for example, is an opportunity to push for universal safe water and sanitation and will go a long way in preventing common diseases. ‘Swachh Hospital Abhiyan’, as part of this campaign builds on this opportunity to eliminate hospital acquired infections. Health Impact Assessment unit needs to be established in the Ministry of Health and Family Welfare and empowered to review the impact on health of all projects in all other sectors Advocacy Advocacy is essential for every health professional to promote effective interventions to address public health problems. Advocacy is the act of pleading or arguing in favour of something. It highlights to change the “what is” into a “what should be".(7) It is a process adopted by an individual or a group to influence policy and resource allocation decisions within political, economic, and social systems and institutions. Advocacy can include many activities that a person or organization undertakes including media campaigns, public speaking, publishing research etc. The information for advocacy can be packaged in many ways including the following depending on the audience: Press Release, Fact Sheet, Power Point, Website/Internet, Television/Radio spots, Article in newspapers, magazines, Research Update, Policy Brief, White paper, Talking Points, research Summary, Publication in Journal etc. One opportunity often missed is short encounter with an important person such as a minister or a top bureaucrat. We can use these opportunities to convey a message effectively. This is often referred to as ‘one minute’ message. A one-minute message includes: The statement of the issue, Evidence to support the issue. An example of the problem, the desired policy action ideally, only one main point should be communicated or, if that is not possible, two or three points at the most. Negotiation Negotiation is a common everyday activity from birth till death. It is a process by which we attempt to influence others to help us achieve our needs, while at the same time taking others’ needs into account. It is a fundamental skill, not only for successful management but also for successful living. This important skill is essential while negotiating to include health action in other sectors.(8) The suggested steps for a successful negotiation: Identify your own goals, priorities and bottom-line before you negotiate Identify your strong points and weak points in negotiation Find out and understand other person's or party's agenda and priorities. Try to accommodate these without compromising on yours. Clear message of what you want and why? How it will best appeal to the person you are negotiating with. Identify the possible outcomes and practices to deal with unfavorable outcome Be prepared to deal with deadlock by revisiting your own priorities and other person's priorities and start with pointing out areas of agreement and move to negotiate areas of disagreement. Networking Networking is a force multiplier in your advocacy efforts to achieve your professional and personal goals. You can do much more through your effective, relevant contacts in your network if you cultivate and sustain it. Networking is the exchange of information or services among individuals, groups, or institutions; specifically: The cultivation of productive relationships for employment or business.(9) Ability to network is becoming more and more important. Maintaining good relations fosters trust and fidelity commitment.(10) Virtual Networking: Internet has made networking very easy. Various professional and social networking sites such as Linkedin, Facebook, Researchgate, Blogs, Twitter and e mail need to be used effectively to reach out those in your and your contacts network easily and fast to communicate and mobilize like-minded persons and groups. These networks help in: Establishing new contacts (both individuals and groups). Keeping in touch with old contacts especially those in distant places in other cities and other parts of the world with whom you may not be able to maintain face-to face contact. Researching potential contacts who may add value. Face to face Networking: Strong way of making new contacts and effectively maintaining old contacts. Attributes that help in networking: Listening skills focus on others, empathy and intimacy Understanding body language: Ability to observe and interpret body language of others Open attitude to new ideas which should also be reflected in body language during the interaction with others. Creating a positive atmosphere: According to Market Watch, more than 85% of success comes from the ability to create good atmosphere and only 15% from professional competence. Practice and deliver an effective message in short time say in one minute or a small talk to cash in the opportunity of casual short encounters with influential persons such as a politician or a bureaucrat. Networking is an arrangement where several individuals or organizations share a common interest. The main activity is information sharing and facilitating. Well-functioning networks usually have an efficient “node” or secretariat. There are three forms of networking. The first helps manage current internal responsibilities, the second boosts personal development, and the third opens one's eyes to new directions and the stakeholders one would need to enlist [Figure 2].(11) Figure 2 Three forms of networking based on what you want to achieve Netweaving Networking has long been cited as an effective means of making new professional contacts and as a way to expand career horizons. Now there's a new twist to this long time career tool-Netweaving. Netweaving is a concept focused on more effectively developing reciprocal business relationships that has far-reaching potential. In Netweaving, the focus is on “How can we help each other?” and the approach is more relaxed and reciprocal.(12) Other Important Skills/Concepts Three pillars of leadership It important for leaders in health care to continuously upgrade their skills in three domains which are Technical: The health sector is dynamic and it is important for a leader to keep updating his technical knowledge. Cognitive: A leader is required to learn new skills to deal with technological advances and keep pace with emerging technology such as using social media to strengthen and retain his networks. Emotional competencies: Emotional competencies contribute to improved professional performance and determine success in life. It also important for one to have a good family and social relationship.(13) Emotional competencies can be learned at any age in life. To be a successful leader one needs to regularly review one's emotional competencies and improve these by learning from interactions one could have done better. Managing difficult colleagues One always comes across people who are difficult to deal with. A leader has to get work done from all his team members, hence must deal with such people effectively. A difficult person is anyone who causes anyone else irritation, upset, stress or anxiety. There are three levels of difficult persons;First level - are difficult some of the times and it includes almost everybody; Second Level - when a person's behavior affects more than one person on a regular basis; Third level - includes persons who purposely hurt or harm others through their behavior. Such persons are rare but really test your skills when you come across them.(14) Difficult colleaguescan be dealt by sharpening the following skills: Separate person from problem. Practice to keep your focus on the problem you are discussing and not on the person. If you keep your focus on the person, even non issues will become issues. Agree on parameters with the person Agree with the person what are the issues that need to be addressed and resolved. Focus your conversation on logic and issues. Look for options that will be agreeable to both of you. Managing 360 degrees Successful leaders and managers manage in all three directions at the same time; downwards- their subordinates, upwards - their bosses, and horizontally - their peers. This is referred to as managing 360 degrees. The skills of managing team always receive attention in most training courses on leadership. The skills of managing up and across are very often neglected. These skills are equally, if not more, important to succeed.(15) To reach leadership position and become an effective leader one must acquire skills to manage 360 degrees. Walk the talk A leader is always under watch by his team and peers. Every step you take, every word you speak, your body language and behavior are under continuous observation. As a leader one is asking his team to have some values and skills. He has to demonstrate these in his day-to-day work and behavior and only then others will take him seriously. Conclusion The three domain model, based on leadership theories, gives a good insight into areas requiring attention in learning leadership skills.(16) All three domains [Figure 3] need attention at every level of career. However, as one moves up in hierarchy, the priority shifts from managing self to devote more time to managing teams and when at the top managing with an eye on what is changing in health and other sectors. In the first domain address skills for managing self(12) and in the second domain the skills of building and leading teams,(17) managing bosses and peers.(14) The third domain includes change management skills(18) and this concluding article covers leveraging your contacts to achieve your goals and other skills such as managing difficult people, concept of 360 degree leadership and need for the leader to walk the talk. Figure 3 Three domains leadership capacity development model Recent understanding of health determinants outside of health sector contribute much more to health and there is a need for public health professionals to convince their peers, administrators and politicians within the health sector to influence other ministries and departments to address these determinants to achieve sustainable improvement and inequities in health. The inequities in health are due to underlying causes such as poverty, lack of water and sanitation, livelihood etc which are essentially in sectors outside health. The health professionals while continuing to advocate for more resources to improve health care need to get other ministries, sectors and departments at all levels to take actions for improving population health. To do this they must acquire skills to identify and use ‘windows of opportunity’, advocacy, networking and negotiation.

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          Health Promotion: An Effective Tool for Global Health

          Health promotion is very relevant today. There is a global acceptance that health and social wellbeing are determined by many factors outside the health system which include socioeconomic conditions, patterns of consumption associated with food and communication, demographic patterns, learning environments, family patterns, the cultural and social fabric of societies; sociopolitical and economic changes, including commercialization and trade and global environmental change. In such a situation, health issues can be effectively addressed by adopting a holistic approach by empowering individuals and communities to take action for their health, fostering leadership for public health, promoting intersectoral action to build healthy public policies in all sectors and creating sustainable health systems. Although, not a new concept, health promotion received an impetus following Alma Ata declaration. Recently it has evolved through a series of international conferences, with the first conference in Canada producing the famous Ottawa charter. Efforts at promoting health encompassing actions at individual and community levels, health system strengthening and multi sectoral partnership can be directed at specific health conditions. It should also include settings-based approach to promote health in specific settings such as schools, hospitals, workplaces, residential areas etc. Health promotion needs to be built into all the policies and if utilized efficiently will lead to positive health outcomes.
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            From theory to action: applying social determinants of health to public health practice.

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              Making Sense of Theories of Leadership for Capacity Building

              Introduction Leadership is defined as an ability to influence a group toward the achievement of goals.(1) There has been an explosion of literature on leadership. In 1999 alone, more than 2,000 books on leadership were published;(2) some of them even repackaging Moses and Shakespeare as leadership gurus.(3) Even though so much has been written about leadership, there is no consensus on the right mix of qualities of a leader. It is dangerous to overdefine the capabilities a good leader should have.(4) Adair was probably the first to demonstrate that leadership is a trainable and transferable skill, rather than being an exclusively inborn ability.(5) The best aspect of leadership is that we all can learn and develop leadership skills. Each one of us has some capacity for leadership though some of us are born with traits that make it easier to become leaders, but all of us can develop leadership skills. If you have the desire and the will power, you can become an effective leader.(6) David Thomas believes leaders are 90% made, may be even more.(7) It is common knowledge that good leadership is essential to improve productivity of an organization. A study by Barling et al.,(6) (1996) found a significant correlation between leadership training and attitudinal and financial outcome. The challenge lies in choosing most appropriate concepts of leadership to apply in various situations to achieve the organization's goals. Historically, learning of leadership has passed through three distinct phases. The first phase is marked by reading about great leaders and trying to imitate their style. This phase lasted a long time and ended in the last century when leadership training industry grew rapidly replacing autobiographies by teaching people skills of leading. The third phase characterized by explosion of readings on leadership and promotion of leadership as a set of skills that can be acquired.(8) This article reviews the literature on concepts, theories, and models of leadership and proposes a simple model to capture different concepts of leadership to train health professionals in leadership skills. Concepts and theories of leadership There are numerous models and theories of leadership in the literature. Google search for leadership model produced about 16.1 million sites in 0.36 seconds. Leadership cannot be described simply in terms of the behavior, rather leadership involves collaborative relationship that leads to collective action grounded in the shared values of people working together to effect positive change.(9) Leaders establish direction by developing a vision, then align people by communicating this vision and inspiring them to overcome hurdles. Effective leadership may be a result of exhibiting the right behaviors at the right moment.(1) Leader cannot have, and should not try to develop, all possible qualities seen among other leaders. Ancona et al.,(5) (2007) say, “It's time to end the myth of the complete leader: the flawless person at the top who's got it all figured out. In fact, the sooner leaders stop trying to be all things to all people, the better off their organizations will be.” The leader holds fast to his basic values to set example for others.(10) He takes ultimate responsibility rather than consider his role as a privilege. Another essential element is that he earns trust. Effective leadership is not based on being clever; it is based primarily on being consistent. Leaders make their organization a high-performing organization that continuously produces outstanding results with the highest level of human commitment to success. We can apply the ancient Chinese author Sun Tzu's concepts elaborated in the context of war to the health sector. According to him the leaders should fully know the tactics and operational methods (the basic concepts of public health and strategic management in the health set up), the terrain (health sector's and organization's internal environment and external factors influencing health and health care delivery), the enemy (in health context the determinants of health and disease, competing priorities within health and its determinants), weapons (the resources at hand and at call within and outside the organization), logistics (to deploy and use available resources effectively), information system (to keep a close watch on what is happening within and outside the organization), and soldiers (the staff and their morale) (adapted from Cantrell R L, 2003(11)). The ability to anticipate and deal with change sets good leaders apart from others. As the pace of change accelerates, there is naturally a greater need for effective leadership.(12) “Everyone of us has experiences, but we aren’t all open to learning from those experiences in the same way.”(13) One characteristic most leaders have in common is the capacity to learn and change throughout their lives.”(7) As a health manager moves into a leadership role, his network must orient itself externally and toward the future to mobilize other sectors for social mobilization and addressing social determinants.(14) Good leaders tend to create their opportunities by ‘selling’ new ideas and winning support for them from those they seek to lead. They display strong transformational skills.(15) The leadership theories that have emerged in the 20th century can be grouped in five broad approaches summarized in Table 1.(16) The earlier approaches included great man leadership theories that dominated prior to 1900 followed by theories that included trait, behavioral, power-influence, situational, and integrative aspects. Subsequently, theorists started to place strong emphasis on situational and environmental factors. Finally, theories of integration have developed around persons and situations, psychoanalysis, role attainment, change, goals, and contingencies.(17) Table 1 Summary of types of leadership models broadly grouped in five categories Jim Collins five levels of leadership, a suitable model for health professionals There are numerous models and theories of leadership. It is important to pick up one that incorporates main features of leadership. The recent model of Jim Collins five levels of leadership based on a study of around 1500 most successful companies offers a very good model for leadership development among health professionals. The five levels are simple, clear, and can be easily applied to understand leadership competencies required among health professionals. The technical skills of level one are core competencies for health professionals and required at every level of leadership hierarchy. The leadership and management skills are required as technical competencies alone are not adequate to lead a team or higher level positions. In Jim Collins model, one level of leadership does not exclude the features of other levels. A health professional at higher level still needs to work on updating lower level skills such as technical competencies and team building. Below mentioned is how the five levels of this model can be applied to health professionals. Level 1: Leader is a highly capable individual with appropriate technical qualification. He/She has the talent, knowledge, skills, and good work habits. He/She is competent to perform all the functions required for his/her job. To remain at this level of leadership hierarchy, he/she needs to continue to update his/her knowledge and skills through continued education. Level 2: The health professional performs not only his/her tasks but contributes to the accomplishment of the team tasks. He/She uses his/her individual skills and capabilities to the achievement of group objectives. He/She has skills to work effectively with others in group settings. This leader is not only a technically highly capable individual who achieves his/her own tasks but also actively engages in the work of his team to ensure achievement of the team goals. Level 3: Health professional becomes a competent manager, having acquired skills to organize people and resources toward the effective and efficient pursuit of set objectives. He/She is a competent professional and a team player who has become an effective health manager clear about the objectives and keeps the focus of human and other resources on achieving the objectives. Level 4: At this level the competent manager of level 3 becomes an effective leader who catalyzes commitment of his organization to vigorous pursuit of a clear and compelling vision, stimulating higher performance standards. These leaders lead the organization well and leverage networks both inside and outside the organization to achieve results and adapt to changing environment successfully. At this level the predominant role is of a leader though certain managerial actions may be required depending on the situation. The orientation of the person reaching this level needs to change to look at the bigger picture both within and outside the health sector environment. Level 5: According to Jim Collins Level 5, leaders are the most successful leaders and very few leaders operate at this level. These leaders embody all levels of the pyramid. These leaders build great organizations and leave behind capable individuals whom they have groomed and processes that sustain the great work even after the leader has left. The level 5 leadership produces excellent and lasting results by building great organizations and act with respect, care, and fairness for the wellbeing of all involved.(30) Three domain leadership model for developing leadership skills It is important to have a simple model to structure training and developing skills for effective leadership. The author has used this simple model [Figure 1] to capture the three domains of leadership for managing self for leadership domain in the center, managing and leading the team and the organization in the next domain, and managing, leading, and adapting to the internal and external environment in the third domain. This model provides a good framework for structuring training to develop leadership skills. It captures the leadership skills mentioned in Jim Collins’ and other models. The three domains of the model represent three dimensions of leadership that are as follows: Figure 1 The three domains of leadership capacity development model Domain 1: Managing self for leadership domain The self-management skills are essential for an effective leader. These include a mix of values and skills such as vision, charisma, integrity, self-awareness, communication skills, anticipating, managing, and adapting to change, time management, social and emotional competencies, and keenness to acquire and learn new things including technical areas of expertise. This predominantly makes him/her a good leader at level 1 of Jim Collins model and enhances his/her capabilities to move up the ladder of leadership. The leader should be a model of behavior, skills, and values he/she wants to inculcate in the team and staff in the organization. Domain 2: Leading and managing the team and organization domain This domain includes skills for developing individuals in the team and the organization to effectively work together for achievement of team and organizational goals. These skills move up from level 1 to higher levels of leadership of Jim Collins model. The leader enables the organization by developing individuals in his/her team and the organization. He/She builds, strengthens, and facilitates team spirit and work. Through his/her traits, skills, and attributes, he/she helps his/her team to execute his/her vision. He/She does this by developing skills in each individual in the organization through putting the right person in the right job, motivating, facilitating learning and skill development in the staff through training, coaching, and mentoring. He/She is strategic in his/her approach and aligns human and other resources to achieve the organizational goals to fulfill the vision. He/She is in constant touch with his/her employees through his/her formal and informal networks and keeps changing his/her approach based on what he/she learns through his/her network to maximize efforts to achieve organizational objectives. He/she transforms the individuals in the organization and motivates them to get the best out of them and channels every ones efforts so that they work in synergy to get the best results. Domain 3: Leading, managing, and adapting to the external environment domain The leader keeps an eye on what is going on outside the organization, how things in the sector and outside the sector are changing, and what are the implications for the organization. These skills are important even at level 1 but are very important for leaders at levels 4 and 5 of Jim Collins hierarchy of leadership. He/she keeps an eye on how the diseases pattern, trends, and projections and how factors within and outside health sector are contributing to this change. A good leader is in constant touch with the external environment within and outside the health sector that affects his/her organization. He/she keeps an eye on how the availability of technology and their application in health sector is changing or going to change the way health institutions function and are managed. The newer health interventions are changing management of health problems. He/she plans ahead and prepares his/her organization to benefit from these developments. He/she also keeps in mind how his/her organization contributes to benefit the society. No organization exists in vacuum, and its existence and growth is linked to the society, its norms and values. He/she actively engages himself and his/her employees in activities to benefit the society. The leader develops and uses a strong network of formal and informal contacts beyond the organization/team he/she leads to get a regular feedback on how the organization he/she leads is perceived. Interaction between these three domains The three domains of leadership capacity development in the model are very helpful in identifying skills to develop. However, these are not watertight compartments and there is a close relationship and overlap in these three domains. This is reflected in the double arrows in the model. The skills of the leader help him/her in learning from the changing environment in health and related sectors and develop and manage individuals and teams within the organization to adapt to that change. The leader also needs to review his/her personal skills and way of working, identify gaps, and acquire new skills and/or adopt new ways of working. Conclusion The literature has described a large number of successful leaders and their qualities; one can emulate and learn from them. But no one can just ape another leader. So the challenge facing prospective leaders is for them to be themselves but with more skills.(3) The foundation of effective leadership is thinking through the organization's mission, defining it, and establishing it, clearly and visibly.(10) Organizations are increasingly searching for managers who can exhibit transformational leadership qualities.(1) Most commonly listed leadership characteristics identified based on responses from more than 10,000 leaders in US listed honesty, competence, being forward-looking, inspiring, and credible.(30) The Jim Collins’ hierarchy of five levels of leadership offers a good model to apply to leadership among health professionals. The three domains of leadership capacity development model [Figure 1] incorporate the key skills of a good leader. This simple model provides a good framework for training to develop leadership skills and has been used by the author for training of mid and senior level health professionals. It looks at three domains of leadership that are (i) self-management skills required for a good leader, (ii) team and organizational management and leadership skills to lead the organization, and (iii) the skills required to network and influence outside the organization she/he leads, i.e. industry/sector the organization is part of an overall external and internal environment to lead the organization one step ahead of the change and into the future and how he/she makes his/her team achieve the organizational goals and contributes to benefit the society in the process. He/She develops and uses his/her formal and informal networks to get information and influences things within and outside the organization. A good leadership is needed in health set up to build a clear vision and steer the team by providing enabling environment to reach the vision and contribute to the overall good of the society.
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                Author and article information

                Journal
                Indian J Community Med
                Indian J Community Med
                IJCM
                Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine
                Medknow Publications & Media Pvt Ltd (India )
                0970-0218
                1998-3581
                Jul-Sep 2015
                : 40
                : 3
                : 158-162
                Affiliations
                [1]Executive Director, Healthcare Financing, National Health Systems Resource Centre, National Health Mission, Ministry of Health and Family Welfare, Government of India, NIHFW Campus, New Delhi, India
                [1 ]Department of Pathology, Faculty of Dentistry, Jamia Millia Islamia, Delhi, India
                [2 ]Department of Community Health Administration, National Institute of Health and Family Welfare, New Delhi, India
                [3 ]Senior Consultant, Healthcare Financing, National Health Systems Resource Centre, National Health Mission, Ministry of Health and Family Welfare, Government of India, NIHFW Campus, New Delhi, India
                Author notes
                Address for correspondence: Dr. Sanjiv Kumar, National Health Systems Resource Centre, National Health Mission, Ministry of Health and Family Welfare, Government of India, NIHFW Campus, Baba Gangnath Marg, Munirka, New Delhi - 110 067, India. E-mail: drsanjivkumardixit@ 123456gmail.com
                Article
                IJCM-40-158
                10.4103/0970-0218.158845
                4478655
                26170538
                b8bcafa6-e9e9-4413-85fb-f2cdba646156
                Copyright: © Indian Journal of Community Medicine

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 21 April 2015
                : 22 May 2015
                Categories
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                Public health
                Public health

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