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Manna S, Singh D, Ghosal S, Rehman T, Kanungo S, Pati S. Out-of-pocket expenditure and its correlates for institutional deliveries in private and public healthcare sectors in India: findings from NFHS 5. BMC Public Health 2023; 23:1474. [PMID: 37532981 PMCID: PMC10398927 DOI: 10.1186/s12889-023-16352-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 07/20/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Increased coverage for institutional delivery (ID) is one of the essential factors for improved maternal and child health (MCH). Though, ID increased over time, out-of-pocket expenditure (OOPE) for the care-seeking families had been found to be growing, parallelly. Hence, we estimated OOPE in public and private health centres for ID, along with their sources and attributing factors and compared state and union territory-wise, so that financial risk protection can be improved for MCH related services. METHODS We used women's data from the National Family Health Survey, 2019-2021 (NFHS-5). Reproductive aged women (15-49 years) delivering one live child in last 5 years (n = 145,386) in any public or private institutions, were included. Descriptive statistics were presented as frequency and proportions. OOPE, was summarized as median and interquartile range (IQR). To estimate the extent for each covariate's effect, linear regression model was conducted. RESULTS Overall median OOPE for ID was Rs. 4066 (median OOPE: private hospitals: Rs.25600, public hospitals: Rs.2067). Health insurance was not sufficient to slash OOPE down at private facilities. Factors associated significantly to high OOPE were mothers' education, elderly pregnancy, complicated delivery, birth order of the latest child etc. CONCLUSION: A standard norm for ID should be implemented as a component of overseeing and controlling inequality. Aiding the needy is probably just one side of the solution, while the focus is required to be shifted towards reducing disparity among the health facilities, so that the beneficiaries do not need to spend on essential services or during emergencies.
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Affiliation(s)
- Sayantani Manna
- Division of Public Health, ICMR-Regional Medical Research Centre, Bhubaneswar-23, Odisha, India
| | - Damini Singh
- Division of Public Health, ICMR-Regional Medical Research Centre, Bhubaneswar-23, Odisha, India
| | - Shishirendu Ghosal
- Division of Public Health, ICMR-Regional Medical Research Centre, Bhubaneswar-23, Odisha, India
| | - Tanveer Rehman
- Division of Public Health, ICMR-Regional Medical Research Centre, Bhubaneswar-23, Odisha, India
| | - Srikanta Kanungo
- Division of Public Health, ICMR-Regional Medical Research Centre, Bhubaneswar-23, Odisha, India.
| | - Sanghamitra Pati
- Division of Public Health, ICMR-Regional Medical Research Centre, Bhubaneswar-23, Odisha, India.
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Kiran T, Junaid KP, Rajagopal V, Gupta M, Sharma D. Measurement and mapping of maternal health service coverage through a novel composite index: a sub-national level analysis in India. BMC Pregnancy Childbirth 2022; 22:761. [PMID: 36217107 PMCID: PMC9552458 DOI: 10.1186/s12884-022-05080-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/27/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Expansion of maternal health service coverage is crucial for the survival and wellbeing of both mother and child. To date, limited literature exists on the measurement of maternal health service coverage at the sub-national level in India. The prime objectives of the study were to comprehensively measure the maternal health service coverage by generating a composite index, map India by categorizing it into low, medium and high zones and examine its incremental changes over time. METHODS Utilising a nationally representative time series data of 15 key indicators spread across three domains of antenatal care, intranatal care and postnatal care, we constructed a novel 'Maternal Health Service Coverage Index' (MHSI) for 29 states and 5 union territories of India for the base (2017-18) and reference (2019-20) years. Following a rigorous procedure, MHSI scores were generated using both arithmetic mean and geometric mean approaches. We categorized India into low, medium and high maternal health service coverage zones and further generated geospatial maps to examine the extent and transition of maternal health service coverage from base to reference year. RESULTS India registered the highest mean percentage coverage (93.7%) for 'institutional delivery' and the lowest for 'treatment for obstetric complications' (9.3%) among all the indicators. Depending on the usage of arithmetic mean and geometric mean approaches, the maternal health service coverage index score for India exhibited marginal incremental change (between 0.015-0.019 index points) in the reference year. West zone exhibited an upward transition in the coverage of maternal health service indicators, while none of the zones recorded a downward movement. The states of Mizoram (east zone) and the Union Territory of Puducherry (south zone) showed a downward transition. Union territories of Dadra & Nagar Haveli (west zone) and Chandigarh (north zone), along with the states of Maharashtra (west zone), Assam, as well as Jharkhand (both from the east & north east zone), showed upward transition. CONCLUSION Overall, maternal health service coverage is increasing across India. Our study offers a novel summary measure to comprehensively quantify the coverage of maternal health services, which can momentously help India identify lagged indicators and low performing regions, thereby warranting the targeted interventions and concentrated programmatic efforts to bolster the maternal health service coverage at the sub-national level.
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Affiliation(s)
- Tanvi Kiran
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - K P Junaid
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Vineeth Rajagopal
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Madhu Gupta
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Divya Sharma
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Sahoo KC, Doley C, Negi S, Das S, Verma P, Kanungo S, Pati S. Experiences of Urban Slum-Dwelling Women With Maternal and Child Health Services During COVID-19 Pandemic: A Multi-City Qualitative Study From India. Int J Public Health 2022; 67:1604348. [PMID: 36204007 PMCID: PMC9530035 DOI: 10.3389/ijph.2022.1604348] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: The COVID-19 pandemic containment necessitated the diversion of substantial health care resources thus affecting the routine essential care, and posing barriers to achieving the Sustainable Development Goals (SDGs). We explored the experiences of vulnerable communities—urban-slum-dwelling women regarding maternal and child health services during COVID-19.Methods: We conducted 48 in-depth interviews in four Indian states—12 in each state among urban-slum antenatal, intra-natal, and postnatal women. We used framework analysis.Results: Amidst the implementation of the mandatory stay-at-home, many women acknowledged that routine immunization services and antenatal check-ups remained uninterrupted, and were mostly provided at the community level. To prevent transmission, the family members and relatives had restricted visits to the health facility during labor or post-delivery. Women preferred to have a shorter hospital stay post-delivery and reduced routine postnatal check-ups for fear of infection.Conclusion: India has a variety of national and state-level programs focused on improving MCH indicators to achieve the SDGs. COVID-19 inadvertently interrupted some components of health services, insinuating the need for a disaster or pandemic-resilient MCH services delivery system.
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King J, Prabhakar P, Singh N, Sulaiman M, Greco G, Mounier-Jack S, Borghi J. Assessing equity of access and affordability of care among South Sudanese refugees and host communities in two districts in Uganda: a cross-sectional survey. BMC Health Serv Res 2022; 22:1165. [PMID: 36114536 PMCID: PMC9482210 DOI: 10.1186/s12913-022-08547-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background The vast majority of refugees are hosted in low and middle income countries (LMICs), which are already struggling to finance and achieve universal health coverage for their own populations. While there is mounting evidence of barriers to health care access facing refugees, there is more limited evidence on equity in access to and affordability of care across refugee and host populations. The objective of this study was to examine equity in terms of health needs, service utilisation, and health care payments both within and between South Sudanese refugees and hosts communities (Ugandan nationals), in two districts of Uganda. Methods Participants were recruited from host and refugee villages from Arua and Kiryandongo districts. Twenty host villages and 20 refugee villages were randomly selected from each district, and 30 households were sampled from each village, with a target sample size of 2400 households. The survey measured condition incidence, health care seeking and health care expenditure outcomes related to acute and chronic illness and maternal care. Equity was assessed descriptively in relation to household consumption expenditure quintiles, and using concentration indices and Kakwani indices (for expenditure outcomes). We also measured the incidence of catastrophic health expenditure- payments for healthcare and impoverishment effects of expenditure across wealth quintiles. Results There was higher health need for acute and chronic conditions in wealthier groups, while maternal care need was greater among poorer groups for refugees and hosts. Service coverage for acute, chronic and antenatal care was similar among hosts and refugee communities. However, lower levels of delivery care access for hosts remain. Although maternal care services are now largely affordable in Uganda among the studied communities, and service access is generally pro-poor, the costs of acute and chronic care can be substantial and regressive and are largely responsible for catastrophic expenditures, with service access benefiting wealthier groups. Conclusions Efforts are needed to enhance access among the poorest for acute and chronic care and reduce associated out-of-pocket payments and their impoverishing effects. Further research examining cost drivers and potential financing arrangements to offset these will be important.
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Sriram S, Albadrani M. A STUDY OF CATASTROPHIC HEALTH EXPENDITURES IN INDIA - EVIDENCE FROM NATIONALLY REPRESENTATIVE SURVEY DATA: 2014-2018. F1000Res 2022; 11:141. [PMID: 35464045 PMCID: PMC9005991 DOI: 10.12688/f1000research.75808.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background: India is taking steps to provide Universal Health Coverage (UHC). Out-of-pocket (OOP) health care payment is the most important mechanism for health care payment in India. This study aims to investigate the effect of OOP health care payments on catastrophic health expenditures (CHE). Methods: Data from the National Sample Survey Organization, Social Consumption in Health 2014 and 2018 are used to investigate the effect of OOP health expenditure on household welfare in India. Three aspects of catastrophic expenditure were analyzed in this paper: (i) incidence and intensity of ‘catastrophic’ health expenditure, (ii) socioeconomic inequality in catastrophic health expenditures, and (iii) factors affecting catastrophic health expenditures. Results: The odds of incidence and intensity of CHE were higher for the poorer households. Using the logistic regression model, it was observed that the odds of incidence of CHE was higher among the households with at least one child aged less than 5 years, one elderly person, one secondary educated female member, and if at least one member in the household used a private healthcare facility for treatment. The multiple regression model showed that the intensity of CHE was higher among households with members having chronic illness, and if members had higher duration of stay in the hospital. Subsidizing healthcare to the households having elderly members and children is necessary to reduce CHE. Conclusion: Expanding health insurance coverage, increasing coverage limits, and inclusion of coverage for outpatient and preventive services are vital to protect households. Strengthening public primary health infrastructure and setting up a regulatory organization to establish policies and conduct regular audits to ensure that private hospitals do not increase hospitalizations and the duration of stay is necessary.
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Affiliation(s)
- Shyamkumar Sriram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Muayad Albadrani
- Department of Famiy and Community Medicine, Taibah University, Medina, Saudi Arabia
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van Duinen AJ, Westendorp J, Ashley T, Hagander L, Holmer H, Koroma AP, Leather AJM, Shrime MG, Wibe A, Bolkan HA. Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative. PLoS One 2021; 16:e0258532. [PMID: 34653191 PMCID: PMC8519447 DOI: 10.1371/journal.pone.0258532] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 09/29/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI. METHODS Women who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed. RESULTS For the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure. CONCLUSION Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone's poorest patients.
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Affiliation(s)
- Alex J. van Duinen
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Surgery, St Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
- * E-mail:
| | - Josien Westendorp
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Thomas Ashley
- Kamakwie Wesleyan Hospital, Kamakwie, Sierra Leone
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - Lars Hagander
- Centre for Surgery and Public Health, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Hampus Holmer
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Alimamy P. Koroma
- Ministry of Health and Sanitation, Freetown, Sierra Leone
- Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Andrew J. M. Leather
- King’s Centre for Global Health & Health Partnerships, King’s College London, London, United Kingdom
| | - Mark G. Shrime
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, United States of America
| | - Arne Wibe
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Surgery, St Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Håkon A. Bolkan
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Surgery, St Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
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Dwivedi R, Pradhan J, Athe R. Measuring catastrophe in paying for healthcare: A comparative methodological approach by using National Sample Survey, India. Int J Health Plann Manage 2021; 36:1887-1915. [PMID: 34196030 DOI: 10.1002/hpm.3272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 06/19/2021] [Accepted: 06/20/2021] [Indexed: 11/07/2022] Open
Abstract
Healthcare expenditure significantly varies among various segments of the population. The appropriate measures of catastrophic health expenditure (CHE) will help to unravel the real burden of spending among households. Present study provides a link between the theoretical insights from Grossman's model and various methodological approaches for the estimation of CHE by using data from the three rounds of nationally representative Consumer Expenditure Surveys, India. Statistical analysis has been carried out by using multivariate logistic regression to identify the major determinants of CHE. Findings indicate that the occurrence of CHE has increased during 1993-2012. Rural residents and households with varying age composition such as with higher numbers of children and elderly were at higher risk. Economic status is significantly associated with CHE and increased demand for healthcare. The measurements differ as per the methodological approaches of CHE and definition of household's capacity to pay. Approach-based variations in the results can be of key importance in determining trends and magnitude in CHE. Despite these variations in measurements, study finds a limited incidence of CHE among the disadvantaged segment of the population though a greater share was devoted to health expenditure in recent years. Better risk pooling mechanism is required to address the healthcare needs of the disadvantaged segment such as elderly, children, poor and rural population in India.
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Affiliation(s)
- Rinshu Dwivedi
- Department of Science and Humanities, Indian Institute of Information Technology, Trichy, Tamil Nadu, India
| | - Jalandhar Pradhan
- Department of Humanities and Social Sciences, National Institute of Technology, Rourkela, Odisha, India
| | - Ramesh Athe
- Department of Humanities and Sciences, Indian Institute of Information Technology, Dharwad, Karnataka, India
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Prinja S, Sharma A, Nimesh R, Sharma V, Madan Gopal K, Badgaiyan N, Lakshmi P, Gupta M. Impact of National Health Mission on infant mortality in India: An interrupted time series analysis. Int J Health Plann Manage 2021; 36:1143-1152. [PMID: 33792075 DOI: 10.1002/hpm.3166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/18/2021] [Accepted: 03/21/2021] [Indexed: 11/07/2022] Open
Abstract
Government of India introduced National Rural Health Mission in 2005-now transformed into National Health Mission (NHM), to bring about architectural reforms in health sector. In this study, we evaluate the overall impact of NHM on infant mortality at national and state level. Annual data on infant mortality rate (IMR) from 1990 to 2016 were obtained from Sample Registration System bulletins. With reporting year 2009 considered as cut-off point, a two-step segmented time series regression analysis was conducted. Estimates of pre-slope, post-slope and change at the point of intervention were computed by applying auto-regressive integrated moving average (1, 0, 0) while adjusting for trend and auto correlation. We found that while IMR reduced from around 80 to 34 per 1000 live births at the national level from 1990 to 2016, the annual rate of reduction increased from 1.6 per 1000 live births before NHM to 2.2 per 1000 live births after NHM. This is estimated to have averted 248,212 infant deaths in India, between 2005 and 2017. The rate of decline in IMR accelerated in 13 out of 17 larger states, most significantly in Andhra Pradesh, Gujarat, Assam, Haryana, Punjab and Uttar Pradesh. NHM has thus been successful in accelerating the overall rate of reduction in IMR in India. There is still a need to identify the determinants of variations at state level. We recommend strengthening of NHM in terms of funding and implementation.
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Affiliation(s)
- Shankar Prinja
- Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Atul Sharma
- Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ruby Nimesh
- Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vineeta Sharma
- Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Pvm Lakshmi
- Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhu Gupta
- Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Mishra PS, Veerapandian K, Choudhary PK. Impact of socio-economic inequity in access to maternal health benefits in India: Evidence from Janani Suraksha Yojana using NFHS data. PLoS One 2021; 16:e0247935. [PMID: 33705451 PMCID: PMC7951864 DOI: 10.1371/journal.pone.0247935] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 02/16/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Caste plays a significant role in Indian society and it influences women to health care access in the community. The implementation of the maternal health benefits scheme in India is biased due to caste identity. In this context, the paper investigates access to Janani Suraksha Yojana (JSY) among social groups to establish that caste still plays a pivotal role in Indian society. Also, this paper aims to quantify the discrimination against Scheduled Castes/Scheduled Tribes (SCs/STs) in accessing JSY. METHODS This paper uses a national-level data set of both NFHS-3 (2005-06) and NFHS-4 (2015-16). Both descriptive statistics and the Fairlie decomposition econometric model have been used to measure the explained and unexplained differences in access to JSY between SCs/STs and non-SCs/STs groups. RESULTS Overall, the total coverage of JSY in India is still, 36.4%. Further, it is found that 72% of access to JSY is explained by endowment variables. The remaining unexplained percentage (28%) indicates that there is caste discrimination (inequity associated social-discrimination) against SCs/STs in access to JSY. The highest difference (54%) between SCs/STs and non-SCs/STs in access to JSY comes from the wealth quintile, with the positive sign indicating that the gap between the two social groups is widening. DISCUSSION AND CONCLUSION It is necessary for the government to implement a better way to counter the caste-based discrimination in access to maternal health benefits scheme. In this regard, ASHA and Anganwadi workers must be trained to reduce the influence of dominant caste groups as well as they must be recruited from the same community to identify the right beneficiaries of JSY and in order to reduce inequity associated with social-discrimination.
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Affiliation(s)
- Prem Shankar Mishra
- PhD Research Scholar, Population Research Centre, Institute for Social and Economic Change, Bengaluru, Karnataka, India
| | - Karthick Veerapandian
- PhD Research Scholar, Center for Economic Studies and Policy, Institute for Social and Economic Change, Bengaluru, Karnataka, India
| | - Prashant Kumar Choudhary
- PhD Research Scholar, Centre for Political Institutions, Governance and Development, Institute for Social and Economic Change, Bengaluru, Karnataka, India
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Phull M, Grimes CE, Kamara TB, Wurie H, Leather AJM, Davies J. What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure. BMJ Open 2021; 11:e039049. [PMID: 34006018 PMCID: PMC7942261 DOI: 10.1136/bmjopen-2020-039049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To measure the financial burden associated with accessing surgical care in Sierra Leone. DESIGN A cross-sectional survey conducted with patients at the time of discharge from tertiary-level care. This captured demographics, yearly household expenditure, direct medical, direct non-medical and indirect costs for surgical care, and summary household assets. Missing data were imputed. SETTING The main tertiary-level hospital in Freetown, Sierra Leone. PARTICIPANTS 335 surgical patients under the care of the hospital surgical team receiving operative or non-operative surgical care on the surgical wards. OUTCOME MEASURES Rates of catastrophic expenditure (a cost >10% of annual expenditure), impoverishment (being pushed into, or further into, poverty as a result of surgical care costs), amount of out-of-pocket (OOP) costs and means used to meet these costs were derived. RESULTS Of 335 patients interviewed, 39% were female and 80% were urban dwellers. Median yearly household expenditure was US$3569. Mean OOP costs were US$243, of which a mean of US$24 (10%) was spent prehospital. Of costs incurred during the hospital admission, direct medical costs were US$138 (63%) and US$34 (16%) were direct non-medical costs. US$46 (21%) were indirect costs. Catastrophic expenditure affected 18% of those interviewed. Concerning impoverishment, 45% of patients were already below the national poverty line prior to admission, and 9% of those who were not were pushed below the poverty line following payment for surgical care. 84% of patients used household savings to meet OOP costs. Only 2% (six patients) had health insurance. CONCLUSION Obtaining surgical care has substantial economic impacts on households that pushes them into poverty or further into poverty. The much-needed scaling up of surgical care needs to be accompanied by financial risk protection.
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Affiliation(s)
- Manraj Phull
- Department of Surgery, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Caris E Grimes
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Surgery, Medway NHS Foundation Trust, Gillingham, UK
| | - Thaim B Kamara
- Department of Surgery, University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Sierra Leone
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Andy J M Leather
- King's Centre for Global Health, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Justine Davies
- Centre of Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Saha R, Paul P. Institutional deliveries in India's nine low performing states: levels, determinants and accessibility. Glob Health Action 2021; 14:2001145. [PMID: 34914883 PMCID: PMC8682830 DOI: 10.1080/16549716.2021.2001145] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Despite the implementation of several national-level interventions, institutional delivery coverage remains unsatisfactory in India’s low performing states (LPS), leading to a high burden of maternal mortality. Objective This study investigates the levels, differentials, and determinants of institutional deliveries in LPS of India. The study also delineates a holistic understanding of barriers to delivery at health facilities and the utilization of the Janani Suraksha Yojana (JSY) specifically designed to improve maternal and child health of disadvantaged communities. Methods A cross-sectional study was conducted using data from the National Family Health Survey (NFHS)-4, 2015–16. The study was carried out over India’s nine LPS utilizing 112,518 women who had a living child in the past five years preceding the survey. Bivariate and multivariate regression analysis techniques were used to yield findings. Results Of the study sample, nearly three-quarters (74%) of women delivered in a health institution in the study area, with the majority delivered in public health facilities. The multivariate analysis indicates that women who lived in rural areas, belonged to disadvantaged social groups (e.g. Scheduled caste/tribes and Muslims), and those who married early (before 18 years) were less likely to utilize institutional delivery services. On the other hand, women’s education, household wealth, and exposure to mass media were found to be strong facilitators of delivering in a health facility. Meeting with a community health worker (CHW) during pregnancy emerged as an important predictor of institutional delivery in our study. Further, interaction analysis shows that women who reported the distance was a ‘big problem’ in accessing medical care had significantly lower odds of delivering at a health facility. Conclusions The study suggests emphasizing the quality of in-facility maternal care and awareness about the importance of reproductive health. Furthermore, strengthening sub-national policies specifically in underperforming states is imperative to improve institutional delivery coverage.
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Affiliation(s)
- Ria Saha
- Public Health Consultant, London, UK
| | - Pintu Paul
- Centre for the Study of Regional Development, School of Social Sciences, Jawaharlal Nehru University, New Delhi, India
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Ravindran TKS, Govender V. Sexual and reproductive health services in universal health coverage: a review of recent evidence from low- and middle-income countries. Sex Reprod Health Matters 2020; 28:1779632. [PMID: 32530387 PMCID: PMC7887992 DOI: 10.1080/26410397.2020.1779632] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
If universal health coverage (UHC) cannot be achieved without the sexual and reproductive health (SRH) needs of the population being met, what then is the current situation vis-à-vis universal coverage of SRH services, and the extent to which SRH services have been prioritised in national UHC plans and processes? This was the central question that guided this critical review of more than 200 publications between 2010 and 2019. The findings are the following. The Essential Package of Healthcare Services (EPHS) across many countries excludes several critical SRH services (e.g. safe abortion services, reproductive cancers) that are already poorly available. Inadequate international and domestic public funding of SRH services contributes to a sustained burden of out-of-pocket expenditure (OOPE) and inequities in access to SRH services. Policy and legal barriers, restrictive gender norms and gender-based inequalities challenge the delivery and access to quality SRH services. The evidence is mixed as to whether an expanded role and scope of the private sector improves availability and access to services of underserved populations. As momentum gathers towards SRH and UHC, the following actions are necessary and urgent. Advocacy for greater priority for SRH in government EPHS and health budgets aligned with SRH and UHC goals is needed. Implementation of stable and sustained financing mechanisms that would reduce the proportion of SRH-financing from OOPE is a priority. Evidence, moving from descriptive towards explanatory studies which provide insights into the "hows" and "whys" of processes and pathways are essential for guiding policy and programme actions.
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Affiliation(s)
- T. K. Sundari Ravindran
- Principal Visiting Fellow, United Nations University, International Institute for Global Health, Kuala Lumpur, Malaysia
| | - Veloshnee Govender
- Scientist, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Pinilla J, López-Valcárcel BG. Income and wealth as determinants of voluntary private health insurance: empirical evidence in Spain, 2008-2014. BMC Public Health 2020; 20:1262. [PMID: 32814549 PMCID: PMC7437046 DOI: 10.1186/s12889-020-09362-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few studies have quantitatively estimated the income elasticity of demand of voluntary private health insurance (VPHI) in countries with a universal National Health Service. Most studies to date have uses cross-sectional data. METHODS In this paper we used a longitudinal database from the Bank of Spain to analyse the financial behaviour of approximately six thousand families per wave. We used three waves (2008, 2011 and 2014). We estimated income and wealth semi-elasticities of VPHI in Spain considering personal and family characteristics (age, sex, level of health, education, composition of the household), i.e. changes in the probability of buying VPHI as result of 1% change in income or wealth. We estimated cross-sectional models for each wave and longitudinal models for families remaining for at least two waves, taking account of possible selection bias due to attrition. RESULTS Cross-sectional models suggest that the income effect on the probability of buying a VPHI increased from 2008 to 2014. The positive impact was observed for, wealth. In 2008 a 1% increase in income is associated with an increase in the probability of having VPHI of 0.064 [95%-CI: 0.023; 0.104] - on the probability scale (0.1) - whereas in 2014, this effect is of 0.116 [95%-CI, 0.094; 0.139]. In 2011 and 2014 the wealth effect is not significant at 5%. The estimation of the longitudinal model leads to different results where both, income and wealth are associated with non- significant results. CONCLUSION Our three main conclusions are: 1) Cross-sectional estimates of semi-elasticities of VPHI might be biased upwards; 2) Wealth is alongside income are economic determinants, of the decision to buy VPHI in high-income countries; 3) The effects of income and wealth on the probability of buying VHPI are neither linear nor log-linear. There are no significant differences among 60% of the most disadvantaged families, while the families of the two upper wealth quintiles show clearly differentiated behaviour with a higher probability of insurance.
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Affiliation(s)
- Jaime Pinilla
- Department of Quantitative Methods for Economics and Management, University of Las Palmas de Gran Canaria, Campus de Tafira sn, 35017, Las Palmas de Gran Canaria, Spain. .,Centre for Research in Health Economics, University Pompeu Fabra, Barcelona, Spain.
| | - Beatriz G López-Valcárcel
- Department of Quantitative Methods for Economics and Management, University of Las Palmas de Gran Canaria, Campus de Tafira sn, 35017, Las Palmas de Gran Canaria, Spain.,Centre for Research in Health Economics, University Pompeu Fabra, Barcelona, Spain
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Zuniga C, Thompson TA, Blanchard K. Abortion as a Catastrophic Health Expenditure in the United States. Womens Health Issues 2020; 30:416-425. [PMID: 32798085 DOI: 10.1016/j.whi.2020.07.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 06/16/2020] [Accepted: 07/10/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE Abortion is a critical reproductive health service that is difficult for many in the United States to afford owing to policies aimed at restricting insurance coverage of this basic health service. This article assesses whether the resulting high out-of-pocket cost for abortion could be considered a catastrophic health expenditure, and explores potential policies that could prevent households from experiencing financial hardship or impoverishment. METHODS We assessed if the average costs of a first and second trimester abortion procedure in 2016 were catastrophic health expenditures by applying a 40% threshold to the monthly nonsubsistence income of households earning their state's median income in all 50 states and Washington, DC. RESULTS The out-of-pocket cost for a first trimester abortion procedure would have been catastrophic for households earning their state's median monthly income in 39 states. In nine of these states, the average cost was between 100% and 199% of a household's nonsubsistence income, and in another nine states, this cost was at least double a household's nonsubsistence income. The out-of-pocket cost of a second trimester abortion would have been catastrophic for households earning their state's median monthly income in all 50 states and Washington, DC. CONCLUSIONS In a majority of states, the out-of-pocket cost of an abortion is financially catastrophic for households earning no more than their state's median monthly income. The United States should implement policies to create or improve health care safety nets to guarantee abortion care for all individuals, regardless of their income or insurance status.
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Tripathi N, John D, Chatterjee PK, Murthy S, Parganiha N, Brokar A. Informal Payments for Maternal and Neonatal Health Services in Public Hospitals in Central India. JOURNAL OF HEALTH MANAGEMENT 2020. [DOI: 10.1177/0972063420908158] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Informal payments are unauthorised ‘unregistered’ out-of-pocket payments, outside the official payment system, for purchase or service meant to be covered/provided by the healthcare system. This study attempts to measure and report the extent and magnitude of informal payments based on the entitlements in Janani-Shishu Suraksha Karyakram (JSSK) in the Indian context. Methods: A cross-sectional study using convenience sampling and a semi-structured interview schedule was conducted among 281 participants in 2016 in 26 JSSK-notifying health facilities from all five divisions of Chhattisgarh. Pregnant women and women who delivered in the previous year, and provided informed consent, were included. After reviewing various definitions, informal payment was operationally defined in the context of JSSK for India as ‘payments made in cash or kind, unregistered or non-reimbursed, made by/on behalf of the beneficiary or someone related thereof, for free and cashless entitlements in a JSSK-listed health facility, to an individual or institutional healthcare provider/staff who provides/arranges for provision of the service’. Results: Of 281 participants, 91.8 per cent reported informal payments across all JSSK entitlements categories. A relative majority of these payments was made at the district hospital (37%), ranging from ₹2 to ₹6,500 (US$0.03–101). Investigations incurred the greatest median amount of informal payments, at, ₹455 (US$7). Informal payments ranged between three and seven times higher than the JSSK price cap in Chhattisgarh. No significant association was found between participant characteristics and informal payments. Conclusion: Further research is required to understand the magnitude and motivation of informal payments made in programmes like JSSK.
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Affiliation(s)
| | - Denny John
- Evidence Synthesis Specialist, Campbell South Asia, New Delhi, India
- ICMR-National Institute of Medical Statistics, New Delhi, India
| | | | - Shruti Murthy
- Department of Statistics, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | | | - Arti Brokar
- State Health Resource Centre, Raipur, Chhattisgarh, India
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Prinja S, Balasubramanian D, Sharma A, Gupta R, Rana SK, Kumar R. Geographic Inequities in Coverage of Maternal and Child health Services in Haryana State of India. Matern Child Health J 2019; 23:1025-1035. [PMID: 30701415 DOI: 10.1007/s10995-019-02733-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction India aims to achieve universal health coverage, with a focus on equitable delivery of services. There is significant evidence on extent of inequities by income status, gender and caste. In this paper, we report geographic inequities in coverage of reproductive, maternal and child health (MCH) services in Haryana state of India. Methods Cross-sectional data on utilization of maternal, child health and family planning services were collected from 12,191 women who had delivered a child in the last one year, 10314 women with 12-23 months old child, and 45864 eligible couples across all districts in Haryana state. Service coverage was assessed based on eight indicators - 6 for maternal health, one for child health and one for family planning. Inter- and intra-district inequalities were compared based on four and three indicators respectively. Results Difference in coverage of full ante-natal care, full immunization and contraceptive prevalence rate between districts performing best and worst was found to be 54%, 65% and 63% respectively. More than one-thirds of the sub-centres (SCs) in Panchkula, Ambala, Gurgaon and Mewat districts had their ante-natal care coverage less than 50% of the respective district average. Similarly, a significant proportion of SCs in Mewat, Panipat and Hisar districts had full immunization rate below 50% of the district average. Conclusion Widespread inter- and intra-district inequities in utilization of MCH services exist. A comprehensive geographical targeting to identify poor performing districts, community development blocks and SCs could result in significant equity gains, besides contributing to quick achievement of sustainable development goals.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Deepak Balasubramanian
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Atul Sharma
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Gupta
- Department of Health and Family Welfare, National Rural Health Mission, Haryana, Panchkula, India
| | - Saroj Kumar Rana
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Kumar
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Prinja S, Bahuguna P, Gupta I, Chowdhury S, Trivedi M. Role of insurance in determining utilization of healthcare and financial risk protection in India. PLoS One 2019; 14:e0211793. [PMID: 30721253 PMCID: PMC6363222 DOI: 10.1371/journal.pone.0211793] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 01/21/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Universal health coverage has become a policy goal in most developing economies. We assess the association of health insurance (HI) schemes in general, and RSBY (National Health Insurance Scheme) in particular, on extent and pattern of healthcare utilization. Secondly, we assess the relationship of HI and RSBY on out-of-pocket (OOP) expenditures and financial risk protection (FRP). METHODS A cross-sectional study was undertaken to interview 62335 individuals among 12,134 households in 8 districts of three states in India i.e. Gujarat, Haryana and Uttar Pradesh (UP). Data on socio-demographic characteristics, assets, education, occupation, consumption expenditure, illness in last 15 days or hospitalization during last 365 days, treatment sought and its OOP expenditure was collected. We computed catastrophic health expenditures (CHE) as indicator for FRP. Hospitalization rate, choice of care provider and CHE were regressed to assess their association with insurance status and type of insurance scheme, after adjusting for other covariates. RESULTS Mean OOP expenditures for outpatient care among insured and uninsured were INR 961 (USD 16) and INR 840 (USD 14); and INR 32573 (USD 543) and INR 24788 (USD 413) for an episode of hospitalization respectively. The prevalence of CHE for hospitalization was 28% and 26% among the insured and uninsured population respectively. No significant association was observed in multivariate analysis between hospitalization rate, choice of care provider or CHE with insurance status or RSBY in particular. CONCLUSION Health insurance in its present form does not seem to provide requisite improvement in access to care or financial risk protection.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Bahuguna
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Indrani Gupta
- Health Policy Research Unit, Institute of Economic Growth, University of Delhi Enclave, Delhi, India
| | - Samik Chowdhury
- Health Policy Research Unit, Institute of Economic Growth, University of Delhi Enclave, Delhi, India
| | - Mayur Trivedi
- Indian Institute of Public Health, Gandhinagar, Gujarat, India
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Bahuguna P, Mukhopadhyay I, Chauhan AS, Rana SK, Selvaraj S, Prinja S. Sub-national health accounts: Experience from Punjab State in India. PLoS One 2018; 13:e0208298. [PMID: 30532271 PMCID: PMC6287852 DOI: 10.1371/journal.pone.0208298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 11/15/2018] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Public health spending in India has been traditionally one of the lowest globally. Punjab is one of the states with highest proportion of out-of-pocket expenditures for healthcare in India. We undertook this study to produce the sub-national health accounts (SNHA) for Punjab state in India. METHODOLOGY We used System of Health Accounts (SHA) 2011 framework for preparing health accounts for Punjab state. Data on health spending by government was obtained from concerned public sector departments both at state and central level. Estimates on Out-of-Pocket Expenditures (OOPE) expenditure were derived from National Sample Survey (NSS) 71st round data, Consumer Expenditure Survey (CES) data and Pharmatrac. Primary surveys were done for assessing health expenditure data by firms and non-governmental organizations. All estimates of healthcare expenditures reported in our paper pertain to 2013-14, and are reported in both Indian National Rupee (INR) and United States Dollar (US $),using average conversion rate of INR 60.50 per US $. RESULTS In 2013-14, the current health expenditures (CE) in Punjab was INR 134,680million (US $ 2245 million) which was 4.02% of its gross state domestic product (GSDP).However, public spending on health was 0.95% of GSDP i.e. 21% of the total health expenditure (THE), while 79% was private expenditure. In per capita terms, THE in Punjab was INR 4963 (US $ 82.03). In terms of functions, medical goods (41.6%) and curative care (37%) consumed larger share of expenditure in the Punjab state. Households spent 52% of expenditures for medicines and other pharmaceutical goods. Risk pooling mechanisms are being adopted to a lesser extent in the state. CONCLUSION The healthcare in Punjab is largely financed through private OOPE. Currently, public health spending in Punjab is inadequate to meet the healthcare demands of population, which is less than 1% of state's GSDP. Monitoring public resources is very important for better resource allocations. Health Accounts production is useful in order to assess future trends and impact of health financing policies on goals of universal health coverage and should be made a part of routine monitoring system both at national and sub-national level.
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Affiliation(s)
- Pankaj Bahuguna
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Akashdeep Singh Chauhan
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj Kumar Rana
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Myint ANM, Liabsuetrakul T, Htay TT, Wai MM, Sundby J, Bjertness E. Impoverishment and catastrophic expenditures due to out-of-pocket payments for antenatal and delivery care in Yangon Region, Myanmar: a cross-sectional study. BMJ Open 2018; 8:e022380. [PMID: 30478109 PMCID: PMC6254407 DOI: 10.1136/bmjopen-2018-022380] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES (1) To assess the levels of impoverishment and catastrophic expenditure due to out-of-pocket (OOP) payments for antenatal care (ANC) and delivery care in Yangon Region, Myanmar; and (2) to explore the determinants of impoverishment and catastrophic expenditure. DESIGN, SETTING AND PARTICIPANTS A community-based cross-sectional survey among women giving birth within the past 12 months in Yangon, Myanmar, was conducted during October to November 2016 using three-stage cluster sampling procedure. OUTCOME MEASURES Poverty headcount ratio, normalised poverty gap and catastrophic expenditure incidence due to OOP payments in the utilisation of ANC and delivery care as well as the determinants of impoverishment and catastrophic expenditure. RESULTS Of 759 women, OOP payments were made by 75% of the women for ANC and 99.6% for delivery care. The poverty headcount ratios after payments increased to 4.3% among women using the ANC services, to 1.3% among those using delivery care and to 6.1% among those using both ANC and delivery care. The incidences of catastrophic expenditure after payments were found to be 12% for ANC, 9.1% for delivery care and 20.9% for both ANC and delivery care. The determinants of impoverishment and catastrophic expenditure were women's occupation, number of household members, number of ANC visits and utilisation of skilled health personnel and health facilities. The associations of the outcomes with these variables bear both negative and positive signs. CONCLUSIONS OOP payments for all ANC and delivery care services are a challenge to women, as one of fifteen women become impoverished and a further one-fifth incur catastrophic expenditures after visiting facilities that offer these services.
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Affiliation(s)
- Aye Nyein Moe Myint
- International Relations Division, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | | | - Thein Thein Htay
- Department of Community and Global Health, University of Oslo, Norway
| | - Myint Myint Wai
- Department of Medical Services (Planning), Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Johanne Sundby
- Department of Community and Global Health, University of Oslo, Norway
| | - Espen Bjertness
- Department of Community and Global Health, University of Oslo, Norway
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Sharma D, Prinja S, Aggarwal AK, Bahuguna P, Sharma A, Rana SK. Out-of-pocket expenditure for hospitalization in Haryana State of India: Extent, determinants & financial risk protection. Indian J Med Res 2018; 146:759-767. [PMID: 29664035 PMCID: PMC5926348 DOI: 10.4103/ijmr.ijmr_2003_15] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background & objectives: India aspires to achieve universal health coverage, which requires ensuring financial risk protection (FRP). This study was done to assess the extent of out-of-pocket (OOP) expenditure and FRP for hospitalization in Haryana State, India. Further, the determinants for FRP were also evaluated. Methods: Data collected as a part of a household level survey conducted in Haryana ‘Concurrent Evaluation of National Rural Health Mission: Haryana Health Survey’ were analyzed. Descriptive analysis was undertaken to assess socio-demographic characteristics, hospitalization rate, extent and determinants of OOP expenditure and FRP. Prevalence of catastrophic health expenditure (CHE) (more than 40% of non-food expenditure) and impoverishment (Int$ 1.25) were estimated. Multivariate logistic regression was used to assess determinants of FRP. Results: Hospitalization rate was found to be 3106 persons or 3307 episodes per 100,000 population. Median OOP expenditure on hospitalization was ₹ 8000 (USD 133), which was predominantly attributed to medicines (37%). Prevalence of CHE was 25.2 per cent with higher prevalence amongst males [odds ratio (OR)=1.30], those belonging to scheduled caste and scheduled tribes (OR=1.35), poorest 20 per cent households (OR=3.05), having injuries (OR=4.03) and non-communicable diseases (OR=3.13) admitted in a private hospital (OR=2.69) and those who were insured (OR=1.74). There was a 12 per cent relative increase in poverty head count due to OOP payments on healthcare. Interpretation & conclusions: Our findings showed that hospitalization resulted in significant OOP expenditure, leading to CHEs and impoverishment of households. Impact of OOP expenditures was inequitably more on the vulnerable groups. OOP expenditure may be curtailed through provision of free medicines and diagnostics and removal of any form of user charges.
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Affiliation(s)
- Deepshikha Sharma
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Shankar Prinja
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Arun Kumar Aggarwal
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Pankaj Bahuguna
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Atul Sharma
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Saroj Kumar Rana
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Prinja S, Balasubramanian D, Jeet G, Verma R, Kumar D, Bahuguna P, Kaur M, Kumar R. Cost of delivering secondary-level health care services through public sector district hospitals in India. Indian J Med Res 2018; 146:354-361. [PMID: 29355142 PMCID: PMC5793470 DOI: 10.4103/ijmr.ijmr_902_15] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND & OBJECTIVES Despite an impetus for strengthening public sector district hospitals for provision of secondary health care in India, there is lack of robust evidence on cost of services provided through these district hospitals. In this study, an attempt was made to determine the unit cost of an outpatient visit consultation, inpatient bed-day of hospitalization, surgical procedure and overall per-capita cost of providing secondary care through district hospitals. METHODS Economic costing of five randomly selected district hospitals in two north Indian States - Haryana and Punjab, was undertaken. Cost analysis was done using a health system perspective and employing bottom-up costing methodology. Quantity of all resources - capital or recurrent, used for delivering services was measured and valued. Median unit costs were estimated along with their 95 per cent confidence intervals. Sensitivity analysis was undertaken to assess the effect of uncertainties in prices and other assumptions; and to generalize the findings for Indian set-up. RESULTS The overall annual cost of delivering secondary-level health care services through a public sector district hospital in north India was ' 11,44,13,282 [US Dollars (USD) 2,103,185]. Human resources accounted for 53 per cent of the overall cost. The unit cost of an inpatient bed-day, surgical procedure and outpatient consultation was ' 844 (USD 15.5), ' 3481 (USD 64) and ' 170 (USD 3.1), respectively. With the current set of resource allocation, per-capita cost of providing health care through district hospitals in north India was ' 139 (USD 2.5). INTERPRETATION & CONCLUSIONS The estimates obtained in our study can be used for Fiscal planning of scaling up secondary-level health services. Further, these may be particularly useful for future research such as benefit-incidence analysis, cost-effectiveness analysis and national health accounts including disease-specific accounts in India.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Deepak Balasubramanian
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Gursimer Jeet
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ramesh Verma
- Department of Community Medicine, Pt. BD Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
| | - Dinesh Kumar
- Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, India
| | - Pankaj Bahuguna
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Manmeet Kaur
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Rajesh Kumar
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Prinja S, Kaur G, Gupta R, Rana SK, Aggarwal AK. Out-of-pocket expenditure for health care: District level estimates for Haryana state in India. Int J Health Plann Manage 2018; 34:277-293. [PMID: 30113728 DOI: 10.1002/hpm.2628] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 07/17/2018] [Accepted: 07/18/2018] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION In this paper, we present district level out-of-pocket (OOP) expenditures with respect to outpatient consultation within last 15 days and hospitalization in last 1 year for Haryana state. METHODS The data from a large cross-sectional household survey covering all 21 districts of Haryana comprising of randomly selected 79 742 households were analyzed. Of the total sample, 56 056 households consisting of 314 639 individuals in 21 districts of Haryana state were surveyed to gather information on OOP expenditure incurred on outpatient consultation within last 15 days. Similarly, 59 901 households and 324 977 respondents were interviewed to elicit OOP expenditures for any hospitalization during the 1 year preceding the survey. Mean OOP expenditure per OP consultation, per hospitalization as well as per capita were computed. Mean OOP expenditure was also estimated by the type of provider, gender, and district. RESULTS The mean OOP expenditure for OP consultation and hospitalization in Haryana was Indian National Rupees (INR) 1005 (US Dollar [USD] 16.1; 95% CI: INR 934-1076) and INR 22 489 (USD 360.0; 95% CI: INR 21 375-23 608), respectively. Mean per capita OOP expenditure for OP consultation, which was INR 85 (USD 1.3) in Haryana, varied from INR 595 (USD 9.5) in district Panipat to INR 29 (USD 0.5) in district Kaithal. CONCLUSION This is the first study to comprehensively present district level estimates for OOP expenditure for health care. These estimates are useful for policy planning, and preparation for district and state health accounts.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gunjeet Kaur
- School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Saroj Kumar Rana
- School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arun Kumar Aggarwal
- School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Jafree SR, Zakar R, Mustafa M, Fischer F. Mothers employed in paid work and their predictors for home delivery in Pakistan. BMC Pregnancy Childbirth 2018; 18:316. [PMID: 30075757 PMCID: PMC6091079 DOI: 10.1186/s12884-018-1945-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 07/19/2018] [Indexed: 11/10/2022] Open
Abstract
Background Pakistan has one of the highest rates of maternal and neonatal mortality in the world. It is assumed that employed mothers in paid work will be more empowered to opt for safer institutional deliveries. There is a need to understand the predictors of home deliveries in order to plan policies to encourage institutional deliveries in the region. Methods The study aimed to ascertain the predictors for home deliveries among mothers employed in paid work in Pakistan. Data analysis is based on secondary data taken from the Pakistan Demographic Health Survey 2012–13. Bivariate and multivariate logistic regression models were conducted. Results The findings show that the majority (53.6%) of employed mothers in Pakistan give birth at home. Employed mothers in paid work with the following characteristics had higher chances for delivering at home: (i) women from rural areas (AOR 1.26; 95% CI: 0.94–1.71), or specific regions within Pakistan, (ii) those occupied in unskilled work (AOR 2.61; 95% CI: 1.76–3.88), (iii) women married to uneducated (AOR 1.70; 95% CI: 1.08–2.66), unemployed (AOR 1.69; 95% CI: 1.21–2.35), or unskilled men (AOR 2.02; 95% CI: 1.49–2.72), (iv) women with more than 7 children (AOR 1.57; 95% CI: 1.05–2.35), (v) women who are unable in the prenatal period to have an institutional check-up (AOR 4.84; 95% CI: 3.53–6.65), take assistance from a physician (AOR 3.98; 95% CI: 3.03–5.20), have a blood analysis (AOR 2.63; 95% CI: 1.95–3.57), urine analysis (AOR 2.48; 95% CI: 1.84–3.33) or taken iron tablets (AOR 2.64; 95% CI: 2.06–3.38), and (vi) are unable to make autonomous decisions with regard to spending their earnings (AOR 1.82; 95% CI: 1.27–2.59) and healthcare (AOR 1.12; 95% CI: 0.75–1.65). Conclusions Greater efforts by the central and provincial state bodies are needed to encourage institutional deliveries and institutional access, quality and cost. Maternal and paternal benefits are needed for workers in both the formal and informal sectors of the economy. Finally, cultural change, through education, media and religious authorities, is necessary to support institutional deliveries and formal sector paid employment and out of home work opportunities for mothers of Pakistan.
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Affiliation(s)
| | - Rubeena Zakar
- Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan
| | - Mudasir Mustafa
- Department of Sociology, Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan
| | - Florian Fischer
- Department of Public Health Medicine, School of Public Health, Bielefeld University, Bielefeld, Germany.
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Prinja S, Bahuguna P, Gupta A, Nimesh R, Gupta M, Thakur JS. Cost effectiveness of mHealth intervention by community health workers for reducing maternal and newborn mortality in rural Uttar Pradesh, India. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:25. [PMID: 29983645 PMCID: PMC6020234 DOI: 10.1186/s12962-018-0110-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 06/13/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND A variety of mobile-based health technologies (mHealth) have been developed for use by community health workers to augment their performance. One such mHealth intervention-ReMiND program, was implemented in a poor performing district of India. Despite some research on the extent of its effectiveness, there is significant dearth of evidence on cost-effectiveness of such mHealth interventions. In this paper we evaluated the incremental cost per disability adjusted life year (DALY) averted as a result of ReMiND intervention as compared to routine maternal and child health programs without ReMiND. METHODS A decision tree was parameterized on MS-Excel spreadsheet to estimate the change in DALYs and cost as a result of implementing ReMiND intervention compared with routine care, from both health system and societal perspective. A time horizon of 10 years starting from base year of 2011 was considered appropriate to cover all costs and effects comprehensively. All costs, including those during start-up and implementation phase, besides other costs on the health system or households were estimated. Consequences were measured as part of an impact assessment study which used a quasi-experimental design. Proximal outputs in terms of changes in service coverage were modelled to estimate maternal and infant illnesses and deaths averted, and DALYs averted in Uttar Pradesh state of India. Probabilistic sensitivity analysis was undertaken to account for parameter uncertainties. RESULTS Cumulatively, from year 2011 to 2020, implementation of ReMiND intervention in UP would result in a reduction of 312 maternal and 149,468 neonatal deaths. This implies that ReMiND program led to a reduction of 0.2% maternal and 5.3% neonatal deaths. Overall, ReMiND is a cost saving intervention from societal perspective. From health system perspective, ReMiND incurs an incremental cost of INR 12,993 (USD 205) per DALY averted and INR 371,577 (USD 5865) per death averted. CONCLUSIONS Overall, findings of our study suggest strongly that the mHealth intervention as part of ReMiND program is cost saving from a societal perspective and should be considered for replication elsewhere in other states.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Pankaj Bahuguna
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Aditi Gupta
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Ruby Nimesh
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Madhu Gupta
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Jarnail Singh Thakur
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
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Prinja S, Bahuguna P, Duseja A, Kaur M, Chawla YK. Cost of Intensive Care Treatment for Liver Disorders at Tertiary Care Level in India. PHARMACOECONOMICS - OPEN 2018; 2:179-190. [PMID: 29623618 PMCID: PMC5972113 DOI: 10.1007/s41669-017-0041-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
BACKGROUND Liver diseases contribute significantly to the health and economic burden globally. We undertook this study to assess the health system costs, out-of-pocket (OOP) expenditure and extent of financial risk protection associated with treatment of liver disorders in a tertiary care public sector hospital in India. METHODOLOGY The present study was undertaken in an intensive care unit (ICU) of a tertiary care hospital in North India. It comprised an ICU and an HDU (high dependency unit). Bottom-up micro-costing was undertaken to assess the health system costs. Data on OOP expenditure and indirect costs were collected for 150 liver disorder patients admitted to the ICU or HDU from December 2013 to October 2014. Per-patient and per-bed-day costs of treatment were estimated from both health system and patient perspectives. Financial risk protection was assessed by computing prevalence of catastrophic health expenditure as a result of OOP expenditure. RESULTS In 2013-2014, health system costs per patient treated in the ICU and HDU were US$2728 [Indian National Rupee (INR) 1,63,664] and US$1966 (INR 1,17,985), respectively. The mean OOP expenditures for treatment in the ICU and HDU were US$2372 (INR 1,42,297) and US$1752 (INR 1,05,093), respectively. Indirect costs of hospitalization in ICU and HDU patients were US$166 (INR 9952) and US$182 (INR 10,903), respectively. CONCLUSION Treatment of chronic liver disorders poses an economic challenge for both the health system and patients. There is a need to focus on prevention of liver disorders, and finding ways to treat patients without exposing their households to the catastrophic effect of OOP expenditure.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Pankaj Bahuguna
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manmeet Kaur
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Yogesh Kumar Chawla
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Kastor A, Mohanty SK. Disease-specific out-of-pocket and catastrophic health expenditure on hospitalization in India: Do Indian households face distress health financing? PLoS One 2018; 13:e0196106. [PMID: 29746481 PMCID: PMC5945043 DOI: 10.1371/journal.pone.0196106] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 04/06/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Rising non-communicable diseases (NCDs) coupled with increasing injuries have resulted in a significant increase in health spending in India. While out-of-pocket expenditure remains the major source of health care financing in India (two-thirds of the total health spending), the financial burden varies enormously across diseases and by the economic well-being of the households. Though prior studies have examined the variation in disease pattern, little is known about the financial risk to the families by type of diseases in India. In this context, the present study examines disease-specific out-of-pocket expenditure (OOPE), catastrophic health expenditure (CHE) and distress health financing. METHODS AND MATERIALS Unit data from the 71st round of the National Sample Survey Organization (2014) was used for this study. OOPE is defined as health spending on hospitalization net of reimbursement, and CHE is defined as household health spending exceeding 10% of household consumption expenditure. Distress health financing is defined as a situation when a household has to borrow money or sell their property/assets or when it gets contributions from friends/relatives to meet its health care expenses. OOPE was estimated for 16 selected diseases and across three broad categories- communicable diseases, NCDs and injuries. Multivariate logistic regression was used to understand the determinants of distress financing and CHE. RESULTS Mean OOPE on hospitalization was INR 19,210 and was the highest for cancer (INR 57,232) followed by heart diseases (INR 40,947). About 28% of the households incurred CHE and faced distress financing. Among all the diseases, cancer caused the highest CHE (79%) and distress financing (43%). More than one-third of the inpatients reported distressed financing for heart diseases, neurological disorders, genito urinary problems, musculoskeletal diseases, gastro-intestinal problems and injuries. The likelihood of incurring distress financing was 3.2 times higher for those hospitalized for cancer (OR 3.23; 95% CI: 2.62-3.99) and 2.6 times for tuberculosis patients (OR 2.61; 95% CI: 2.06-3.31). A large proportion of households who had reported distress financing also incurred CHE. RECOMMENDATIONS Free treatment for cancer and heart diseases is recommended for the vulnerable sections of the society. Risk-pooling and social security mechanisms based on contributions from both households as well as the central and state governments can reduce the financial burden of diseases and avert households from distress health financing.
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Affiliation(s)
- Anshul Kastor
- Department of Fertility Studies, International Institute for Population Sciences (IIPS), Deonar, Mumbai, India
- * E-mail:
| | - Sanjay K. Mohanty
- Department of Fertility Studies, International Institute for Population Sciences (IIPS), Deonar, Mumbai, India
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Sharma A, Prinja S, Aggarwal AK. Measurement of health system performance at district level: A study protocol. J Public Health Res 2018; 6:917. [PMID: 29441330 PMCID: PMC5806037 DOI: 10.4081/jphr.2017.917] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 09/20/2017] [Accepted: 10/04/2017] [Indexed: 01/17/2023] Open
Abstract
Background Limited efforts have been observed in low and middle income countries to undertake health system performance assessment at district level. Absence of a comprehensive data collection tool and lack of a standardised single summary measure defining overall performance are some of the main problems. Present study has been undertaken to develop a summary composite health system performance index at district level. Methods A broad range of indicators covering all six domains as per building block framework were finalized by an expert panel. The domains were classified into twenty sub-domains, with 70 input and process indicators to measure performance. Seven sub-domains for assessing health system outputs and outcomes were identified, with a total of 28 indicators. Districts in Haryana state from north India were selected for the study. Primary and secondary data will be collected from 378 health facilities, district and state health directorate headquarters. Indicators will be normalized, aggregated to generate composite performance index at district level. Domain specific scores will present the quality of individual building block domains in the public health system. Robustness of the results will be checked using sensitivity analysis. Expected impact for public health: The study presents a methodology for comprehensive assessment of all health system domains on basis of input, process, output and outcome indicators which has never been reported from India. Generation of this index will help identify policy and implementation areas of concern and point towards potential solutions. Results may also help understand relationships between individual building blocks and their sub-components. Significance for public health Measuring performance of health system is important to understand progress and challenges, and create systems that are efficient, equitable and patient-focused. However, very few assessments of such nature have been observed in low and middle income countries, especially at district level, mainly because of methodological challenges. This study presents a methodology for comprehensive assessment of all domains of health system and generation of a composite Health System Performance Index on the basis of input, process, output and outcome indicators. It will help identify policy and implementation problems worthy of attention and point towards potential solutions to health system bottlenecks resulting in poor performance. The results may also help better understand the relationships between individual building blocks and their sub-components and the overall performance of the health system.
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Affiliation(s)
- Atul Sharma
- School of Public Health, Post-graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shankar Prinja
- School of Public Health, Post-graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arun Kumar Aggarwal
- School of Public Health, Post-graduate Institute of Medical Education and Research, Chandigarh, India
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Dalinjong PA, Wang AY, Homer CSE. The operations of the free maternal care policy and out of pocket payments during childbirth in rural Northern Ghana. HEALTH ECONOMICS REVIEW 2017; 7:41. [PMID: 29168019 PMCID: PMC5700011 DOI: 10.1186/s13561-017-0180-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 11/09/2017] [Indexed: 05/27/2023]
Abstract
BACKGROUND To promote skilled attendance at births and reduce maternal deaths, the government of Ghana introduced the free maternal care policy under the National Health Insurance Scheme (NHIS) in 2008. The objective is to eliminate financial barriers associated with the use of services. But studies elsewhere showed that out of pocket (OOP) payments still exist in the midst of fee exemptions. The aim of this study was to estimate OOP payments and the financial impact on women during childbirth in one rural and poor area of Northern Ghana; the Kassena-Nankana municipality. Costs were taken from the perspective of women. METHODS Quantitative and qualitative data collection techniques were used in a convergent parallel mixed methods study. The study used structured questionnaire (n = 353) and focus group discussions (FGDs =7) to collect data from women who gave birth in health facilities. Quantitative data from the questionnaire were analysed, using descriptive statistics. Qualitative data from the FGDs were recorded, transcribed and analysed to determine common themes. RESULTS The overall mean OOP payments during childbirth was GH¢33.50 (US$17), constituting 5.6% of the average monthly household income. Over one-third (36%, n = 145) of women incurred OOP payments which exceeded 10% of average monthly household income (potentially catastrophic). Sixty-nine percent (n = 245) of the women perceived that the NHIS did not cover all expenses incurred during childbirth; which was confirmed in the FGDs. Both survey and FGDs demonstrated that women made OOP payments for drugs and other supplies. The FGDs showed women bought disinfectants, soaps, rubber pads and clothing for newborns as well. Seventy-five percent (n = 264) of the women used savings, but 19% had to sell assets to finance the payments; this was supported in the FGDs. CONCLUSION The NHIS policy has not eliminated financial barriers associated with childbirth which impacts the welfare of some women. Women continued to make OOP payments, largely as a result of a delay in reimbursement by the NHIS. There is need to re-examine the reimbursement system in order to prevent shortage of funding to health facilities and thus encourage skilled attendance for the reduction of maternal deaths as well as the achievement of universal health coverage.
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Affiliation(s)
- Philip Ayizem Dalinjong
- Faculty of Health, University of Technology Sydney, Building 10, Level 7&8, Jones Street, Ultimo, PO Box 222, Sydney, NSW 2007 Australia
| | - Alex Y. Wang
- Faculty of Health, University of Technology Sydney, Building 10, Level 7&8, Jones Street, Ultimo, PO Box 222, Sydney, NSW 2007 Australia
| | - Caroline S. E. Homer
- Faculty of Health, University of Technology Sydney, Building 10, Level 7&8, Jones Street, Ultimo, PO Box 222, Sydney, NSW 2007 Australia
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Anderson GA, Ilcisin L, Kayima P, Abesiga L, Portal Benitez N, Ngonzi J, Ronald M, Shrime MG. Out-of-pocket payment for surgery in Uganda: The rate of impoverishing and catastrophic expenditure at a government hospital. PLoS One 2017; 12:e0187293. [PMID: 29088302 PMCID: PMC5663485 DOI: 10.1371/journal.pone.0187293] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 10/17/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES It is Ugandan governmental policy that all surgical care delivered at government hospitals in Uganda is to be provided to patients free of charge. In practice, however, frequent stock-outs and broken equipment require patients to pay for large portions of their care out of their own pocket. The purpose of this study was to determine the financial impact on patients who undergo surgery at a government hospital in Uganda. METHODS Every surgical patient discharged from a surgical ward at a large regional referral hospital in rural southwestern Uganda over a 3-week period in April 2016 was asked to participate. Patients who agreed were surveyed to determine their baseline level of poverty and to assess the financial impact of the hospitalization. Rates of impoverishment and catastrophic expenditure were then calculated. An "impoverishing expense" is defined as one that pushes a household below published poverty thresholds. A "catastrophic expense" was incurred if the patient spent more than 10% of their average annual expenditures. RESULTS We interviewed 295 out of a possible 320 patients during the study period. 46% (CI 40-52%) of our patients met the World Bank's definition of extreme poverty ($1.90/person/day). After receiving surgical care an additional 10 patients faced extreme poverty, and 5 patients were newly impoverished by the World Bank's definition ($3.10/person/day). 31% of patients faced a catastrophic expenditure of more than 10% of their estimated total yearly expenses. 53% of the households in our study had to borrow money to pay for care, 21% had to sell possessions, and 17% lost a job as a result of the patient's hospitalization. Only 5% of our patients received some form of charity. CONCLUSIONS AND RELEVANCE Despite the government's policy to provide "free care," undergoing an operation at a government hospital in Uganda can result in a severe economic burden to patients and their families. Alternative financing schemes to provide financial protection are critically needed.
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Affiliation(s)
- Geoffrey A. Anderson
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Lenka Ilcisin
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Peter Kayima
- Department of Surgery, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lenard Abesiga
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Joseph Ngonzi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mayanja Ronald
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark G. Shrime
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Tripathy JP, Shewade HD, Mishra S, Kumar AMV, Harries AD. Cost of hospitalization for childbirth in India: how equitable it is in the post-NRHM era? BMC Res Notes 2017; 10:409. [PMID: 28810897 PMCID: PMC5556367 DOI: 10.1186/s13104-017-2729-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 08/06/2017] [Indexed: 11/24/2022] Open
Abstract
Background and objective Information on out-of-pocket (OOP) expenditure during childbirth in public and private health facilities in India is needed to make rational decisions for improving affordability to maternal care services. We undertook this study to evaluate the OOP expenditure due to hospitalization from childbirth and its impact on households. Methods This is a secondary data analysis of a nationwide household survey by the National Sample Survey Organization in 2014. The survey reported health service utilization and health care related expenditure by income quintiles and type of health facility. The recall period for hospitalization expenditure was 365 days. OOP expenditure amounting to more than 10% of annual consumption expenditure was termed as catastrophic. Results Median expenditure per episode of hospitalisation due to childbirth was US$54. The expenditure incurred was about six times higher among the richest quintile compared to the poorest quintile. Median private sector OOP hospitalization expenditure was nearly nine times higher than in the public sector. Hospitalization in a private sector facility leads to a significantly higher prevalence of catastrophic expenditure than hospitalization in a public sector (60% vs. 7%). Indirect cost (43%) constituted the largest share in the total expenditure in public sector hospitalizations. Urban residence, poor wealth quintile, residing in eastern and southern regions of India and delivery in private hospital were significantly associated with catastrophic expenditure. Conclusions We strongly recommend cash transfer schemes with effective pro-poor targeting to reduce the impact of catastrophic expenditure. Strengthening of public health facilities is required along with private sector regulation.
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Affiliation(s)
- Jaya Prasad Tripathy
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, C-6, Qutub Institutional Area, New Delhi, 110016, India.
| | - Hemant D Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, C-6, Qutub Institutional Area, New Delhi, 110016, India
| | | | - A M V Kumar
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, C-6, Qutub Institutional Area, New Delhi, 110016, India
| | - A D Harries
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,London School of Hygiene and Tropical Medicine, London, UK
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Kaur G, Prinja S, Malhotra P, Lad DP, Prakash G, Khadwal A, Ramachandran R, Varma S. Cost of Treatment of Multiple Myeloma in a Public Sector Tertiary Care Hospital of North India. Indian J Hematol Blood Transfus 2017; 34:25-31. [PMID: 29398796 DOI: 10.1007/s12288-017-0843-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/27/2017] [Indexed: 12/22/2022] Open
Abstract
Multiple myeloma (MM) is a neoplastic disorder, which accounts for 13% of all hematological malignancies globally. While, conventional chemotherapy used to be the mainstay treatment for the disease, the landscape of treatment witnessed a paradigm shift with the introduction of high-dose chemotherapy and autologous stem cell transplant (ASCT). In this paper, we present a cost analysis of various services provided to multiple myeloma patients, using either of the two modalities of treatments i.e. conventional chemotherapy or ASCT. Bottom-up costing methodology was used to collect data on all health system resources, i.e. capital or recurrent, which were used to provide various services to MM patients. Capital costs were annualized for their useful life using a discount rate of 5%. Out of pocket expenditure on treatment was also ascertained. Cost was assessed for various services, including outpatient consultation, bed day hospitalization in general ward, high dependency unit intensive care setting and bone marrow transplant unit. Unit costs were calculated from both health system and patient perspective. The overall cost per patient for ASCT (including high dose chemotherapy) and conventional chemotherapy from societal perspective was INR 395,527 (USD 6085) and INR 62,785 (USD 966) respectively. Estimates on cost from our study could be used for planning health services, and evaluating cost effectiveness of different modalities of care for multiple myeloma.
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Affiliation(s)
- Gunjeet Kaur
- 1School of Public Health, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Shankar Prinja
- 1School of Public Health, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Pankaj Malhotra
- 2Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepesh P Lad
- 2Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Prakash
- 2Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alka Khadwal
- 2Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- 3Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhash Varma
- 2Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Downey LE, Mehndiratta A, Grover A, Gauba V, Sheikh K, Prinja S, Singh R, Cluzeau FA, Dabak S, Teerawattananon Y, Kumar S, Swaminathan S. Institutionalising health technology assessment: establishing the Medical Technology Assessment Board in India. BMJ Glob Health 2017; 2:e000259. [PMID: 29225927 PMCID: PMC5717947 DOI: 10.1136/bmjgh-2016-000259] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 05/20/2017] [Accepted: 05/22/2017] [Indexed: 11/04/2022] Open
Abstract
India is at crossroads with a commitment by the government to universal health coverage (UHC), driving efficiency and tackling waste across the public healthcare sector. Health technology assessment (HTA) is an important policy reform that can assist policy-makers to tackle inequities and inefficiencies by improving the way in which health resources are allocated towards cost-effective, appropriate and feasible interventions. The equitable and efficient distribution of health budget resources, as well as timely uptake of good value technologies, are critical to strengthen the Indian healthcare system. The government of India is set to establish a Medical Technology Assessment Board to evaluate existing and new health technologies in India, assist choices between comparable technologies for adoption by the healthcare system and improve the way in which priorities for health are set. This initiative aims to introduce a more transparent, inclusive, fair and evidence-based process by which decisions regarding the allocation of health resources are made in India towards the ultimate goal of UHC. In this analysis article, we report on plans and progress of the government of India for the institutionalisation of HTA in the country. Where India is home to one-sixth of the global population, improving the health services that the population receives will have a resounding impact not only for India but also for global health.
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Affiliation(s)
- Laura E Downey
- Global Health and Development, Imperial College London, London, UK
| | - Abha Mehndiratta
- Global Health and Development, Imperial College London, London, UK
| | - Ashoo Grover
- Indian Council of Medical Research, New Delhi, Delhi, India
| | - Vijay Gauba
- Department of Health Research, Ministry of Health and Family Welfare, New Delhi, Delhi, India
| | - Kabir Sheikh
- Public Health Foundation of India, New Delhi, Delhi, India
| | | | - Ravinder Singh
- Indian Council of Medical Research, New Delhi, Delhi, India
| | | | - Saudamini Dabak
- Health Intervention and Technology Assessment Program, Nonthaburi, Thailand
| | | | - Sanjiv Kumar
- National Health Systems Resource Centre, Delhi, India
| | - Soumya Swaminathan
- Indian Council of Medical Research, New Delhi, Delhi, India.,Public Health Foundation of India, New Delhi, Delhi, India
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Prinja S, Nimesh R, Gupta A, Bahuguna P, Gupta M, Thakur JS. Impact of m-health application used by community health volunteers on improving utilisation of maternal, new-born and child health care services in a rural area of Uttar Pradesh, India. Trop Med Int Health 2017; 22:895-907. [PMID: 28510997 DOI: 10.1111/tmi.12895] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To raise the quality of counselling by community health volunteers resulting in improved uptake of maternal, neonatal and child health services (MNCH), an m-health application was introduced under a project named 'Reducing Maternal and Newborn Deaths (ReMiND)' in district Kaushambi in India. We report the impact of this project on coverage of key MNCH services. METHODS A pre- and post-quasi-experimental design was undertaken to assess the impact of intervention. This project was introduced in two community development blocks in Kaushambi district in 2012. Two other blocks from the same district were selected as controls after matching for coverage of two indicators at baseline - antenatal care and institutional deliveries. The Annual Health Survey conducted by the Ministry of Health and Family Welfare in 2011 served as pre-intervention data, whereas a household survey in four blocks of Kaushambi district in 2015 provided post-intervention coverage of key services. Propensity score matched samples from intervention and control areas in pre-intervention and post-intervention periods were analysed using difference-in-difference method to estimate the impact of ReMiND project. RESULTS We found a statistically significant increase in coverage of iron-folic acid supplementation (12.58%), self-reporting of complication during pregnancy (13.11%) and after delivery (19.6%) in the intervention area. The coverage of three or more antenatal care visits, tetanus toxoid vaccination, full antenatal care and ambulance usage increased in intervention area by 10.3%, 4.28%, 1.1% and 2.06%, respectively; however, the changes were statistically insignificant. CONCLUSION Three of eight services which were targeted for improvement under ReMiND project registered a significant improvement as result of m-health intervention.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ruby Nimesh
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aditi Gupta
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Bahuguna
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhu Gupta
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jarnail Singh Thakur
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Gupta A, Reddy BV, Semwal V, Singh AK. Financial Burden of Out-of-Pocket Expenditures for Primary Health Care in Hilly Areas of Garhwal Region, Uttarakhand, North India. J Clin Diagn Res 2017; 11:LC08-LC11. [PMID: 28571170 DOI: 10.7860/jcdr/2017/24761.9646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 02/14/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION High total health expenditures via Out-of-Pocket (OOP) as formal user fees and informal payments put India in challenging situation to achieve towards universal health coverage. AIM To assess the (OOP) expenditure and its determinants among outpatient in primary care settings of Uttarakhand, North India. MATERIALS AND METHODS A hospital based cross-sectional study was conducted in a Outpatient Department of Urban Health Training Centre, Srinagar, Uttarakhand, India and Rural Health Training Centre, Kritinagar, Uttarakhand in 2015. A total of 200 patients were enrolled in the study using random sampling. Questionnaire covering costs like: travel cost, drug cost, investigation cost, and others was used for measuring OOP expenditure incurred toward health care by patients. RESULTS Of the total 200 patients, 43.5% were males and 56.5% were females with mean age 40.36 (SD 19.45) in years. Average annual family income was 11718.5 INR±13457.3 INR. Of the total study subjects, 42.5% were unskilled or had no occupation (unemployed, student, and homemaker). The majority (68.5%) had travelled less than or equal to 10 km to reach the health facility. About 50% of the study subjects presented with communicable diseases and 20% with non-communicable diseases. The health expenditure of the outpatient revealed that major part of the expenditure is the direct cost of the treatment, including registration fee, drugs, and investigation. Mean OOP expenditure for drugs and investigations was 509 INR and 673.1 INR, respectively. Mean total out-of-patient expenditure was 303.1 INR. The proportion of monthly family income spent on out-of-patient expenditure was 2.58%. CONCLUSION The implementation of primary health care needs to be further strengthened in order to improve access of public sector hospitals for curative care.
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Affiliation(s)
- Arti Gupta
- Assistant Professor, Department of Community Medicine, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Garhwal, Uttrakhand, India
| | - B Venkatashiva Reddy
- Assistant Professor, Department of Community Medicine, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Garhwal, Uttarahand, India
| | - Vandana Semwal
- Assistant Professor, Department of Community Medicine, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Garhwal, Uttarakhand, India
| | - Amit Kumar Singh
- Professor and Head, Department of Community Medicine, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Garhwal, Uttarahand, India
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Prinja S, Kaur G, Malhotra P, Jyani G, Ramachandran R, Bahuguna P, Varma S. Cost-Effectiveness of Autologous Stem Cell Treatment as Compared to Conventional Chemotherapy for Treatment of Multiple Myeloma in India. Indian J Hematol Blood Transfus 2017; 33:31-40. [PMID: 28194053 PMCID: PMC5280872 DOI: 10.1007/s12288-017-0776-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 12/27/2016] [Indexed: 12/12/2022] Open
Abstract
Recent innovations in treatment of multiple myeloma include autologous stem cell transplantation (ASCT) along with high dose chemotherapy (HDC). We undertook this study to estimate incremental cost per quality adjusted life year gained (QALY) with use of ASCT along with HDC as compared to conventional chemotherapy (CC) alone in treatment of multiple myeloma. A combination of decision tree and markov model was used to undertake the analysis. Incremental costs and effects of ASCT were compared against the baseline scenario of CC (based on Melphalan and Prednisolone regimen) in the patients of multiple myeloma. A lifetime study horizon was used and future costs and consequences were discounted at 5%. Consequences were valued in terms of QALYs. Incremental cost per QALY gained using ASCT as against CC for treatment of multiple myeloma was estimated using both a health system and societal perspective. The cost of providing ASCT (with HDC) for multiple myeloma patients was INR 500,631, while the cost of CC alone was INR 159,775. In the long run, cost per patient per year for ASCT and CC arms was estimated to be INR 119,740 and INR 111,565 respectively. The number of QALYs lived per patient in case of ASCT and HDC alone were found to be 4.1 and 3.5 years respectively. From a societal perspective, ASCT was found to incur an incremental cost of INR 334,433 per QALY gained. If the ASCT is initiated early to patients, the incremental cost for ASCT was found to be INR 180,434 per QALY gained. With current mix of patients, stem cell treatment for multiple myeloma is not cost effective at a threshold of GDP per capita. It becomes marginally cost-effective at 3-times the GDP per capita threshold. However, accounting for the model uncertainties, the probability of ASCT to be cost effective is 59%. Cost effectiveness of ASCT can be improved with early detection and initiation of treatment.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Gunjeet Kaur
- School of Public Health, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Pankaj Malhotra
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Jyani
- School of Public Health, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Raja Ramachandran
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Bahuguna
- School of Public Health, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Prinja S, Chauhan AS, Karan A, Kaur G, Kumar R. Impact of Publicly Financed Health Insurance Schemes on Healthcare Utilization and Financial Risk Protection in India: A Systematic Review. PLoS One 2017; 12:e0170996. [PMID: 28151946 PMCID: PMC5289511 DOI: 10.1371/journal.pone.0170996] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 01/13/2017] [Indexed: 11/18/2022] Open
Abstract
Several publicly financed health insurance schemes have been launched in India with the aim of providing universalizing health coverage (UHC). In this paper, we report the impact of publicly financed health insurance schemes on health service utilization, out-of-pocket (OOP) expenditure, financial risk protection and health status. Empirical research studies focussing on the impact or evaluation of publicly financed health insurance schemes in India were searched on PubMed, Google scholar, Ovid, Scopus, Embase and relevant websites. The studies were selected based on two stage screening PRISMA guidelines in which two researchers independently assessed the suitability and quality of the studies. The studies included in the review were divided into two groups i.e., with and without a comparison group. To assess the impact on utilization, OOP expenditure and health indicators, only the studies with a comparison group were reviewed. Out of 1265 articles screened after initial search, 43 studies were found eligible and reviewed in full text, finally yielding 14 studies which had a comparator group in their evaluation design. All the studies (n-7) focussing on utilization showed a positive effect in terms of increase in the consumption of health services with introduction of health insurance. About 70% studies (n-5) studies with a strong design and assessing financial risk protection showed no impact in reduction of OOP expenditures, while remaining 30% of evaluations (n-2), which particularly evaluated state sponsored health insurance schemes, reported a decline in OOP expenditure among the enrolled households. One study which evaluated impact on health outcome showed reduction in mortality among enrolled as compared to non-enrolled households, from conditions covered by the insurance scheme. While utilization of healthcare did improve among those enrolled in the scheme, there is no clear evidence yet to suggest that these have resulted in reduced OOP expenditures or higher financial risk protection.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Akashdeep Singh Chauhan
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anup Karan
- Indian Institute of Public Health, Delhi, Public Health Foundation of India, Delhi NCR, India
| | - Gunjeet Kaur
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Kumar
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Das S, Alcock G, Azad K, Kuddus A, Manandhar DS, Shrestha BP, Nair N, Rath S, More NS, Saville N, Houweling TAJ, Osrin D. Institutional delivery in public and private sectors in South Asia: a comparative analysis of prospective data from four demographic surveillance sites. BMC Pregnancy Childbirth 2016; 16:273. [PMID: 27649897 PMCID: PMC5029035 DOI: 10.1186/s12884-016-1069-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 09/13/2016] [Indexed: 11/29/2022] Open
Abstract
Background Maternity care in South Asia is available in both public and private sectors. Using data from demographic surveillance sites in Bangladesh, Nepal and rural and urban India, we aimed to compare institutional delivery rates and public-private share. Methods We used records of maternity care collected in socio-economically disadvantaged communities between 2005 and 2011. Institutional delivery was summarized by four potential determinants: household asset index, maternal schooling, maternal age, and parity. We developed logistic regression models for private sector institutional delivery with these as independent covariates. Results The data described 52 750 deliveries. Institutional delivery proportion varied and there were differences in public-private split. In Bangladesh and urban India, the proportion of deliveries in the private sector increased with wealth, maternal education, and age. The opposite was observed in rural India and Nepal. Conclusions The proportion of institutional delivery increased with economic status and education. The choice of sector is more complex and provision and perceived quality of public sector services is likely to play a role. Choices for safe maternity are influenced by accessibility, quantity and perceived quality of care. Along with data linkage between private and public sectors, increased regulation should be part of the development of the pluralistic healthcare systems that characterize south Asia. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1069-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sushmita Das
- SNEHA (Society for Nutrition, Education and Health Action), 310, Urban Health Centre, 60 Feet Road, Dharavi, Mumbai, 400 017, Maharashtra, India
| | - Glyn Alcock
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Kishwar Azad
- Perinatal Care Project, Diabetic Association of Bangladesh, 122 Kazi Nazrul Islam Avenue, Dhaka, 1000, Bangladesh
| | - Abdul Kuddus
- Perinatal Care Project, Diabetic Association of Bangladesh, 122 Kazi Nazrul Islam Avenue, Dhaka, 1000, Bangladesh
| | - Dharma S Manandhar
- Mother and Infant Research Activities (MIRA), YB Bhavan, Thapathali, GPO Box 921, Kathmandu, Nepal
| | - Bhim Prasad Shrestha
- Mother and Infant Research Activities (MIRA), YB Bhavan, Thapathali, GPO Box 921, Kathmandu, Nepal
| | - Nirmala Nair
- Ekjut, Plot 556B, Potka, Chakradharpur, West Singhbhum, Jharkhand, India
| | - Shibanand Rath
- Ekjut, Plot 556B, Potka, Chakradharpur, West Singhbhum, Jharkhand, India
| | - Neena Shah More
- SNEHA (Society for Nutrition, Education and Health Action), 310, Urban Health Centre, 60 Feet Road, Dharavi, Mumbai, 400 017, Maharashtra, India
| | - Naomi Saville
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Tanja A J Houweling
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - David Osrin
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK.
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Cost of Delivering Health Care Services in Public Sector Primary and Community Health Centres in North India. PLoS One 2016; 11:e0160986. [PMID: 27536781 PMCID: PMC4990301 DOI: 10.1371/journal.pone.0160986] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 07/28/2016] [Indexed: 11/19/2022] Open
Abstract
Background With the commitment of the national government to provide universal healthcare at cheap and affordable prices in India, public healthcare services are being strengthened in India. However, there is dearth of cost data for provision of health services through public system like primary & community health centres. In this study, we aim to bridge this gap in evidence by assessing the total annual and per capita cost of delivering the package of health services at PHC and CHC level. Secondly, we determined the per capita cost of delivering specific health services like cost per antenatal care visit, per institutional delivery, per outpatient consultation, per bed-day hospitalization etc. Methods We undertook economic costing of fourteen public health facilities (seven PHCs and CHCs each) in three North-Indian states viz., Haryana, Himachal Pradesh and Punjab. Bottom-up costing method was adopted for collection of data on all resources spent on delivery of health services in selected health facilities. Analysis was undertaken using a health system perspective. The joint costs like human resource, capital, and equipment were apportioned as per the time value spent on a particular service. Capital costs were discounted and annualized over the estimated life of the item. Mean annual costs and unit costs were estimated along with their 95% confidence intervals using bootstrap methodology. Results The overall annual cost of delivering services through public sector primary and community health facilities in three states of north India were INR 8.8 million (95% CI: 7,365,630–10,294,065) and INR 26.9 million (95% CI: 22,225,159.3–32,290,099.6), respectively. Human resources accounted for more than 50% of the overall costs at both the level of PHCs and CHCs. Per capita per year costs for provision of complete package of preventive, curative and promotive services at PHC and CHC were INR 170.8 (95% CI: 131.6–208.3) and INR162.1 (95% CI: 112–219.1), respectively. Conclusion The study estimates can be used for financial planning of scaling up of similar health services in the urban areas under the aegis of National Health Mission. The estimates would be also useful in undertaking equity analysis and full economic evaluations of the health systems.
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Prinja S, Gupta R, Bahuguna P, Sharma A, Kumar Aggarwal A, Phogat A, Kumar R. A composite indicator to measure universal health care coverage in India: way forward for post-2015 health system performance monitoring framework. Health Policy Plan 2016; 32:43-56. [PMID: 27497138 DOI: 10.1093/heapol/czw097] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is limited work done on developing methods for measurement of universal health coverage. We undertook a study to develop a methodology and demonstrate the practical application of empirically measuring the extent of universal health coverage at district level. Additionally, we also develop a composite indicator to measure UHC. METHODS A cross-sectional survey was undertaken among 51 656 households across 21 districts of Haryana state in India. Using the WHO framework for UHC, we identified indicators of service coverage, financial risk protection, equity and quality based on the Government of India and the Haryana Government's proposed UHC benefit package. Geometric mean approach was used to compute a composite UHC index (CUHCI). Various statistical approaches to aggregate input indicators with or without weighting, along with various incremental combinations of input indicators were tested in a comprehensive sensitivity analysis. FINDINGS The population coverage for preventive and curative services is presented. Adjusting for inequality, the coverage for all the indicators were less than the unadjusted coverage by 0.1-6.7% in absolute term and 0.1-27% in relative term. There was low unmet need for curative care. However, about 11% outpatient consultations were from unqualified providers. About 30% households incurred catastrophic health expenditures, which rose to 38% among the poorest 20% population. Summary index (CUHCI) for UHC varied from 12% in Mewat district to 71% in Kurukshetra district. The inequality unadjusted coverage for UHC correlates highly with adjusted coverage. CONCLUSION Our paper is an attempt to develop a methodology to measure UHC. However, careful inclusion of others indicators of service coverage is recommended for a comprehensive measurement which captures the spirit of universality. Further, more work needs to be done to incorporate quality in the measurement framework.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Rakesh Gupta
- Office of Chief Minister, Government of Haryana, Chandigarh 160012, India
| | - Pankaj Bahuguna
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Atul Sharma
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Arun Kumar Aggarwal
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Amit Phogat
- National Rural Health Mission, Department of Health and Family Welfare, Panchkula - 134109, Haryana, India
| | - Rajesh Kumar
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Effectiveness of Multiple-Strategy Community Intervention in Reducing Geographical, Socioeconomic and Gender Based Inequalities in Maternal and Child Health Outcomes in Haryana, India. PLoS One 2016; 11:e0150537. [PMID: 27003589 PMCID: PMC4803212 DOI: 10.1371/journal.pone.0150537] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 02/15/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The implemented multiple-strategy community intervention National Rural Health Mission (NRHM) between 2005 and 2012 aimed to reduce maternal and child health (MCH) inequalities across geographical, socioeconomic and gender categories in India. The objective of this study is to quantify the extent of reduction in these inequalities pre- and post-NRHM in Haryana, North India. METHODS Data of district-level household surveys (DLHS) held before (2002-04), during (2007-08), and after (2012-13) the implementation of NRHM has been used. Geographical, socioeconomic and gender inequalities in maternal and child health were assessed by estimating the absolute differences in MCH indicators between urban and rural areas, between the most advantaged and least advantaged socioeconomic groups and between male and female children. Logistic regression analyses were done to observe significant differences in these inequalities between 2005 and 2012. RESULTS There were significant improvements in all MCH indicators (p<0.05). The geographical and socioeconomic differences between urban and rural areas, and between rich and poor were significantly (p<0.05) reduced for pregnant women who had an institutional delivery (geographical difference declining from 22% to 7.6%; socioeconomic from 48.2% to 13%), post-natal care within 2 weeks of delivery (2.8% to 1.5%; 30.3% to 7%); and for children with full vaccination (10% to 3.5%, 48.3% to 14%) and who received oral rehydration solution (ORS) for diarrhea (11% to -2.2%; 41% to 5%). Inequalities between male and female children were significantly (p<0.05) reversed for full immunization (5.7% to -0.6%) and BCG immunization (1.9 to -0.9 points), and a significant (p<0.05) decrease was observed for oral polio vaccine (4.0% to 0%) and measles vaccine (4.2% to 0.1%). CONCLUSIONS The implemented multiple-strategy community intervention National Rural Health Mission (NRHM) between 2005 and 2012 might have resulted in significant reductions in geographical, socioeconomic and gender inequalities in MCH in Haryana, as causal relationships cannot be established with descriptive research.
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