Utilization of health care services in public and private healthcare in India: Causes and determinants

Demand side financing for promoting institutional delivery: experiences of Janani Suraksha Yojana in Indian states

Public expenditure for the improvement of maternal health is crucial in addressing the major social and demographic challenges in developing countries like India. Accordingly, the Government of India initiated the Janani Suraksha Yojana (JSY) in 2005 as a flagship conditional cash transfer scheme to encourage institutional delivery in the country. While the provisions under the JSY remain uniform throughout the country, there are apprehensions that the impact would differ across the states as well as between the rural and urban setups depending on varied socio-economic conditions and local level dynamics. Besides, households' choice of the type of institution (i.e., government versus private healthcare centres) may also change following the implementation of the JSY. This paper examines these two critical but interrelated aspects. Using secondary data compiled mainly from the last two rounds of the National Family Health Survey and estimating panel data econometric models, the paper finds that interactions with health facilitators during pregnancy, and per capita income contribute positively to the increase in institutional delivery in India irrespective of whether the households are located in rural or urban areas. Importantly, the paper does not find any significant role of the JSY in this regard. On the contrary, the JSY encourages households to prefer public to private hospitals in both rural and urban areas, whereas preference for private hospitals is positively associated with the household head literacy rate in urban area and health insurance coverage and per capita income in rural areas. The findings suggest greater emphasis on quality enhancement of the government healthcare centres. Besides, active engagement of the health workers should also be encouraged, particularly in mobilising the community towards institutional delivery and linking them effectively with the related initiatives of the government.

Patterns and factors associated with healthcare utilisation in Cambodia: a cross-sectional study based on the World Health Survey Plus 2023

Background

The Cambodian government aims to boost healthcare utilisation in public facilities and reduce the spending burden for disadvantaged households. This study aims to describe patterns of public and private outpatient and inpatient healthcare use and investigate the factors associated with public healthcare usage in Cambodia.

Method

A cross-sectional study was conducted in all provinces in Cambodia, including the capital, Phnom Penh. The analysis included 4603 individuals aged ≥18 who had received care within the last 12 months.

Results

Around 9% of outpatient and 50% of inpatient visits were made to public healthcare facilities. The number of outpatient visits made to public healthcare compared with private healthcare facilities was significantly higher in women (aOR 1.4, 95% CI 1.1, 1.8), living in rural settings (aOR 1.4, 95% CI 1.1, 1.7), those in the poorest (aOR 1.7, 95% CI 1.2, 2.3) and poor (aOR 1.5, 95% CI 1.1, 2.1) compared with the richest wealth quintiles, and respondents with insurance coverage (aOR 2.0, 95% CI 1.6, 2.5). The number of inpatient visits made to public healthcare compared with private healthcare facilities was significantly higher in the poorest (aOR 2.4, 95% CI 1.4, 3.9), poor (aOR 2.4, 95% CI 1.5, 4.0) and middle (aOR 2.5, 95% CI 1.5, 4.1) compared with those in the richest wealth quintiles and respondents with insurance coverage (aOR 2.1, 95% CI 1.5, 3.2).

Conclusion

Our study shows that private healthcare dominates outpatient services in Cambodia, while public healthcare is more significant for inpatient care. Individuals with low socioeconomic status and those with insurance showed higher public healthcare utilisation for outpatient and inpatient services, with women more likely to use public outpatient care. To progress towards universal health coverage, it is essential to improve public healthcare quality, especially in rural areas, expand service coverage and social health protection and develop strategies to engage the private sector.

Determinants of treatment-seeking behaviour and healthcare provider choice in Afghanistan in 2018: a cross-sectional study

ABSTRACT

Introduction

In Afghanistan, remarkable achievements have been made in improving access to healthcare and health outcomes since the introduction of essential healthcare packages. Nonetheless, sociodemographic and geographical inequities persist, and out-of-pocket expenditures are high. This study investigates the client and provider determinants of access to care that affect treatment-seeking behaviour in 2018.

Methods

Secondary data analysis using data on treatment-seeking behaviour in public and private healthcare from the Afghanistan Health Survey 2018 was combined with data on the quality of public healthcare facilities from a national healthcare facility assessment of the same year. Logistic regression analyses were performed to explore associations between client characteristics and accessibility of public healthcare facilities, and treatment-seeking behaviour and choice of public versus private healthcare provider.

Results

The results suggest that the odds of seeking treatment are lowest among the rural poor. The odds of treatment-seeking and choosing a public healthcare provider are higher for pregnancy-related health needs but lower for chronic conditions. Affordability of healthcare was associated with lower odds of treatment-seeking (OR 0.96, 95% CI 0.95 to 0.98) and using private healthcare providers (OR 0.97, 95% CI 0.96 to 0.99). Increased satisfaction with opening hours (OR 1.04, 95% CI 1.02 to 1.05) and availability of a female nurse or doctor (OR 1.03, 95% CI 1.01 to 1.04) in public health facilities, and a higher level of trust in healthcare provider (OR 1.04, 95% CI 1.03 to 1.06) were associated with higher odds of using public healthcare.

Conclusion

Afghanistan's public healthcare system is vital in providing care to the economically disadvantaged and managing infectious diseases and maternal health problems. The private sector plays a dominant role, particularly for those illnesses not covered under the essential healthcare packages. The study suggests opportunities for the public healthcare system to alleviate financial barriers to healthcare access and broaden its service offerings to encompass the management of chronic illnesses.

Healthcare service utilisation among adults with coronary artery disease in rural Aluva, South India: a community-based cross-sectional study

OBJECTIVES

To assess the pattern and determinants of healthcare service utilisation among adults with coronary artery disease (CAD) in a rural setting in Kerala, India.

DESIGN

A community-based cross-sectional analysis conducted within a study cohort.

SETTING

The study was conducted from January 2022 to March 2022 within the ENDIRA Cohort (Epidemiology of Non-communicable Diseases In Rural Areas) in the rural part of Aluva municipality of Ernakulam district, Kerala, India, which comprises five adjacent panchayats with a population of approximately 100, 000 individuals.

PARTICIPANTS

Patients with CAD aged 35-80 years from the ENDIRA cohort with a history of at least one event of myocardial infarction in the past decade.

OUTCOME MEASURES

The main outcome measured was the inadequacy of healthcare service utilisation among patients with CAD. The factors evaluated included age, gender, socioeconomic status, insurance, out of pocket expenses, choice of health care facility for follow up, distance from health centre as well as reported alcohol use, tobacco use and healthcare satisfaction RESULTS: The study encompassed 623 participants with a mean age of 65.12 (±8.55) years, of whom 71% were males. The prevalence of inadequate utilisation of health services was 58.7%. The independent predictors of underutilisation included reported alcohol consumption (adjusted OR (AOR) 2.36; 95% CI 1.41 to 3.95), living more than 20 km from healthcare facilities (AOR 1.96; 95% CI 1.14 to 3.37) as well as the preferences for specific doctors and adequate services at healthcare facilities (AOR 3.43; 95% CI 1.46 to 8.04). The patients with monthly CAD medication expenses exceeding Rs4000 had 0.26 times lesser odds to underuse healthcare services (AOR 0.26; 95% CI 0.10 to 0.65).

CONCLUSION

The study reveals a suboptimal pattern of healthcare service utilisation among patients with CAD. Ensuring community access to standardised, high-quality follow-up care is crucial for enhancing healthcare utilisation following CAD.

Advancing Equity in Health Care Among Dalits and Tribal People in India: The Progress, Current Realities, and the Way Forward

The caste system and resulting social exclusion are important social determinants of health inequity in India. This article critically analyzes the influence of the caste system on health inequity in India, starting with a historical perspective and moving to the current status. The article argues that the caste system has deprived Dalits and tribal people in India of achieving health equity. The programs to promote health are often disease-specific and not culturally informed, leading to poor attention at the policy level to the intersecting disadvantages that make Dalits and tribal communities vulnerable, resulting in poor health. The authors suggest strengthening and promoting primary care, improving health access for Dalit and tribal populations, and the need for pivotal changes in the medical education system, shifting the emphasis from specialized care to training family physicians to be oriented toward community health needs, keeping health equity in perspective.

Factors associated with public and private healthcare utilization for outpatient care among older adults in India: A Wagstaff's decomposition of Anderson's behavioural model

In India, an expanding ageing population will become a public health alarm, putting additional pressure on the healthcare system. Therefore, the current study aimed to examine the factors associated with outpatient healthcare choices among older Indian adults. We used data from the first wave of the Longitudinal Ageing Study in India (LASI, 2017-2018). A total of 34,588 individuals (age 45 years and over) who accessed outpatient healthcare services in the last 12 months during the survey were included in this research. A bivariate chi-square test was used to present the percentage distribution of types of outpatient healthcare utilisation by background characteristics. Multinomial logistic regression and Wagstaff's decomposition analyses were employed to explore the interplay of outpatient healthcare utilisation and allied predisposing, enabling, and need factors and examine these factors' contributions to the wealth-based inequalities in public, private, and other healthcare utilisation. Outpatient healthcare utilisation varied significantly according to socioeconomic and demographic factors. The findings suggest that consumption quintiles, place of residence, education, and health insurance were significant determinants of private and public healthcare utilisation and contributed to wealth-based inequalities in healthcare choices. The current study emphasises the need to strengthen and promote public healthcare services.

An Examination of Inter-State Variation in Utilization of Healthcare Services, Associated Financial Burden and Inequality: Evidence from Nationally Representative Survey in India

This study examines the health care utilization pattern, associated financial catastrophes, and inequality across Indian states to understand the subnational variations and aid the policy makers in this regard. Data from recent National Sample Survey (2017-2018), titled, "Household Social Consumption: Health," covering 113,823 households, was employed in the study. Descriptive statistics, Erreygers concentration index (CI), and recentered influence function decomposition were applied in the study. We found that, in India, 7 percent of households experienced catastrophic health expenditure (CHE) and 1.9 percent of households were pushed below poverty line due to out-of-pocket expenditure on hospitalization. Notably, outpatient care was more burdensome (CHE: 12.1%; impoverishment: 4%). Substantial interstate variations were observed, with high financial burden in poorer states. Utilization of health care services from private health care providers was pro-rich (hospitalization CI 0.31; outpatient CI 0.10), while the occurrence of CHE incidence was pro-poor (hospitalization CI -0.10; outpatient CI -0.14). Education level, economic status, health insurance, and area of residence contributed significantly to inequalities in utilization of health care services from private providers and financial burden. The high financial burden of seeking health care necessitates the need to increase public health spending and strengthen public health infrastructure. Also, concerted efforts directed towards increasing awareness about health insurance and introducing comprehensive health insurance products (covering both inpatient and outpatient services) are imperative to augment financial risk protection in India.

Users' perception of quality as a driver of private healthcare use in Mexico: Insights from the People's Voice Survey

OBJECTIVE

The Mexican government has pursued multiple initiatives to improve healthcare coverage and financial protection. Yet, out-of-pocket health spending and use of private sector providers in Mexico remains high. In this paper, we sought to describe the characteristics of public and private healthcare users, describe recent visit quality across provider types, and to assess whether perceiving the public healthcare sector as poor quality is associated with private health sector use.

METHODS AND FINDINGS

We analyzed the cross-sectional People's Voice Survey conducted from December 2022 to January 2023. We used Chi-square tests to compare contextual, individual, and need-for-care factors and ratings of most recent visits between users of public (social security and other public providers) and private sector providers (stand-alone private providers and providers adjacent to pharmacies). We used a multivariable Poisson regression model to assess associations between low ratings of public healthcare sources and the use of private care. Among the 811 respondents with a healthcare visit in the past year, 31.2% used private sources. Private healthcare users were more educated and had higher incomes than public healthcare users. Quality of most recent visit was rated more highly in private providers (70.2% rating the visit as excellent or very good for stand-alone private providers and 54.3% for pharmacy-adjacent doctors) compared to social security (41.6%) and other public providers (46.6%). Those who perceived public health institutions as low quality had a higher probability of seeking private healthcare.

CONCLUSION

Users rated public care visits poorly relative to private care; at the population level, perceptions of poor quality care may drive private care use and hence out-of-pocket costs. Improving public healthcare quality is necessary to ensure universal health coverage.

Making the health system work for over 25 million births annually: drivers of the notable decline in maternal and newborn mortality in India

INTRODUCTION

India's progress in reducing maternal and neonatal mortality since the 1990s was faster than the regional average. We systematically analysed how national health policies, services for maternal and newborn health, and socioeconomic contextual changes, drove these mortality reductions.

METHODS

The study's mixed-methods design integrated quantitative trend analyses of mortality, intervention coverage and equity since the 1990s, using the sample registration system and national surveys, with interpretive understandings from policy documents and 13 key informant interviews.

RESULTS

India's maternal mortality ratio (MMR) declined from 412 to 103 maternal deaths per 100 000 live births between 1997-1998 and 2017-2019. The neonatal mortality rate (NMR) declined from 46 to 22 per 1000 live births between 1997 and 2019. The average annual rate of mortality reduction increased over time. During this period, coverage of any antenatal care (57%-94%), quality antenatal care (37%-85%) and institutional delivery (34%-90%) increased, as did caesarean section rates among the poorest tertile (2%-9%); these coverage gains occurred primarily in the government (public) sector. The fastest rates for increasing coverage occurred during 2005-2012.The 2005-2012 National Rural Health Mission (which became the National Health Mission in 2012) catalysed bureaucratic innovations, additional resources, pro-poor commitments and accountability. These efforts occurred alongside smaller family sizes and improvements in macroeconomic growth, mobile and road networks, women's empowerment, and nutrition. These together reduced high-risk births and improved healthcare access, particularly among the poor.

CONCLUSION

Rapid reduction in NMR and MMR in India was accompanied by increased coverage of maternal and newborn health interventions. Government programmes strengthened public sector services, thereby expanding the reach of these interventions. Simultaneously, socioeconomic and demographic shifts led to fewer high-risk births. The study's integrated methodology is relevant for generating comprehensive knowledge to advance universal health coverage.

Utilisation of public healthcare services by an indigenous group: a mixed-method study among Santals of West Bengal, India

A barrier to meeting the goal of universal health coverage in India is the inequality in utilisation of health services between indigenous and non-indigenous people. This study aimed to explore the determinants of utilisation, or non-utilisation, of public healthcare services among the Santals, an indigenous community living in West Bengal, India. The study holistically explored the utilisation of public healthcare facilities using a framework that conceptualised service coverage to be dependent on a set of determinants - viz. the nature and severity of the ailment, availability, accessibility (geographical and financial), and acceptability of the healthcare options and decision-making around these further depends on background characteristics of the individual or their family/household. This cross-sectional study adopts ethnographic approach for detailed insight into the issue and interviewed 422 adult members of Santals living in both rural (Bankura) and urban (Howrah) areas of West Bengal for demographic, socio-economic characteristics and healthcare utilisation behaviour using pre-tested data collection schedule. The findings revealed that utilisation of the public healthcare facilities was low, especially in urban areas. Residence in urban areas, being female, having higher education, engaging in salaried occupation and having availability of private allopathic and homoeopathic doctors in the locality had higher odds of not utilising public healthcare services. Issues like misbehaviour from the health personnel, unavailability of medicine, poor quality of care, and high patient load were reported as the major reasons for non-utilisation of public health services. The finding highlights the importance of improving the availability and quality of care of healthcare services for marginalised populations because these communities live in geographically isolated places and have low affordability of private healthcare. The health programme needs to address these issues to improve the utilisation and reduce the inequality in healthcare utilisation, which would be beneficial for all segments of Indian population.

Decomposing the inequalities in the catastrophic health expenditures on the hospitalization in India: empirical evidence from national sample survey data

Introduction

Sustainable Development Goal (SDG) Target 3.8.2 entails financial protection against catastrophic health expenditure (CHE) by reducing out-of-pocket expenditure (OOPE) on healthcare. India is characterized by one of the highest OOPE on healthcare, in conjunction with the pervasive socio-economic disparities entrenched in the population. As a corollary, India has embarked on the trajectory of ensuring financial risk protection, particularly for the poor, with the launch of various flagship initiatives. Overall, the evidence on wealth-related inequities in the incidence of CHE in low- and middle-Income countries has been heterogenous. Thus, this study was conducted to estimate the income-related inequalities in the incidence of CHE on hospitalization and glean the individual contributions of wider socio-economic determinants in influencing these inequalities in India.

Methods

The study employed cross-sectional data from the nationally represented survey on morbidity and healthcare (75th round of National Sample Survey Organization) conducted during 2017-2018, which circumscribed a sample size of 1,13,823 households and 5,57,887 individuals. The inequalities and need-adjusted inequities in the incidence of CHE on hospitalization care were assessed via the Erreygers corrected concentration index. Need-standardized concentration indices were further used to unravel the inter- and intra-regional income-related inequities in the outcome of interest. The factors associated with the incidence of CHE were explored using multivariate logistic regression within the framework of Andersen's model of behavioral health. Additionally, regression-based decomposition was performed to delineate the individual contributions of legitimate and illegitimate factors in the measured inequalities of CHE.

Results

Our findings revealed pervasive wealth-related inequalities in the CHE for hospitalization care in India, with a profound gap between the poorest and richest income quintiles. The negative value of the concentration index (EI: -0.19) indicated that the inequalities were significantly concentrated among the poor. Furthermore, the need-adjusted inequalities also demonstrated the pro-poor concentration (EI: -0.26), denoting the unfair systemic inequalities in the CHE, which are disadvantageous to the poor. Multivariate logistic results indicated that households with older adult, smaller size, vulnerable caste affiliation, poorest income quintile, no insurance cover, hospitalization in a private facility, longer stay duration in the hospital, and residence in the region at a lower level of epidemiological transition level were associated with increased likelihood of incurring CHE on hospitalization. The decomposition analysis unraveled that the contribution of non-need/illegitimate factors (127.1%) in driving the inequality was positive and relatively high vis-à-vis negative low contribution of need/legitimate factors (35.3%). However, most of the unfair inequalities were accounted for by socio-structural factors such as the size of the household and enabling factors such as income group and utilization pattern.

Conclusion

The study underscored the skewed distribution of CHE as the poor were found to incur more CHE on hospitalization care despite the targeted programs by the government. Concomitantly, most of the inequality was driven by illegitimate factors amenable to policy change. Thus, policy interventions such as increasing the awareness, enrollment, and utilization of Publicly Financed Health Insurance schemes, strengthening the public hospitals to provide improved quality of specialized care and referral mechanisms, and increasing the overall budgetary share of healthcare to improve the institutional capacities are suggested.

Transitional care for older adults with chronic illness: A qualitative inquiry

BACKGROUND

Improved public health strategies and medical advancements have expanded older adults' survival after acute insults from chronic diseases. The resultant increase in disability and care requirements among older adults is significant. However, transitional care interventions to support the efficient transition from acute care settings to home are primitive in developing countries like India.

OBJECTIVE

This qualitative survey aimed to estimate the transitional care requirements of older adults with chronic illness discharged from acute care facilities.

METHODS

Descriptive phenomenological approach was utilised for this qualitative study. The older adult-family caregiver dyads fulfilling the inclusion criteria were interviewed until the achievement of information saturation. The transcribed narratives between the researcher, older adults and their caregivers were thematically analysed. Consolidated Criteria for Reporting Qualitative Research (COREQ) served as the framework for reporting this research.

RESULTS

Thirteen older adult-caregiver dyads participated in the semi-structured interview, which yielded six themes. Older adults have a hidden self with characteristics ranging between a continuum of 'insistence' to 'giving up'. Caregiver attributes identified from this inquiry were exhaustion, engagement and empowerment. The remaining four themes which constitute the framework for the 'transitional care progression' model include 'complications are mature when identified among older adults', 'medication knowledge is proportionate with its compliance', 'ignorance of supportive care increases caregiver burden' and 'deficient follow-up practices compromise health'.

CONCLUSIONS

Transitional care for older adults with chronic illness is premature in developing countries. However, the needs of older adults with chronic disease and their caregivers evolved from the present study align with global perspectives. Themes generated from the current qualitative interview, blended with evidence-based interventions, yielded the transitional care progression model, which serves as the only available framework for implementing transitional care in the region.

IMPLICATIONS FOR PRACTICE

Future research to establish the feasibility and validity of the 'transitional care progression model' is forecasted. The model requires inclusion within the healthcare curriculum. Professional nurses prepared to implement coordinated transitional care pathways are recommended.

Healthcare seeking behavior among patients visiting public primary and secondary healthcare facilities in an urban Indian district: A cross-sectional quantitative analysis

In this work, we examined healthcare seeking behavior (HSB) of patients visiting public healthcare facilities in an urban context. We conducted a cross-sectional survey across twenty-two primary and secondary public healthcare facilities in the South-west Delhi district in India. The quantitative survey was designed to ascertain from patients at these facilities their HSB-i.e., on what basis patients decide the type of healthcare facility to visit, or which type of medical practitioner to consult. Based on responses from four hundred and forty-nine participants, we observed that factors such as wait time, prior experience with care providers, distance from the facility, and also socioeconomic and demographic factors such as annual income, educational qualification, and gender significantly influenced preferences of patients in choosing healthcare facilities. We used binomial and multinomial logistic regression to determine associations between HSB and socioeconomic and demographic attributes of patients at a 0.05 level of significance. Our statistical analyses revealed that patients in the lower income group preferred to seek treatment from public healthcare facilities (OR = 3.51, 95% CI = (1.65, 7.46)) irrespective of the perceived severity of their illness, while patients in the higher income group favored directly consulting specialized doctors (OR = 2.71, 95% CI = (1.34, 5.51)). Other factors such as having more than two children increased the probability of seeking care from public facilities. This work contributes to the literature by: (a) providing quantitative evidence regarding overall patient HSB, especially at primary and secondary public healthcare facilities, regardless of their presenting illness, (b) eliciting information regarding the pathways followed by patients visiting these facilities while seeking care, and (c) providing operational information regarding the surveyed facilities to facilitate characterizing their utilization. This work can inform policy designed to improve the utilization and quality of care at public primary and secondary healthcare facilities in India.

In search of a fix to the primary health care chasm in India: can institutionalizing a public health cadre and inducting family physicians be the answer?

India's woes with an underprioritized and hence underfunded and understaffed public health system continue to plague public healthcare delivery. Though the need for appropriately qualified public health cadre to lead public health programmes is well established, a well-meaning conducive approach to implementing this is lacking. As the COVID-19 pandemic brought back the focus on India's fragmented health system and primary healthcare deficiencies, we discuss the primary healthcare conundrum in India in search of a quintessential fix. We argue for instituting a well-thought and inclusive public health cadre to lead preventive and promotive public health programmes and manage public health delivery. With the aim being to increase community confidence in primary health care, along with the need to augment primary healthcare infrastructure, we argue for a need to augment primary healthcare with physicians trained in family medicine. Provisioning medical officers and general practitioners trained in family medicine can salvage community's confidence in primary care, increase primary healthcare utilization, stymie over-specialization of care, channelize and prioritize referrals, and guarantee competence in healthcare quality for rural communities.

Comparing treatment delays and pathways to early intervention services for psychosis in urban settings in India and Canada

INTRODUCTION

Although extensively studied in high-income countries (HICs) and less so in low- and middle-income countries (LMICs), pathways to care and treatment delays in early psychosis have not been compared across contexts. We compared pathways to early intervention for psychosis in an HIC (Montreal, Canada) and an LMIC (Chennai, India). We hypothesised that the duration of untreated psychosis (DUP) would be longer in Chennai.

METHODS

The number of contacts preceding early intervention, referral sources, first contacts, and DUP and its referral and help-seeking components of first-episode psychosis patients at both sites were similarly measured and compared using chi-square analyses and t tests/one-way ANOVAs.

RESULTS

Overall and help-seeking DUPs of Chennai (N = 168) and Montreal (N = 165) participants were not significantly different. However, Chennai patients had shorter referral DUPs [mean = 12.0 ± 34.1 weeks vs. Montreal mean = 13.2 ± 28.7 weeks; t(302.57) = 4.40; p < 0.001] as the early intervention service was the first contact for 44% of them (vs. 5% in Montreal). Faith healers comprised 25% of first contacts in Chennai. Those seeing faith healers had significantly shorter help-seeking but longer referral DUPs. As predicted, most (93%) Montreal referrals came from medical sources. Those seeing psychologists/counsellors/social workers as their first contact had longer DUPs.

CONCLUSION

Differences in cultural views about mental illnesses and organizational structures shape pathways to care and their associations with treatment delays across contexts. Both formal and informal sources need to be targeted to reduce delays. Early intervention services being the first portal where help is sought can reduce DUP especially if accessed early on in the illness course.

Survey of healthcare worker perceptions of changes in infection control and antimicrobial stewardship practices in India and South Africa during the COVID-19 pandemic

Objective

To identify perceptions and awareness of changes in infection prevention and control (IPC) and antimicrobial stewardship (AMS) practices among healthcare workers (HCWs) during the COVID-19 pandemic in India and South Africa (SA).

Method

A self-administered online survey which included participant demographics, knowledge and sources of COVID-19 infection, perceived risks and barriers, and self-efficacy. Data were analysed using descriptive statistics.

Results

The study received 321 responses (response rate: 89.2%); 131/321 (40.8%) from India and 190/321 (59.2%) from SA; male to female response rate was 3:2, with majority of respondents aged 40-49 (89/321, 27.7%) and 30-39 (87/321, 27.1%) years. Doctors comprised 47.9% (57/119) of respondents in India and 74.6% (135/181) in SA. Majority of respondents in India (93/119, 78.2%) and SA (132/181, 72.9%) were from the private and public sectors, respectively, with more respondents in SA (123/174, 70.7%) than in India (38/104, 36.5%) involved in antimicrobial prescribing.Respondents reported increased IPC practices since the pandemic and noted a need for more training on case management, antibiotic and personal protective equipment (PPE) use. While they noted increased antibiotic prescribing since the pandemic, they did not generally associate their practice with such an increase. A willingness to be vaccinated, when vaccination becomes available, was expressed by 203/258 (78.7%) respondents.

Conclusions

HCWs reported improved IPC practices and changes in antibiotic prescribing during the COVID-19 pandemic. Targeted education on correct use of PPE was an identified gap. Although HCWs expressed concerns about antimicrobial resistance, their self-perceived antibiotic prescribing practices seemed unchanged. Additional studies in other settings could explore how our findings fit other contexts.

Factors associated with poor self-rated health among chronic kidney disease patients and their health care utilization: Insights from LASI wave-1, 2017-18

Background

Chronic kidney disease (CKD), associated with other chronic conditions affects the physical, behavioral, and psychological aspects of an individual, leading to poor self-rated health. Hence, we aimed to assess the factors associated with poor self-rated health (SRH) in CKD patients. Additionally, we assessed their health care utilization.

Methods

This is an observational study consisting of 527 CKD patients from Longitudinal Aging Study in India (LASI), 2017-2018. A descriptive statistic computed prevalence. Regression analysis assessed the association between poor SRH and socio-demographic variables presented as adjusted odds ratio with a confidence interval of 95%. Health care utilization among CKD patients was graphically presented.

Results

Around 64% of CKD patients had poor SRH. Aged 75 years and above (AOR=1.8, 95% CI= 0.5-6.8), rural residents (AOR= AOR 1.8, 95% CI =1.0 -3.1) and those with other chronic conditions (AOR=5.1, 95% CI= 2.3-11.0) were associated with poor SRH. Overall 79% of the CKD patients availed health care facility, most (44.8%) of those visit private facility.

Conclusion

We observed older adults, females, rural residents, and having other chronic conditions were associated with poor SRH among CKD patients which highlights the need for equitable and strengthened health care system. There is an urgent need to provide accessible, affordable and quality healthcare services for these individuals so as to maintain continuity of care.

Examining the predictors of healthcare facility choice for outpatient care among older adults in India using Andersen's revised healthcare utilization framework model

BACKGROUND

In India, the demand for outpatient care is substantially higher than inpatient care among older adults. Therefore, the current study examines the level, patterns, and factors associated with outpatient care use.

METHODS

The present research used data from the first wave of the Longitudinal Ageing Study in India (LASI, 2017-18). A total of 34,588 older adults (45 years and above) who accessed outpatient healthcare services in one year prior to the survey were included in this study. A bivariate chi-square test was applied to present the percentage distribution of types of outpatient healthcare utilization by background characteristics and healthcare responsiveness. Multinomial logistic regression analyses were employed to explore the interplay of outpatient healthcare utilization and allied predisposing, enabling, and need factors.

RESULTS

About 63.7% of total older adults used a private facility, followed by 22.8% used a public facility, and 13.5% used other facilities. Years of schooling, household wealth status, place of residence, self-rated health, and health insurance were all found to be significant determinants of public or private facility use. In contrast, respondents' sex was found to be a significant determinant of private healthcare use only. The study finds that there was inadequate healthcare reaction to public health facilities.

CONCLUSION

The current study revealed that the use of private facility for outpatient care is noticeably high in India. Older adults' educational attainments, health insurance coverage, and household level economic background were found to be significant factors in healthcare choice. The current study emphasizes the need to strengthen public healthcare services for outpatient care.

Effects of a smartphone application on maternal health knowledge and dietary diversity among pregnant women in India: a randomized single center pilot study

Background

India contributes to one-fifth of infant and maternal deaths globally. Healthy lifestyles during pregnancy combined with good quality health care can help to avoid many maternal and neonatal deaths. Access to appropriate information is important for developing or maintaining a healthy lifestyle. The increased coverage of smartphones across low- and middle-income countries (LMICs) has given rise to smartphone apps supporting healthy pregnancies. The objective of this study is to evaluate the effects of the smartphone application Together For Her on maternal health knowledge and dietary diversity among pregnant Indian women.

Methods

We ran a randomised single-centre pilot study in a private hospital in Maharashtra, India. We randomly selected pregnant women at ≤20 weeks of gestation who were invited to download the application, in addition to regular antenatal care. The control group only received regular antenatal care. Knowledge about a healthy lifestyle during pregnancy, self-reported dietary diversity and individual characteristics were collected via telephone interviews at baseline (T0), midline (T0 + 4 weeks) and endline (T0 + 12 weeks).

Results

Complete data were collected for 179 respondents (intervention:94; control:85). Respondents in the intervention group showed larger increases in their knowledge over the 12-week study period, with an overall knowledge increase of 13.4 percentage points (P<0.001). The largest effects were found in the modules anaemia, breastfeeding and skin-to-skin contact. Self-reported diversity in nutritional intake also improved significantly more in the intervention group than in the control group.

Conclusions

Smartphone applications can effectively supplement antenatal care by increasing women’s knowledge about a healthy lifestyle during pregnancy, which is likely to reduce the risk of adverse maternal health outcomes. Future research includes the roll-out of a larger multi-centre RCT to assess the effect of the smartphone application on health outcomes.

A public-private partnership based model for regulating out-of-pocket expenditures to strengthen primary care system

In developing countries like India, the cost of health care is largely borne by patient out-of-pocket payments. Recent studies have reported that patients skip public-funded clinics providing free consultation for distant private care providers. Some of the reasons identified for such behaviour include longer waiting times, perception regarding quality of care, etc. Therefore, optimal allocation of existing and new capacity is critical for a greater public interest. This article presents a decision-making framework towards this intent for strengthening the existing government primary healthcare network. In this article, a mixed-integer linear programing (MILP) model is developed for optimal reconfiguration of the existing government primary healthcare network to minimise patient out-of-pocket expenditures (OOPE). The model involves three types of facilities: Primary Health Centre (PHC), Community Health Centre (CHC), and Private OPD (outpatient department). Implementation of the proposed model can help in reducing out-of-pocket expenditures. The optimization model proposed in the article is unique as it incorporates for the first time, patient out-of-pocket expenditure, capacity reconfiguration, and public-private partnership decisions in the primary healthcare system. A solution algorithm is also proposed for the optimization model. The model would be useful for theory development and also in policy-making.

A contextual exploration of healthcare service use in urban slums in Nigeria

Introduction

Many urban residents in low- and middle-income countries live in unfavorable conditions with few healthcare facilities, calling to question the long-held view of urban advantage in health, healthcare access and utilization. We explore the patterns of healthcare utilization in these deprived neighborhoods by studying three such settlements in Nigeria.

Methods

The study was conducted in three slums in Southwestern Nigeria, categorized as migrant, indigenous or cosmopolitan, based on their characteristics. Using observational data of those who needed healthcare and used in-patient or out-patient services in the 12 months preceding the survey, frequencies, percentages and odds-ratios were used to show the study participants’ environmental and population characteristics, relative to their patterns of healthcare use.

Results

A total of 1,634 residents from the three slums participated, distributed as 763 (migrant), 459 (indigenous) and 412 (cosmopolitan). Residents from the migrant (OR = 0.70, 95%CI: 0.51 to 0.97) and indigenous (OR = 0.65, 95%CI: 0.45 to 0.93) slums were less likely to have used formal healthcare facilities than those from the cosmopolitan slum. Slum residents were more likely to use formal healthcare facilities for maternal and perinatal conditions, and generalized pains, than for communicable (OR = 0.50, 95%CI: 0.34 to 0.72) and non-communicable diseases (OR = 0.61, 95%CI: 0.41 to 0.91). The unemployed had higher odds (OR = 1.45, 95%CI: 1.08 to 1.93) of using formal healthcare facilities than those currently employed.

Conclusion

The cosmopolitan slum, situated in a major financial center and national economic hub, had a higher proportion of formal healthcare facility usage than the migrant and indigenous slums where about half of families were classified as poor. The urban advantage premise and Anderson behavioral model remain a practical explanatory framework, although they may not explain healthcare use in all possible slum types in Africa. A context-within-context approach is important for addressing healthcare utilization challenges in slums in sub-Saharan Africa.

Did the poor gain from India's health policy interventions? Evidence from benefit-incidence analysis, 2004-2018

Background

Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context.

Methods

Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups.

Results

Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018.

Conclusions

Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01489-0.

Associations between private vaccine and antimicrobial consumption across Indian states, 2009-2017

Vaccines can reduce antibiotic use and, consequently, antimicrobial resistance by averting vaccine-preventable and secondary infections. We estimated the associations between private vaccine and antibiotic consumption across Indian states during 2009-2017 using monthly and annual consumption data from IQVIA and employed fixed-effects regression and the Arellano-Bond Generalized Method of Moments (GMM) model for panel data regression, which controlled for income and public sector vaccine use indicators obtained from other sources. In the annual data fixed-effects model, a 1% increase in private vaccine consumption per 1000 under-5 children was associated with a 0.22% increase in antibiotic consumption per 1000 people (P < 0.001). In the annual data GMM model, a 1% increase in private vaccine consumption per 1000 under-5 children was associated with a 0.2% increase in private antibiotic consumption (P < 0.001). In the monthly data GMM model, private vaccine consumption was negatively associated with antibiotic consumption when 32, 34, 35, and 44-47 months had elapsed after vaccine consumption, with a positive association with lags of fewer than 18 months. These results indicate vaccine-induced longer-term reductions in antibiotic use in India, similar to findings of studies from other low- and middle-income countries.

Trends in and determinants of visiting private health facilities for maternal and child health care in Nepal: comparison of three Nepal demographic health surveys, 2006, 2011, and 2016

BACKGROUND

Maternal and child health care services are available in both public and private facilities in Nepal. Studies have not yet looked at trends in maternal and child health service use over time in Nepal. This paper assesses trends in and determinants of visiting private health facilities for maternal and child health needs using nationally representative data from the last three successive Nepal Demographic Health Surveys (NDHS).

METHODS

Data from the NDHS conducted in 2006, 2011, and 2016 were used. Maternal and child health-seeking was established using data on place of antenatal care (ANC), place of delivery, and place of treatment for child diarrhoea and fever/cough. Logistic regression models were fitted to identify trends in and determinants of health-seeking at private facilities.

RESULTS

The results indicate an increase in the use of private facilities for maternal and child health care over time. Across the three survey waves, women from the highest wealth quintile had the highest odds of accessing ANC services at private health facilities (AOR = 3.0, 95% CI = 1.53, 5.91 in 2006; AOR = 5.6, 95% CI = 3.51, 8.81 in 2011; AOR = 6.0, 95% CI = 3.78, 9.52 in 2016). Women from the highest wealth quintile (AOR = 3.3, 95% CI = 1.54, 7.09 in 2006; AOR = 7.3, 95% CI = 3.91, 13.54 in 2011; AOR = 8.3, 95% CI = 3.97, 17.42 in 2016) and women with more years of schooling (AOR = 1.2, 95% CI = 1.17, 1.27 in 2006; AOR = 1.1, 95% CI = 1.04, 1.14 in 2011; AOR = 1.1, 95% CI = 1.07, 1.16 in 2016) were more likely to deliver in private health facilities. Likewise, children belonging to the highest wealth quintile (AOR = 8.0, 95% CI = 2.43, 26.54 in 2006; AOR = 6.4, 95% CI = 1.59, 25.85 in 2016) were more likely to receive diarrhoea treatment in private health facilities.

CONCLUSIONS

Women are increasingly visiting private health facilities for maternal and child health care in Nepal. Household wealth quintile and more years of schooling were the major determinants for selecting private health facilities for these services. These trends indicate the importance of collaboration between private and public health facilities in Nepal to foster a public private partnership approach in the Nepalese health care sector.