Cost of scaling-up comprehensive primary health care in India: Implications for universal health coverage

A political economy analysis of health policymaking in Nigeria: the genesis of the 2014 National Health Act

This article explores the ideologies, interests, and institutions affecting health policymaking in Nigeria, and the role of the private sector therein. It covers the period from the late-1950s, the years leading up to independence, to 2014, when the country enacted its first-ever law to govern its healthcare system. The National Health Act (NHAct) was adopted after a decade of preparation and civil society-driven advocacy, making the objective of universal health coverage (UHC) explicit. However, in its final version, the NHAct earmarked only a small share of public funds for UHC, solidifying the country's reliance on private healthcare and out-of-pocket payments. To examine the specific set of ideologies, interests, and institutions defining Nigeria's pathway toward UHC and the contribution of the private sector, we adopted the political economy framework, situating the genesis of the 2014 NHAct within the broader political and economic context of Nigeria's health system reform process since the 1950s. Drawing on qualitative data collected during interviews and focus groups, we found that the deep entrenchment of private-sector healthcare in Nigeria is the result of a path-dependent process. This implies that Nigeria's current reliance on the private sector is influenced by historical patterns, competing interests, and institutional practices that have reinforced the role of private actors over time. We identified three major explanatory factors that have shaped health policymaking in Nigeria. First, since the 1980s, the ideology that private healthcare is the solution to an underfunded and underperforming public healthcare system has been reinforced by leading international organizations. Second, private actors in Nigeria have been in a strong position to influence health policymaking since independence. Third, Nigeria's challenging socio-economic context and the limitations of its federal governance structure have fostered a general level of public distrust in the capacity of the public sector to provide quality healthcare.

Evaluating the costs, work patterns and efficiency (CORE) of comprehensive primary healthcare (CPHC) in India (The CPHC CORE study): a top-down micro-costing study protocol

INTRODUCTION

Primary healthcare is broadly acknowledged as the cornerstone of any strategy aimed at achieving Universal Health Coverage (UHC). This study aims to evaluate the costs, work patterns and efficiency of comprehensive primary healthcare (CPHC) in India.

METHODS AND ANALYSIS

We will use a top-down microcosting approach to estimate the economic cost of services delivered at the primary healthcare facilities in India. A multistage stratified random sampling approach will be applied to select the primary healthcare facilities-Ayushman Arogya Mandirs (AAMs), formerly Health and Wellness Centres (HWCs). First, states will be selected based on key supply-side and demand-side healthcare indicators. Second, two districts will be chosen in each state based on advanced functionality criteria of AAMs. Finally, AAM-subhealth centres (SHCs) and AAM-primary health centres (PHCs) will be randomly selected within each district, implying a total of 48 SHCs and 24 PHCs. Data on both quantity and prices of capital (such as space, building, equipment and furniture) and recurrent resources (including salaries, medicines, consumables, stationery and overheads) used for delivering primary healthcare services during the period from April 2022 to March 2023 will be collected. All costs will be reported in current India Rupees (₹) and US Dollar (USD) ($) at an exchange rate of $1 = ₹86. A time and motion study will be undertaken to collect data from a total of 48 Community Health Officers (CHOs) and 48 auxiliary nurse midwives (ANMs) over a period of 6 days. This will be complemented by interviews to ascertain time spent on various services and activities. The data will be analysed to derive the annual cost of delivering CPHC services at an AAM, unit cost of individual services as a part of the 12 CPHC packages, as well as time spent by the healthcare workers (CHO and ANM) on various activities and services. Finally, a data envelopment analysis will be used to assess the level of technical efficiency in delivering primary healthcare services. The evidence on cost generated through the study will be useful for decisions related to better planning of healthcare services by aligning the work pattern to desired goals, efficient resource allocation, as well as future research on cost-effectiveness and benefit incidence over health accounts of primary healthcare services.

ETHICS AND DISSEMINATION

The study has been approved by the Institute Ethics Committee of the Post Graduate Institute of Medical Education and Research, Chandigarh, India vide IEC no: PGI/IEC/2023/EIC000588. The study results will be published in peer-reviewed journals and presented to the policymakers at the national level. Furthermore, the cost estimates generated by the study will be integrated into the National Health System Cost Database for India, providing information to policymakers and researchers.

Epidemiological trends and age-period-cohort effects on ischemic stroke burden across the BRICS-plus from 1992 to 2021

BACKGROUND

Ischemic stroke, accounting for 85% of stroke cases, leads to severe disabilities and increased mortality. Its global incidence rose by 87.55% from 1990 to 2019, posing significant health and economic burdens. The BRICS-plus nations-Brazil, Russia, India, China, South Africa, and five others-represent a large global population, presenting unique public health challenges. This study aims to evaluate the epidemiological trends and variations in the burden of ischemic stroke across BRICS-plus nations in a timely manner.

METHODS

Data on the number, all-age rate, age-standardized rate, and relative change in ischemic stroke disability-adjusted life years (DALYs) from 1992 to 2021 within BRICS-plus were obtained from the Global Burden of Disease Study (GBD) 2021. Relationships between the DALYs rate and the Socio-demographic Index (SDI) were evaluated using Pearson correlation analyses. Additionally, age-period-cohort modeling was employed to estimate net drift, local drift, age, period, and cohort effects over the past three decades.

RESULTS

From 1992 to 2021, total DALYs due to ischemic stroke increased by 47.14%, while the age-standardized DALYs rate decreased by 33.79%. All BRICS-plus countries exhibited a declining trend in the age-standardized DALYs rate over the past three decades. Egypt reported the highest age-standardized DALYs rate (2,462.60 per 100,000 population) in 2021, whereas the most substantial reduction of 59.37% was observed in Brazil. The annual net drift in the ischemic stroke DALYs rate ranged from -3.04% for Brazil to -0.48% for Egypt among the ten countries. A significant positive correlation was observed between the DALYs rate of ischemic stroke and SDI values. Countries exhibited similar age effect patterns, with an increasing risk of DALYs rate with advancing age. Period and cohort effects highlighted declines in observed nations, indicating improved ischemic stroke management strategies.

CONCLUSION

The burden of ischemic stroke showed an overall declining trend across the BRICS-plus from 1992 to 2021, but persistent health inequalities between these countries were driven by socioeconomic disparities. Furthermore, it emphasizes the necessity for targeted interventions across age, period, and cohort dimensions to address the distinct challenges posed by ischemic stroke in these rapidly developing countries.

Cost of Care for Non-communicable Diseases: Which Types of Healthcare Providers are the Most Economical in India's Chhattisgarh State?

BACKGROUND

Non-communicable diseases (NCDs) affect a large number of people globally and their burden has been growing. Healthcare for NCDs often involves high out-of-pocket expenditure and rising costs of providing services. Financing and providing care for NCDs have become a major challenge for health systems. Despite the high burden of NCDs in India, there is little information available on the costs involved in NCD care.

METHODS

The study was aimed at finding out the average monthly cost of outpatient care per NCD patient. The average cost was defined as all resources spent directly by government and citizens to get a month of care for a NCD patient. The cost borne by the government on public facilities was taken into account and activity-based costing was used to apportion it to the function of providing outpatient NCD care. For robustness, time-driven activity-based costing and sensitivity analyses were also performed. The study was conducted in Chhattisgarh State and involved a household survey and a facility survey, conducted simultaneously at the end of 2022. The surveys had a sample representative of the state, covering 3500 individuals above age of 30 years and 108 health facilities.

RESULTS

The average monthly cost per NCD patient was Indian Rupees (INR) 688 for public providers, INR 1389 for formal for-profit providers and INR 408 for informal private providers and they managed 53.5, 34.3 and 12.0% of NCD patients respectively. The disease profile of patients handled by different types of providers was similar. The average cost per patient was lowest for the primary care facilities in the public sector.

CONCLUSIONS

The average direct cost of NCD care for government and citizens put together was substantially higher in case of formal for-profit providers compared with public facilities, even after taking into account the government subsidies to public sector. This has implications for allocative efficiency and the desired public-private provider mix in health systems.

Preparedness of diabetic patients for receiving telemedical health care: A cross-sectional study

Introduction

This study evaluates feasibility of telemedicine to deliver diabetic care among different regions of the country.

Materials and Methods

Medical interns affiliated with Rotaract Club of Medicrew (RCM) organized a Free Diabetes Screening Camp called "Diab-at-ease" at multiple sites across the country. Of all beneficiaries of the camp >18 years of age, patients previously diagnosed with diabetes and undiagnosed patients with a random blood sugar level of more than 200 mg/dL were interviewed regarding their knowledge, attitude, and practice regarding diabetes care and preparedness and vigilance to receiving care through telemedicine. Random blood sugar, height, weight, and waist circumference were also documented.

Results

About 51.1% (N = 223) of female patients aged 57.57 ± 13.84 years (>18 years) with body mass index (BMI) =26.11 ± 4.63 were the beneficiaries of the health camps. About 75.3% (n = 168) of them were on oral hypoglycemic agents (OHAs), 15.7% (n = 35) were on insulin preparations, and 59.6% (n = 156) and 88.5% (n = 31) of which were highly compliant with treatment, respectively. About 35% (n = 78) and 43.9% (n = 98) of them were unaware of their frequency of hypoglycemic and hyperglycemic episodes, respectively. About 64.6% (n = 144) of the patients were equipped for receiving teleconsultation. Glucometer was only possessed by 51.6% (115) of which only 46.95% (n = 54) can operate it independently. Only 80 patients (35.9%) were aware of the correct value of blood glucose levels.

Conclusion

While a majority of the population is compliant with treatment and aware about diabetes self-care, they lack adequate knowledge and resource equipment for the same leading to very limited utilization.

Successes, weaknesses, and recommendations to strengthen primary health care: a scoping review

BACKGROUND

Primary health care (PHC) is a roadmap for achieving universal health coverage (UHC). There were several fragmented and inconclusive pieces of evidence needed to be synthesized. Hence, we synthesized evidence to fully understand the successes, weaknesses, effective strategies, and barriers of PHC.

METHODS

We followed the PRISMA extension for scoping reviews checklist. Qualitative, quantitative, or mixed-approach studies were included. The result synthesis is in a realistic approach with identifying which strategies and challenges existed at which country, in what context and why it happens.

RESULTS

A total of 10,556 articles were found. Of these, 134 articles were included for the final synthesis. Most studies (86 articles) were quantitative followed by qualitative (26 articles), and others (16 review and 6 mixed methods). Countries sought varying degrees of success and weakness. Strengths of PHC include less costly community health workers services, increased health care coverage and improved health outcomes. Declined continuity of care, less comprehensive in specialized care settings and ineffective reform were weaknesses in some countries. There were effective strategies: leadership, financial system, 'Diagonal investment', adequate health workforce, expanding PHC institutions, after-hour services, telephone appointment, contracting with non-governmental partners, a 'Scheduling Model', a strong referral system and measurement tools. On the other hand, high health care cost, client's bad perception of health care, inadequate health workers, language problem and lack of quality of circle were barriers.

CONCLUSIONS

There was heterogeneous progress towards PHC vision. A country with a higher UHC effective service coverage index does not reflect its effectiveness in all aspects of PHC. Continuing monitoring and evaluation of PHC system, subsidies to the poor, and training and recruiting an adequate health workforce will keep PHC progress on track. The results of this review can be used as a guide for future research in selecting exploratory and outcome parameters.

Impact and cost-effectiveness evaluation of nutritional supplementation and complementary interventions for tuberculosis treatment outcomes under mukti pay-for-performance model in Madhya Pradesh, India: A study protocol

Background

A.

"pay-for-performance" (P4P) intervention model for improved tuberculosis (TB) outcomes, called "Mukti," has been implemented in an underdeveloped tribal area of central India. The target of this project is to improve nutritional status, quality of life (QoL), and treatment outcomes of 1000 TB patients through four interventions: food baskets, personal counseling, peer-to-peer learning and facilitation for linkage to government schemes. The current study aims to assess the success of this model by evaluating its impact and cost-effectiveness using a quasi-experimental approach.

Methods

Data for impact assessment have been collected from 1000 intervention and control patients. Study outcomes such as treatment completion, sputum negativity, weight gain, and health-related QoL will be compared between matched samples. Micro costing approach will be used for assessing the cost of routine TB services provision under the national program and the incremental cost of implementing our interventions. A decision and Markov hybrid model will estimate long-term costs and health outcomes associated with the use of study interventions. Measures of health outcomes will be mortality, morbidity, and disability. Cost-effectiveness will be assessed in terms of incremental cost per quality-adjusted life-years gained and cost per unit increase in patient weight in intervention versus control groups.

Results

The evidence generated from the present study in terms of impact and cost-effectiveness estimates will thus help to identify not only the effectiveness of these interventions but also the optimal mode of financing such measures. Our estimates on scale-up costs for these interventions will also help the state and the national government to consider scale-up of such interventions in the entire state or country.

Discussion

The study will generate important evidence on the impact of nutritional supplementation and other complementary interventions for TB treatment outcomes delivered through P4P financing models and on the cost of scaling up these to the state and national level in India.

Application of Health Technology Assessment for Oncology Care in India: Implications for Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana

A health system is considered efficient when it provides maximum health gains to the population from the available resources. Newer drugs, diagnostics and treatment strategies aim to improve the health of the population, however, they come at an increased cost. Therefore, for an efficient health system, it needs to be decided if the extra cost being incurred is justified to achieve the extra health gains. In this regard, health technology assessment (HTA) helps to make evidence informed decisions by evaluating relative cost and benefits of the available interventions. Economic evidence generated by HTA can also be used in framing standard treatment guidelines (STGs) for high-cost cancer care. In multi-payer systems like India, the decisions regarding the clinical management of patients are taken based on the patients' ability to pay, which creates inequities in utilization of healthcare. Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (AB PM-JAY) offers an opportunity to ensure equity as it reduces financial barriers, besides having a potential to affect efficiency by including only cost-effective interventions in the benefit package. As a result, informed clinical decisions based upon HTA evidence can make cancer treatment more efficient, equitable and affordable for the patients.

Cost-effectiveness of population-based screening for diabetes and hypertension in India: an economic modelling study

BACKGROUND

India faces a high burden of diabetes and hypertension. Currently, there is a dearth of economic evidence about screening programmes, affected age groups, and frequency of screening for these diseases in Indian settings. We assessed the cost effectiveness of population-based screening for diabetes and hypertension compared with current practice in India for different scenarios, according to type of screening test, population age group, and pattern of health-care use.

METHODS

We used a hybrid decision model (decision tree and Markov model) to estimate the lifetime costs and consequences from a societal perspective. A meta-analysis was done to assess the effectiveness of population-based screening. Primary data were collected from two Indian states (Haryana and Tamil Nadu) to assess the cost of screening. The data from the National Health System Cost Database and the Costing of Health Services in India study were used to determine the health system cost of diagnostic tests and cost of treating diabetes or hypertension and their complications. A total of 962 patients were recruited to assess out-of-pocket expenditure and quality of life. Parameter uncertainty was evaluated using univariate and multivariable probabilistic sensitivity analyses. Finally, we estimated the incremental cost per quality-adjusted life-year (QALY) gained with alternative scenarios of scaling up primary health care through a health and wellness centre programme for the treatment of diabetes and hypertension.

FINDINGS

The incremental cost per QALY gained across various strategies for population-based screening for diabetes and hypertension ranged from US$0·02 million to $0·03 million. At the current pattern of health services use, none of the screening strategies of annual screening, screening every 3 years, and screening every 5 years was cost-effective at a threshold of 1-time per capita gross domestic product in India. In the scenario in which health and wellness centres provided primary care to 20% of patients who were newly diagnosed with uncomplicated diabetes or hypertension, screening the group aged between 30 and 65 years every 5 years or 3 years for either diabetes, hypertension, or a comorbid state (both diabetes and hypertension) became cost-effective. If the share of treatment for patients with newly diagnosed uncomplicated diabetes or hypertension at health and wellness centres increases to 70%, from the existing 4% at subcentres and primary health centres, annual population-based screening becomes a cost saving strategy.

INTERPRETATION

Population-based screening for diabetes and hypertension in India could potentially reduce time to diagnosis and treatment and be cost-effective if it is linked to comprehensive primary health care through health and wellness centres for provision of treatment to patients who screen positive.

FUNDING

None.