Health care and equity in India

Who drive the health policy agenda in India? Actors in National Health Committees since Independence

Introduction

Health policies reflect the ideas and interests of the actors involved. The Indian Government constituted many health committees for policy recommendations on myriad issues concerning public health, ranging from tribal health to drug regulation. However, little is known about their composition and backgrounds. We reviewed these committees to map the actors and institutions.

Methods

We elicited information on all relevant health committees available in the public domain. All were constituted post-independence, except two, with recommendations that remain pertinent to date. Data for chairpersons and members - their professions, gender, institutions, and location were extracted and analysed. Reliable online sources were used to collate the information.

Results

We identified 23 national health committees from 1943 to 2020 with available reports. There were 25 chairpersons and 316 members. All except three chairpersons were men. Among members, only 11% were women. The majority (51%) had experience working in health systems; however, most were medical doctors, with negligible representation of other cadres. We noted the centralization of location, with 44% of members based in the national capital of Delhi. Government administrators were maximally represented (55%), followed by medical academia (19%). Post-2000, we have observed slightly improved diversity across some parameters like gender (15% women vs 9% earlier) and affiliation. However, the centralization of the location to the national capital had increased (55% post-2000 vs. 39% pre-2000).

Conclusion

Indian health committees lack diversity in representation from multiple perspectives. Henceforth, health policymakers should prioritize including diverse social, geographical, and health systems actors to ensure equitable policymaking.

Addressing the Need for Economic Evaluation of Cardiovascular Medical Devices in India

This article emphasizes the pivotal role of economic evaluation in the management of cardiovascular diseases (CVDs) within the Indian healthcare system. It explores the importance of economic evaluation methodologies such as cost-effectiveness analysis, cost-utility analysis, and cost-benefit analysis in guiding informed healthcare decisions related to CVD management. Additionally, it discusses the unique challenges and opportunities surrounding health technology assessment (HTA) and economic evaluation specific to India, providing insights into potential areas for improvement. By giving precedence to economic evaluation, India can optimize the allocation of resources, improve patient outcomes, and alleviate the economic burden associated with CVDs. The implementation of these recommendations has the potential to significantly enhance the efficiency and effectiveness of CVD management strategies in India, ultimately leading to improved healthcare outcomes for the population.

Multilevel analysis of determinants in postnatal care utilisation among mother-newborn pairs in India, 2019-21

Background

Postnatal care (PNC) utilisation within 24 hours of delivery is a critical component of health care services for mothers and newborns. While substantial geographic variations in various health outcomes have been documented in India, there remains a lack of understanding regarding PNC utilisation and underlying factors accounting for these geographic variations. In this study, we aimed to partition and explain the variation in PNC utilisation across multiple geographic levels in India.

Methods

Using India's 5th National Family Health Survey (2019-21), we conducted four-level logistic regression analyses to partition the total geographic variation in PNC utilisation by state, district, and cluster levels, and to quantify how much of theses variations are explained by a set of 12 demographic, socioeconomic, and pregnancy-related factors. We also conducted analyses stratified by selected states/union territories.

Results

Among 149 622 mother-newborn pairs, 82.29% of mothers and 84.92% of newborns were reported to have received PNC within 24 hours of delivery. In the null model, more than half (56.64%) of the total geographic variation in mother's PNC utilisation was attributed to clusters, followed by 26.06% to states/union territories, and 17.30% to districts. Almost 30% of the between-state variation in mother's PNC utilisation was explained by the demographic, socioeconomic, and pregnancy-related factors (i.e. state level variance reduced from 0.486 (95% confidence interval (CI) = 0.238, 0.735) to 0.320 (95% CI = 0.152, 0.488)). We observed consistent results for newborn's PNC utilisation. State-specific analyses showed substantial geographic variation attributed to clusters across all selected states/union territories.

Conclusions

Our findings highlight the consistently large cluster variation in PNC utilisation that remains unexplained by compositional effects. Future studies should explore contextual drivers of cluster variation in PNC utilisation to inform and design interventions aimed to improve maternal and child health.

Self-Care Practices and Health-Seeking Behaviors Among Older Adults in Urban Indian Slums: A Mixed Methods Study

Background Effective self-care is crucial for maintaining health among older adults in resource-constrained communities. This study examined self-care practices, health-seeking behaviors, and associated factors among older adults in urban slums in India. Materials and methods A mixed methods study was conducted among 432 adults aged ≥65 years. Participants were selected through multistage random sampling from five slum areas. Self-care practices, health-seeking behaviors, demographic information, chronic conditions, self-efficacy, and health literacy were assessed through interviews. The qualitative data was explored through in-depth interviews with 30 participants. Results Inadequate health literacy (194, 45%) and low self-efficacy (162, 37.5%) were common. While 324 (75%) had an adequate diet and 378 (87.5%) took medications properly, only 86 (20%) monitored diabetes complications. Only 194 (45%) of the patients underwent recommended cancer screening, and 324 (75%) of the patients saw doctors ≥twice a year. Age, sex, education, income, comorbidities, self-efficacy, and health literacy had significant associations. Alongside facilitators such as social support, barriers such as limited healthcare access and suboptimal prevention orientation emerged. Conclusion Suboptimal prevention orientation and overreliance on secondary care instead of self-care among elderly people are problematic given the limited use of geriatric services. Grassroots health workers can improve health literacy and self-efficacy through home visits to enable self-care. Healthcare access inequities for vulnerable groups merit policy attention.

Perceptions and Experiences of Healthcare Providers and Patients Towards Digital Health Services in Primary Health Care: A Cross-Sectional Study

BACKGROUND

Digital health has the potential to help achieve the Sustainable Development Goals (SDGs) by supporting health systems and enhancing health promotion and disease prevention. However, obstacles such as restricted internet access, inadequate technical assistance, clinical resource disparity, and insufficient user training can impede the utilization and growth of digital health. Researchers should examine healthcare providers' and patients' perspectives to identify challenges and enhance usability.

METHODOLOGY

The study was conducted among women health volunteers, staff nurses, and patients who used the VinCense mobile application (MedIoTek Health Systems Private Limited, Chennai, India) to record vital signs. A semi-structured questionnaire was used to evaluate participants' sociodemographic characteristics, perception of digital health monitoring, and patients' attitudes toward digital health monitoring devices. The data were analyzed using R programming, Version 4.3.3 (www.r-project.org). A multinomial logistic regression analysis was used to examine the association between sociodemographic characteristics and attitudes of patients toward digital health monitoring.

RESULTS

The study involved 27 healthcare providers and 406 patients. The majority (66.6%) of healthcare providers found the device convenient and efficient. Around 74.1% faced technical difficulties like internet connectivity and device battery issues. Among patients, 79.8% were satisfied with their digital health monitoring experience, 86.2% found device usage comfortable and 78.1% expressed satisfaction with health education and feedback. Around 354 (87.2%) patients stated that technology has improved healthcare, and 326 (80.3%) said that health technologies have improved ease. The results indicate that female gender (p=0.00), age above 50 years (p=0.04), and occupation status as a semiskilled worker (p=0.03), skilled worker (p=0.00), and clerical/shop/farmer (p=0.01) were statistically significant and associated with the positive attitude for digital health monitoring.

CONCLUSIONS

The digital health monitoring experience was found satisfactory by both patients and healthcare providers. The mobile health (mHealth) has tremendous potential for enhancing patient health. Therefore, it is advisable to contemplate an expansion of the VinCense mHealth Platform and other digital solutions to improve service delivery in primary healthcare setups.

Determinants of obesity in Latin America

Obesity rates are increasing almost everywhere in the world, although the pace and timing for this increase differ when populations from developed and developing countries are compared. The sharp and more recent increase in obesity rates in many Latin American countries is an example of that and results from regional characteristics that emerge from interactions between multiple factors. Aware of the complexity of enumerating these factors, we highlight eight main determinants (the physical environment, food exposure, economic and political interest, social inequity, limited access to scientific knowledge, culture, contextual behaviour and genetics) and discuss how they impact obesity rates in Latin American countries. We propose that initiatives aimed at understanding obesity and hampering obesity growth in Latin America should involve multidisciplinary, global approaches that consider these determinants to build more effective public policy and strategies, accounting for regional differences and disease complexity at the individual and systemic levels.

Field based research in the era of the pandemic in resource limited settings: challenges and lessons for the future

The coronavirus pandemic that began in December 2019, has had an unprecedented impact on the global economy, health systems and infrastructure, in addition to being responsible for significant mortality and morbidity worldwide. The "new normal" has brought along, unforeseen challenges for the scientific community, owing to obstructions in conducting field-based research in lieu of minimizing exposure through in-person contact. This has had greater ramifications for the LMICs, adding to the already existing concerns. As a response to COVID-19 related movement restrictions, public health researchers across countries had to switch to remote data collections methods. However, impediments like lack of awareness and skepticism among participants, dependence on paper-based prescriptions, dearth of digitized patient records, gaps in connectivity, reliance on smart phones, concerns with participant privacy at home and greater loss to follow-up act as hurdles to carrying out a research study virtually, especially in resource-limited settings. Promoting health literacy through science communication, ensuring digitization of health records in hospitals, and employing measures to encourage research participation among the general public are some steps to tackle barriers to remote research in the long term. COVID-19 may not be a health emergency anymore, but we are not immune to future pandemics. A more holistic approach to research by turning obstacles into opportunities will not just ensure a more comprehensive public health response in the coming time, but also bolster the existing infrastructure for a stronger healthcare system for countries.

Risk factors of multimorbidity among older adults in India: A systematic review and meta-analysis

Background

Multimorbidity among older adults is a growing concern in India. Multimorbidity is defined as the coexistence of two or more chronic health conditions in an individual. Primary studies have been conducted on risk factors of multimorbidity in India, but no systematic review has been conducted on this topic. This systematic review aimed to synthesize the existing evidence on risk factors of multimorbidity among older adults in India.

Methods

The JBI and Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. Several databases were searched for published and unpublished studies until August 03, 2022. The screening of titles and abstracts and full texts, data extraction, and quality assessment were conducted by two independent reviewers. Any disagreements were resolved through discussion or by involving a third reviewer. Data synthesis was conducted using narrative synthesis and random effects meta-analysis, where appropriate.

Results

Out of 8781 records identified from the literature search, 16 and 15 studies were included in the systematic review and meta-analysis, respectively. All included studies were cross-sectional, and 10 met a critical appraisal score of more than 70%. Broadly, sociodemographic, lifestyle, and health conditions-related factors were explored in these studies. The pooled odds of multimorbidity were higher in people aged ≥70 years compared to 60-69 years (odds ratio (OR) 1.51; 95% confidence interval (CI) 1.20-1.91), females compared to males (1.38; 1.09-1.75), single, divorced, separated, and widowed compared to married (1.29; 1.11-1.49), economically dependent compared to economically independent (1.54; 1.21-1.97), and smokers compared to non-smokers (1.33; 1.16-1.52) and were lower in working compared to not working (0.51; 0.36-0.72).

Conclusion

This systematic review and meta-analysis provided a comprehensive picture of the problem by synthesizing the existing evidence on risk factors of multimorbidity among older adults in India. These synthesized sociodemographic and lifestyle factors should be taken into consideration when developing health interventions for addressing multimorbidity among older adults in India.

Magnitude of health expenditure induced removable poverty in India: Some reflections of Ayushman Bharat

The authors have measured the health expenditure-induced removable poverty in India using nationally representative consumer expenditure surveys of three quinquennial rounds conducted by the National Sample Survey Organization (NSSO). This study has also focused on the reflections of Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), the world's largest Government-funded health insurance scheme, on these poverty rates in the country. The study has used headcount, payment gap, and concentration index to measure the economic burden and impoverishment impact of out-of-pocket (OOP) health expenditure. The analysis shows that the incidence and depth of poverty are substantially understated because of overlooking OOP health expenditure in the country's standard poverty measure. Outpatient care contributes almost four times more than inpatient care to health expenditure-induced impoverishment in India, though this care has not been covered in the AB-PMJAY. Muslims, among all religious groups, Scheduled Castes among social groups, and casual labourers among different household types are more vulnerable to OOP health expenditure-induced removable poverty in the country. Poverty, in general, has dropped significantly, but the share of health expenditure-induced poverty in general poverty has increased substantially. It has risen considerably in rural areas and among India's most vulnerable sections of society in the past 20 years. We emphasised that universal health insurance coverage is needed in India. Implementing comprehensive health insurance schemes that cover both inpatient and outpatient care can help alleviate the financial burden of healthcare expenses on households and contribute to reducing poverty rates.

How do children's hospitals address health inequalities: a grey literature scoping review

OBJECTIVES

Health inequalities are systematic differences in health between people, which are avoidable and unfair. Globally, more political strategies are required to address health inequalities, which have increased since the global SARS-CoV-2/COVID-19 pandemic, with a disproportionate impact on children. This scoping review aimed to identify and collate information on how hospitals around the world that deliver care to children have addressed health inequalities.

DESIGN

Scoping review focused solely on grey literature.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Following Joanna Briggs Institute guidelines, a four-step approach to identifying literature was adopted.

DATA SOURCES

Overton, OpenGrey, OpenMD, Trip Database, DuckDuckGo, Google, targeted websites and children's hospital websites were searched on March 2023 for items published since 2010.

DATA EXTRACTION AND SYNTHESIS

Retrieved items were screened against clear inclusion and exclusion criteria before data were extracted by two independent reviewers using a data extraction tool. Studies were tabulated by a hospital. A meta-analysis was not conducted due to the varied nature of studies and approaches.

RESULTS

Our study identified 26 approaches to reduction of health inequalities, from 17 children's hospitals. Approaches were categorised based on their size and scope. Seven approaches were defined as macro, including hospital-wide inequality strategies. Ten approaches were classed as meso, including the establishment of new departments and research centres. Micro approaches (n=9) included one-off projects or interventions offered to specific groups/services. Almost half of the reported approaches did not discuss the evaluation of impact.

CONCLUSIONS

Children's hospitals provide a suitable location to conduct public health interventions. This scoping review provides examples of approaches on three scales delivered at hospitals across high-income countries. Hospitals with the most comprehensive and extensive range of approaches employ dedicated staff within the hospital and community. This review indicates the value of recruitment of both public health-trained staff and culturally similar staff to deliver community-based interventions.

Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide

The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

Cancer care and economic burden-A narrative review

Cancer care poses a significant economic burden in India, where noncommunicable diseases contribute to a large number of deaths and disability-adjusted life-years. Despite economic growth, equitable wealth distribution remains a challenge, leading to inequalities in healthcare access. India's healthcare system is primarily privatized, financed through out-of-pocket expenditure (OOPE), and lacks coverage for a majority of the population. As a result, individuals without financial means face catastrophic health consequences when seeking necessary healthcare. OOPE in India's healthcare system is a major concern, with medicines accounting for a significant portion of expenses, followed by diagnostic tests and consultation fees. Nonmedical expenses also contribute to the financial burden. Cancer care specifically faces substantial financial challenges, with high treatment costs, reduced workforce participation, and the need for distress financing. Cancer-related OOPE is predominantly borne by patients and their families, leading to significant financial strain. The lack of comprehensive health insurance coverage and limited access to publicly funded healthcare services exacerbate the problem. Catastrophic health expenditure (CHE) in cancer care is prevalent, pushing households into financial distress and potentially impoverishment. Efforts have been made to address this issue, such as increasing public spending on healthcare and implementing health insurance schemes. However, challenges remain in ensuring their effectiveness and reach. The role of family care physicians is crucial in supporting patients and their families during catastrophic health expenditures related to cancer-related palliative care. They coordinate care, provide advocacy, emotional support, symptom management, and facilitate end-of-life discussions. Comprehensive measures are needed to strengthen healthcare infrastructure, improve access to affordable cancer care, enhance health insurance coverage, and implement supportive measures for cancer patients. Additionally, promoting preventive measures and early detection can help reduce the need for expensive treatments and decrease the risk of catastrophic health expenditures.

Morbidity and utilisation of healthcare services among people with cardiometabolic disease in three diverse regions of rural India

OBJECTIVES

To assess the prevalence and determinants of cardiometabolic disease (CMD), and the factors associated with healthcare utilisation, among people with CMD.

METHODS

Using a cross-sectional design, 11,657 participants were recruited from randomly selected villages in 3 regions located in Kerala and Andhra Pradesh from 2014 to 2016. Multivariable logistic regression was used to identify factors independently associated with CMD and healthcare utilisation (public or private).

RESULTS

Thirty-four per cent (n = 3629) of participants reported having ≥1 CMD, including hypertension (21.6%), diabetes (11.6%), heart disease (5.0%) or chronic kidney disease (CKD) (1.6%). The prevalence of CMD was progressively greater in regions of greater socio-economic position (SEP), ranging from 19.1% to 40.9%. Among those with CMD 41% had sought any medical advice in the last month, with only 19% utilising public health facilities. Among people with CMD, those with health insurance utilised more healthcare (age-gender adjusted odds ratio (AOR) (95% confidence interval (CI)): 1.31 (1.13, 1.51)) as did those who reported accessing private rather than public health services (1.43 (1.23, 1.66)).

DISCUSSION

The prevalence of CMD is high in these regions of rural India and is positively associated with indices of SEP. The utilisation of outpatient health services, particularly public services, among those with CMD is low.

The Gut Microbiota: a Novel Player in the Pathogenesis of Uterine Fibroids

Uterine fibroid is a common gynecological disorder that affects women of reproductive age and has emerged as a major public health concern. The symptoms have a negative influence on both their physical health and quality of life. The cost of treatment has a significant impact on the disease's burden. Even though its origin is uncertain, estrogen is thought to be a key player in fibroid pathophysiology. Many theories, including those based on genetic and environmental factors, explain what causes hyper-estrogenic condition in fibroid patients. One such possibility that is currently being explored is the hypothesis that an altered gut microbiome can contribute to the development of diseases characterized by estrogen dominance. Gut dysbiosis is often a "hot area" in the health sciences. According to a recent study, uterine fibroid patients have altered gut microbiome. A variety of risk factors influence both fibroid development and gut homeostasis. Diet, lifestyle, physical activity, and environmental contaminants have an impact on estrogen and the gut flora. A better understanding of uterine fibroids' pathophysiology is required to develop effective preventative and treatment options. A few ways by which the gut microbiota contributes to UF include estrogen, impaired immune function, inflammation, and altered gut metabolites. Therefore, in the future, while treating fibroid patients, various strategies to deal with changes in the gut flora may be advantageous. For developing suggestions for clinical diagnosis and therapy, we reviewed the literature on the relationship between uterine fibroids and the gut microbiota.

Outcomes of a hypertension care program based on task-sharing with private pharmacies: a retrospective study from two blocks in rural India

Low density of formal care providers in rural India results in restricted and delayed access to standardized management of hypertension. Task-sharing with pharmacies, typically the first point of contact for rural populations, can bridge the gap in access to formal care and improve health outcomes. In this study, we implemented a hypertension care program involving task-sharing with twenty private pharmacies between November 2020 and April 2021 in two blocks of Bihar, India. Pharmacists conducted free hypertension screening, and a trained physician offered free consultations at the pharmacy. We calculated the number of subjects screened, initiated on treatment (enrolled) and the change in blood pressure using the data collected through the program application. Of the 3403 subjects screened at pharmacies, 1415 either reported having a history of hypertension or had elevated blood pressure during screening. Of these, 371 (26.22%) were enrolled in the program. Of these, 129 (34.8%) made at least one follow-up visit. For these subjects, the adjusted average difference in systolic and diastolic blood pressure between the screening and follow-up visits was -11.53 (-16.95 to -6.11, 95% CI) and -4.68 (-8.53 to -0.82, 95% CI) mmHg, respectively. The adjusted odds of blood pressure being under control in this group during follow-up visits compared to screening visit was 7.07 (1.29 to 12.85, 95% CI). Task-sharing with private pharmacies can lead to early detection and improved control of blood pressure in a resource-constrained setting. Additional strategies to increase patient screening and retention rates are needed to ensure sustained health benefits.

Prevalence, contributing factors, and economic implications of strokes among older adults: a study of North-East India

Stroke is a significant cause of mortality and disability in India, with its economic impact on the rise. This study aims to investigate the prevalence and factors associated with stroke among the elderly population in seven north-eastern states of India and its economic consequences. Data from the initial phase of the Longitudinal Ageing Study in India (2017-2018) were utilized, and bivariate and multivariate analyses were done. Stroke prevalence (1.53%) was notable among both genders, with approximately 1% in females and 2.3% in males. Individuals with low physical activity, higher socio-economic status, and unemployment faced a higher risk of stroke. Females exhibited a 60% lower likelihood [AOR 0.40; (CI 0.250-0.627)] of stroke compared to males and hypertension was a significant risk factor. Stroke patients incur up to INR 50,000 of financial burden, with a considerable proportion facing disability in comprehension and speech. The economic burden of stroke-related hospitalization was significantly high, emphasizing the need for government-funded health insurance to cover stroke-related medications and reducing out-of-pocket expenses for patients seeking treatment in healthcare facilities. The study highlights the urgency for better schemes to address the growing threat of strokes in the north-eastern parts of India for comprehensively tackling this public health challenge.

Small Area Geographic Estimates of Cardiovascular Disease Risk Factors in India

Importance

With an aging population, India is facing a growing burden of cardiovascular diseases (CVDs). Existing programs on CVD risk factors are mostly based on state and district data, which overlook health disparities within macro units.

Objective

To quantify and geovisualize the extent of small area variability within districts in CVD risk factors (hypertension, diabetes, and obesity) in India.

Design, Setting, and Participants

This cross-sectional study analyzed nationally representative data from the National Family Health Survey 2019-2021, encompassing individuals aged 15 years or older, for hypertension (n = 1 715 895), diabetes (n = 1 807 566), and obesity (n = 776 023). Data analyses were conducted from July 1, 2022, through August 1, 2023.

Exposures

Geographic units consisting of more than 30 000 small areas, 707 districts, and 36 states or Union Territories across India.

Main Outcomes and Measures

For primary outcomes, CVD risk factors, including hypertension, diabetes, and obesity, were considered. Four-level logistic regression models were used to partition the geographic variability in each outcome by state or Union Territory (level 4), district (level 3), and small area (level 2) and compute precision-weighted small area estimates. Spatial distribution of district-wide means, within-district small area variability, and their correlation were estimated.

Results

The final analytic sample consisted of 1 715 895 individuals analyzed for hypertension (mean [SD] age, 39.8 [17.3] years; 921 779 [53.7%] female), 1 807 566 for diabetes (mean [SD] age, 39.5 [17.2] years; 961 977 [53.2%] female), and 776 023 for obesity (mean [SD] age, 30.9 [10.2] years; 678 782 [87.5%] women). Overall, 21.2% of female and 24.1% of male participants had hypertension, 5.0% of female and 5.4% of men had diabetes, and 6.3% of female and 4.0% of male participants had obesity. For female participants, small areas (32.0% for diabetes, 34.5% for obesity, and 56.2% for hypertension) and states (30.0% for hypertension, 46.6% for obesity, and 52.8% for diabetes) accounted for the majority of the total geographic variability, while districts accounted for the least (13.8% for hypertension, 15.2% for diabetes, and 18.9% for obesity). There were moderate to strong positive correlations between district-wide mean and within-district variability (r = 0.66 for hypertension, 0.94 for obesity, and 0.96 for diabetes). For hypertension, a significant discordance between district-wide mean and within-district small area variability was found. Results were largely similar for male participants across all categories.

Conclusions and Relevance

This cross-sectional study found a substantial small area variability, suggesting the necessity of precise policy attention specifically to small areas in program formulation and intervention to prevent and manage CVD risk factors. Targeted action on policy-priority districts with high prevalence and substantial inequality is required for accelerating India's efforts to reduce the burden of noncommunicable diseases.

Determinants of nutritional status among under-five children receiving Integrated Child Development Services (ICDS) in India

Background: Undernutrition is a significant public health problem and the leading risk factor for India's disease burden. Aim: To understand the determinants of nutritional status among under-five children receiving Integrated Child Development Services (ICDS) in India. Methods: The study used the National Family Health Survey-4 (2015-16) data. The analysis was carried out for under-five children who have availed of any ICDS services in the 12 months preceding the survey (n = 1,27,813). Stunting, wasting, and underweight were estimated following the World Health Organization guideline and used as the outcome variables. The binary logistic regression was conducted to examine the association of ICDS utilization and socioeconomic-demographic predictors with under-five children's nutritional status. STATA (V 13) was used for statistical analyses. Results: A sizable proportion of under-five children receiving any ICDS services suffer from undernutrition. The undernutrition prevalence varied considerably by socioeconomic and demographic characteristics. Logistic regression found an insignificant association of ICDS utilization with the nutritional status of under-five children. Children not immunized in ICDS centers were less likely to be stunted (OR: 0.93; P < 0.01), wasted (OR: 0.93; P < 0.01), and underweight (OR: 0.90; P < 0.01) than their counterparts. The child's age and gender, maternal education and nutrition status, wealth index, social group, region, residence, and region were significant determinants of undernutrition among ICDS beneficiaries. Conclusion: The study suggests the need to ensure all available services to children enrolled in the Anganwadi Center (AWC). The program should also emphasize feeding practices and educate parents about improving child health and nutrition.

Is Artificial Intelligence the Cost-Saving Lens to Diabetic Retinopathy Screening in Low- and Middle-Income Countries?

Diabetes is a rapidly growing global health crisis disproportionately affecting low- and middle-income countries (LMICs). The emergence of diabetes as a global pandemic is one of the major challenges to human health, as long-term microvascular complications such as diabetic retinopathy (DR) can lead to irreversible blindness. Leveraging artificial intelligence (AI) technology may improve the diagnostic accuracy, efficiency, and accessibility of DR screenings across LMICs. However, there is a gap between the potential of AI technology and its implementation in clinical practice. The main objective of this systematic review is to summarize the currently available literature on the health economic assessments of AI implementation for DR screening in LMICs. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We conducted an extensive systematic search of PubMed/MEDLINE, Scopus, and the Web of Science on July 15, 2023. Our review included full-text English-language articles from any publication year. The Joanna Briggs Institute's (JBI) critical appraisal checklist for economic evaluations was used to rate the quality and rigor of the selected articles. The initial search generated 1,423 records and was narrowed to five full-text articles through comprehensive inclusion and exclusion criteria. Of the five articles included in our systematic review, two used a cost-effectiveness analysis, two used a cost-utility analysis, and one used both a cost-effectiveness analysis and a cost-utility analysis. Across the five articles, LMICs such as China, Thailand, and Brazil were represented in the economic evaluations and models. Overall, three out of the five articles concluded that AI-based DR screening was more cost-effective in comparison to standard-of-care screening methods. Our systematic review highlights the need for more primary health economic analyses that carefully evaluate the economic implications of adopting AI technology for DR screening in LMICs. We hope this systematic review will offer valuable guidance to healthcare providers, scientists, and legislators to support appropriate decision-making regarding the implementation of AI algorithms for DR screening in healthcare workflows.

Achieving health equity through healthcare technology: Perspective from India

India aims to provide universal health coverage to all individuals and communities thus ensuring accessibility, promotive, curative, preventive, rehabilitative, and palliative health services to all. Healthcare technologies play a critical role in ensuring eliminating healthcare disparities and encouraging quality healthcare at all levels. Technology solutions such as indigenous medical devices and diagnostic products, telemedicine, artificial intelligence, and drone technology can best integrate rural needs, improve health outcomes, patient safety, and healthcare quality and experience for patients' values and strengths and can therefore be important contributors to advancing rural health equity. These technologies can transform India's healthcare system by providing quality care and mitigating the risk of catastrophic financial hardship.

The Economic Cost of Rising Non-communicable Diseases in India: A Systematic Literature Review of Methods and Estimates

BACKGROUND AND OBJECTIVES

India has one of the world's highest proportions of out-of-pocket expenditure (OOPE) payments. The low share of public health expenditure coupled with the double burden of disease (communicable and non-communicable) has a direct financial impact on individual OOPE and an indirect impact in the form of decreasing life expectancy, reduced productivity, and hence a negative impact on economic growth. This systematic review aims to compare and assess the estimated economic cost of non-communicable diseases (NCDs) in India and ascertain the methods used to derive these estimates.

METHODS

This paper reviews the past 12-year (2010-22) literature on the economic impact of health shocks due to NCDs. Three databases were searched for the literature: PubMed, Scopus, and Google Scholar. Thematic analysis has been performed to analyse the findings of the study.

RESULTS

The OOPE was very high for NCDs. The increasing cost was high and unaffordable, pushing many people into financial distress measured by catastrophic payments and rising impoverishment.

CONCLUSION

The results indicate both the direct and indirect impact of NCDs, but the indirect burden of loss of employment and productivity, despite its relevance, has been less studied in the literature. A robust economic analysis will allow an evidence-based policy decision perspective to reduce the rising burden of NCDs.

From East to West: A Narrative Review of Healthcare Models in India and the United States

The global healthcare landscape is fraught with quality, cost, equity, and innovation challenges. Despite this, successful healthcare interventions have emerged from unexpected locations. In India, the eradication of certain communicable diseases, the expansion of access to primary care, and the implementation of innovative methods such as telemedicine have demonstrated the potential for community-centered care. In the United States (US), improvements in healthcare quality, accessibility, and the utilization of medical technology, such as the incorporation of telehealth and artificial intelligence, have highlighted opportunities for technological innovation in healthcare delivery. This manuscript reviews the history and development of healthcare systems in India and the US, highlighting each system's strengths, weaknesses, lessons learned, and opportunities for improvement. By examining both systems, we strive to promote a healthcare model that incorporates lessons from each country to improve community-centered care and ultimately provide equitable access to all.

Evidence from the first Shared Medical Appointments (SMAs) randomised controlled trial in India: SMAs increase the satisfaction, knowledge, and medication compliance of patients with glaucoma

In Shared Medical Appointments (SMAs), patients with similar conditions meet the physician together and each receives one-on-one attention. SMAs can improve outcomes and physician productivity. Yet privacy concerns have stymied adoption. In physician-deprived nations, patients' utility from improved access may outweigh their disutility from loss of privacy. Ours is to our knowledge the first SMA trial for any disease, in India, where doctors are scarce. In a 1,000-patient, single-site, randomized controlled trial at Aravind Eye Hospital, Pondicherry, we compared SMAs and one-on-one appointments, over four successive visits, for patients with glaucoma. We examined patients' satisfaction, knowledge, intention-to-follow-up, follow-up rates, and medication compliance rates (primary outcomes) using intention-to-treat analysis. Of 1,034 patients invited between July 12, 2016 -July 19, 2018, 1,000 (96.7%) consented to participate, and were randomly assigned to either SMAs (NSMA = 500) or one-on-one appointments (N1-1 = 500). Patients who received SMAs showed higher satisfaction (MeanSMA = 4.955 (SD 0.241), Mean1-1 = 4.920 (SD 0.326); difference in means 0.035; 95% CI, 0.017-0.054, p = 0.0002) and knowledge (MeanSMA = 3.416 (SD 1.340), Mean1-1 = 3.267 (SD 1.492); difference in means 0.149; 95% CI, 0.057-0.241, p = 0.002) than patients who received one-on-one appointments. Across conditions, there was no difference in patients' intention-to-follow-up (MeanSMA = 4.989 (SD 0.118), Mean1-1 = 4.986 (SD 0.149); difference in means 0.003; 95% CI, -0.006-0.012, p = 0.481) and actual follow-up rates (MeanSMA = 87.5% (SD 0.372), Mean1-1 = 88.7% (SD 0.338); difference in means -0.012; 95% CI, -0.039-0.015, p = 0.377). Patients who received SMAs exhibited higher medication compliance rates (MeanSMA = 97.0% (SD 0.180), Mean1-1 = 94.9% (SD 0.238); difference in means 0.020; 95% CI, 0.004-0.036, p = 0.013). SMAs improved satisfaction, learning, and medication compliance, without compromising follow-up rates or measured clinical outcomes. Peer interruptions were negatively correlated with patient satisfaction in early-trial SMAs and positively correlated with patient satisfaction in later-trial SMAs. Trial registration: The trial was registered with Clinical Trials Registry of India (https://ctri.nic.in/) with reference no. REF/2016/11/012659 and registration no. CTRI/2018/02/011998.

Pattern of Surgical Diseases Affecting Females in a Teaching Hospital in Central India: A Demographic Study

Introduction  Despite progress in eliminating the social and health disparity between men and women during the last century, gender equality remains an elusive goal, particularly in the developing world. This gender-based bias has been found to directly result into poor health outcome in females. Hence, it is vital to know the number and pattern of surgical diseases affecting females in any setup, so as to improve their admission rates and reach out to this neglected half of population. Materials and Methods  This was a demographic study done at a teaching hospital in Central India from January to June 2020. Data of patients discharged from female surgery ward were collected from medical record department. Age, diagnosis, urban-rural distribution, and length of hospital stay of patients were noted, and data were analyzed statistically. Results  A total of 187 patient records were studied, which revealed that the mean age of the patients was 40.35 years; maximum patients were of gastrointestinal surgery (53.42%) in which the most common diagnosis was cholelithiasis (25.13%). Urological diseases (15.50%), breast diseases (12.83%), perianal disease (9.09%), and thyroid diseases (5.34%) were found in decreasing order of frequency. Overall hospital stays of patients ranged from 1 to 14 days with average stay of 6.35 days. Conclusion  In our study, cholelithiasis was found to be the most common surgically treated disease followed by urological diseases. Breast symptoms, although commonly affecting females, did not turn into admissions as there remains a social taboo attached to it. Breast cancer still presents late, despite being the most common cancer in females in India. Approximately 65% patients were discharged within first 5 days of their admission, which indicates good hospital care and improves patient satisfaction levels. Still there is greater need for public health efforts to improve the monitoring, safety, and availability of surgical services to female patients.

Income-related inequality in out-of-pocket health-care expenditures under Taiwan's national health insurance system: An international comparable estimation based on A System of Health Accounts

National estimates of out-of-pocket health-care expenditures (OOP-HCEs) that use comparable international guidelines based on A Systems of Health Accounts (SHA) are generally unavailable in Taiwan. International comparable OOP are essential for designing universal health-coverage (UHC) policy. We designed an SHA-based household OOP questionnaire. A nationally representative cross-sectional survey was then conducted from January to August 2022. The final questionnaire was completed by 657 households and 1969 individuals. The total OOPs were divided into expenditures related to curative care (HC.1), rehabilitative care (HC.2), long-term care (HC.3), ancillary services (HC.4), and medical goods (HC.5). National estimates were calculated by accounting for the complex survey design. Variance was estimated through Taylor series linearization. The concentration index was calculated using household income as the ranking variable. We then identified factors contributing to the inequality in OOP distribution by household income. National estimates revealed an OOP of NT$424 billion, which accounted for 29.6% of Taiwan's national health expenditure in 2021. Private health insurance (PHI) reimbursements accounted for 9.0% of the total OOP. The OOPs for curative care and medical goods accounted for 50.1% and 39.0% of the total OOP, respectively. The OOPs after PHI reimbursements were progressive (concentration index = 0.103, P = 0.012). The frequency of medical-care use and the number of medical visits negatively affected progressive OOPs. International comparable OOPs revealed that under the Taiwanese National Health Insurance (NHI), OOPs can still be high. However, the NHI might have caused OOPs to be progressive from the perspective of income but regressive from the perspective of health status. Countries striving for UHC should consider the redistribution effect of public health insurance and possible inequalities in health.

Diagnostic concordance of telemedicine as compared to face-to-face care in primary health care clinics in rural India: a randomized crossover trial

BACKGROUND

Introduction Equitable access to primary health care remains an elusive dream in rural India [1]. The rural health system faces a shortage of health workers at every level [2]. Almost 77% of all qualified health workers in India are based in urban centers where 31% of the population resides [2]. Nurses, community health workers and other paramedical personnel at the primary health care level can manage some part of the disease burden. However, several commonly seen primary health conditions such as management of hypertension, diabetes, family planning, severe malnutrition, high-risk pregnancies, dermatological conditions, osteoarthritis require intervention from a doctor, and such patients are referred to higher-level health centres such as a Primary Health Centre (PHC) or a Community Health Centre (CHC). The average distance traveled to a PHC is 8.7 km and to a CHC is 17.64 km [3], making physical visits to a doctor challenging to access for remote areas, especially where transportation is a challenge. One emerging model of mitigating the primary health care access gap is provider-to-provider telemedicine [4]. This provider-to-provider telemedicine approach connecting paramedical frontline health providers at 150,000 Health and Wellness Centres (HWCs) to doctors at secondary or tertiary facilities has been envisioned in India's Ayushman Bharat program [5,6]. The Indian Government's eSanjeevani AB-HWC telemedicine system that operates in a hub and spoke model facilitating consultations between HWCs (spokes) and tertiary hospitals (hubs) [6] has already achieved over 6.7 million consultations [7]. With over 2000 hubs [7] and 28,000 spokes [7] the program demonstrates that this approach is feasible and expands health access, especially in the context of the COVID-19 pandemic. This approach can bridge the urban-rural disparity in the availability of trained medical professionals, improve the quality of available primary health services, and reduce patient referrals [8]. However, an important consideration for patients, providers, and policymakers is whether virtual doctors' visits facilitated by a frontline health worker are an appropriate standard of care in this setting and an acceptable alternative when in-person doctor visits are not possible. The authors of this paper developed an enhanced provider-to-provider telemedicine approach where a frontline health worker powered by an appropriate job aid or training, can interact with the patient meaningfully to elicit clinical signs and symptoms and share them with the help of a synchronous or asynchronous network of telemedicine doctors for a diagnosis and management plan [9]. We studied the diagnostic concordance and provider acceptability of this provider-to-provider telemedicine program that connected nurses in primary health care facilities with remote teledoctors through a randomized crossover study in 10 rural HWCs in the Morbi district of Gujarat. Several telemedicine studies in developed countries have shown that telemedicine can provide comparable care at lower costs and greater convenience for patients [10,11]. Another study reciprocates that telemedicine can be a great opportunity in the care of disadvantaged populations and has the potential to break down inequalities[12]. Telemedicine is an important tool for health care delivery, which has achieved even greater significance in the context of the COVID-19 pandemic [13,14]. However, there are certain limitations of telemedicine-based care. There are few rigorous systematic evaluations on the clinical benefits of telemedicine and its impact of telemedicine on the quality and safety of care [15]. Therefore, it is essential to understand when telemedicine can deliver comparable diagnostic outcomes and whether it provides high-quality care. Various studies have shown good or very good levels of diagnostic concordance between face-to-face (F2F) and telemedicine-based (TM) care with concordance rates between 73 to 99% [16-22]. However, very few studies have been conducted comparing teleconsultation's diagnostic and treatment outcomes to F2F consultations in developing countries. We found only one such study that showed a 78% diagnostic concordance and an 89% treatment concordance between an in-person nurse visit and a virtual nurse visit for an asynchronous telemedicine program in Kenya [18]. The impact of telemedicine in developing countries is greater where there are significant geographic disparities in the distribution of available healthcare professionals, especially between urban and rural areas [4]. However, there is a gap in the literature with very few randomized evaluations of telemedicine. Systematic randomized evaluations of telemedicine are possible but rarely undertaken or published in developing countries due to financial and resource constraints [18]. In addition, our telemedicine program used a task-shifting digital assistant, called "Ayu", that provided just in time job aids to nurses so they could collect a comprehensive patient history and physical exam information to share with the remote physician [9]. A major concern in the use of this digital assistant is its impact on the overall quality of the consultation. If the nurse collects too little or incorrect information, it could adversely impact the quality of the consult. At the very least, the digital assistant should maintain diagnostic accuracy in a consult and increase the overall efficiency of the consult. In this study we also examined the impact of this digital assistant on the overall consult quality and efficiency.

OBJECTIVE

To compare the diagnosis and treatment decisions from teleconsultations to those of in person care in teleclinics in rural Gujarat.

METHODS

Study site: The MyTeleDoc project is a telemedicine network where Community Health Officers (CHOs) at HWCs can facilitate virtual visits with doctors using a mobile application. CHOs use the app for patients presenting with health conditions that they cannot manage and otherwise refer to a higher-level facility. The project's pilot phase was implemented at 22 HWCs in two blocks of Morbi district - Maliya and Tankara (see district location in Figure 1), i.e., in 11% of the total HWCs (198) in the district. We randomly selected 10 HWCs out of the total 22 HWCs in the project for this study. The Morbi District Administration implemented the pilot project in HWCs in difficult-to-reach parts of the district. Thus, these HWCs served a patient population with poorer health and socioeconomic indicators than the district median and the median for Gujarat. Figure 1: Location of Morbi district. Image credit: By Milenioscuro - Own work (CC BY-SA 4.0). These HWCs have outpatient primary care clinics run by the CHOs [5] who are trained nurses or Ayurveda practitioners with additional training in comprehensive primary healthcare delivery received through an accredited bridge training program [23]. They also conduct screening programs and community health activities. Using primary data collected from the district health administration, we found that there are a sufficient number of general practitioners within the Morbi government health system. However, the district faces a severe shortage in the number of available specialists, with only one internal medicine physician, one pediatrician, and no obstetricians or gynecologists in the district health administration for the entire population of 10 lakh (1 million) people. This dearth of specialist providers in the public health system, and especially of obstetricians and pediatricians is also seen all over Gujarat with 97% of posts vacant as per one study [23]. The project recruited general practitioners (called Medical Officers or MOs) from within the Morbi health system and volunteer specialists from private facilities and NGOs in the nearby district of Rajkot to serve as remote doctors for the project. These were allopathic doctors with an MBBS or MD degree. Thus, the project aims to reduce the health access barriers for rural patients while also increasing the available capacity of providers in the district through private sector support. This project was implemented just before the COVID-19 pandemic in December 2019 and was used during the pandemic to remotely manage patients and reduce referrals to crowded tertiary facilities overburdened with COVID patients. Sample Size: Our study sample consists of 104 patients attending at ten randamoly selected telemedicine primary care clinics of Morbi district. These patients were randomly assigned to first receive an in-person doctor consultation (n = 59, i.e. 57%) and the other group (n = 45, i.e. 43%) to first receive a health worker-assisted telemedicine consultation. Then the two groups were then switched, with the first group undergoing a telemedicine consultation following the in-person consultation and the second group receiving an in-person consultation after the teleconsultation. Technology: The MyTeleDoc application is a white-labeled version of an open-source telemedicine software product, called Intelehealth [9]. It is distributed as a Digital Public Good and is free to adapt, use and implement by health organizations [9]. A description of the platform's design, development, and architecture has been described in a prior publication [9]. The MyTeleDoc application consists of a digital health assistant called Ayu that guides the CHO in collecting a comprehensive patient history through adaptive questionnaires depending on the patient's presenting complaint. The CHO uploads the case to a remote doctor who views it through a mobile application for doctors. The doctor conducts a video or audio call with the CHO and/or the patient and provides an ePrescription with a diagnosis, medicines, tests, advice, or referral (synchronous teleconsultation). At the doctor's discretion, they may also provide a diagnosis and triage decision without speaking with the CHO and/or the patient if they feel the information by the CHO is sufficient for them to arrive at a management plan for the patient (asynchronous teleconsultation). The CHO can then discuss the diagnosis with the patient, dispense the required medications, and manage follow-up care as needed. We trained CHOs in using the app and telemedicine-based care over 1.5 days of training. Figure 2 and 3 demonstrate the MyTeleDoc CHO application and the digital assistant. Figure 2: MyTeleDoc application with the digital assistant Ayu. Figure 3: A Community Health Officer using the digital assistant Ayu in the MyTeleDoc app to collect a patient history and facilitate a teleconsultation. Study protocol: Ethical approval for the study was obtained from a local ethics committee in India from the DY Patil Institute of Medical Sciences and the Johns Hopkins University Institutional Review Board. We enrolled patients from all age groups in need of curative primary health care services but not emergent care at 10 HWCs that participated in the study. Community Health workers called ASHA workers (Accredited Social Health Activist) identified patients meeting the study's inclusion and exclusion criteria and contacted them through home visits inviting them to participate in the study. In addition, the ASHA and CHO also approached patients who came to the HWC on the study day to participate. Several patients in the Morbi district were screened during hypertension and diabetes screening camps; they were also invited to participate in the study to confirm their diagnosis and adjust medications as needed. All patients who indicated an interest in participating underwent a consent process through an IRB-approved consent form conducted in the local language of Gujarati. A study team member read out the consent form developed in simple language and available in Gujarati explaining the study procedures, risks, and limitations. Adequate time was given for patients to understand the study and ask questions. Since the study involved a randomized crossover design and patients would need to spend more than twice as much time at the clinic as they usually would, patients were compensated Rs.500 for participation. CHOs were compensated Rs.2500 for their participation in the study. Eleven ASHAs participated in patient enrolment and were compensated Rs.500 for the same. The participating doctors received no additional compensation for this study. After enrolment, we randomly allocated half the patients to receive a F2F doctor consultation (standard of care). This was followed by a CHO-facilitated teleconsultation with a remote doctor. The other half were randomly allocated to receive the teleconsultation first, followed by the F2F consultation (randomized crossover design) to control for order and crossover effects. A gap of 30 - 90 minutes was given between the consultations. Doctors participating in the study were highly experienced family physicians with more than 30 years of work experience to minimize misdiagnosis due to provider skill level. Both consultations occurred in separate rooms, and participating providers in each arm were blinded to the outcomes of the other. Patients were instructed to share the same health issue during both the consultations and not discuss the results of one consultation with the other doctor to minimize the effect of one treatment arm biasing the other. Participating patients received the standard of care, i.e., the in-person consultation treatment plan. The in-person doctor used a paper form to record the patient's presenting complaints, physical exams, medications, and treatment plan during the F2F consultation. During the teleconsultation, the CHO used the MyTeleDoc app to elicit and document the patient's history and physical exam findings and share the same with the remote doctor, who then used the MyTeleDoc doctor's app to share the medications and treatment plan. All patients received a unique identifier. After the study concluded, a study team member entered the data from the F2F consultation from the paper forms into a digital format. We extracted the data from the teleconsultation from the MyTeleDoc portal. We excluded personal identifiers such as name, phone number, address, and face photographs from the F2F consultation and teleconsultation records. We included age, gender, occupation, and physical exam images of the patient's body in the data extraction due to their relevance to the treatment plan. We matched the F2F and teleconsultation patient records using the patient identifier. Similarly, we did not include information that would identify the provider, such as the name of the CHO and doctor, and replaced them with a pseudo identifier. However, due to the small number of CHOs (10) and doctors (3), complete anonymization was not possible. We compared the medical records of the teleconsultation and the F2F consultation to determine the concordance between the two modalities. For our study, we considered the F2F diagnosis as the gold standard. We measured the concordance as the percentage of cases for which the F2F and TM physician had the same diagnosis (diagnostic concordance) and treatment (treatment concordance). Percent agreement has been used to measure inter-rater agreement in several similar non-randomized studies on telemedicine [18,19]. The doctors participating in the study discussed the patient cases to determine if the in-person care and telemedicine-based care provided were substantially similar in diagnosis and treatment plan. Allowable differences in treatment planning, such as medication prescribing preferences or differences in how diagnoses were entered, were not considered discordant. While analyzing the impact of the digital assistant on the teleconsultation outcome, the doctors discussed the cases and put in descriptive notes for each case. To minimize bias, the final analysis was audited by another study team member (NV) who was not one of the participating doctors. Changes were made in one record after the audit, where we found a data entry error, and the diagnosis concordance for that case was changed from concordant to discordant. The descriptive notes were analyzed and summarized by a study team member (NV) who also conducted the data analysis using SPSS and Excel.

RESULTS

We selected 10 HWCs and enrolled 105 patients across all the study locations. We excluded one patient case as the paper form for the F2F encounter was misplaced, bringing a total of 104 patients into the study. Table 1 shows the gender and age (self-reported) distribution of patients. Table 1: Age and gender distribution of patients No. of patients (n) Percentage (%) Gender Female 70 67% Male 34 33% Age group 0 - 5 years 12 12% 6 - 18 years 5 5% 19 - 35 years 18 17% 36 - 60 years 36 35% 61 - 100 years 33 32% Total 104 100% A total of 10 CHOs participated in the study, one at each HWC. The average age of CHOs was 27 years. All the CHOs had a Bachelor's degree in Nursing. The CHOs varied in the total number of years of work experience as a nursing professional before becoming a CHO from one to six years. They were very comfortable using technology and had undergone training in using the app. We enrolled three doctors in the study, two to provide in-person care and one for remote care. The average age of these physicians was 63 years, and each had over 30 years of experience as a family physician. The physicians routinely used smartphones and were comfortable using the telemedicine portal. All providers were fluent in Gujarati, Hindi, and English. Diagnostic & Treatment concordance between F2F and TM consultation Overall, we observed a 74% (n=77) diagnostic concordance between F2F and TM consultation, and an 80% (n=83) treatment concordance. There was no statistically significant difference in the diagnostic concordance (P = 0.65, Fisher's Exact test two-sided) or the treatment concordance (P = 0.81, Fisher's Exact test two-sided) between the cases where F2F or TM consultation was conducted first. Similarly, we could not find any statistically significant association between the diagnostic/treatment concordance and other key variables that may influence the consultation, such as the CHO-doctor pair, gender of the patient, and mode of consultation (see Table 2 for P-values). Table 2: Diagnostic & treatment concordance with patient and visit characteristics No. of patients (n) Percentage (%) Diagnosis concordance (% agreement) P-value* (two-sided) Treatment concordance (% agreement) P-value* (two-sided) Order of consultation 104 100% 74% (n=77) P = 0.65 80% (n=83) P = 0.81 F2F consultation first 59 57% 76% (n=45) 81% (n=48) TM consultation first 45 43% 71% (n=32) 78% (n=35) Location/CHO-doctor pair 104 100% 74% (n=77) P = 0.93 80% (n=83) P = 0.93 HWC 1 11 11% 73% (n=8) 91% (n=10) HWC 2 11 11% 73% (n=8) 82% (n=9) HWC 3 8 8% 50% (n=4) 63% (n=5) HWC 4 10 10% 70% (n=7) 80% (n=8) HWC 5 10 10% 70% (n=7) 70% (n=7) HWC 6 10 10% 80% (n=8) 80% (n=8) HWC 7 13 13% 85% (n=11) 85% (n=11) HWC 8 9 9% 78% (n=7) 89% (n=8) HWC 9 11 11% 82% (n=9) 82% (n=9) HWC 10 11 11% 73% (n=8) 73% (n=8) Gender 104 100% 74% (n=77) P = 1.00 80% (n=83) P =1.00 Female 70 67% 74% (n=52) 80% (n=56) Male 34 33% 74% (n=25) 79% (n=27) Type of case/Speciality 113 100% 74% (n=113) P = 0.004 80% (n=90) P = 0.028 Hypertension 21 19% 95% (n=20) 95% (n=20) Diabetes 15 13% 93% (n=14) 93% (n=14) Obstetrics 10 9% 80% (n=8) 80% (n=8) Pediatrics 17 15% 76% (n=13) 88% (n=15) Orthopedics 18 16% 72% (n=13) 78% (n=14) Gastroenterology 6 5% 67% (n=4) 67% (n=4) Dermatology 8 7% 63% (n=5) 75% (n=6) Gynecology 5 4% 60% (n=3) 60% (n=3) Cardiology 3 3% 33% (n=1) 33% (n=1) Miscellaneous 10 9% 30% (n=3) 50% (n=5) Mode of teleconsultation 100 100% 73% (n=73) P = 0.32 79% (n=79) P = 0.29 Asynchronous 84 84% 71% (n=60) 77% (n=65) Synchronous 16 16% 81% (n=13) 88% (n=14) *Fisher's exact test was used to determine if there was a significant association between diagnosis and treatment concordance and the order of consultation, CHO-doctor pair, gender, type of case and mode of teleconsultation Since a patient may have multiple diagnoses, a patient case could be classified into multiple specialties. We observed a statistically significant association between the type of case and the diagnostic concordance (P = 0.004, Fisher's Exact test two-sided) and the treatment concordance (P = 0.028, Fisher's Exact test two-sided). Inter-rater reliability for diagnosis of Hypertension & Diabetes (Cohen's Kappa) Twenty-one patients with diabetes and 17 patients with hypertension participated in the study. Historic blood pressure (BP) and random blood sugar (RBS) values were available for these patients with the nurse. Thus, the diagnosis of hypertension and diabetes was based on multiple readings taken in the clinic over several visits. Due to the wide range in diagnosis, Cohen's Kappa, which is accepted as a more robust measure of concordance [25,26], could only be calculated for the most common diagnosis where there was a sufficient sample size - hypertension & diabetes. Twenty-one patients were diagnosed as hypertensive by the F2F physician. The sensitivity of diagnosis of hypertension in the telemedicine encounter compared to a F2F consultation was 0.95, and specificity was 0.97. Cohen's Kappa for diagnosis for hypertension was 0.89, indicating a strong agreement. Fifteen patients were diagnosed with Type II diabetes by an in-person physician. The sensitivity of diagnosis of diabetes in the telemedicine encounter compared to a F2F consultation was 0.93, and specificity was 0.99. Cohen's Kappa for diagnosis of diabetes was 0.93, indicating a near-perfect agreement. Since this was a diagnostic setting, the telemedicine physician gave a higher focus on specificity. Impact of the digital assistant on the teleconsultation outcome The digital assistant allowed the CHO to collect a lot of the initial clinical information and share it with the doctor, and in 84% of the cases the doctor felt this information was sufficient to arrive at a diagnosis and did not feel the need to speak with the patient. This allowed most consultations to be delivered asynchronously. The output clinical notes also allowed remote doctor to spend lesser time and resulted in a more efficient use of their time. CHOs reported that they were able to assess a patient thoroughly and were less likely to skip any steps. Finally, it eliminated the remote doctor's documentation burden. We observed that the skill of the CHO in using the digital assistant was very important. In at least 12 out of the 27 discordant cases (44%) missing, incorrect or incomplete information provided by the CHO led to a discordant diagnosis. Limitations of telemedicine A majority of patients (58%, n = 60) had just one diagnosis, 31% of patients (n = 32) had two diagnoses, 11% (n = 11) had three diagnoses and 1% (n = 1) patient had four diagnoses. Across all 104 patients, there were a total of 65 diagnoses and 162 patient-diagnosis pairs (see Table 3). Table 3: List of diagnoses No. Diagnosis No. of patients No. Diagnosis No. of patients 1 Essential hypertension 29 34 Residual hemiplegia 1 2 Diabetes Mellitus, Type II 17 35 Residual hemiparesis 1 3 Anemia 11 36 Recurrent Tonsilitis 1 4 Osteoarthritis 8 37 Pruritus 1 5 Routine ANC checkup 6 38 Primary sterility 1 6 Anxiety neurosis 5 39 Preeclampsia 1 7 Sciatic neuralgia 4 40 Postural hypotension 1 8 Atopic Dermatitis 4 41 Post ringworm hyperpigmentation 1 9 Soft tissue injury 3 42 Post pimples scarring 1 10 Rhematoid arthritis 3 43 Peripheral neuritis 1 11 Malnourished child 3 44 Perimenopausal syndrome 1 12 Helminthiasis 3 45 Non healing ulcer 1 13 Vitamin A deficiency 2 46 Ischemic heart disease 1 14 Vaginal discharge syndrome 2 47 Intrauterine growth restriction (IUGR) 1 15 Upper Respiratory Tract Infection 2 48 Infected psoriasis 1 16 Ring worm 2 49 Hyperthyroidism 1 17 Psoriasis 2 50 High arched feet deformity 1 18 Polyneuritis 2 51 Hemorrhoids 1 19 Myositis around shoulder 2 52 Gall stones 1 20 Myalgia 2 53 Exertional dyspnea 1 21 High risk ANC checkup 2 54 Esophageal cancer 1 22 General debility 2 55 Early cardiac failure 1 23 Gastritis 2 56 Congenital valvular heart disease 1 24 Constipation 2 57 Chronic kidney disease 1 25 Cataract 2 58 Cervical Spondylosis 1 26 Vitamin C deficiency 1 59 Cerebral Palsy 1 27 Viral fever 1 60 Calcium Deficiency 1 28 Ventral hernia 1 61 Bronchopneumonia 1 29 Urinary tract infection 1 62 Atheromatous arthritis 1 30 Tinea Versicolor 1 63 Ankle sprain 1 31 Scabies 1 64 Allergic Dermatitis 1 32 Sacroilliac strain 1 65 Age-related debility 1 33 Rule out angina pectoris 1 Grand Total 162 Of these, 113 diagnoses were considered "primary", where the diagnosis corresponded to the patient's presenting complaints. Forty-nine diagnoses were considered "secondary" or incidental findings, where the patient was not complaining specifically of this health issue, but the in-person physician identified these during a routine physical exam. The remote physician did not identify these in the telemedicine encounter due to their inability to conduct a physical exam. The CHO would also likely not have the proficiency to conduct a high-quality exam and identify these salient findings, which an experienced clinician observed. Noteworthy missed diagnoses included anemia, cataract, osteoarthritis, anxiety disorder, and a potential esophageal cancer. Physical examination and careful history taking are essential to diagnosing these conditions. We observed that while telemedicine can help identify and treat the root cause of a patient's primary concerns, diseases without any prominent presentation or symptoms negatively impacting the patient's quality of life would likely be missed and can be identified only during a routine review of systems. However, this observation may be due to the nature of our study, where the in-person doctor provided a thorough consultation spending more than 20 minutes per patient. In a busy outpatient setting, the physician may not have the time to conduct a review of systems and would likely only address the patient's presenting complaint. In addition, we observed that many study participants had multiple unaddressed comorbidities, which we attributed to the health access gap resulting in patients' delay in seeking primary health care, an underlying issue that telemedicine solves.

CONCLUSIONS

Provider-to-provider telemedicine, where nurses at Health and Wellness Centres connect with remote physicians to provide care for patients they would otherwise have referred to a tertiary facility, is a feasible and safe intervention. Telemedicine is less reliable than in-person care but a safe and effective alternative where in-person care cannot be provided. We found it most effective for managing high-burden primary health conditions such as hypertension, diabetes, and remote antenatal care. The use of a digital assistant to facilitate the collection of an evidence-based medical history can result in more efficient teleconsultations, support asynchronous consultations and greater adherence to clinical protocols. However, we cannot conclude if the use of the assistant increases the quality of the outcome of the consultation and this needs to be further explored. Training for remote physicians and nurses on the limitations of telemedicine and the indications for referral could improve the quality of care. Telemedicine has significant benefits, including improved healthcare access for women, reduced costs for the patient, and improved health system efficiency by reducing overcrowding at secondary & tertiary facilities and reducing the risk of COVID transmission at facilities. Further research is needed to assess this approach's long-term outcomes, provider and patient satisfaction, and financial sustainability.

CLINICALTRIAL

Life before Death in India: A Narrative Review

Palliative care is an ever-increasing need in India, with its large population and rising burden of chronic illness. India ranks 67th out of 80 countries in the quality of death index, which measures the availability and quality of palliative care. Community-led projects in Kerala have proven successful in improving palliative care access with modest resources and volunteer involvement. In India, the number of hospice facilities is increasing; however, <1% of the Indian population has access to palliative care. Financial and human resources limitations in the health-care system, poverty and high health-care expenditure, the lack of awareness among the public about end-of-life care, hesitance to seek care due to social stigma, strict laws regarding opiates that hinder adequate pain relief and the apparent conflict between traditional social values and western values regarding death are the major obstacles to improving palliative care. Significant efforts focused on public awareness of end-of-life care and locally-tailored programmes with family and community involvement are necessary to address this issue and integrate palliative care into the primary care system. Furthermore, we discuss the effects of the COVID-19 pandemic that has been managed effectively by palliative care involvement.

Towards understanding accountability for physicians practice in India

The lack of accountability is considered to be a major cause of the crisis in health care in India. Physicians as key stakeholders in the health care delivery system have traditionally been accountable for health concerns at the doctor-patient interface. Following social and organizational dynamics, the interpretations of accountability have broadened and shifted in the recent literature, expanding accountability to the community, national and global levels and to social domains. The objective of this study is to provide a comprehensive framework of accountability in medical practice that can be used as a vehicle for further contextualized research and policy input. Through literature review, this paper is presented in two parts. First, a description of accountability of a physician inclusive of the social domains is extracted by posing three pertinent questions: who is accountable? accountability to whom? and accountability for what? which addresses the roles, relationships with other stakeholders and domains of accountability. Second, a framework of accountability of a physician is designed and presented to illustrate the professional and social domains. This study revealed a shift from individual physician's accountability to collective accountability involving multiple stakeholders through complex reciprocal and multi-layered mechanisms inclusive of the social dimensions. We propose a comprehensive framework of accountability of the physician to include the social domains that its multidimensional and integrative of all stakeholders. Furthermore, we discuss the utility of the framework in the Indian health care system and how this can facilitate further research in understanding the social dimensions of all stakeholders.

Predictors of Out-of-Pocket Expenditure on Health Incurred by Elderly Persons Residing in a Rural Area of Faridabad District

BACKGROUND

A significant portion of India's 1.2 billion population consists of elderly individuals, accounting for approximately 8.6%, who incur substantial out-of-pocket (OOP) healthcare expenses. Any policy for the elderly should encompass financial protection from illness-related expenditures. However, the lack of comprehensive information on OOP expenditure and its determinants precludes such action.

METHODS

We conducted a cross-sectional study of 400 elderly persons residing in the rural town of Ballabgarh. The participants were randomly selected using the health demographic surveillance system. We utilized questionnaires and tools to assess the costs associated with outpatient and inpatient services in the previous year, as well as gather information on socio-demographics (individual characteristics), morbidity (motivation for seeking care), and social engagement (health-seeking).

RESULTS

A total of 396 elderly persons participated, with a mean (SD) age of 69.4 (6.7), and 59.4% females. Nearly 96% and 50% of the elderly availed of outpatient and inpatient services, respectively, in the preceding year. The mean (IQR) annual OOP expenditure, as per the consumer price index 2021, was INR 12,543 (IQR, INR 8,288-16,787), with a median of INR 2,860 (IQR, INR 1,458-7,233), explained significantly by sex, morbidity status, social engagement, and mental health.

CONCLUSION

In low-middle-income countries like India, policymakers may consider pre-payment mechanisms like health insurance for the elderly, using such prediction scores.

Inequality in time to first antenatal care visits and its predictors among pregnant women in India: an evidence from national family health survey

For countries with high maternal mortality and morbidity, on-time initiation of antenatal care (ANC) is indispensable. Therefore this paper aims for studying the median survival time (MST) of first ANC among pregnant women as well as understanding the contextual factors that influence a mother's decision to access ANC services in India. The study used cross-sectional survey data obtained from the NFHS-4 conducted in 2015-2016. The MST of the timing of the first ANC visit was estimated using the Kaplan-Meir estimate. A multivariate Cox-proportional hazard regression model was used to identify the factors related to the timing of the first ANC visit with a 95% confidence interval (CI). Overall at least one ANC checkup was assessed by 60.15% of women and the median survival time for the first ANC checkup was found to be 4 months. Early initiation of ANC in pregnant women increased by 37% (AHR: 1.37, CI:1.34-1.39) for primary education, and 88% (AHR:1.88, CI:1.86-1.90) for secondary education compared to women having no formal education. Results of the current study revealed that the median survival time of the first ANC visit was 4 months in India which is delayed compared to recommendations of WHO. Therefore boosting the access and utilization of antenatal care coverage among pregnant women can ensure the best health outcomes for their pregnancy.

Multiple Vulnerabilities in Access to and Utilising of Maternal and Child Health Services in India: A Spatial–Regional Analysis

Introduction

Although there are multiple vulnerabilities in the utilisation of maternal and child health (MCH) services in India, research has always been focused on single-dimension vulnerabilities like economic or social vulnerabilities. Individuals who are poor may also face other types of vulnerabilities that together affect access to health services. This article, therefore, investigates the linkages between multiple vulnerabilities and the utilisation of MCH care services.

Materials and Methods

Data from National Family Health Survey (2015–2016) for India and states were used for analysing the key outcome variables namely women received four or more antenatal care (ANC), institutional delivery, postnatal care (PNC) and full immunisation for children in the age group of 12–23 months. Bivariate analysis and binomial-logistic regression analysis were employed to examine the multiple vulnerabilities on utilising MCH services across three dimensions of vulnerabilities, such as education, wealth and caste.

Results

Women with multiple vulnerabilities were less likely to utilise essential MCH services. Women who faced vulnerabilities in all three dimensions were less likely to have received four or more ANC and postnatal care than those who were not deprived of any vulnerabilities (0.3 vs. 0.9 and 0.4 vs. 0.8, respectively). They were also less likely to deliver in health facilities and avail child immunisation (0.5 vs. 0.8 and 0.3 vs. 0.7, respectively).

Conclusion

A multi-sectoral approach is therefore required to deal with the issues of low access and underutilisation of MCH services.

Barriers and Facilitators of COVID-19 Vaccination Outreach Program in Rural India: A Qualitative Study

Background Primary health centres are in charge of effectively implementing the COVID-19 vaccination program in rural areas. So, the study was planned to seek insight into the challenges faced by health personnel in the effective implementation of the COVID-19 vaccination program. Methodology The study was conducted in a rural area of Akola district which lies in the western parts of Maharashtra State and belongs to the Vidarbha region and is said to be one of the progressive districts in the region. A qualitative study was planned to understand the barriers and facilitators of the COVID-19 vaccine implementation program at rural and tribal areas. The study participants were medical officers from rural and tribal areas who actively planned and implemented COVID-19 vaccination at the primary health centre. A total of 30 medical officers were interviewed. Interview questions were focussed on the planning of COVID-19 vaccination in their area. Other questions were the problem faced during the implementation of the COVID-19 vaccination program and how it has been tackled. Results The factors identified were grouped into three groups: Health system factors, Human resource factors and Community level factors. Health system factors like shortage of vaccines and syringes, tablet paracetamol, online digital method of vaccination registration, overcrowding at the initial stage, and inadequate infrastructure were barriers to vaccination. Fear about vaccine adverse events, even in healthcare workers (HCWs), and overburdened healthcare workers were also factors affecting vaccination. At the community level, high resistance initially and misconception about the vaccine, and also the fear about post-vaccination side effects have an impact on the COVID-19 vaccination program in rural and tribal areas. Conclusion The successful vaccination rate among the population needs community leadership and a community-centred approach when conducting outreach and strengthening primary health care in terms of infrastructure, manpower, and capacity building of healthcare staff.

Differential impact of maternal education on under-five mortality in rural and urban India

Under-five mortality rate (U5MR) differs by rural-urban place of residence and mother's education; however, the rural-urban gap in U5MR by mother's educational attainment is unclear in the existing literature. Using five rounds of the national family health surveys (NFHS I-V) conducted between 1992-93 and 2019-21 in India, this study estimated the main and interaction effects of rural-urban and maternal education on U5MR. The mixed effect Cox proportional hazard (MECPH) model was used to predict the risk of under-five mortality (U5M). The finding shows that unadjusted U5MR remained 50 per cent higher in rural areas than in urban areas across the surveys. Whereas, after controlling for demographic, socioeconomic, and maternal health care predictors of U5M, the MECPH regression results indicated that urban children had a higher risk of death than their rural counterparts in NFHS I-III. However, there are no significant rural-urban differences in the last two surveys (NFHS IV -V). In addition, increasing maternal education levels were associated with lower U5M in all surveys. Though, in recent years, primary education has had no significant effect. The U5M risk was additionally lower for urban children than rural children whose mothers had secondary and higher education by NFHS-III; however, this additional urban advantage was no longer significant in recent surveys. The higher impact of secondary education on U5MR in urban areas in the past may be attributed to poor socio-economic, healthcare conditions in rural areas. Overall, maternal education, particularly secondary education, remained a protective factor for U5M in both rural and urban areas, even after controlling for predictors. Therefore, there is a need to increase the focus on secondary education for girls for a further decline in U5M.

Perception of Perioperative Risk for Arthroplasty Patients: A Poll of Indian Orthopedic Surgeons

BACKGROUND

A survey of the American Association of Hip and Knee Surgeons (AAHKS) reported that 95% of respondents attempted to modify risk factors prior to arthroplasty. This study investigated Indian arthroplasty surgeons' approach to patients who have modifiable risk factors.

METHODS

The AAHKS survey tool was adapted for Indian surgeons and distributed to the membership of the Indian Society of Hip and Knee Surgeons and Indian Arthroplasty Association via a Survey Monkey. A total of 92 survey responses were received, representing a response rate of 12%.

RESULTS

Overall, 87% of respondents restricted access to arthroplasty surgery for patients who have modifiable risk factors, but only 51% of respondents reported delays or restricted treatment because of risk factors. Respondents reported that financial implications were more likely to delay or restrict treatment in 97% and social/family reasons in 66%. Poor diabetic control (81%), previous infection (57%), and malnutrition/hypoalbuminemia (47%) were the most frequent modifiable risk factors. There were 82% of surgeons reporting that the patient's socioeconomic status influenced treatment including: 71% of patients who have low socioeconomic status, 57% who do not have insurance, and 45% who have limited social supports. Most surgeons (92%) reported that funding influenced the type of care provided and the choice of implants.

CONCLUSION

Over 97% of Indian arthroplasty surgeons thought socioeconomic factors impaired access to orthopaedic treatment. Only half the surgeons restricted access for comorbidities and these were more often related to infection risks and diabetes. These findings contrast dramatically to the practice patterns of American AAHKS members.

Dietary practices, physical activity and social determinants of non-communicable diseases in Nepal: A systemic analysis

Unhealthy dietary habits and physical inactivity are major risk factors of non-communicable diseases (NCDs) globally. The objective of this paper was to describe the role of dietary practices and physical activity in the interaction of the social determinants of NCDs in Nepal, a developing economy. The study was a qualitative study design involving two districts in Nepal, whereby data was collected via key informant interviews (n = 63) and focus group discussions (n = 12). Thematic analysis of the qualitative data was performed, and a causal loop diagram was built to illustrate the dynamic interactions of the social determinants of NCDs based on the themes. The study also involved sense-making sessions with policy level and local stakeholders. Four key interacting themes emerged from the study describing current dietary and physical activity practices, influence of junk food, role of health system and socio-economic factors as root causes. While the current dietary and physical activity-related practices within communities were unhealthy, the broader determinants such as socio-economic circumstances and gender further fuelled such practices. The health system has potential to play a more effective role in the prevention of the behavioural and social determinants of NCDs.

Development of a Digital Assistant to Support Teleconsultations Between Remote Physicians and Frontline Health Workers in India: User-Centered Design Approach

BACKGROUND

Many low- and middle-income countries have adopted telemedicine programs that connect frontline health workers (FHWs) such as nurses, midwives, or community health workers in rural and remote areas with physicians in urban areas to deliver care to patients. By leveraging technology to reduce temporal, financial, and geographical barriers, these health worker-to-physician telemedicine programs have the potential to increase health care quality, expand the specialties available to patients, and reduce the time and cost required to deliver care.

OBJECTIVE

We aimed to identify, validate, and prioritize unmet needs in the health care space of health worker-to-physician telemedicine programs and develop and refine a solution that addresses those needs.

METHODS

We collected information regarding user needs through ethnographic research, direct observation, and semistructured interviews with 37 stakeholders (n=5, 14% physicians; n=1, 3% public health program manager; n=12, 32% community health workers; and n=19, 51% patients) at 2 telemedicine clinics in rural West Bengal, India. We used the Spiral-Iterative Innovation Model to design and develop a prototype solution to meet these needs.

RESULTS

We identified 74 unmet needs through our immersion in health worker-to-physician telemedicine programs. We identified a critical unmet need that achieving optimal teleconsultations in low- and middle-income countries often requires shifting tasks such as history taking and physical examination from high-skilled remote physicians to FHWs. To meet this need, we developed a prototype digital assistant that would allow FHWs to assume some of the tasks carried out by remote clinicians. The user needs of multiple stakeholder groups (patients, FHWs, physicians, and health organizations) were incorporated into the design and features of the task-shifting tool. The final prototype was shared with the health workers, physicians, and public health program managers who expressed that the tool would be useful and valuable.

CONCLUSIONS

The final prototype that was developed was released as an open-source digital public good and may improve the quality and efficiency of care delivery in health worker-to-physician telemedicine programs.

Impact of India's publicly financed health insurance scheme on public sector district hospitals: a health financing perspective

Background

Districts hospitals in India play a pivotal role in delivering health care services in the public sector and are empanelled under India's national health insurance scheme i.e. Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PMJAY). In this paper, we evaluate the extent to which the PMJAY impacts the district hospitals from a financing perspective.

Methods

We used cost data from India's nationally representative costing study-'Costing of Health Services in India' (CHSI) to determine the incremental cost of treating PMJAY patients, after adjusting for resources that are paid through supply-side government financing route. Second, we used data on number and claim value paid to public district and sub-district hospitals during 2019, to determine the additional revenue generated through PMJAY. The annual net financial gain per district hospital was estimated as the difference between payments under PMJAY, and the incremental cost of delivering the services.

Findings

At current levels of utilisation, the district hospitals in India gain a net annual financial benefit of $ 26.1 (₹ 1839.3) million, which can potentially increase up to $ 41.8 (₹ 2942.9) million with an increase in the share of patient volume. For an average district hospital, we estimate net annual financial gain of $ 169,607 (₹ 11.9 million), increasing up to $ 271,372 (₹ 19.1 million) per hospital with increased utilisation.

Interpretation

Demand-side financing mechanisms can be used to strengthen the public sector. Increasing utilisation of district hospitals, by either gatekeeping or improving availability of services will enhance financial gains for district hospitals and strengthen public sector.

Funding

Department of Health Research, Ministry of Health & Family Welfare, Government of India.

Ethical Framework to Address Barriers to Healthcare for People with Disabilities in India

Disability is one of the key public health issues in India and the burden will increase given the trend of an aging population. People with disabilities experience greater vulnerability as they may develop secondary health issues. They face various barriers while accessing health services. This is a major ethical concern. In this article, we frame the barriers to healthcare provision to persons with disabilities and propose an ethical framework to address these barriers. This ethical framework is derived from the basic ethical principles of justice, fairness, trust, solidarity, stewardship, proportionality, and responsiveness. The framework proposes strategies to address these barriers to healthcare service delivery for persons with disabilities in India.

The importance of wage loss in the financial burden of illness: Longitudinal evidence from India

BACKGROUND

A key aim of Universal Health Coverage (UHC) is to protect individuals and households against the financial risk of illness, and large-scale health insurance expansions are a central focus of the UHC agenda. Importantly, however, health insurance does not protect against a key dimension of financial risk associated with illness: forgone wage income. In this paper, we quantify the economic burden of illness in India attributable - separately - to wage loss and to medical care spending, as well as differences in them across the socio-economic distribution.

METHODS

We use data from two longitudinal Indian household surveys: (i) the Village Dynamics in South Asia (VDSA) survey (1300 households surveyed every month for 60 months between 2010 and 2015) and (ii) the Indian Human Development Survey (IHDS) (more than 40,000 households surveyed in 2005 and again in 2011). Our regression models include a series of fixed effects that account for time-invariant household- (or individual-) level and time-varying unobservables common across households.

FINDINGS

We find that, in the VDSA sample, wage loss accounts for more than 80% of the total economic burden of illness among the poorest households, but only about 20% of the economic burden of illness among the most affluent. Estimates from the IHDS sample confirm that this socio-economic gradient is present in the Indian population generally.

CONCLUSIONS

Wage loss accounts for a substantial share of the total economic burden of illness in India - and disproportionately so among the poorest households. Our findings imply that if UHC is to achieve its objective of protecting households against the financial risk of illness - particularly poor households, the inclusion of wage loss insurance or another illness-related income replacement benefit is needed.

Informal sector employment and the health outcomes of older workers in India

A large proportion of the older population in India constitutes an undeniable share of workforce after the retirement age. This stresses the need to understand the implications of working at older ages on health outcomes. The main objective of this study is to examine the variations in health outcomes by formal/informal sector of employment of older workers using the first wave of the Longitudinal Ageing Study in India. Using binary logistic regression models, the results of this study affirm that type of work does play a significant role in determining health outcomes even after controlling socio-economic, demographic, life-style behaviour, childhood health and work characteristics. The risk of Poor Cognitive Functioning (PCF) is high among informal workers, while formal workers suffer greatly from Chronic Health Conditions (CHC) and Functional Limitations (FL). Moreover, the risk of PCF and/or FL among formal workers increases with the increase in risk of CHC. Therefore, the present research study underscores the relevance of policies focusing on providing health and healthcare benefits by respective economic activity and socio-economic position of older workers.

Out-of-pocket expenditure on childhood infections and its financial burden on Indian households: Evidence from nationally representative household survey (2017-18)

The key objective of this research was to estimate out of pocket expenditure (OOPE) incurred by the Indian households for the treatment of childhood infections. We estimated OOPE estimates on outpatient care and hospitalization by disease conditions and type of health facilities. In addition, we also estimated OOPE as a share of households' total consumption expenditure (TCE) by MPCE quintile groups to assess the quantum of the financial burden on the households. We analyzed the Social Consumption: Health (SCH) data from National Sample Survey Organization (NSSO) 75th round (2017-18). Outcome indicators were prevalence of selected infectious diseases in children aged less than 5 years, per episode of OOPE on outpatient care in the preceding 15 days, hospitalization in the preceding year and OOPE as a share of households' total consumption expenditure. Our analysis suggests that the most common childhood infection was 'fever with rash' followed by 'acute upper respiratory infection' and 'acute meningitis'. However, the highest OOPE for outpatient care and hospitalization was reported for 'viral hepatitis' and 'tuberculosis' episodes. Among the households reporting childhood infections, OOPE was 4.8% and 6.7% of households' total consumption expenditure (TCE) for outpatient care and hospitalization, respectively. Furthermore, OOPE as a share of TCE was disproportionately higher for the poorest MPCE quintiles (outpatient, 7.9%; hospitalization, 8.2%) in comparison to the richest MPCE quintiles (outpatient, 4.8%; hospitalization, 6.7%). This treatment and care-related OOPE has equity implications for Indian households as the poorest households bear a disproportionately higher burden of OOPE as a share of TCE. Ensuring financial risk protection and universal access to care for childhood illnesses is critical to addressing inequity in care.

Antifungal Drugs Shortage in India amidst Looming Increase in Invasive Fungal Infections among COVID-19 Patients: An Impending Crisis

The widespread prevalence of fungal infections in the second wave of COVID-19 pandemic could be owed to ubiquitous and injudicious use of steroids and immunosuppressive nature of the virus. However, these fungal infections also meant increased use of antifungal drugs, hence endangering their supply. Amphotericin B is the first line drug for mucormycosis which was declared as an epidemic in India during the second wave. With the increasing demand of the drug, came challenges to manufacture and supply large quantities of the drug and exploitation by creating a black market and spread of false information and imprudent usage. It is of utmost importance to be prepared with adequate supply all over the nation and implementing safety regulations in manufacturing and supply of large quantities of drugs during the demanding times and make them accessible at a reasonable rate.

Socioeconomic Inequalities in the Prevalence of Non-Communicable Diseases among Older Adults in India

Understanding socioeconomic inequalities in non-communicable disease prevalence and preventive care usage can help design effective action plans for health equality programs among India's aging population. Hypertension (HTN) and diabetes mellitus (DM) are frequently used as model non-communicable diseases for research and policy purposes as these two are the most prevalent NCDs in India and are the leading causes of mortality. For this investigation, data on 31,464 older persons (aged 60 years and above) who took part in the Longitudinal Ageing Survey of India (LASI: 2017-2018) were analyzed. The concentration index was used to assess socioeconomic inequality whereas relative inequalities indices were used to compare HTN, DM, and preventive care usage between the different groups of individuals based on socioeconomic status. The study reveals that wealthy older adults in India had a higher frequency of HTN and DM than the poor elderly. Significant differences in the usage of preventive care, such as blood pressure/blood glucose monitoring, were found among people with HTN or DM. Furthermore, economic position, education, type of work, and residential status were identified as important factors for monitoring inequalities in access to preventive care for HTN and DM. Disparities in non-communicable diseases can be both a cause and an effect of inequality across social strata in India.

Associations between sociodemographic factors and receiving "ask and advise" services from healthcare providers in India: analysis of the national GATS-2 dataset

Background

India is home to about 12% of the world's tobacco users, with about 1.35 million tobacco-related deaths each year. The morbidity and mortality rates are socially patterned based on gender, rural vs. urban residence, education, and other factors. Following the World Health Organization's guidance, it is critical to offer tobacco users support for cessation as a complement to policy and environmental changes. Such guidance is typically unavailable in low-resource systems, despite the potential for population-level impact. Additionally, service delivery for tobacco control tends to be patterned by sociodemographic factors. To understand current activity in this area, we assessed the percentage of daily tobacco users being asked about tobacco use and advised to quit by a healthcare provider. We also examined social patterning of receipt of services (related to by rural vs. urban residence, age, gender, education, caste, and wealth).

Methods

We analyzed cross-sectional data from India's 2016-2017 Global Adult Tobacco Survey (GATS-2), a nationally representative survey. Among 74,037 respondents, about 25% were daily users of smoked and/or smokeless tobacco. We examined rates of being asked and advised about tobacco use overall and based on rural vs. urban residence, age, gender, education, caste, and wealth. We also conducted multivariate logistic regression to assess the association of demographic and socioeconomic conditions with participants' receipt of “ask and advise” services.

Results

Nationally, among daily tobacco users, we found low rates of individuals reporting being asked about tobacco use or advised to quit by a healthcare provider (22% and 19%, respectively). Being asked and advised about tobacco use was patterned by age, gender, education, caste, and wealth in our final regression model.

Conclusions

This study offers a helpful starting point in identifying opportunities to address a critical service delivery gap in India. Given the existing burden on the public health and health systems, scale-up will require innovative, resource-appropriate solutions. The findings also point to the need to center equity in the design and scale-up of tobacco cessation supports so that marginalized and underserved groups will have equitable access to these critical services.

Challenges in management of microbial keratitis during COVID-19 pandemic related lockdown: a comparative analysis with pre pandemic data

Purpose

To study the challenges of managing microbial keratitis(MK) during the COVID19 pandemic related lockdown and assess the outcomes of treatment at a tertiary cornea service.

Methods

Retrospective, non comparative study of electronic medical records of MK presenting to a network of four tertiary care cornea services. The medical history, presenting clinical features, microbiology work up and treatment outcomes were analyzed. The primary outcome measure was final outcome at last follow up. Secondary outcomes measures were non-compliance to treatment due to travel restrictions, therapeutic PKP not done due non availability of corneal tissues. Results- MK was noted in 330 eyes of 330 patients between April and May 2020. Of these 237(71.8%) were males. Median age was 45 years(IQR, 33-56). Low socioeconomic status noted in 102(30.9%). Patients travelling beyond the district from where the hospital was located comprised of 64.9%(n=214). At a median follow up of 32 days(IQR, 9-54), 118(35.8%) patients had resolved, with medical management, 73(22.1%) patients were under active treatment, 139(42.1%) were lost to follow up. Sixty-six patients(20%) were non-compliant to treatment of which 59 could not follow appointment schedule due to travel restrictions. Therapeutic PKP (TPK) was planned in 48/128 (37.5%) patients, but was performed in only 34/48 (70.8%) due to non-availability of donor corneas.

Conclusions

Abnormal social circumstances due to the COVID pandemic and the ensuing impediments to travel for access to health care affected compliance to treatment of ocular emergencies such as microbial keratitis.

Applications of new measures of population ageing using quantity and quality of remaining life years to India and selected states

In the latter part of the third stage, India is in demographic transition with declining fertility and mortality. This marked decline in death rates is driven by improvements in health conditions due to medical progress and better living conditions. The conventional measures of ageing do not account for the significant improvements in health and life expectancy, thus leading to a tendency to overestimate the impact of population ageing when these indicators are used. The old-age threshold in the conventional measures of ageing depends on chronological age. The present study estimated the multi-dimensional old-age thresholds (MOAT) based on the remaining life expectancy (RLE), self-rated health, activities of daily living (ADL), handgrip strength, and cognition in India and selected states. The standard population was derived for each dimension for 50 and over in states using the WHO Study on Global AGEing and Adult Health data. Keeping the dimensional characteristics as of the standard population, the estimated MOAT for India was 67 years where Maharashtra stands at the top (68.6), followed by, West Bengal (66.5) and Karnataka (66). A 64 year old woman was similar to 68.8 year old man, and a 66 year old rural person was equivalent to 68 year old urban person. The study suggests implications of MOATs on reducing the burden of ageing and increment in retirement age.

Child Marriage and Problems Accessing Healthcare in Adulthood: Evidence from India

The association between child marriage and the access to or utilization of maternal and antenatal healthcare has been widely studied. However, little is known about child brides' access to healthcare for illnesses later in life. Using data on 496,283 married women aged 18 to 49 years from the India National Family and Health Survey 2015-2016, we developed an 11-point composite score (ranging from 0 to 10) outlining the extent of problems accessing healthcare, as follows: (i) no/little problem (score 0 to 2), (ii) some problems (score 3 to 6), and (iii) big problems (score 7 to 10). The differences between child brides and their peers married as adults were assessed by the relative risk ratios obtained from multinomial logistic regressions. The adjusted risk of having "some problems" and "big problems" accessing healthcare relative to "no/little problem" for child brides was found to be 1.22 (95% CI: 1.20-1.25) and 1.26 (95% CI: 1.22-1.29) times that of those married as adults, respectively. These findings highlight the disproportionate barriers to healthcare access faced by women married as children compared to women married as adults and the need for further research to inform policies regarding effective public health interventions to improve healthcare access.

Intersectional Inequalities in Anthropometric Failure among Indian Children: Evidence from the National Family Health Survey (2015-2016)

Increasing body of health planning and policy research focused upon unravelling the fundamental drivers of population health and nutrition inequities, such as wealth status, educational status, caste/ethnicity, gender, place of residence, and geographical context, that often interact to produce health inequalities. However, very few studies have employed intersectional framework to explicitly demonstrate how intersecting dimensions of privilege, power, and resources form the burden of anthropometric failures of children among low-and-middle income countries including India. Data on 2,15,554 sampled children below 5 years of age from the National Family Health Survey 2015-2016 were analysed. This study employed intersectional approach to examine caste group inequalities in the anthropometric failure (i.e. moderate stunting, severe stunting, moderate underweight, severe underweight, moderate wasting, severe wasting) among children in India. Descriptive statistics and multinomial logistic regression models were fitted to investigate the heterogeneities in the burden of anthropometric failure across demographic, socioeconomic and contextual factors. Interaction effects were estimated to model the joint effects of socioeconomic position (household wealth, maternal education, urban/rural residence and geographical region) and caste groups with the likelihood of anthropometric failure among children.More than half of under-5 children suffered from anthropometric failure in India. Net of the demographic and socioeconomic characteristics, children from the disadvantageous caste groups whose mother were illiterate, belonged to economically poor households, resided in the rural areas, and coming from the central and eastern regions experienced disproportionately higher risk of anthropometric failure than their counterparts in India. Concerted policy processes must recognize the existing heterogeneities between and within population groups to improve the precision targeting of the beneficiary and enhance the efficiency of the nutritional program among under-5 children, particularly for the historically marginalized caste groups in India.