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Thomas AR, Muhammad T, Sahu SK, Dash U. Examining the factors contributing to a reduction in hardship financing among inpatient households in India. Sci Rep 2024; 14:7164. [PMID: 38532118 DOI: 10.1038/s41598-024-57984-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 03/24/2024] [Indexed: 03/28/2024] Open
Abstract
In India, the rising double burden of diseases and the low fiscal capacity of the government forces people to resort to hardship financing. This study aimed to examine the factors contributing to the reduction in hardship financing among inpatient households in India. The study relies on two rounds of National Sample Surveys with a sample of 34,478 households from the 71st round (2014) and 56,681 households from the 75th round (2018). We employed multivariable logistic regression and multivariate decomposition analyses to explore the factors associated with hardship financing in Indian households with hospitalized member(s) and assess the contributing factors to the reduction in hardship financing between 2014 and 2018. Notably, though hardship financing for inpatient households has decreased between 2014 and 2018, households with catastrophic health expenditure (CHE) had higher odds of hardship financing than those without CHE. While factors such as CHE, prolonged hospitalization, and private hospitals had impoverishing effects on hardship financing in 2014 and 2018, the decomposition model showed the potential of CHE (32%), length of hospitalization (32%), and private hospitals (24%) to slow down this negative impact over time. The findings showed the potential for further improvements in financial health protection for inpatient care over time, and underscore the need for continuing efforts to strengthen the implementation of public programs and schemes in India such as Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY).
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Affiliation(s)
- Arya Rachel Thomas
- Department of Humanities and Social Sciences, Indian Institute of Technology (IIT), Madras, Chennai, Tamil Nadu, 600036, India.
| | - T Muhammad
- Department of Family and Generations, International Institute for Population Sciences, Mumbai, Maharashtra, 400088, India
| | - Santosh Kumar Sahu
- Department of Humanities and Social Sciences, Indian Institute of Technology (IIT), Madras, Chennai, Tamil Nadu, 600036, India
| | - Umakant Dash
- Institute of Rural Management Anand (IRMA), Near NDDB, PO Box-60, Anand, Gujarat, 388001, India
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Aashima, Sharma R. A Systematic Review of the World's Largest Government Sponsored Health Insurance Scheme for 500 Million Beneficiaries in India: Pradhan Mantri Jan Arogya Yojana. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:17-32. [PMID: 37801262 DOI: 10.1007/s40258-023-00838-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND AND OBJECTIVE In pursuit of universal health coverage, India has launched the world's largest government-sponsored health insurance scheme, Pradhan Mantri Jan Arogya Yojana (PM-JAY) in 2018. This study aims to provide a holistic review of the scheme's impact since its inception. METHODS We reviewed studies (based on interviews or surveys) published from September 2018 to January 2023, which were retrieved from PubMed, Web of Science, and Scopus database. The main outcomes studied were: (1) awareness; (2) utilization of scheme; (3) experiences; (4) financial protection; and (5) challenges encountered by both beneficiaries and healthcare providers. RESULTS A total of 18 studies conducted across 14 states and union territories of India were reviewed. The findings revealed that although PM-JAY has become a familiar name, there remains a low level of awareness regarding various facets of the scheme such as benefits entitled, hospitals empanelled, and services covered. The scheme is benefitting the poor and vulnerable population to access healthcare services that were previously unaffordable to them. However, financial protection provided by the scheme exhibited mixed results. Several challenges were identified, including continued spending by beneficiaries on drugs and diagnostic tests, delays in issuance of beneficiary cards, and co-payments demanded by healthcare providers. Additionally, private hospitals expressed dissatisfaction with low health package rates and delays in claims reimbursement. CONCLUSIONS Concerted efforts such as population-wide dissemination of clear and complete knowledge of the scheme, providing training to healthcare providers, addressing infrastructural gaps and concerns of healthcare providers, and ensuring appropriate stewardship are imperative to achieve the desired objectives of the scheme in the long-run.
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Affiliation(s)
- Aashima
- University School of Management and Entrepreneurship, Delhi Technological University, New Delhi, India
| | - Rajesh Sharma
- Department of Humanities and Social Sciences, National Institute of Technology Kurukshetra, Kurukshetra, 136119, Haryana, India.
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Sharma SK, Joseph J, D HS, Nambiar D. Assessing inequalities in publicly funded health insurance scheme coverage and out-of-pocket expenditure for hospitalization: findings from a household survey in Kerala. Int J Equity Health 2023; 22:197. [PMID: 37759247 PMCID: PMC10537906 DOI: 10.1186/s12939-023-02005-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Increasing financial risk protection is a key feature of Universal Health Coverage and the path towards health for all. Publicly Funded Health Insurance Schemes (PFHIS) have been considered as one of the pathways to safeguard against financial shocks and potentially reduce Out-of-Pocket Expenditure (OOPE). The south Indian state of Kerala has roughly a decade-long experience in implementing PFHIS. To date, there have been very few assessments of the coverage of these schemes and their impact on expenditure. Aiming to fill this gap, we explored the extent of and inequalities in insurance coverage, as well as choice of providers, and median cost of hospitalization in Kerala among insured and uninsured individuals. METHODS A cross-sectional household survey was conducted in four districts of Kerala as part of a larger health systems research study from July-October 2019. We employed multistage random sampling to collect data from 13,064 individuals covering 3234 households in the catchment area of eight primary health care facilities. We used descriptive statistics, bivariate and multivariate analysis. We evaluated socioeconomic disparities using an absolute measure of inequality-the Slope Index of Inequality (SII) and a relative measure-the Relative Concentration Index (RCI). RESULTS A substantial proportion of our study respondents reported that they were covered by PFHIS (45.8%). Respondents belonging to lowest and middle wealth quintiles of household had significantly greater odds of being covered by insurance than respondents belonging to the richest wealth quintile. The negative magnitude of RCI [-16.8% (95%CI: -25.3, -8.4)] and SII [-21.5% (95%CI: -36.1, -7.0)] suggest a higher concentration of PFHIS coverage among the poor. Median OOPE for hospitalisation at private health facilities was INR 9000 (approx. USD 108.70) among those covered by PFHIS, whereas it was INR 10500 (approx. USD 126.82) at private health facilities among those not covered by insurance. CONCLUSION While PFHIS seems to be appropriately targeting poorer populations, among the insured, OOPE for hospitalization persists. Among the uninsured, population subgroups with advantage are spending the greatest amount, raising questions about whether those facing relative disadvantage are forgoing care altogether or seeking care using cheaper, public avenues. Further policy action to more effectively reduce financial burden among left behind eligible populations under PFHIS will be essential to UHC progress in the state.
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Affiliation(s)
| | - Jaison Joseph
- The George Institute for Global Health, New Delhi, India.
| | - Hari Sankar D
- The George Institute for Global Health, New Delhi, India
| | - Devaki Nambiar
- The George Institute for Global Health, New Delhi, India
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
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Gupta SL, Goswami S, Anand A, Naman N, Kumari P, Sharma P, Jaiswal RK. An assessment of the strategy and status of COVID-19 vaccination in India. Immunol Res 2023; 71:565-577. [PMID: 37041424 PMCID: PMC10089693 DOI: 10.1007/s12026-023-09373-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/14/2023] [Indexed: 04/13/2023]
Abstract
The COVID-19 disease continues to cause devastation for almost 3 years of its identification. India is one of the leading countries to set clinical trials, production, and administration of COVID-19 vaccination. Recent COVID-19 vaccine tracker record suggests that 12 vaccines are approved in India, including protein subunit, RNA/DNA, non-replicating viral vector, and inactivated vaccine. Along with that 16 more vaccines are undergoing clinical trials to counter COVID-19. The availability of different vaccines gives alternate and broad perspectives to fight against viral immune resistance and, thus, viruses escaping the immune system by mutations. Using the recently published literature on the Indian vaccine and clinical trial sites, we have reviewed the development, clinical evaluation, and registration of vaccines trial used in India against COVID-19. Moreover, we have also summarized the status of all approved vaccines in India, their associated registered clinical trials, manufacturing, efficacy, and their related safety and immunogenicity profile.
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Affiliation(s)
| | - Surbhi Goswami
- National Institute of Immunology, New Delhi, 110067 India
| | - Ananya Anand
- Department of Zoology, Patna Science College, Patna University, Bihar, India
| | - Namrata Naman
- Department of Zoology, Patna Science College, Patna University, Bihar, India
| | - Priya Kumari
- Department of Zoology, Patna Science College, Patna University, Bihar, India
| | - Priyanka Sharma
- Department of Zoology, Patna Science College, Patna University, Bihar, India
| | - Rishi K. Jaiswal
- Department of Cancer Biology, Cardinal Bernardin Cancer Center, Loyola University Chicago, Stritch School of Medicine, Maywood, IL 60153 USA
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Mohanty SK, Upadhyay AK, Maiti S, Mishra RS, Kämpfen F, Maurer J, O'Donnell O. Public health insurance coverage in India before and after PM-JAY: repeated cross-sectional analysis of nationally representative survey data. BMJ Glob Health 2023; 8:e012725. [PMID: 37640493 PMCID: PMC10462969 DOI: 10.1136/bmjgh-2023-012725] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/08/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION The provision of non-contributory public health insurance (NPHI) to marginalised populations is a critical step along the path to universal health coverage. We aimed to assess the extent to which Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PM-JAY)-potentially, the world's largest NPHI programme-has succeeded in raising health insurance coverage of the poorest two-fifths of the population of India. METHODS We used nationally representative data from the National Family Health Survey on 633 699 and 601 509 households in 2015-2016 (pre-PM-JAY) and 2019-2021 (mostly, post PM-JAY), respectively. We stratified by urban/rural and estimated NPHI coverage nationally, and by state, district and socioeconomic categories. We decomposed coverage variance between states, districts, and households and measured socioeconomic inequality in coverage. For Uttar Pradesh, we tested whether coverage increased most in districts where PM-JAY had been implemented before the second survey and whether coverage increased most for targeted poorer households in these districts. RESULTS We estimated that NPHI coverage increased by 11.7 percentage points (pp) (95% CI 11.0% to 12.4%) and 8.0 pp (95% CI 7.3% to 8.7%) in rural and urban India, respectively. In rural areas, coverage increased most for targeted households and pro-rich inequality decreased. Geographical inequalities in coverage narrowed. Coverage did not increase more in states that implemented PM-JAY. In Uttar Pradesh, the coverage increase was larger by 3.4 pp (95% CI 0.9% to 6.0%) and 4.2 pp (95% CI 1.2% to 7.1%) in rural and urban areas, respectively, in districts exposed to PM-JAY and the increase was 3.5 pp (95% CI 0.9% to 6.1%) larger for targeted households in these districts. CONCLUSION The introduction of PM-JAY coincided with increased public health insurance coverage and decreased inequality in coverage. But the gains cannot all be plausibly attributed to PM-JAY, and they are insufficient to reach the goal of universal coverage of the poor.
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Affiliation(s)
- Sanjay K Mohanty
- Department of Population and Development, International Institute for Population Sciences, Mumbai, Maharashtra, India
| | | | - Suraj Maiti
- International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Radhe Shyam Mishra
- International Institute for Population Sciences, Mumbai, Maharashtra, India
| | | | - Jürgen Maurer
- Department of Economics and Lausanne Center for Health Economics, Behavior and Policy, Faculty of Business and Economics (HEC), University of Lausanne, Lausanne, Switzerland
| | - Owen O'Donnell
- Erasmus University Rotterdam, Rotterdam, The Netherlands
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Mistry N, Venkateswaran S, Baru R, Patel V. Editorial: Realizing universal health coverage in India. Front Public Health 2023; 11:1243676. [PMID: 37575104 PMCID: PMC10421653 DOI: 10.3389/fpubh.2023.1243676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 07/17/2023] [Indexed: 08/15/2023] Open
Affiliation(s)
| | - Sandhya Venkateswaran
- Centre for Social and Economic Progress, New Delhi, India
- Lancet Citizen's Commission on Reimagining India's Health System, New Delhi, India
| | - Rama Baru
- Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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Prinja S, Singh MP, Bahuguna P. India's publicly financed insurance scheme: scope for revision - authors' reply. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 14:100236. [PMID: 37492422 PMCID: PMC10363489 DOI: 10.1016/j.lansea.2023.100236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 05/25/2023] [Indexed: 07/27/2023]
Affiliation(s)
- Shankar Prinja
- Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
- National Health Authority, Government of India, New Delhi, India
| | - Maninder Pal Singh
- Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Pankaj Bahuguna
- Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Srivastava S, Bertone MP, Basu S, De Allegri M, Brenner S. Implementation of PM-JAY in India: a qualitative study exploring the role of competency, organizational and leadership drivers shaping early roll-out of publicly funded health insurance in three Indian states. Health Res Policy Syst 2023; 21:65. [PMID: 37370159 DOI: 10.1186/s12961-023-01012-7] [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: 12/28/2022] [Accepted: 06/01/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The Pradhan Mantri Jan Arogya Yojana (PM-JAY), a publicly funded health insurance scheme, was launched in India in September 2018 to provide financial access to health services for poor Indians. PM-JAY design enables state-level program adaptations to facilitate implementation in a decentralized health implementation space. This study examines the competency, organizational, and leadership approaches affecting PM-JAY implementation in three contextually different Indian states. METHODS We used a framework on implementation drivers (competency, organizational, and leadership) to understand factors facilitating or hampering implementation experiences in three PM-JAY models: third-party administrator in Uttar Pradesh, insurance in Chhattisgarh, and hybrid in Tamil Nadu. We adopted a qualitative exploratory approach and conducted 92 interviews with national, state, district, and hospital stakeholders involved in program design and implementation in Delhi, three state capitals, and two anonymized districts in each state, between February and April 2019. We used a deductive approach to content analysis and interpreted coded material to identify linkages between organizational features, drivers, and contextual elements affecting implementation. RESULTS AND CONCLUSION PM-JAY guideline flexibilities enabled implementation in very different states through state-adapted implementation models. These models utilized contextually relevant adaptations for staff and facility competencies and organizational and facilitative administration, which had considerable scope for improvement in terms of recruitment, competency development, programmatic implementation support, and rationalizing the joint needs of the program and implementers. Adaptations also created structural barriers in staff interactions and challenged implicit power asymmetries and organizational culture, indicating a need for aligning staff hierarchies and incentive structures. At the same time, specific adaptations such as decentralizing staff selection and task shifting (all models); sharing of claims processing between the insurer and state agency (insurance and hybrid model); and using stringent empanelment, accreditation, monitoring, and benchmarking criteria for performance assessment, and reserving secondary care benefit packages for public hospitals (both in the hybrid model) contributed to successful implementation. Contextual elements such as institutional memory of previous schemes and underlying state capacities influenced all aspects of implementation, including leadership styles and autonomy. These variations make comparisons across models difficult, yet highlight constraints and opportunities for cross-learning and optimizing implementation to achieve universal health coverage in decentralized contexts.
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Affiliation(s)
- Swati Srivastava
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
| | - Maria Paola Bertone
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, EH21 6UU, United Kingdom
| | - Sharmishtha Basu
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, B - 5/1 & 5/2 Ground Floor, Safdurjung Enclave, 110029, New Delhi, Delhi, India
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
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Kamath R, Brand H, Ravandhur Arun H, Lakshmi V, Sharma N, D'souza RMC. Spatial Patterns in the Distribution of Hypertension among Men and Women in India and Its Relationship with Health Insurance Coverage. Healthcare (Basel) 2023; 11:healthcare11111630. [PMID: 37297771 DOI: 10.3390/healthcare11111630] [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: 05/10/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
The present study explores district-level data associated with health insurance coverage (%) and the prevalence of hypertension (mildly, moderately, and severely elevated) observed across men and women as per NFHS 5. Coastal districts in the peninsular region of India and districts in parts of northeastern India have the highest prevalence of elevated blood pressure. Jammu and Kashmir, parts of Gujarat and parts of Rajasthan have a lower prevalence of elevated blood pressure. Intrastate heterogeneity in spatial patterns of elevated blood pressure is mainly seen in central India. The highest burden of elevated blood pressure is in the state of Kerala. Rajasthan is among the states with higher health insurance coverage and a lower prevalence of elevated blood pressure. There is a relatively low positive relationship between health insurance coverage and the prevalence of elevated blood pressure. Health insurance in India generally covers the cost of inpatient care to the exclusion of outpatient care. This might mean that health insurance has limited impact in improving the diagnosis of hypertension. Access to public health centers raises the probability of adults with hypertension receiving treatment with antihypertensives. Access to public health centers has been seen to be especially significant at the poorer end of the economic spectrum. The health and wellness center initiative under Ayushman Bharat will play a crucial role in hypertension control in India.
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Affiliation(s)
- Rajesh Kamath
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal 576104, Karnataka, India
- Department of International Health, Care and Public Health Research Institute-CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Helmut Brand
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal 576104, Karnataka, India
- Department of International Health, Care and Public Health Research Institute-CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Harshith Ravandhur Arun
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal 576104, Karnataka, India
| | - Vani Lakshmi
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal 576104, Karnataka, India
| | | | - Reshma Maria Cocess D'souza
- Department of Medical Laboratory Technology, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal 576104, Karnataka, India
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Grewal H, Sharma P, Dhillon G, Munjal RS, Verma RK, Kashyap R. Universal Health Care System in India: An In-Depth Examination of the Ayushman Bharat Initiative. Cureus 2023; 15:e40733. [PMID: 37485096 PMCID: PMC10360977 DOI: 10.7759/cureus.40733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 07/25/2023] Open
Abstract
This editorial provides an in-depth review of the Ayushman Bharat initiative, India's universal healthcare scheme, designed to address significant disparities in healthcare access and quality across the country. Following the structure of the healthcare system and socioeconomic trends, the manuscript assesses the reasons for the initiative's creation, its coverage, implementation strategies, role during the COVID-19 pandemic, auxiliary pilot programs, and challenges for future progress. It focuses on how the initiative has increased healthcare accessibility, financial protection, transformed the healthcare infrastructure, and provided relief during the COVID-19 crisis. Critical issues such as gaps between supply and demand, the need for increased government spending, and the challenges of access and quality in rural health centers are also discussed. We aim to raise awareness about the program's benefits among potential beneficiaries, which is a key to the initiative's success and a potential role model for equitable global healthcare.
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Affiliation(s)
- Harpreet Grewal
- Radiology, Florida State University College of Medicine, Pensacola, USA
| | - Pranjal Sharma
- Nephrology, Northeast Ohio Medical University, Rootstown, USA
| | - Gagandeep Dhillon
- Internal Medicine, University of Maryland Baltimore Washington Medical Center, Glen Burnie, USA
| | | | - Ram K Verma
- Sleep Medicine, Internal Medicine, and Obesity Medicine, Parkview Health System, Fort Wayne, USA
| | - Rahul Kashyap
- Medicine, Drexel University College of Medicine, Philadelphia, USA
- Medicine, Harvard Medical School, Boston, USA
- Research, Global Remote Research Program, Saint Paul, USA
- Critical Care Medicine, Mayo Clinic, Rochester, USA
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Kamath R, Brand H. A Critical Analysis of the World's Largest Publicly Funded Health Insurance Program: India's Ayushman Bharat. Int J Prev Med 2023; 14:20. [PMID: 37033284 PMCID: PMC10080577 DOI: 10.4103/ijpvm.ijpvm_39_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 09/23/2022] [Indexed: 04/11/2023] Open
Abstract
Background Launched in September 2018, the ABPMJAY is the world's largest publicly funded health insurance (PFHI) program with population coverage of 500 million. A systematic review was conducted. Methods A comprehensive literature search was conducted in four databases: PubMed, Web of Science, Scopus, and Google Scholar. The literature search was conducted with the search terms: "Ayushman Bharat OR ABPMJAY OR modicare AND RSBY." The search was set to title and abstract. Gray literature and government websites were also searched for relevant documents. A total of 881 documents were identified (PubMed: 53, Web of Science: 46, Scopus: 97, Google Scholar: 681, government websites: two, and gray literature: two). Fifty-two duplicates were identified. After the elimination of the duplicates, 829 unique documents were identified. These 829 unique citations were then subjected to a review of title and abstract independently by 2 reviewers. Six-hundred and ninety-two articles were rejected after review of title and abstract. One-hundred and thirty-seven articles were screened for full text independently by two reviewers. Sixty-six articles were rejected after review of the full text. Disagreements were resolved by discussion. Seventy-one unique articles were included in the final review. To attain the objective of the study, which is to critically analyze and provide an overview of Ayushman Bharat, a narrative synthesis was performed. Results Seven themes were identified from the review: (1) health and wellness centers (HWCs); (2) out-of-pocket health expenditure (OOPHE); (3) fraud; (4) upcoding and provision of unnecessary medical care; (5) moving focus away from primary care; (6) coverage; and (7) lop-sided access, exclusion at the periphery, and brain drain. There is very little impact evidence of the ABPMJAY available. Conclusions The government could plan impact evaluation studies in every state that the ABPMJAY is functional in. Any high-quality feedback generated might enable the National Health Authority, the government body leading and coordinating the ABPMJAY, to take necessary steps operationally and advice the government on strategy. Another concern is that the ABPMJAY PFHI might negatively impact the ongoing process of continuous strengthening and development of the government health-care system at all levels-primary, secondary, and tertiary. Continual recalibration and course corrections on the basis of high-quality feedback might enable ABPMJAY reduce catastrophic OOPHE for 500 million Indians. This is more than 6% of humanity: the largest block of people served by a single PFHI in history.
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Affiliation(s)
- Rajesh Kamath
- Department of Health Innovation, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
- Address for correspondence: Dr. Rajesh Kamath, Cabin Number 65, 1 Floor, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - 576 104, Karnataka, India. E-mail:
| | - Helmut Brand
- Department of International Health, Care and Public Health Research Institute – CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Vaishnav LM, Joshi SH, Joshi AU, Mehendale AM. The National Programme for Health Care of the Elderly: A Review of its Achievements and Challenges in India. Ann Geriatr Med Res 2022; 26:183-195. [PMID: 36039665 PMCID: PMC9535372 DOI: 10.4235/agmr.22.0062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/22/2022] [Indexed: 11/18/2022] Open
Abstract
Aging care is critical. Projections for 2020 indicate that India’s older population will comprise 6.57% of the overall population. The best-known newly developed technologies must be provided to the older population. Non-governmental organizations and private institutions are increasingly providing more door-to-door guidance and help. This study evaluated the impact of the National Programme for Health Care of the Elderly (NPHCE) in India and analyzed its achievements and challenges. The program’s key strategies include providing preventive and promotional care and sickness management, empowering geriatric services, and guaranteeing optimal rehabilitation. The NPHCE is an excellent project for caring for a rapidly aging population. This study described the existing programs and schemes related to older people in India, with a focus on the NPHCE and an analysis of the program’s achievements and challenges.
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Affiliation(s)
- Lokesh Mukut Vaishnav
- Department of Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), India
| | - Shiv Hiren Joshi
- Department of Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), India
| | - Abhishek Upendra Joshi
- Department of Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), India
- Corresponding Author: Shiv Hiren Joshi, MD Department of Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), 442001, India E-mail:
| | - Ashok Madhukar Mehendale
- Department of Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), India
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Thomas S, Sivaram S, Shroff Z, Mahal A, Desai S. ‘We are the bridge’: an implementation research study of SEWA Shakti Kendras to improve community engagement in publicly funded health insurance in Gujarat, India. BMJ Glob Health 2022; 7:bmjgh-2022-008888. [PMID: 36379589 PMCID: PMC9511541 DOI: 10.1136/bmjgh-2022-008888] [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: 02/21/2022] [Accepted: 08/13/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction India’s efforts towards universal health coverage include a national health insurance scheme that aims to protect the most vulnerable from catastrophic health expenditure. However, emerging evidence on publicly funded health insurance, as well as experience from community-based schemes, indicates that women face specific barriers to access and utilisation. Community engagement interventions have been shown to improve equitable utilisation of public health services, but there is limited research specific to health insurance. We examined how existing community-based resource centres implemented by a women’s organisation could improve women’s access to, and utilisation of, health insurance. Methods We conducted an implementation research study in Gujarat, India to examine how SEWA Shakti Kendras, established by the Self-Employed Women’s Association, worked to improve community engagement in health insurance. SEWA organises women in the informal sector and provides social protection through health, insurance and childcare services. We examined administrative data, programme reports and conducted 30 in-depth qualitative interviews with users and staff. Data were analysed thematically to examine intervention content, context, and implementation processes and to identify enablers and barriers to improving women’s access to health insurance through SEWA’s community engagement approach. Results The centres worked through multiple channels—doorstep services, centre-based support and health system navigation—to strengthen women’s capability to access health insurance. Each centre’s approach varied by contextual factors, such as women’s digital literacy levels and rural–urban settings. Effective community engagement required local leadership, strong government partnerships and the flexibility to address a range of public services, with implementation by trusted local health workers. Conclusion SEWA Shakti Kendras demonstrate how a local, flexible and community-based model can serve as a bridge to improve utilisation of health insurance, by engaging women and their households through multiple channels. Scaling up this approach will require investing in partnerships with community-based organisations as part of strategies towards universal health coverage.
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Affiliation(s)
- Susan Thomas
- Lok Swasthya SEWA Trust, Self-Employed Women’s Association (SEWA), Ahmedabad, Gujarat, India
| | | | - Zubin Shroff
- Alliance For Health Policy and System Research, Geneva, Switzerland
| | - Ajay Mahal
- The University of Melbourne Nossal Institute for Global Health, Carlton, Victoria, Australia
| | - Sapna Desai
- Population Council Institute, New Delhi, India
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Gadsden T, Ford B, Angell B, Sumarac B, de Oliveira Cruz V, Wang H, Tsilaajav T, Jan S. Health financing policy responses to the COVID-19 pandemic; a review of the first stages in the WHO South East Asia Region. Health Policy Plan 2022; 37:1317-1327. [PMID: 36066247 DOI: 10.1093/heapol/czac071] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 08/16/2022] [Accepted: 09/06/2022] [Indexed: 11/12/2022] Open
Abstract
COVID-19 imposed unprecedented financing requirements on countries to rapidly implement effective prevention and control measures while dealing with severe economic contraction. The challenges were particularly acute for the 11 countries in the WHO South East Asia Region (SEAR), home to the lowest average level of public expenditure on health of all WHO Regions. We conducted a narrative review of peer-reviewed, grey literature and publicly available sources to analyse the immediate health financing policies adopted by countries in the WHO SEAR in response to COVID-19 in the first 12 months of the pandemic, i.e. from March 1, 2020, to March 1, 2021. Our review focused on the readiness of health systems to address the financial challenges of COVID-19 in terms of revenue generation, financial protection and strategic purchasing including public financial management issues. Twenty peer-reviewed articles were included, and web searches identified media articles (n=21), policy reports (n=18) and blog entries (n=5) from reputable sources. We found that countries in the SEAR demonstrated great flexibility in responding to the COVID-19 pandemic, including exploring various options for revenue raising, removing financial barriers to care and rapidly adapting purchasing arrangements. At the same time, the pandemic exposed pre-existing health financing policy weaknesses such as underinvestment, inadequate regulatory capacity of the private health sector and passive purchasing which should give countries an impetus for reform towards more resilient health systems. Further monitoring and evaluation is needed to assess the long-term implications of policy responses on issues such as government capacity for debt servicing and fiscal space for health and how they protect progress towards the objectives of universal health coverage.
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Affiliation(s)
- Thomas Gadsden
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Belinda Ford
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Blake Angell
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Bojan Sumarac
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Hui Wang
- World Health Organization South East Asia Regional Office, New Delhi, India
| | - Tsolmon Tsilaajav
- World Health Organization South East Asia Regional Office, New Delhi, India
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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15
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Singh MP, Prinja S, Rajsekar K, Gedam P, Aggarwal V, Sachin O, Naik J, Agarwal A, Kumar S, Sinha S, Singh V, Patel P, Patel AC, Joshi R, Hazra A, Misra R, Mehrotra D, Biswal SB, Panigrahy A, Gaur KL, Pankaj JP, Sharma DK, Madhavi K, Madhusudana P, Narayanasamy K, Chitra A, Velhal GD, Bhondve AS, Bahl R, Sachdeva A, Kaur S, Nagar A, Bhargava B. Cost of Surgical Care at Public Sector District Hospitals in India: Implications for Universal Health Coverage and Publicly Financed Health Insurance Schemes. PHARMACOECONOMICS - OPEN 2022; 6:745-756. [PMID: 35733075 PMCID: PMC9216290 DOI: 10.1007/s41669-022-00342-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND In low- and middle-income countries (LMICs), provisioning for surgical care is a public health priority. Ayushman Bharat Pradhan Mantri-Jan Aarogya Yojana (AB PM-JAY) is India's largest national insurance scheme providing free surgical and medical care. In this paper, we present the costs of surgical health benefit packages (HBPs) for secondary care in public district hospitals. METHODS The costs were estimated using mixed (top-down and bottom-up) micro-costing methods. In phase II of the Costing of Health Services in India (CHSI) study, data were collected from a sample of 27 district hospitals from nine states of India. The district hospitals were selected using stratified random sampling based on the district's composite development score. We estimated unit costs for individual services-outpatient (OP) visit, per bed-day in inpatient (IP) and intensive care unit (ICU) stays, and surgical procedures. Together, this was used to estimate the cost of 250 AB PM-JAY HBPs. RESULTS At the current level of utilization, the mean cost per OP consultation varied from US$4.10 to US$2.60 among different surgical specialities. The mean unit cost per IP bed-day ranged from US$13.40 to US$35.60. For the ICU, the mean unit cost per bed-day was US$74. Further, the unit cost of HBPs varied from US$564 for bone tumour excision to US$49 for lid tear repair. CONCLUSIONS Data on the cost of delivering surgical care at the level of district hospitals is of critical value for evidence-based policymaking, price-setting for surgical care and planning to strengthen the availability of high quality and cost-effective surgical care in district hospitals.
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Affiliation(s)
- Maninder Pal Singh
- Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education & Research, Sector-12, Chandigarh, 160012, India
| | - Shankar Prinja
- Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education & Research, Sector-12, Chandigarh, 160012, India.
| | - Kavitha Rajsekar
- Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Praveen Gedam
- National Health Authority, Government of India, New Delhi, India
| | - Vipul Aggarwal
- National Health Authority, Government of India, New Delhi, India
| | - Oshima Sachin
- Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Jyotsna Naik
- Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Ajai Agarwal
- National Health Authority, Government of India, New Delhi, India
| | - Sanjay Kumar
- Indira Gandhi Institute of Medical Science, Patna, Bihar, India
| | - Setu Sinha
- Indira Gandhi Institute of Medical Science, Patna, Bihar, India
| | - Varsha Singh
- Indira Gandhi Institute of Medical Science, Patna, Bihar, India
| | - Prakash Patel
- Surat Municipal Institute of Medical Education & Research, Surat, Gujarat, India
| | - Amit C Patel
- Surat Municipal Institute of Medical Education & Research, Surat, Gujarat, India
| | - Rajendra Joshi
- Surat Municipal Institute of Medical Education & Research, Surat, Gujarat, India
| | - Avijit Hazra
- Institute of Postgraduate Medical Education & Research, Kolkata, West Bengal, India
| | - Raghunath Misra
- Institute of Postgraduate Medical Education & Research, Kolkata, West Bengal, India
| | - Divya Mehrotra
- King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Sashi Bhusan Biswal
- Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India
| | - Ankita Panigrahy
- Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India
| | | | | | | | - Kondeti Madhavi
- Sri Venkateswara Medical College, Tirupati, Andhra Pradesh, India
| | | | | | - A Chitra
- Madras Medical College, Chennai, Tamil Nadu, India
| | - Gajanan D Velhal
- Seth G S Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Amit S Bhondve
- Seth G S Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Rakesh Bahl
- Government Medical College, Jammu, Jammu & Kashmir, India
| | - Amit Sachdeva
- Government Medical College, Jammu, Jammu & Kashmir, India
| | | | - Anu Nagar
- Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Balram Bhargava
- Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India
- Indian Council of Medical Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India
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Furtado KM, Raza A, Mathur D, Vaz N, Agrawal R, Shroff ZC. The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states. BMC Health Serv Res 2022; 22:1056. [PMID: 35982425 PMCID: PMC9389741 DOI: 10.1186/s12913-022-08407-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 07/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Pradhan Mantri Jan Arogya Yojana (PMJAY), a publicly funded health insurance scheme for the poor in India, was launched in 2018. Early experiences of states with various purchasing arrangements can provide valuable insights for its future performance. We sought to understand the institutional agencies and performance of the trust and insurance models of purchasing with respect to; a) Provider contracting b) Claim management c) Implementation costs. METHODS A mixed methods case study design was adopted. Two states, Uttar Pradesh (representing a trust model) and Jharkhand (representing the insurance model) were purposively selected. Data sources included document reviews, key informant interviews, quantitative scheme data from the provider empanelment and claims database, and primary data on costs. Descriptive statistics were reported for quantitative data, content analysis was used for thematic reporting of qualitative data. RESULTS In both models, the state was the final authority on empanelment decisions, with no significant influence of the insurance company. Private hospitals constituted the majority of empanelled providers, with wide variations in district-wise distribution of bed capacities in both states. The urgency of completing empanelment in the early days of the scheme created the need for both states to re-review hospitals and de-empanel those not meeting requirements. Very few quality- accredited private hospitals were empaneled. The trust displayed more oversight of support agencies for claim management, longer processing times, a higher claim rejection rate and numbers of queries raised, as compared to the insurance model. Support agencies in both states faced challenges in assessing the clinical decisions of hospitals. Cost-effectiveness showed mixed results; the trust cost less than the insurance model per beneficiary enrolled, but more per claim generated. CONCLUSIONS Efforts are required to enable a better distribution and ensure quality of care in empanelled hospitals. The adoption of standard treatment guidelines is needed to support hospitals and implementing agencies in better claim management. The oversight of agencies through enforcement of contracts remains vital in both models. Assessing the comparative performance of trusts and insurance companies in more states at later stages of scheme implementation, would be further useful to determine their cost-effectiveness as purchasers.
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Affiliation(s)
| | - Arif Raza
- Goa Institute of Management, Poriem, Sattari, Goa, India, 403505
| | | | - Nafisa Vaz
- Goa Institute of Management, Poriem, Sattari, Goa, India, 403505
| | - Ruchira Agrawal
- National Health Authority, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Zubin Cyrus Shroff
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
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Pillai K, Obasanjo I. Assessing the implementation of India's new health reform program, Ayushman Bharat, in two Southern states: Kerala and Tamil Nadu. WORLD MEDICAL & HEALTH POLICY 2022. [DOI: 10.1002/wmh3.535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Kalyani Pillai
- Department of Health Sciences College of William and Mary Williamsburg Virginia USA
| | - Iyabo Obasanjo
- Department of Health Sciences College of William and Mary Williamsburg Virginia USA
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Malik MA. Fragility and challenges of health systems in pandemic: lessons from India's second wave of coronavirus disease 2019 (COVID-19). GLOBAL HEALTH JOURNAL 2022; 6:44-49. [PMID: 35070474 PMCID: PMC8767801 DOI: 10.1016/j.glohj.2022.01.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 01/02/2022] [Accepted: 01/17/2022] [Indexed: 12/14/2022] Open
Abstract
The unprecedented healthcare demand due to sudden outbreak of coronavirus disease 2019 (COVID-19) pandemic has almost collapsed the health care systems especially in the developing world. Given the disastrous outbreak of COVID-19 second wave in India, the health system of country was virtually at the brink of collapse. Therefore, to identify the factors that resulted into breakdown and the challenges, Indian healthcare system faced during the second wave of COVID-19 pandemic, this paper analysed the health system challenges in India and the way forward in accordance with the six building blocks of world health organization (WHO). Applying integrated review approach, we found that the factors such as poor infrastructure, inadequate financing, lack of transparency and poor healthcare management resulted into the overstretching of healthcare system in India. Although health system in India faced these challenges from the very beginning, but early lessons from first wave should have been capitalized to avert the much deeper crisis in the second wave of the pandemic. To sum-up given the likely future challenges of pandemic, while healthcare should be prioritized with adequate financing, strong capacity-building measures and integration of public and private sectors in India. Likewise fiscal stimulus, risk assessment, data availability and building of human resources chain are other key factors to be strengthened for mitigating the future healthcare crisis in country.
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19
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Impact of COVID-19 and containment measures on burn care: A qualitative exploratory study. Burns 2021; 48:1497-1508. [PMID: 34903406 PMCID: PMC8595323 DOI: 10.1016/j.burns.2021.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/18/2021] [Accepted: 11/04/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Burn care in India is limited by multiple constraints. The COVID-19 pandemic and the containment measures restricted access to non-COVID emergency conditions, including burns. The aim of this study was to explore the impact of the pandemic on burn care in India. METHODS Using the qualitative exploratory methods, we conducted in-depth interviews (IDI) with plastic and general surgeons representing burn units from across India. Participants were selected purposively to ensure representation and diversity and the sample size was guided by thematic saturation. Thematic analysis was undertaken adopting an inductive coding using NVivo 12 Pro. RESULTS 19 participants from diverse geographic locations and provider types were interviewed. Three major emerging themes were, change in patient and burn injury characteristics; health system barriers, adaptation, and challenges; and lessons and emerging recommendations for policy and practice. There was change in patient load, risk factors, and distribution of burns. The emergency services were intermittently disrupted, the routine and surgical services were rationally curtailed, follow-up and rehabilitation services were most affected. Measures like telemedicine and decentralising burn services emerged as the most important lesson. CONCLUSIONS The ongoing pandemic has compounded the challenges for burns care in India. Urgent action is required to prioritise targeted prevention, emergency transport, decentralise service delivery, and harnessing technology for ensuring resilience in burns services.
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