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Background: Though over three-fourths of all births receive medical attention in India, the rate of cesarean delivery (22%) is twice higher than the WHO recommended level. Cesarean deliveries entail high costs and may lead to financial catastrophe for households. This paper examines the out-of-pocket expenditure (OOPE) and distress financing of cesarean deliveries in India. Methods: We used data from the latest round of the National Family Health Survey conducted during 2019–21. The survey covered 636,699 households, and 724,115 women in the age group 15–49 years. We have used 159,643 births those delivered three years preceding the survey for whom the question on cost was canvassed. Descriptive analysis, bivariate analysis, concentration index (CI), and concentration curve (CC) were used in the analysis. Result: Cesarean deliveries in India was estimated at 14.08%, in private health centres and 9.96% in public health centres. The prevalence of cesarean delivery increases with age, educational attainment, wealth quintile, BMI and high for those who had pregnancy complications, and previous birth as cesarean. The OOPE on cesarean births was US$133. It was US$498 in private health centres and US$99 in public health centres. The extent of distress financing of any cesarean delivery was 15.37%; 27% for those who delivered in private health centres compared to 16.61% for those who delivered in public health centres. The odds of financial distress arising due to OOPE on cesarean delivery increased with the increase of OOPE [AOR:10.00, 95% CI, 9.35–10.70]. Distress financing increased with birth order and was higher among those with low education and those who belonged to lower socioeconomic strata. Conclusion: High OOPE on a cesarean delivery leads to distress financing in India. Timely monitoring of pregnancy and providing comprehensive pregnancy care, improving the quality of primary health centres to conduct cesarean deliveries, and regulating private health centres may reduce the high OOPE and financial distress due to cesarean deliveries in India. [ABSTRACT FROM AUTHOR]

Introduction: Outpatient services are crucial for strengthening primary healthcare and reducing out-of-pocket spending, which has been one of the major causes of impoverishment. So it is also critical to comprehend the people's preferences in accessing primary healthcare facilities, as government primary healthcare facilities in India are underutilized. The current paper explores the factors that construct the individual's decision to seek outpatient care in primary healthcare facilities in India's largest state Rajasthan. Methods: It was a cross-sectional survey conducted in 72 primary sample units of 24 primary health centers in 11 districts of Rajasthan, India, from November 2019 to January 2020. The study selected 368 households through purposive sampling. Out of 368 households, 460 people reported any illness and 326 reported outpatient visit to any health facility in the last 30 days from the date of the survey. Analysis: The focus was on analyzing the data in the context of public and private health facilities to understand the factors influencing people's choice to access outpatient services. The principal component analysis is used to understand the relationship between facility preparedness and OPD uptake. Also, multivariate logistic regression is applied to assess the significant predictors in using primary health facility services. Result: Except for the 29% of patients who received no care, the proportion of patients attended public health facilities was 35%, and the rest were utilizing private health facilities. Those who sought care at PHCs were mostly over 45 years age, non-literate, and from the lowest wealth quintile. Logistic regression suggests that people belong to upper wealth quintile (OR = 0.298; 95% 0.118–0.753) are less likely to visit PHCs for treatment. Also, increase in distance of PHC (OR = 0.203; 95% CI 0.076–0.539) reduces the likelihood of their visit outpatient care. People are 9.7 times (OR = 9.740; 95% CI 2.856–33.217) more likely to visit a PHCs that are better equipped in terms of human resources, equipment, and medicine. Conclusion: The uptake of PHCs depends on several factors, which should be considered to ensure that all segments of society have equitable access to them. Through improved accessibility and quality of service, PHCs can be made more appealing to the larger population. [ABSTRACT FROM AUTHOR]

Background: Utilisation of continuum of maternal health care services is crucial for a healthy pregnancy and childbirth and plays an important role in attaining Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs) related to maternal and child health. This paper aims to assess the percentage of dropouts across various stages of utilization of continuum of maternal health services (CMHS) in India and also investigates the factors hindering the utilization of these services.Methods: We used recent data from National Family Health Survey(NFHS) encompassing a total sample of 1,70,937 pregnant women for the period 2015-16. The percentage of women dropping out while seeking maternal health care is measured using descriptive statistics. While, the factors impeding the utilization of maternal health services is estimated using a Multinomial Logistic Regression Model, where dependent variable (CMHS) is defined as complete care, incomplete care and no care.Results: Only17% of pregnant women availed the utilisation of complete care and 83% either did not seek any care or dropped after seeking one or two services. For instance, it is found that 79% of women who registered for antenatal care services (ANC) did not avail the same adequately. An empirical investigation of determinants of inadequate utilization of CMHS revealed that factors like individual characteristics, for instance- access to media (RRR: 2.06) and mother's education play (RRR: 3.61) a vital role in the uptake of CMHS. It is also found that the interaction between wealth index and place of residence plays a pivotal role in seeking complete care. Lastly, the results revealed that male participation (RRR: 2.69) and contacting multi-purpose worker (MPW) (RRR: 2.33) are also at play.Conclusion: The study suggests that the major determinants of utilisation of CMHS are access to media, mother's education, affordability barriers and male participation. Hence, policy recommendations should be oriented towards strengthening these dimensions and the utilisation of adequate ANC has to be considered as the need of the hour. [ABSTRACT FROM AUTHOR]

The 'Cost of Health Services in India (CHSI)' is the first large scale multi-site facility costing study to incorporate evidence from a national sample of both private and public sectors at different levels of the health system in India. This paper provides an overview of the extent of heterogeneity in costs caused by various supply-side factors.A total of 38 public (11 tertiary care and 27 secondary care) and 16 private hospitals were sampled from 11 states of India. From the sampled facilities, a total of 327 specialties were included, with 48, 79 and 200 specialties covered in tertiary, private and district hospitals respectively. A mixed methodology consisting of both bottom-up and top-down costing was used for data collection. Unit costs per service output were calculated at the cost centre level (outpatient, inpatient, operating theatre, and ICU) and compared across provider type and geographical location.The unadjusted cost per admission was highest for tertiary facilities (₹ 5690, 75 USD) followed by private facilities (₹ 4839, 64 USD) and district hospitals (₹ 3447, 45 USD). Differences in unit costs were found across types of providers, resulting from both variations in capacity utilisation, length of stay and the scale of activity. In addition, significant differences in costs were found associated with geographical location (city classification).The reliance on cost information from single sites or small samples ignores the issue of heterogeneity driven by both demand and supply-side factors. The CHSI cost data set provides a unique insight into cost variability across different types of providers in India. The present analysis shows that both geographical location and the scale of activity are important determinants for deriving the cost of a health service and should be accounted for in healthcare decision making from budgeting to economic evaluation and price-setting. [ABSTRACT FROM AUTHOR]

Background: In the last two decades, cesarean section (CS) deliveries in India have increased by six-fold and created economic hardship for families and households. Although several schemes and policies under the National Health Mission (NHM) have reduced the inequality in the use of maternal care services in India, the distributive effect of public health subsidies on CS deliveries remains unclear. In this context, this paper examines the usage patterns of CS delivery and estimates the share of public health subsidies on CS deliveries among mothers by different background characteristics in India.Data: Data from the fourth round of the National Family Health Survey (NFHS-4) was used for the study. Out-of-pocket (OOP) payment for CS delivery was used as a dependent variable and was analyzed by level of care that is, primary (PHC, UHC, other) and secondary (government/municipal, rural hospital). Descriptive statistics, binary logistic regression, benefit incidence analysis, concentration curve and concentration index were used for the analysis.Results: A strong economic gradient was observed in the utilization of CS delivery from public health facilities. Among mothers using any public health facility, 23% from the richest quintile did not pay for CS delivery compared to 13% from the poorest quintile. The use of the public subsidy among mothers using any type of public health facility for CS delivery was pro-rich in nature; 9% in the poorest quintile, 16.1% in the poorer, 24.5% in the middle, 27.5% among richer and 23% in the richest quintile. The pattern of utilization and distribution of public subsidy was similar across the primary and secondary health facilities but the magnitude varied. The findings from the benefit-incidence analysis are supported by those obtained from the inequality analysis. The concentration index of CS was 0.124 for public health centers and 0.291 for private health centers. The extent of inequality in the use of CS delivery in public health centers was highest in the state of Mizoram (0.436), followed by Assam (0.336), and the lowest in Tamil Nadu (0.060), followed by Kerala (0.066).Conclusion: The utilization of CS services from public health centers in India is pro-rich. Periodically monitoring and evaluating of the cash incentive schemes for CS delivery and generating awareness among the poor would increase the use of CS delivery services in public health centers and reduce the inequality in CS delivery in India. [ABSTRACT FROM AUTHOR]

Background: Government-sponsored health insurance schemes (GSHIS) aim to improve access to and utilization of healthcare services and offer financial protection to the population. India's Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one such GSHIS. This paper aims to understand how the processes put in place to manage hospital-based transactions, from the time a beneficiary arrives at the hospital to discharge are being implemented in PM-JAY and how to improve them to strengthen the scheme's operation.Methods: Guidelines were reviewed for the processes associated with hospital-based transactions, namely, beneficiary authentication, treatment package selection, preauthorization, discharge, and claims payments. Across 14 hospitals in Gujarat and Madhya Pradesh states, the above-mentioned processes were observed, and using a semi-structured interview guide fifty-three respondents were interviewed. The study was carried out from March 2019 to August 2019.Results: Average turn-around time for claim reimbursement is two to six times higher than that proposed in guidelines and tender. As opposed to the guidelines, beneficiaries are incurring out-of-pocket expenditure while availing healthcare services. The training provided to the front-line workers is software-centric. Hospital-based processes are relatively more efficient in hospitals where frontline workers have a medical/paramedical/managerial background.Conclusions: There is a need to broaden capacity-building efforts from enabling frontline staff to operate the scheme's IT platform to developing the technical, managerial, and leadership skills required for them. At the hospital level, an empowered frontline worker is the key to efficient hospital-based processes. There is a need to streamline back-end processes to eliminate the causes for delay in the processing of claim payment requests. For policymakers, the most important and urgent need is to reduce out-of-pocket expenses. To that end, there is a need to both revisit and streamline the existing guidelines and ensure adherence to the guidelines. [ABSTRACT FROM AUTHOR]

Background: Primary mental healthcare (PMHC) allows for complex mental health issues in old age to be addressed. India has sought to improve PMHC through legislation, strategies and programmes. This study analyses the challenges and opportunities involved in strengthening PMHC for older persons in India from the perspectives of key stakeholders. Methods: Semistructured interviews were conducted with 14 stakeholders selected from the PMHC system in India and analysed using thematic analysis. First, the analysis was organizationally structured in accordance with the six WHO mental health system domains: (1) policy and legislative framework, (2) mental health services, (3) mental health in primary care, (4) human resources, (5) public information and links to other sectors, and (6) monitoring and research. Second, for each building block, challenges and opportunities were derived using inductive coding. Results: This study highlights the numerous challenges that may be encountered when attempting to strengthen age-inclusive PMHC. Among these challenges are poor public governance, a lack of awareness and knowledge among policy-makers and other stakeholders, and existing policies that make unrealistic promises to weak primary healthcare (PHC) structures with an excessive focus on medicalizing mental health problems. Thus, the mental health system often fails to reach vulnerable older people through PHC. Established approaches to comprehensive, family- and community-oriented PHC support attempts to strengthen intersectoral approaches to PMHC that emphasize mental health promotion in old age. Targeting the PHC workforce through age-inclusive mental health education is considered particularly necessary. Experts further argue that adequate monitoring structures and public spending for mental health must be improved. Conclusions: In this study, we aim to elaborate on the mental healthcare developments that may serve to achieve equity in access to mental healthcare in India. Coordinated and collaborative efforts by public and private stakeholders involved in the care of older persons, both with and without lived mental health experiences, as well as their families and communities, are necessary to bring the vision of those policies for PMHC to fruition. The findings presented in this study can also inform future research, policies and practice in other low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Background: There is limited understanding of how universal health coverage (UHC) schemes such as publicly-funded health insurance (PFHI) benefit women as compared to men. Many of these schemes are gender-neutral in design but given the existing gender inequalities in many societies, their benefits may not be similar for women and men. We contribute to the evidence by conducting a gender analysis of the enrolment of individuals and households in India's national PFHI scheme, Rashtriya Swasthya Bima Yojana (RSBY). Methods: We used data from a cross-sectional household survey on RSBY eligible families across eight Indian states and studied different outcome variables at both the individual and household levels to compare enrolment among women and men. We applied multivariate logistic regressions and controlled for several demographic and socio-economic characteristics. Results: At the individual level, the analysis revealed no substantial differences in enrolment between men and women. Only in one state were women more likely to be enrolled in RSBY than men (AOR: 2.66, 95% CI: 1.32-5.38), and this pattern was linked to their status in the household. At the household level, analyses revealed that female-headed households had a higher likelihood to be enrolled (AOR: 1.36, 95% CI: 1.14-1.62), but not necessarily to have all household members enrolled. Conclusion: Findings are surprising in light of India's well-documented gender bias, permeating different aspects of society, and are most likely an indication of success in designing a policy that did not favour participation by men above women, by mandating spouse enrolment and securing enrolment of up to five family members. Higher enrolment rates among female-headed households are also an indication of women's preferences for investments in health, in the context of a conducive policy environment. Further analyses are needed to examine if once enrolled, women also make use of the scheme benefits to the same extent as men do. India is called upon to capitalise on the achievements of RSBY and apply them to newer schemes such as PM-JAY. [ABSTRACT FROM AUTHOR]

Introduction: With the escalating burden of chronic disease and multimorbidity in India, owing to its ageing population and overwhelming health needs, the Indian Health care delivery System (HDS) is under constant pressure due to rising public expectations and ambitious new health goals. The three tired HDS should work in coherence to ensure continuity of care, which needs a coordinated referral system. This calls for optimising health care through Integrated care (IC). The existing IC models have been primarily developed and adopted in High-Income Countries. The present study attempts to review the applicability of existing IC models and frame a customised model for resource-constrained settings. Methods: A two-stage methodology was used. Firstly, a narrative literature review was done to identify gaps in existing IC models, as per the World Health Organization framework approach. The literature search was done from electronic journal article databases, and relevant literature that reported conceptual and theoretical concepts of IC. Secondly, we conceptualised an IC concept according to India's existing HDS, validated by multiple rounds of brainstorming among co-authors. Further senior co-authors independently reviewed the conceptualised IC model as per national relevance. Results: Existing IC models were categorised as individual, group and disease-specific, and population-based models. The limitations of having prolonged delivery time, focusing only on chronic diseases and being economically expensive to implement, along with requirement of completely restructuring and reorganising the existing HDS makes the adoption of existing IC models not feasible for India. The Indian Model of Integrated Healthcare (IMIH) model proposes three levels of integration: Macro, Meso, and Micro levels, using the existing HDS. The core components include a Central Gateway Control Room, using existing digital platforms at macro levels, a bucket overflow model at the meso level, a Triple-layered Concentric Circle outpatient department (OPD) design, and a three-door OPD concept at the micro level. Conclusion: IMIH offers features that consider resource constraints and local context of LMICs while being economically viable. It envisages a step toward UHC by optimising existing resources and ensuring a continuum of care. However, health being a state subject, various socio-political and legal/administrative issues warrant further discussion before implementation. [ABSTRACT FROM AUTHOR]

Background: India has rolled out Early Infant Diagnosis (EID) program for HIV infection in all states. EID program consists of testing of Infants exposed to HIV periodically over 18 months of age which is a multi-step complex testing cascade. Caregivers represent the primary beneficiary of EID program i.e., infants exposed to HIV and face multiple challenges to access EID services. As part of national EID program outcome assessment study, this study narrates caregivers' perspectives on barriers and facilitators to access and utilize EID services. Methods: The study was conducted in 31 integrated counselling and testing centres (ICTCs) located in 11 high burden HIV states. A total of 66 in-depth interviews were conducted with caregivers' of infants enrolled in EID program. Thematic analysis was carried out to help identify themes underlying barriers and facilitators to access EID services and utilization from caregivers' perspectives. Results: The stigma and discrimination prevalent in society about HIV remains a key demand side (caregiver-level) barrier. Non-disclosure or selective disclosure of HIV status led to missed or delayed EID tests and delayed HIV diagnosis and initiation of Anti-Retroviral Therapy (ART) for infants exposed to HIV. On supply side (health system-level), accessibility of healthcare facility with EID services was reported as a key barrier. The distance, time and cost were key concerns. Many caregivers faced difficulties to remember the details of complex EID test schedule and relied on a phone call from ICTC counsellor for next due EID test. Delayed EID test results and lack of communication of test results to caregiver were reported as primary barriers for completing the EID test cascade. Discussion: The study reports caregiver-level and health system-level barriers and facilitators for access to EID services from the caregivers' perspectives. While, decentralisation and single window approaches can improve the access, timely communication of test results to the caregiver also need to be built in with appropriate use of technology. A holistic intervention including PLHIV support networks and the peer-led support mechanisms would be useful to address societal factors. Conclusion: The study findings have high significance for developing program implementation strategies to improve access and to build right-based and patient-centred EID services. [ABSTRACT FROM AUTHOR]

Background: A structured and organized public health set up with systematically trained personnel to manage and deliver public health services from grassroot levels to higher administrative levels with separate public health directorate is the need of the hour. The objective of this study was to conduct a situational analysis of public health cadre in select states in India to gain an in-depth understanding of the progress and explore the gaps and challenges in its implementation. Methods: Four states from the country were selected based on stages of implementation of the cadre. The WHO health systems framework was the basis of assessment. In-depth interviews of 78 stakeholders from public health system across various categories and levels were conducted. Results: Every state has a dedicated cadre for public health in the form of a separate hierarchical structure and Directorate. There are deficits in human resources skilled enough to manage and implement public health across all levels. Its penetration below districts level is limited. There are limited opportunities available for contractual staffs in terms of remuneration and job progression. The respondents strongly emphasized on having personnel with training in public health, especially at leadership positions. Funding was not reported to be a problem although some challenges in the timeliness of release of funds were reported. Under the existing Health Management Information System, duplication of data exists and there is underutilization of data for policy making. Conclusion: A dedicated public health cadre is under evolution in India. The main challenge is inadequate workforce skilled in public health management. States are committed to finding solutions to overcome these barriers. [ABSTRACT FROM AUTHOR]

Background: In an effort to encourage Family Planning (FP) adoption, since 1952, the Government of India has been implementing various centrally sponsored schemes that offer financial incentives (FIs) to acceptors as well as service providers, for services related to certain FP methods. However, understanding of the role of FIs on uptake of FP services, and the quality of FP services provided, is limited and mixed., Methods: A qualitative descriptive study was conducted in Chatra and Palamu districts of Jharkhand state. A total of 64 interviews involving multiple stakeholders were conducted. The stakeholders included recent FP acceptors or clients, FP service providers of public health facilities including Accredited Social Healthcare Activists (ASHAs), government health officials managing FP programs at the district and state level, and members of development partners supporting FP programs in Jharkhand. Data analysis included both inductive and deductive strategies. It was done using the software Atlas ti version 8., Results: It has emerged that there is a strong felt need for FP among majority of the clients, and FIs may be a motivator for uptake of FP methods only among those belonging to the lower socio economic strata. For ASHAs, FI is the primary motivator for providing FP related services. There may be a tendency among them and the nurses to promote methods which have more financial incentives linked with them. There are mixed opinions on discontinuing FIs for clients or replacing them with non-financial incentives. Delays in payment of FIs to both clients and the ASHAs is a common issue and adversely effects the program., Conclusion: FIs for clients have limited influence on their decision to take up a FP method while different amounts of FIs for ASHAs and nurses, linked with different FP methods, may be influencing their service provision. More research is needed to determine the effect of discontinuing FI for FP services., (© 2021. The Author(s).)

Context: Expeditious diagnosis and treatment of chronic conditions are critical to control the burden of non-communicable disease in low- and middle-income countries. We aimed to estimate sociodemographic and geographic inequalities in diagnosis and treatment of chronic conditions among adults aged 45 + in India. Methods: We used 2017–18 nationally representative data to estimate prevalence of chronic conditions (hypertension, diabetes, lung disease, heart disease, stroke, arthritis, cholesterol, and neurological) reported as diagnosed and percentages of diagnosed conditions that were untreated by sociodemographic characteristics and state. We used concentration indices to measure socioeconomic inequalities in diagnosis and lack of treatment. Fully adjusted inequalities were estimated with multivariable probit and fractional regression models. Findings: About 46.1% (95% CI: 44.9 to 47.3) of adults aged 45 + reported a diagnosis of at least one chronic condition and 27.5% (95% CI: 26.2 to 28.7) of the reported conditions were untreated. The percentage untreated was highest for neurological conditions (53.2%; 95% CI: 50.1 to 59.6) and lowest for diabetes (10.1%; 95% CI: 8.4 to 11.5). Age- and sex-adjusted prevalence of any diagnosed condition was highest in the richest quartile (55.3%; 95% CI: 53.3 to 57.3) and lowest in the poorest (37.7%: 95% CI: 36.1 to 39.3). Conditional on reported diagnosis, the percentage of conditions untreated was highest in the poorest quartile (34.4%: 95% CI: 32.3 to 36.5) and lowest in the richest (21.1%: 95% CI: 19.2 to 23.1). Concentration indices confirmed these patterns. Multivariable models showed that the percentage of untreated conditions was 6.0 points higher (95% CI: 3.3 to 8.6) in the poorest quartile than in the richest. Between state variations in the prevalence of diagnosed conditions and their treatment were large. Conclusions: Ensuring more equitable treatment of chronic conditions in India requires improved access for poorer, less educated, and rural older people who often remain untreated even once diagnosed. Highlights: • Little is known about sociodemographic and geographic inequalities in the diagnosis and treatment of chronic illness among middle-aged and older adults in India. • Self-reported diagnosed chronic conditions are more prevalent among socially advantaged groups but the disadvantaged are more likely to be untreated. • To ensure more equitable treatment of chronic conditions, efforts to improve access should be directed towards poorer, less educated, and ruralolder people. [ABSTRACT FROM AUTHOR]

Introduction: Low- and middle-income countries (LMICs) are committed to achieving the Sustainable Development Goal 3.1 to reduce maternal mortality. The Ministry of Health and Family Welfare of India recommends prophylactic uterotonic administration to every woman following delivery to reduce the risk of postpartum hemorrhage (PPH), as PPH is the leading cause of maternal mortality in LMICs, including India. In 2018, the World Health Organization first recognized heat-stable carbetocin for PPH prevention. Governments are now considering its introduction into their public health systems. Methods: A decision-tree model was developed from the public healthcare system perspective to compare the value of heat-stable carbetocin versus oxytocin and misoprostol among women giving birth in public sector healthcare facilities in India. The model accounted for differences in PPH risk and costs based on mode of delivery and healthcare setting, as well as provider behavior to mitigate quality concerns of oxytocin. Model outcomes for each prophylactic uterotonic included the number of PPH events, DALYs due to PPH, deaths due to PPH, and direct medical care costs. The budget impact was estimated based on projected uterotonic uptake between 2022–2026. Results: Compared to oxytocin, heat-stable carbetocin avoided 5,468 additional PPH events, 5 deaths, and 244 DALYs per 100,000 births. Projected direct medical costs to the public healthcare system were lowered by US $171,700 (₹12.8 million; exchange rate of ₹74.65 = US$1 from 2 Feb 2022) per 100,000 births. Benefits were even greater when compared to misoprostol (7,032 fewer PPH events, 10 fewer deaths, 470 fewer DALYs, and $230,248 saved per 100,000 births). In the budget impact analysis, India's public health system is projected to save US$11.4 million (₹849 million) over the next five years if the market share for heat-stable carbetocin grows to 19% of prophylactic uterotonics administered. Conclusions: Heat-stable carbetocin is expected to reduce the number of PPH events and deaths, avoid more DALYs, and reduce costs to the public healthcare system of India. Greater adoption of heat-stable carbetocin for the prevention of PPH could advance India's efforts to achieve its maternal health goals and increase efficiency of its public health spending. [ABSTRACT FROM AUTHOR]

Background: India, the seventh-largest country in the world and the second-most populated faces enormous challenges when it comes to healthcare. The country's healthcare system was close to collapse due to the detrimental effects of the COVID-19 pandemic. Telehealth, which enables treating patients remotely, played a critical role during these challenging times. This systematic review investigates in detail the role of telehealth during COVID-19 and its application beyond the pandemic. Methods: Database searches on PubMed, Scopus, Science Direct and Web of Science were carried out for studies published on telehealth, and articles were included if they focused on any audio or video telehealth consultation during the pandemic in India. Findings were synthesised into three main themes: applications, benefits and challenges of telehealth services. Methodological quality was assessed using JBI critical appraisal tools. Results: The initial search on databases yielded 1143 articles. Of those, 19 met the eligibility criteria. Findings highlight the effective utilisation of telehealth across multiple medical specialities. Although insufficient technological infrastructure and other barriers due to the virtual consultation challenge the successful implementation of telehealth in India, it has the potential to bridge the rural-urban healthcare divide with cost-effective and easily accessible services. Conclusion: High patient/provider satisfaction underscores the need to integrate telehealth into routine healthcare practices in the country. However, the review urges the government and healthcare practitioners to address the telehealth challenges with prime importance to ensure quality healthcare throughout the nation even after the pandemic. [ABSTRACT FROM AUTHOR]

Background: The economic burden of autism is substantial and includes a range of costs, including healthcare, education, productivity losses, informal care and respite care, among others. In India, approximately, 2 million children aged 2-9 years have autism. Given the likely substantial burden of illness and the need to identify effective and cost-effective interventions, this research aimed to produce a comprehensive cost of illness inventory (COII) suitable for children with autism in South Asia (India) to support future research.Methods: A structured and iterative design process was followed to create the COII, including literature reviews, interviews with caregivers, pilot testing and translation. Across the development of the COII, thirty-two families were involved in the design and piloting of the tool. The COII was forward translated (from English to Hindi) and back translated. Each stage of the process of development of the COII resulted in the further refinement of the tool.Results: Domains covered in the final COII include education, childcare, relocation, healthcare contacts (outpatient, inpatient, medical emergencies, investigations and medication), religious retreats and rituals, specialist equipment, workshops and training, special diet, support and care, certification, occupational adjustments and government rebates/schemes. Administration and completion of the COII determined it to be feasible to complete in 35 minutes by qualified and trained researchers. The final COII is hosted by REDCap Cloud and is a bilingual instrument (Hindi and English).Conclusions: The COII was developed using experiences gathered from an iterative process in a metropolitan area within the context of one low- and middle-income country (LMIC) setting, India. Compared to COII tools used for children with autism in high-income country settings, additional domains were required, such as complimentary medication (e.g. religious retreats and homeopathy). The COII will allow future research to quantify the cost of illness of autism in India from a broad perspective and will support relevant economic evaluations. Understanding the process of developing the questionnaire will help researchers working in LMICs needing to adapt the current COII or developing similar questionnaires. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia that affects 60 million people worldwide. Limited evidence on AF management exists from low- and middle-income countries and none from Sri Lanka. We aimed to investigate the existing AF care pathway and patients' perception on AF management to identify barriers and enablers for optimal AF care in Northern Province, Sri Lanka.Methods: A rapid evaluation was undertaken with use of qualitative methods. Local healthcare providers (HCPs) mapped the intended pathway of care for AF patients which was then explored and annotated through 12 iterative sessions with additional HCPs. Topics of inefficiencies identified from the finalised map were used to guide focus group discussions (FGDs) with AF patients. AF patients who were attending the anticoagulation clinic at the only tertiary hospital in Northern Province were recruited and invited to participate using purposive sampling. The topic guide was developed in collaboration with local clinicians and qualitative experts. FGDs were conducted in the native Tamil language and all sessions were recorded, transcribed verbatim and thematically analysed using a deductive approach.Results: The mapped pathway revealed inefficiencies in referral, diagnosis and ongoing management. These were explored through three FGDs conducted with 25 AF patients aged 25 to 70 years. Two key themes that contributed to and resulted in delays in accessing care and ongoing management were health seeking behaviours and atomistic healthcare structures. Four cross-cutting sub-themes identified were decision making, paternalistic approach to care, cost impacts and lifestyle impacts. These are discussed across 10 unique categories with consideration of the local context.Conclusions: Strengthening primary healthcare services, improving public health literacy regarding AF and building patient autonomy whilst understanding the importance of their daily life and family involvement may be advantageous in tackling the inefficiencies in the current AF care pathway in Sri Lanka. [ABSTRACT FROM AUTHOR]

Objective: Sterilization is the only family planning method that involves relatively large amount compensation. So, the study attempts to examine the role of incentives received against the sterilization procedures on the reporting of sterilization regret in India.Methods: The study used data from the fourth round of National Family Health Survey, 2015-16, which gathered the information on sterilization regret from 1,94,207 ever-married women. Multivariate logistic analysis and predicted probabilities approach was used to study the effect of compensation received on the sterilization regret in India.Results: Results show that women who have received compensation were 33% less likely to report sterilization regret. It was found that 70% of women who undergone sterilization in public facility didn't incur any expenditure, rather received incentives. It is observed that women who had undergone operation in private facility spent a large amount than women who had done their operation in public facility. The regret in the private facility mainly results from high out of pocket expenditure on sterilization procedures. Around eight percent of women regretted getting sterilized in a private hospital and received some compensation amount, vis a vis the six percent who regretted undergoing sterilization in public facility and received compensation.Conclusion: The study calls for a need to standardize the cost of sterilization procedure in India's health facilities. A good alternative for reducing the cost could be Public-Private Partnership. [ABSTRACT FROM AUTHOR]

Background: In spite of being the 'pharmacy of the world', access to essential medicines for a large majority of Indians is constrained by both physical and financial reasons. According to an estimate, medicines account for 69% of household out-of-pocket spending on health care. To make quality generic medicine affordable, India's People's Medicine Scheme (Jan Aushadhi) was launched in 2008 and then revamped and rebranded as Pradhan Mantri Bhartiya Jan Ausadhi Pariyojana (PMBJP) in 2015. The current study focuses on the availability, affordability and acceptability aspects of PMBJP essential medicines.Methods: We have used a mixed-methods approach, with the survey-based quantitative component supplemented by a qualitative component consisting of in-depth interviews (IDIs). The survey was conducted in 11 PMBJP pharmacies in Mumbai and Palghar. Data were gathered on the availability, stock-outs, price and affordability of 35 essential medicines and 2 consumables.Results: Apart from the limited coverage of essential medicines and the significant presence of Fixed dose combinations (FDCs) in the PMBJP medicine list, the availability of surveyed essential drugs was also found to be low (47%) in PMBJP outlets. Across Mumbai and Palghar districts, around 50% and 42% of medicines were found to be out of stock for the period of 3-6 months respectively. The cost of generic medicines of PMBJP outlets for treating various conditions range from 0.01 days' wages to 0.47 days' wages for the lowest paid unskilled worker in Maharashtra.Conclusions: The study findings show that PMBJP's unbranded generics offer great opportunities for substantial cost savings. But, in order to fully realise the potential of this scheme, some policy actions are urgently required. First, the PMBJP drug list must include all essential drugs that feature in NLEM. Second, BPPI should procure only those drugs that pass the bioequivalence test. Third, compulsory de-branding of generics should be done in a phased manner. Fourth, PMBJP's medicine procurement and distribution policies must be reviewed to address the supply chain issues. Moreover, there is a need for major pharmaceutical policy reforms to promote generic medicines in a big way. Regulations to support mandatory generic prescribing and generic substitution by pharmacists are needed. [ABSTRACT FROM AUTHOR]

Background: Experience of care is a pillar of quality care; positive experiences are essential during health care encounters and integral to quality health service delivery. Yet, we lack synthesised knowledge of how private sector delivery of quality care affects experiences of care amongst mothers, newborns, and children. To fill this gap, we conducted a systematic review that examined quantitative, qualitative, and mixed-methods studies on the provision of maternal, newborn, and child health (MNCH) care by private providers in low- and middle-income countries (LMICs). This manuscript focuses on experience of care, including respectful care, and satisfaction with care.Methods: Our protocol followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Searches were conducted in eight electronic databases (Cumulative Index to Nursing and Allied Health, EconLit, Excerpta Medica Database, International Bibliography of the Social Sciences, Popline, PubMed, ScienceDirect, and Web of Science) and two websites and supplemented with hand-searches and expert recommendations. For inclusion, studies examining private sector delivery of quality care amongst mothers, newborns, and children in LMICs must have examined maternal, newborn, and/or child morbidity or mortality; quality of care; experience of care; and/or service utilisation. Data were extracted for descriptive statistics and thematic analysis.Results: Of the 139 studies included, 45 studies reported data on experience of care. Most studies reporting experience of care were conducted in India, Bangladesh, and Uganda. Experiences of private care amongst mothers, newborns, and children aligned with four components of quality of care: patient-centeredness, timeliness, effectiveness, and equity. Interpersonal relationships with health care workers were essential to experience of care, in particular staff friendliness, positive attitudes, and time spent with health care providers. Experience of care can be a stronger determining factor in MNCH-related decision-making than the quality of services provided.Conclusion: Positive experiences of care in private facilities can be linked more broadly to privileges of private care that allow for shorter waiting times and more provider time spent with mothers, newborns, and children. Little is known about experiences of private sector care amongst children.Trial Registration: This systematic review was registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42019143383 ). [ABSTRACT FROM AUTHOR]

Background: Effective and safe COVID 19 vaccines have been approved for emergency use since the end of 2020 and countries are actively vaccinating their people. Nevertheless, hesitancy towards the vaccines exist globally.Objectives: We conducted this study to understand the attitudes towards COVID 19 vaccines and hesitancy to accept it among urban and rural communities in Tamil Nadu, India.Methods: We conducted a community based cross sectional study in urban and rural communities among 564 persons who had not been vaccinated yet, selected through multistage random sampling. The vaccine attitude scale (VAX) was used to measure attitudes towards the vaccines and their acceptance of the vaccine was captured by responses to a direct question.Results: More than 50% of the respondents had positive attitudes towards the COVID 19 vaccines. Based on their attitudes, they were segmented into four clusters, first with preference for natural immunity compared to vaccines and low concern regarding adverse effects. Second with high level of trust in vaccines and low mistrust. The third cluster members had high level of concern regarding the adverse effects and low levels of mistrust in vaccines and the fourth had high trust in vaccines and low preference for natural immunity. Older individuals with higher education and occupation were more likely to belong to cluster four with high trust in the vaccines. Younger individuals, women, rural residents, belonging to low income labourer class were highly mistrusting of the vaccines. The prevalence of vaccine hesitancy was 40.7% (95% CI - 36.67 - 44.73%), while 19.5% (95% CI = 16.23 - 22.77%) of the respondents were vaccine deniers. While vaccine acceptance was greatest in cluster 1, it was least in cluster 3.Conclusions: Vaccine hesitancy was high in urban and rural Tamil Nadu. The population could be effectively segmented into groups based on their attitudes and this understanding can be used to develop targeted behaviour change communication campaigns. [ABSTRACT FROM AUTHOR]

Background: In 2018, 875 000 under-five children died in India with children from poor families and rural communities disproportionately affected. Community health centres are positioned to improve access to quality child health services but capacity is often low and the systems for improvements are weak.Methods: Secondary analysis of child health program data from the Uttar Pradesh Technical Support Unit was used to delineate how program activities were temporally related to public facility readiness to provide child health services including inpatient admissions. Fifteen community health centres were mapped regarding capacity to provide child health services in July 2015. Mapped domains included human resources and training, infrastructure, equipment, drugs/supplies and child health services. Results were disseminated to district health managers. Six months following dissemination, Clinical Support Officers began regular supportive supervision and gaps were discussed monthly with health managers. Senior pediatric residents mentored medical officers over a three-month period. Improvements were assessed using a composite score of facility readiness for child health services in July 2016. Usage of outpatient and inpatient services by under-five children was also assessed.Results: The median essential composition score increased from 0.59 to 0.78 between July 2015 and July 2016 (maximum score of 1) and the median desirable composite increased from 0.44 to 0.58. The components contributing most to the change were equipment, drugs and supplies and service provision. Scores for trained human resources and infrastructure did not change between assessments. The number of facilities providing some admission services for sick children increased from 1 in July 2015 to 9 in October 2016.Conclusions: Facility readiness for the provision of child health services in Uttar Pradesh was improved with relatively low inputs and targeted assessment. However, these improvements were only translated into admissions for sick children when clinical mentoring was included in the support provided to facilities. [ABSTRACT FROM AUTHOR]

Background: Stakeholder engagement is essential to the design, implementation and evaluation of complex mental health interventions like peer support. Theory of Change (ToC) is commonly used in global health research to help structure and promote stakeholder engagement throughout the project cycle. Stakeholder insights are especially important in the context of a multi-site trial, in which an intervention may need to be adapted for implementation across very different settings while maintaining fidelity to a core model. This paper describes the development of a ToC for a peer support intervention to be delivered to people with severe mental health conditions in five countries as part of the UPSIDES trial., Methods: One hundred thirty-four stakeholders from diverse backgrounds participated in a total of 17 workshops carried out at six UPSIDES implementing sites across high-, middle- and low-income settings (one site each in India, Israel, Uganda and Tanzania; two sites in Germany). The initial ToC maps created by stakeholders at each site were integrated into a cross-site ToC map, which was then revised to incorporate additional insights from the academic literature and updated iteratively through multiple rounds of feedback provided by the implementers., Results: The final ToC map divides the implementation of the UPSIDES peer support intervention into three main stages: preparation, implementation, and sustainability. The map also identifies three levels of actors involved in peer support: individuals (service users and peer support workers), organisations (and their staff members), and the public. In the UPSIDES trial, the ToC map proved especially helpful in characterising and distinguishing between (a) common features of peer support, (b) shared approaches to implementation and (c) informing adaptations to peer support or implementation to account for contextual differences., Conclusions: UPSIDES is the first project to develop a multi-national ToC for a mental health peer support intervention. Stakeholder engagement in the ToC process helped to improve the cultural and contextual appropriateness of a complex intervention and ensure equivalence across sites for the purposes of a multi-site trial. It may serve as a blueprint for implementing similar interventions with a focus on recovery and social inclusion among people with mental ill-health across diverse settings., Trial Registration: ISRCTN26008944 (Registration Date: 30/10/2019)., (© 2024. The Author(s).)

Background: The Manyata program is a quality improvement initiative for private healthcare facilities in India which provided maternity care services. Under this initiative, technical assistance was provided to selected facilities in the states of Uttar Pradesh, Jharkhand and Maharashtra which were interested in obtaining 'entry level certification' under the National Accreditation Board for Hospitals and Healthcare Providers (NABH) for provision of quality services. This paper describes the change in quality at those Manyata-supported facilities when assessed by the NABH standards of care., Methods: Twenty-eight private-sector facilities underwent NABH assessments in the three states from August 2017 to February 2019. Baseline assessment (by program staff) and NABH assessment (by NABH assessors) findings were compared to assess the change in quality of care as per NABH standards of care. The reported performance gaps from NABH assessments were then also classified by thematic areas and suggested corrective actions based on program implementation experience., Results: The overall adherence to NABH standards of care improved from 9% in the baseline assessment to 80% in the NABH assessment. A total of 831 performance gaps were identified by the NABH assessments, of which documentation issues accounted for a majority (70%), followed by training (19%). Most performance gaps could be corrected either by revising existing documentation or creating new documentation (62%), or by orienting facility staff on various protocols (35%)., Conclusion: While the adherence of facilities to the NABH standards of care improved considerably, certain performance gaps remained, which were primarily related to documentation of facility policies and protocols and training of staff, and required corrective actions for the facilities to achieve NABH entry level certification., (© 2023. The Author(s).)

Background: In India, the distribution and retention of biomedical doctors in public sector facilities in rural areas is an obstacle to improving access to health services. The Government of Uttar Pradesh is developing a comprehensive, ten-year Human Resources for Health (HRH) strategy, which includes policies to address rural distribution and retention of government doctors in Uttar Pradesh (UP). We undertook a stakeholder analysis to understand stakeholder positions on particular policies within the strategy, and to examine how stakeholder power and interests would shape the development and implementation of these proposed policies. This paper focuses on the results of the stakeholder analysis pertaining to rural distribution and retention of doctors in the government sector in UP. Our objectives are to 1) analyze stakeholder power in influencing the adoption of policies; 2) compare and analyze stakeholder positions on specific policies, including their perspectives on the conditions for successful policy adoption and implementation; and 3) explore the challenges with developing and implementing a coordinated, 'bundled' approach to strengthening rural distribution and retention of doctors., Methods: We utilized three forms of data collection for this study - document review, in-depth interviews and focus group discussions. We conducted 17 interviews and three focus group discussions with key stakeholders between September and November 2019., Results: We found that the adoption of a coordinated policy approach for rural retention and distribution of doctors is negatively impacted by governance challenges and fragmentation within and beyond the health sector. Respondents also noted that the opposition to certain policies by health worker associations created challenges for comprehensive policy development. Finally, respondents believed that even in the event of policy adoption, implementation remained severely hampered by several factors, including weak mechanisms of accountability and perceived corruption at local, district and state level., Conclusion: Building on the findings of this analysis, we propose several strategies for addressing the challenges in improving access to government doctors in rural areas of UP, including additional policies that address key concerns raised by stakeholders, and improved mechanisms for coordination, accountability and transparency., (© 2021. The Author(s).)

Background: Despite the Indian government's Universal Immunization Program (UIP), the progress of full immunization coverage is plodding. The cost of delivering routine immunization varies widely across facilities within country and across country. However, the cost an individual bears on child immunization has not been focussed. In this context, this study tries to estimate the expenditure on immunization which an individual bears and the factors affecting immunization coverage at the regional level., Methods: Using the 75th round of National Sample Survey Organization data, the present paper attempts to check the individual expenditure on immunization and the factors affecting immunization coverage at the regional level. Descriptive statistics and multivariate regression analysis were used to fulfil the study objectives. The two-part model has been employed to inspect the determinants of expenditure on immunization., Results: The overall prevalence of full immunization was 59.3 % in India. Full immunization was highest in Manipur (75.2 %) and lowest in Nagaland (12.8 %). The mean expenditure incurred on immunization varies from as low as Rs. 32.7 in Tripura to as high as Rs. 1008 in Delhi. Children belonging to the urban area [OR: 1.04; CI: 1.035, 1.037] and richer wealth quintile [OR: 1.14; CI: 1.134-1.137] had higher odds of getting immunization. Moreover, expenditure on immunization was high among children from the urban area [Rs. 273], rich wealth quintile [Rs. 297] and who got immunized in a private facility [Rs. 1656]., Conclusions: There exists regional inequality in immunization coverage as well as in expenditure incurred on immunization. Based on the findings, we suggest looking for the supply through follow-up and demand through spreading awareness through mass media for immunization., (© 2021. The Author(s).)