Is provision of healthcare sufficient to ensure better access? An exploration of the scope for public-private partnership in India

Public-Private Partnerships Model Applied to Hospitals-A Critical Review

In this paper, a conceptual framework for investigating the PPP model as it relates to hospitals is proposed. When the PPP model is applied to healthcare (hospitals), it is possible to discover the path to success by developing a critical assessment and deriving a clear model. It is concluded that most PPP model implementations in hospitals around the world have produced favorable outcomes, both in terms of the performance of healthcare units and in terms of cost-effectiveness. Additionally, a path-to-success model that applies to hospitals is offered, taking into account six PPP model dimensions: (i) Environment; (ii) Potentiate Benefits; (iii) Constant Measure; (iv) Evaluation; (v) Management; and (vi) Enhance Strengths. The PPP model only applies case by case and under specific requirements that should be met cumulatively to provide additional value to healthcare's quality of service. The right conditions are created, the right benefits are amplified, public concerns are frequently assessed, private contributions are carefully considered, and all pressing challenges are managed by enhancing both public and private strengths. Leading decision- and action-making processes in corporate, governmental, and social sectors is the goal of managing PPP models.

Lacunae in Laboratory Medicine Services and in Pathology Education in Medical Schools in India

CONTEXT.—

Laboratories of many medical college hospitals in India do not offer important diagnostic tests, most of which are routine in the West. This detracts from the service as well as the educational function of the college.

OBJECTIVES.—

To provide the background to pathology and laboratory medicine services and education in India, and to create a questionnaire that will put the lack of tertiary care laboratory services in perspective. This article will help illustrate the lacunae in laboratory medicine services and in the education of students. For this, we present information on the health services and pathology education facilities in India. We propose a questionnaire comprising 30 questions in various disciplines in pathology and laboratory medicine. These questions will help administrators and bureaucrats evaluate the status of the laboratories with respect to the services provided.

DATA SOURCES.—

Sources include Web sites of the government of India, including that of the National Accreditation Board for Testing and Calibration Laboratories; indexed medical journal articles; and standard books and white papers on health care in India. We also used our personal experiences and interpretations of the laboratory and medical education sector in India.

CONCLUSIONS.—

Medical colleges in India need to offer specialized diagnostic services if they are to achieve the targets of universal health care as well as turning out competent doctors. The agencies responsible for health care in India should use the questionnaire as a first step toward improving laboratory services. Other low- and middle-income countries should also adopt this method.

A Critical Analysis of the World's Largest Publicly Funded Health Insurance Program: India's Ayushman Bharat

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.

Financial burden for families of children with type 1 diabetes: a cross-sectional survey from North India

Introduction

Type 1 diabetes (T1D) incurs substantial out-of-pocket expenses (OOPE) on insulin and diabetes-related supplies. The information on OOPE is scarce from low- and middle-income countries. We aimed to estimate annual OOPE for children with T1D attending our diabetes clinic located in North India.

Methods

An online survey was conducted among parents of 380 children with T1D (mean age: 10.3 ± 4.6 years). Modified BG Prasad scale was used to estimate the socioeconomic status (SES).

Results

The mean duration of T1D was 3.6 ± 2.6 years; 54.9% of children were boys. The median HbA1c (IQR) was 7.9% (5–15%). 51.9% belonged to lower or lower-middle SES. Mean annual spending on glucose monitoring, insulin administration, and laboratory investigations were Indian Rupee (INR) 21,576, INR 28,965, and INR 5069, respectively (total INR 55,185, IQR: 26,575–105,027). The cost of a single visit to the doctor was approximately INR 2889. Thirty children required hospitalization during the last year, which costs INR 27,495 on average. 30.3% had more than 50% of their total family income spent on diabetes care, with a significant negative correlation with their SES (r =  – 0.738, p = 0.00). Only 11.6% were receiving financial support from any agency. 36.6% of families had to borrow money; the OOPE exceeded income from all sources in 8.2% of families.

Conclusions

There is a high financial burden of T1D care for North Indian children, almost on the verge of losing sustainability. Further studies are warranted to furnish larger OOPE data to guide policy decisions aimed at reducing direct costs to patients.

An Internet-based study on the impact of COVID-19 pandemic-related lockdown on migraine in India

OBJECTIVES

To assess the impact of lockdown during the COVID-19 pandemic on migraine patients in India on disease activity, healthcare accessibility, and quality of life (QoL).

MATERIALS & METHODS

This internet-based survey study using a structured questionnaire was conducted from 27th April to 31st July 2020. Previous physician-diagnosed migraine patients or those fulfilling any two of three clinical features (limitation of activities for >1 day, associated nausea or vomiting, and photophobia or phonophobia) were diagnosed as migraine patients. QoL was captured using a Likert scale and determinants of poor QoL were identified by logistic regression.

RESULTS

A total of 4078 persons completed the full survey out of which 984 (24.1%) had migraine (mean age 35.3 ±11.2). Compared to pre-lockdown, 51.3% of migraineurs reported worsening of their headaches in terms of increased attack frequency (95.6%), increased headache days (95%), increased attack duration (89.9%) and increased headache severity (88.1%). The worsening was attributed to anxiety due to the pandemic (79.7%), inability or difficulty to access healthcare (48.4%) and migraine medicines (48.9%), and financial worries (60.9%). 26.8% of migraineurs reported poor QoL compared to 7.37% of non-migraineurs [p<0.0001]. Migraine affected QoL in 61.4% of migraineurs. The predictors of poor QoL on logistic regression included worsening migraine during the lockdown (AOR 4.150; CI 2.704- 6.369) and difficulty accessing migraine medicines (AOR 4.549; CI 3.041- 6.805). Employment as an essential COVID-19 worker (AOR 0.623; CI 0.409- 0.950) protected against poor QoL.

CONCLUSIONS

COVID-19 pandemic-related lockdown greatly impacted migraine patients in India which significantly reduced their QoL.

Public-Private Partnership Policy in Primary Health Care: A Scoping Review

BACKGROUND

Given the challenges of governments to deliver primary health care (PHC), engaging private sector in the form of public-private partnership (PPP) can be effective policy. The aim of present study is to review the experiences of implementing PPP policy in PHC.

METHODS

This scoping review study was conducted in 2019 using the framework proposed by Arkesy and O'Malley. Required data were collected through search the related keywords in databases, manual search of some journals, websites, and other sources of information and through references check, from January 2000 to May 2019. All studies, which focused on the results of PPP in PHC, and published in English or Persian were included in the study.

RESULTS

A total of 108 articles were included in the study. The studies were mostly conducted in low- and middle-income countries. The quantitative studies have demonstrated the success of this policy in improving PHC indicators. Based on the qualitative studies PPP in PHC has many benefits, including access improvement, economic benefits, and service quality enhancement.

CONCLUSIONS

The present study provides useful information on the experiences of different countries in the field of PPP in PHC that can be used by experts and decision makers to decide whether to engage the private sector in the form of PPP model.

Digital Health Care in Public Private Partnership Mode

Background: Health care is provided in developing countries, in a milieu of acute shortages of health care infrastructure and personnel. Governments are realizing that digital health through public private partnerships (PPPs) could address this issue. Literature review did not reveal reports on primary use of telemedicine or Technology-enabled Remote Health care (TeRH) in a PPP mode. Materials and Methods: The authors report using digital health in a mega PPP project in nine districts in Andhra Pradesh, a state in South India, where millions are benefiting from TeRH. Strategies deployed to address operational, technical, and clinical challenges in virtually reaching the unreached deploying technology are described. A detailed analysis was made of services provided in 183 Urban Primary Health Centres (UPHCs) over 47 months. Results: 2,648,322 unique patients had quality digital health care. Of 11,055,936 consultations, 1,013,996 were specialist teleconsultations, including cardiology, endocrinology, general medicine, orthopedics and OB/Gynecology. 7,408,283 laboratory tests were done. Costs for laboratory tests was 28.84% of that in private laboratories. Cost per specialist teleconsultation was 165 (Rupees). Quality control of laboratories was ensured through remote monitoring. Discussion: Implementing digital health in PPP projects requires expertise across clinical, technology, contract management, financing, data standards, information security, project planning, and cost-effective implementation. Conclusions: This successful mega project has confirmed that given a dedicated cooperative team e-health in a PPP mode in a developing country is eminently doable. Digital health care records were introduced and maintained for 100% of the beneficiaries (2.6 million in this study). TeRH can now bridge the health care divide.

Approaches to osteoarthritis - A qualitative study among patients in a rural setting in Central Western India

BACKGROUND

Osteoarthritis (OA) represents a major cause of disability in India. For implementation of best practice management, it is important to consider the views of people in India since they might deviate from those expressed in previous studies by people with OA in the Western world.

OBJECTIVE

The purpose of this study was to explore and describe approaches toward OA and its management among patients in a rural setting in Central Western India.

DESIGN AND METHOD

Conventional content analysis was used to analyze semi-structured interviews with 24 patients diagnosed with OA from the target area of Pravara University Hospital and ten adjacent primary health care centers in Maharashtra, India.

RESULTS

Four categories; lack of power, active ambivalence, taking control and a constant struggle were identified as patients' approaches to OA. The categories were further elaborated on in seven subcategories.

CONCLUSION

Daily challenges and efforts, of which some may be unique to patients in a rural setting in India, underlie passive and active approaches to OA and its management. Understanding these may enhance Indian physiotherapists' implementation of evidence-based self-management programs adapted to Indian conditions and reduce the distress of their patients.

Preparedness for health-related SDGs among healthcare workers in a rural district of Maharashtra with reference to achievements of MDGs 4, 5 and 6

BACKGROUND

Healthcare workers at field level constitute a major pillar in the large public health infrastructure of India. At this juncture, it becomes necessary to understand their role in achieving MDGs, issues, and challenges on the field and how 'prepared' they are to embark upon the new responsibilities in the coming 15 years to achieve the SDGs. This will form a springboard for the next generation of healthcare providers to successfully achieve the SDGs.

MATERIALS AND METHODS

This qualitative research study was conducted in the rural part of Thane district from September 2016- March 2017. Four Focus Group Discussions (FGDs) were done to assess the role, activities, reasons for successes and shortcomings of MDG indicators for healthcare providers and thereby assess preparedness for achieving health-related SDGs at the grass-root level.

RESULTS

Major challenges faced in the field were cultural barriers, poverty, illiteracy, fear, disregard for the health workers. There were challenges in human resource management such as workload, unpaid work, dissatisfaction, grievance redressal, leaves, etc., Suggested technical and health-centric interventions were skill development, supportive supervision, incentives and better implementation of new policies. Training in soft skills is needed.

CONCLUSIONS

The health workers seem to be unaware of the term MDGs/SDGs but, showed a deep sense of commitment towards improving the health of people and meeting their work targets despite the challenges faced in the field. Their justified concerns need to be addressed to have better retention and improved performance.

India-Based Knee Osteoarthritis Evaluation (iKare): A Multi-Centre Cross-Sectional Study on the Management of Knee Pain and Early Osteoarthritis in India

Background

Access to early knee osteoarthritis treatment in low and middle income nations is often believed to be limited. We conducted a cross-sectional study in India to assess prior access to treatment among patients presenting with knee pain to specialist orthopaedic clinics.

Methods

The multi-centre, cross-sectional study included patients presenting with knee pain at 3 hospitals in India. Patients who met the inclusion criteria and provided informed consent completed a questionnaire designed to assess patient demographics, socioeconomic status, knee pain, treatment method, and patient's knowledge on osteoarthritis (OA). Their orthopaedic surgeons also completed a questionnaire on the severity of patient's OA and their recommended treatments. The impact of demographic characteristics on the prescription of treatment options was analyzed using logistic regression.

Results

A total of 714 patients met the eligibility criteria and participated in this study. The majority of patients had been experiencing pain for less than 1 year (64.8%) and had previously been prescribed medications (91.6%), supplements (68.6%), and nonpharmacological (81.9%) treatments to manage their knee OA. Current treatment recommendations included oral medications (83.3%), intra-articular injections (29.8%), and surgical intervention (12.7%). Prescription of oral medications was related to younger age, lack of deformities, and lower Kellgren-Lawrence grades (p < 0.01). Patients treated in private hospital settings were more likely to have been previously treated with medications (range, 84.3% to 92.6%; p < 0.01) and physical treatments (range, 61.8% to 84.8%; p < 0.01) than patients treated at government hospitals.

Conclusions

Contrary to the perception, our findings suggest a similar proportion of early knee OA treatment between India and North America.

Role of health insurance in enabling universal health coverage in India: A critical review

India has set itself a long-term goal of providing universal health coverage for all its citizens and over the past few decades, significant progress has been achieved by the government, towards meeting this goal. But, due to funding inadequacy, public health infrastructure continues to suffer from perennial shortages, impacting the rural and indigent population segments the most. As a consequence of these shortages, nearly 70% of health spending is borne by households, out-of-pocket sources, and delivered by private health care facilities. This scenario usually leaves the families impoverished and in debt, as private sector medical costs are mostly unaffordable. Universal health coverage in India is, hence, severely constrained by resource shortages and affordability. Health insurance, which has made a presence in India over the past decade, can deliver a solution to the above challenges. While, government health insurance schemes have demonstrated varying degrees of success, funding shortfalls have constrained their expansion plans. Private health insurance, on the other hand, can recalibrate their approach and play a significant role in spreading universal health coverage. By developing a strategy of addressing primary care needs and intelligently coexisting with public health insurance, private health insurance can provide an immense boost to universal coverage, by providing affordable health care access for all Indian citizens.

Institutional delivery in public and private sectors in South Asia: a comparative analysis of prospective data from four demographic surveillance sites

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.