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Purpose: The study aims to compare India's public health expenditure at the international and state levels. The paper also empirically examines the regional disparities in NRHM spending across the 21 selected states of India. Design/methodology/approach: The tools of absolute β-and σ-convergence are used in the analysis to test the regional convergence. The average annual growth rate across the states is the dependent variable for β-convergence, and time is the second dependent variable but is used for s-convergence. In contrast, the initial value of NRHM expenditure and the coefficient of variation of NRHM expenditure are used as independent variables, respectively. Descriptive statistics are also used for the study. The data are annual and cover the panel from 2007 to 2020. Findings: The study attests to the hypothesis of β-and σ-convergence for the selected states in the period mentioned. The observed convergence in NRHM expenditure is due to the shift in the government's attention from the non-high focus high focus states to high states through the national rural health mission policy. The coefficient of variation across the states also shows a declining trend and provides the robustness of the σ-convergence. Originality/value: As far as the literature is concerned, none of the existing studies examines the convergence of a public health expenditure scheme like the National Rural Health Mission across the Indian states by applying the techniques of β-and σ-convergence. The novelty of the study is using the newly updated dataset and validating the convergence hypotheses in the National Rural Health Mission expenditure case. [ABSTRACT FROM AUTHOR]

Background: This paper examines two state-led public-private demand-side financial support programs aiming to raise hospital delivery rates in two neighbouring Indian states-Gujarat and Madhya Pradesh. The national Janani Suraksha Yojana (JSY) was complemented with a public-private partnership program Janani Sahayogi Yojana (JSaY) in Madhya Pradesh in which private obstetricians were paid to deliver poor women. A higher amount was paid for caesarean sections (CS) than for vaginal deliveries (VD). In Gujarat state, the state program Chiranjeevi Yojana (CY) paid private obstetricians a fixed amount for a block 100 deliveries irrespective of delivery mode. The two systems thus offered an opportunity to observe the influence of supplier-induced demand (SID) from opposite incentives related to delivery mode. Methods: The data from the two programs was sourced from the Departments of Health and Family Welfare, Governments of Gujarat and Madhya Pradesh, India. Results: In JSaY program the CS rate increased from 26.6 % (2007-2008) to 40.7 % (2010-2011), against the background rate for CS in Madhya Pradesh, of only 4.9 % (2004-2006). Meanwhile in CY program in Gujarat, the CS rate decreased to 4.3 % (2010-2011) against a background CS rate of 8.1 % (2004-2006). Conclusions: The findings from India are unique in that they not only point to a significant impact from the introduction of the financial incentives but also how disincentives have an inverse impact on the choice of delivery method. [ABSTRACT FROM AUTHOR]

Background: Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context. Methods: Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups. Results: Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018. Conclusions: Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results. [ABSTRACT FROM AUTHOR]

Objectives: Understanding past trends and forecasting future changes in health spending is vital for planning and reducing reliance on out-of-pocket (OOP) expenses. The current study analyzed health expenditure patterns in India and forecasted future trends and patterns until 2035. Methods: Data on health expenditure in India from 2000 to 2019 was collected from the Organisation for Economic Co-operation and Development (OECD) iLibrary and National Health Accounts 2019 databases. Gross domestic product (GDP) data from the World Bank was also utilized. Descriptive statistics analyzed the composition and pattern, while the exponential smoothing model forecasted future health expenditures. Results: The findings revealed that expenditure made by OOP is the primary health financing source, followed by government and pre-paid private spending. The percentage of GDP allocated to total health expenditure remains stable, while the per capita health expenditure fluctuates. Variations in expenditure among states are observed, with Karnataka relying heavily on pre-paid private coverage. Future projections suggest a decline in per capita and total health expenditure as a share of GDP, with a slight increase in the government's share. Pre-paid private expenditure per capita and OOP health expenditure as a share of the total is projected to remain relatively constant but still high in absolute terms. Conclusion: The study highlights variations in health spending in India, characterized by high OOP spending, limited public coverage, and a need for investments, and reforms to improve healthcare access and equity. [ABSTRACT FROM AUTHOR]

Background: Universal health coverage (UHC) has emerged as one of the important health policy discourses under the current sustainable development goals in the world. UHC in individual disease conditions is a must for attaining overall UHC. This study measures progress towards UHC in terms of access to health care and financial protection among individuals with mental disorders in India. Methods: Data from the 75th Round National Sample Survey (NSS), 2017-18, was used, which is the latest round on health in India. Data collected from 555,115 individuals (rural: 325,232; urban: 229,232), from randomly selected 8077 villages and 6181 urban areas, included 283 outpatient and 374 hospitalization cases due to mental disorders in India. Logistic regression models were used for analyses. Results: Self-reporting of mental disorders was considerably lower than the actual disease burden in India. However, self-reporting of ailment was 1.73 times higher (95% CI: 1.18–2.52, p < 0.05) among the richest income group population compared to the poorest in India. The private sector was a major service provider of mental health services with a larger share for outpatient (66.1%) than inpatient care (59.2%). Over 63% of individuals with a mental disorder who reported private sector hospitalization noted unavailability or poor service quality at public facilities. Only 23% of individuals hospitalized had health insurance coverage at All India level. However, health insurance coverage among poorest economic class was a meagre 3.4%. Average out-of-pocket expenditure during hospitalization (public: 123 USD; private: 576 USD) and outpatient care (public: 8 USD; private: 37 USD) was significantly higher in the private sector than in the public sector. Chances of facing catastrophic health expenditure at 10% threshold were 23.33 times (95% CI: 10.85–50.17; p < 0.001) higher under private sector than public sector during hospitalization. Expenditure on medicine, as the share of total medical expenditure, was highest for hospitalization (public: 45%, private:39.5%) and outpatient care (public: 74.1%, private:39.7%). Conclusions: Social determinants play a vital role in access to healthcare and financial protection among individuals with mental disorders in India. For achieving UHC in mental disorders, India needs to address the gaps in access and financial protection for individuals with mental disorders. Trial registration: Not applicable. [ABSTRACT FROM AUTHOR]

Janani Suraksha Yojana (JSY) is more often than not recognized only as a cash transfer scheme for institutional deliveries. Since its pan India introduction in 2005, the scheme has passed through various stages which affected its implementation in multiple ways. The scheme, however, could not earn the reputation of an intervention which affected maternal health in any phenomenal way other than increasing institutional deliveries. After five years of its implementation, the present paper attempts to highlight the areas where JSY has positively contributed; if not directly, indirectly in affecting maternal health and the psyche of the community. The article provides evidence from primary data collected from 424 women who delivered during April 2010–March 2011 in selected villages of four districts of Rajasthan, India. Findings from other population-based studies conducted in the state of Rajasthan since the launch of JSY have also been considered to support the findings of the current study presented in the paper. It attempts to show that though JSY incentives were contingent on institutional delivery alone; it led to improvement of other services which have positively affected maternal and child health in terms of health seeking behaviour of the community. Chi square test was employed and it shows health behaviour of those who availed JSY benefits to be significantly associated with registration of pregnancy (p < 0.01), antenatal checkups (p < 0.05), duration of stay at the institution post-delivery (p < 0.01), initiation of breastfeeding (p < 0.5) and postnatal checkup (p < 0.01). [ABSTRACT FROM PUBLISHER]

Large scale investment in the National Rural Health Mission is expected to increase the utilization and reduce the cost of maternal care in public health centres in India. The objective of this paper is to examine recent trends in the utilization and cost of hospital based delivery care in the Empowered Action Group (EAG) states of India. The unit data from the District Level Household Survey 3, 2007-2008 is used in the analyses. The coverage and the cost of hospital based delivery at constant price is analyzed for five consecutive years preceding the survey. Descriptive and multivariate analyses are used to understand the socio-economic differentials in cost and utilization of delivery care. During 2004-2008, the utilization of delivery care from public health centres has increased in all the eight EAG states. Adjusting for inflation, the household cost of delivery care has declined for the poor, less educated and in public health centres in the EAG states. The cost of delivery care in private health centres has not shown any significant changes across the states. Results of the multivariate analyses suggest that time, state, place of residence, economic status; educational attainment and delivery characteristics of mother are significant predictors of hospital based delivery care in India. The study demonstrates the utility of public spending on health care and provides a thrust to the ongoing debate on universal health coverage in India. [ABSTRACT FROM AUTHOR]

Background Socioeconomic development has been considered as a solution to the problem of sex differentials at birth and under-five mortality. This paper analyses longitudinal data from the Ballabgarh Health and Demographic Surveillance System (HDSS) site in north India to check its veracity.Methods A cohort of children born between 1 January 2006 and 31 December 2011 at Ballabgarh HDSS were followed till death, emigration, 3 years of age or end of the study. Socioeconomic status (SES) was measured by caste, parental combined years of schooling and wealth index and divided into low, mid and high strata for each of them. Sex ratio at birth (SRB) was reported as the number of girls per 1000 boys. The Kaplan-Meier survival curves were drawn and a Cox Proportional HR of girls over boys was estimated. Results A total of 12 517 native born children (25 797 child years) were enrolled of which 710 died (death rate of 56.7/1000-live births and 27.5/1000 child-years. Socioeconomically advantaged children had significantly lower death rates. The SRB (10–16% lower) and neonatal death rate were consistently adverse for girls in the advantaged groups by all the three indicators of SES. The first month survival rates were better for girls in the lower SES categories (significant only in caste (HR 0.58; 0.37 to 0.91). High SES categories consistently showed adverse survival rates for girls (HR of 1.22 to 1.59). Conclusions Better socioeconomic situation worsened the sex differentials, especially at birth. Therefore,specific interventions targeting gender issues are required, at least as a short-term measure. [ABSTRACT FROM AUTHOR]

Abstract Increasing caesarean births is a global trend and of recent origin in India. Besides its utility and disutility, increasing caesarean births exert higher economic burden on households and the nation. Using 148,746 births from the National Family Health Survey, 2015–16, this paper examines the correlates and provides comparable estimates of out of pocket expenditure (OOPE) on caesarean births in public and private health centres in India. The monthly state specific rural-urban consumer price index and the OOPE on births over seven years are used to derive comparable OOPE estimate at 2016 prices. A composite variable combining type of birth and place of delivery is computed and classified as private and caesarean, public and caesarean, private and non-caesarean, public and non-caesarean. Descriptive statistics, logistic and tobit regression model were used to understand the differentials and determinants of OOPE on caesarean births. Caesarean births were significantly higher among mothers belonging to higher socioeconomic status, first order births, mothers with high BMI, pregnancy complications, repeat caesarean and in private health centres confirming that both maternal demand and institutional factors are leading to the increasing in caesarean rates in India. The mean OOPE of caesarean births in public health centres of poorer states was higher than that in the richer states of India (US$107 in low performing states compared to US$88 in high performing states) while such differentials across private health centres are small. The marginal effect of a caesarean birth in private health centres in low performing states was US$296 dollar higher than that of non-caesarean births. Improving the public health centres for conducting caesarean births, developing standard guideline for clinical practices in conducting caesarean births and creating awareness on comprehensive pregnancy care can reduce the caesarean rates and OOPE on caesarean birth in India. Highlights • Incraese in caesarean births are due to both maternal and clinical factors. • Three of ten first-order births were caesarean; higher than any subsequent order. • Caesarean rate among mothers with prior caesarean births was above 90 percent. • OOPE of a caesarean birth in public health centre of poorer states was high. • Medicine and test accounts larger share of OOPE in public health centers in India. [ABSTRACT FROM AUTHOR]

Introduction: Maharashtra, India, remained a hotspot during the COVID-19 pandemic. After the initial complete lockdown, the state slowly relaxed restrictions. We aim to estimate the lockdown's impact on COVID-19 cases and associated healthcare costs. Methods: Using daily case data for 84 days (9 March–31 May 2020), we modeled the epidemic's trajectory and predicted new cases for different phases of lockdown. We fitted log-linear models to estimate the growth rate, basic (R0), daily reproduction number (Re), and case doubling time. Based on pre-restriction and Phase 1 R0, we predicted new cases for the rest of the restriction phases, and we compared them with the actual number of cases during each phase. Furthermore, using the published and gray literature, we estimated the costs and savings of implementing these restrictions for the projected period, and we performed a sensitivity analysis. Results: The estimated median R0 during the different phases was 1.14 (95% CI: 0.85, 1.45) for pre-lockdown, 1.67 (95% CI: 1.50, 1.82) for phase 1 (strict mobility restrictions), 1.24 (95% CI: 1.12, 1.35) for phase 2 (extension of phase 1 with no restrictions on agricultural and essential services), 1.12 (95% CI: 1.01, 1.23) for phase 3 (extension of phase 2 with mobility relaxations in areas with few infections), and 1.05 (95% CI: 0.99, 1.123) for phase 4 (implementation of localized lockdowns in high-case-load areas with fewer restrictions on other areas), respectively. The corresponding doubling time rate for cases (in days) was 17.78 (95% CI: 5.61, −15.19), 3.87 (95% CI: 3.15, 5.00), 10.37 (95% CI: 7.10, 19.30), 20.31 (95% CI: 10.70, 212.50), and 45.56 (95% CI: 20.50, –204.52). For the projected period, the cases could have reached 631,819 without the lockdown, as the actual reported number of cases was 64,975. From a healthcare perspective, the estimated total value of averted cases was INR 194.73 billion (USD 2.60 billion), resulting in net cost savings of 84.05%. The Incremental Cost-Effectiveness Ratio (ICER) per Quality Adjusted Life Year (QALY) for implementing the lockdown, rather than observing the natural course of the pandemic, was INR 33,812.15 (USD 450.83). Conclusion: Maharashtra's early public health response delayed the pandemic and averted new cases and deaths during the first wave of the pandemic. However, we recommend that such restrictions be carefully used while considering the local socio-economic realities in countries like India. [ABSTRACT FROM AUTHOR]

Over the years various plans and programmes have been initiated and implemented by the state government of Orissa. But, state’s health indicators have not improved substantially. Moreover, in recent years, health seeking behaviour of the people has been affected due to increasing cost of health care. Health care is not free of cost any more due to introduction of user fee, increasing trend of privatization and the technological innovation. As a result, out of pocket expenditure has increased enormously affecting the socio-economically disadvantaged groups the most. In consequence, they tend to depend more upon borrowing, dis-saving, selling valuable assets and curtailing expenditure on education of their children. Hence, in this paper we try to investigate broadly into three main aspects, namely, health seeking behaviour, health care burden and most importantly the source of financing of their health expenditure across socio-economic groups by using bi-variate and regression techniques (logit) to provide policy suggestions with respect to health care financing, especially focusing health insurance. Our findings show that there exists a statistical significant difference in health seeking behaviour, health expenditure and financing health care among socio-economic groups. Socio-economic groups fall behind in terms of health care utilization and experiencing higher health care burden as well as depending more on inefficient mechanism to finance their health expenditure. Hence, we advocate that state government should increase its expenditure share towards health sector substantially to achieve desired outcomes and also provide comprehensive health insurance to the targeted socio-economic backward groups. [ABSTRACT FROM PUBLISHER]

Policy Points: Per‐capita household health spending was higher in economically developed states and was associated with ability to pay, but catastrophic health spending (CHS) was equally high in both poorer and more developed states in India. Based on multilevel modeling, we found that the largest geographic variation in health spending and CHS was at the state and village levels, reflecting wide inequality in the accessibility to and cost of health care at these levels. Contextual factors at macro and micro political units are important to reduce health spending and CHS in India. Context: In India, health care is a local good, and households are the major source of financing it. Earlier studies have examined diverse determinants of health care spending, but no attempt has been made to understand the geographical variation in household and catastrophic health spending. We used multilevel modeling to assess the relative importance of villages, districts, and states to health spending in India. Methods: We used data on the health expenditures of 101,576 households collected in the consumption expenditure schedule (68th round) carried out by the National Sample Survey in 2011‐2012. We examined 4 dependent variables: per‐capita health spending (PHS), per‐capita institutional health spending (PIHS), per‐capita noninstitutional health spending (PNHS), and catastrophic health spending (CHS). CHS was defined as household health spending exceeding 40% of its capacity to pay. We used multilevel linear regression and logistic models to decompose the variation in each outcome by state, region, district, village, and household levels. Findings: The average PHS was 1,331 Indian rupees (INR), which varied by state‐level economic development. About one‐fourth of Indian households incurred CHS, which was equally high in both the economically developed and poorer states. After controlling for household level factors, 77.1% of the total variation in PHS was attributable to households, 10.1% to states, 9.5% to villages, 2.6% to districts, and 0.7% to regions. The pattern in variance partitioning was similar for PNHS. The largest interstate variation was found for CHS (15.9%), while the opposite was true for PIHS (3.2%). Conclusions: We observed substantial variations in household health spending at the state and village levels compared with India's districts and regions. The large variation in CHS attributable to states indicates interstate inequality in the accessibility to and cost of health care. Our findings suggest that contextual factors at the macro and micro political units are important to reduce India's household health spending and CHS. [ABSTRACT FROM AUTHOR]

Background: Depression often interferes with self-management and treatment of medical conditions. This may result in serious medical complications and escalated health-care cost. Objectives: Study distribution of heart failure (HF) cases estimates the prevalence of depression and its effects on HF-related hospital costs by ethnicity and gender. Methods: Secondary data files of California Hospital Discharge System for he year 2010 were examined. For patients with a HF diagnosis, details regarding depression, demographics, comorbid conditions, and hospital costs were studied. Age-adjusted HF rates and depression were examined for whites, blacks, Hispanics, and Asians/Pacific Islanders (AP) by comparing HF patients with depression (HF +D) versus HF without depression (HFND). Results: HF cases (n = 62,685; average age: 73) included nearly an equal number of males and females. HF rates were higher (P < 0.001) among blacks compared to Hispanics, AP, and whites and higher among males than females. One-fifth of HF patients had depression, higher among females and whites compared to males and other ethnic groups. Further, HF hospital costs for blacks and AP were higher (P < 0.001) compared to other groups. The cost for HF +D was 22% higher compared to HFND, across all gender and ethnic groups, largely due to higher comorbidities, more admissions, and longer hospitalization. Conclusion: Depression, ethnicity, and gender are all associated with increased hospital costs of HF patients. The higher HF and HF +D costs among blacks, AP, and males reflect additional burden of comorbidities (hypertension and diabetes). Prospective studies to assess if selective screening and treating depression among HF patients can reduce hospital costs are warranted. [ABSTRACT FROM AUTHOR]

India has one of the highest rates of underweight burden, with signs of rising obesity. Coexistence of underweight and overweight persons is symptomatic of the "double burden of malnutrition. " The present study throws new light on the "double burden of malnutrition" among Indian women in the age group 22-49 years. The analysis is based on a nationally representative household survey, India Human Development Survey. Our results indicate the continuing pattern of socioeconomic segregation of underweight and overweight/obese women, with a large concentration of underweight women among the low socioeconomic group and of overweight/obese women among the high socioeconomic group. Further, relative food prices of food items like cereals and vegetables are significantly associated with the risk of being underweight and overweight/obese. Additionally, we find notable rural/urban differences. The relationship between socioeconomic factors and the probability of being underweight and overweight/obese is stronger in urban than in rural areas. Given that the health implications of being underweight and overweight/obese are equally grim, provision of healthy food items at affordable prices and implementation of programs for preventive and curative care of plausible illnesses related to underweight and overweight/obese are imperative. [ABSTRACT FROM AUTHOR]

UNAIDS set an ambitious target of "90-90-90" by 2020. The first 90 being 90% of those HIV-infected will be diagnosed; the second 90 being 90% of those diagnosed will be linked to medical care and on antiretroviral therapy (ART). While there has been dramatic improvement in HIV testing and ART use, substantial losses continue to occur at linkage-to-care following HIV diagnosis. Data on linkage among men who have sex with men (MSM) and people who inject drugs (PWID) are sparse, despite a greater burden of HIV in these populations. This cross-sectional study was conducted in 27 sites across India. Participants were recruited using respondent-driven sampling and had to be ⩾18 years and self-identify as male and report sex with a man in the prior year (MSM) or injection drug use in the prior 2 years (PWID). Analyses were restricted to HIV-infected persons aware of their status. Linkage was defined as ever visiting a doctor for management of HIV after diagnosis. We explored factors that discriminated between those linked and not linked to care using multi-level logistic regression and area under the receiver operating curves (AUC), focusing on modifiable factors. Of 1726 HIV-infected persons aware of their status, 80% were linked to care. Modifiable factors around the time of diagnosis that best discriminated linkage included receiving assistance with HIV medical care (odds ratio [OR]: 10.0, 95% confidence interval [CI]): 5.6-18.2), disclosure of HIV-positive status (OR: 2.8; 95% CI: 2.4-6.1) and receiving information and counseling on management of HIV (OR: 2.3; 95% CI: 1.1-4.6). The AUC for these three factors together was 0.85, higher than other combinations of factors. We identified three simple modifiable factors around the time of diagnosis that could facilitate linkage to care among MSM and PWID in low- and middle-income countries to achieve UNAIDS targets. [ABSTRACT FROM AUTHOR]

Background: To expand access to safe deliveries, some developing countries have initiated demand-side financing schemes promoting institutional delivery. In the context of conditional cash incentive scheme and free maternity care in public health facilities in India, studies have highlighted high out of pocket expenditure (OOPE) of Indian families for delivery and maternity care. In this context the study assesses the components of OOPE that women incurred while accessing maternity care in public health facilities in Uttar Pradesh, India. It also assesses the determinants of OOPE and the level of maternal satisfaction while accessing care from these facilities. Method: It is a cross-sectional analysis of 558 recently delivered women who have delivered at four public health facilities in Uttar Pradesh, India. All OOPE related information was collected through interviews using structured pre-tested questionnaires. Frequencies, Mann-Whitney test and categorical regression were used for data reduction. Results: The analysis showed that the median OOPE was INR 700 (US$ 11.48) which varied between INR 680 (US$ 11.15) for normal delivery and INR 970 (US$ 15.9) for complicated cases. Tips for getting services (consisting of gifts and tips for services) with a median value of INR 320 (US$ 5.25) contributed to the major share in OOPE. Women from households with income more than INR 4000 (US$ 65.57) per month, general castes, primi-gravida, complicated delivery and those not accompanied by community health workers incurred higher OOPE. The significant predictors for high OOPE were caste (General Vs. OBC, SC/ST), type of delivery (Complicated Vs. Normal), and presence of ASHA (No Vs. Yes). OOPE while accessing care for delivery was one among the least satisfactory items and 76 % women expressed their dissatisfaction. Conclusion: Even though services at the public health facilities in India are supposed to be provided free of cost, it is actually not free, and the women in this study paid almost half of their mandated cash incentives to obtain delivery care. [ABSTRACT FROM AUTHOR]

Introduction: Promotion of reproductive health through institutional delivery has been adopted by government as a strategy for reducing maternal mortality rate but still about half of the deliveries have been conducted at home. Cost barrier is one of the major cause for preferring home delivery instead of institutional delivery. Not only the direct costs responsible for low institutional delivery but also indirect costs too accountable for less number of institutional births in the country. Aims & Objectives: To estimate the out of pocket expenditure incurred by households during delivery and its determinants. Materials and methods: A community based cross sectional study was conducted during which a total 272 households having women who had recently delivered in government institutions were interviewed. Result: The mean out of pocket expenditure was found to be Rs. 1406.04 ± 103.27 including spending's on drugs, travel, pathological tests and unofficial payments. Low socioeconomic class, residence outside the catchment area of delivery point, tertiary and secondary health care facilities as place of delivery and low literacy status of head of the family below high school were found to be significantly associated with out of pocket expenditure bivariate analysis (p<0.05). On multivariate analysis low socioeconomic (OR 22.40; 95% CI 9.44-53.15; p = 0.01) and residence (OR 13.07; 95% CI (1.58-116.55); p = 0.03) outside the catchment area of delivery point were found to be independent predictors of catastrophic out of pocket expenditure during delivery. Conclusions: Although government has been running lot of schemes for availing free of cost health services but still one has to pay from their pocket as medical expenses. In order to bear these expenses, they have to borrow money, sell their assets and securities due to which households suffer a lot. In the present study, unofficial payment was found prevalent in public institutions and these informal payments make the health service unaffordable for households. [ABSTRACT FROM AUTHOR]

To quantify the economic burden of maternal health care services on Indian households and examine the levels of expenditure incurred in public and private health care institutions at the national, state and community levels. Cross-sectional population data from the 2004 National Sample Survey Organisation were used, which considered 9,643 households for the analysis where at least one woman received maternal health care services during the year preceding the survey. Multilevel linear regression techniques were used to estimate the effect of household, cluster and state characteristics on the proportion of maternal health care expenditures over total household expenditures. Over 80 % of households reported paying for maternal health care services, with those using private care facilities paying almost 4 times more than those using public facilities. Multilevel analyses show evidence of high burden of maternal health care expenditures, which varied significantly across states according to the level of health care utilisation, and with considerable heterogeneity at the household and community levels. Maternal health care services in India are offered free at the point of delivery, yet many families face significant out-of-pocket expenditures. The recent governmental policy interventions to encourage institutional births by providing nominal financial assistance is a welcome step but this might not help to compensate mothers for other indirect expenditures, especially those living in rural areas and poorer communities who are increasingly seeking care in private facilities. [ABSTRACT FROM AUTHOR]

Aim: This study sheds light on the high cost of inpatient care of decedents in comparison to that of survivors, a less known aspect of out of pocket (OOP) healthcare cost in India. The main objective is to compare the differentials in OOP inpatient care expenditures of decedents and survivors and examine the significant correlates of inpatient care cost controlling for survival status. Subject and methods: This study uses nationally representative unit level data from the 60th round (2004-2005) of the National Sample Survey on morbidity and healthcare. Descriptive statistics and bivariate analysis are employed to describe characteristics of inpatients and compare unadjusted mean OOP expenditures for care of inpatient decedents and survivors, between public and private health facilities. A multilevel hierarchical model is used to model OOP expenditures for inpatient care. Results: The inpatient care cost of decedents is much higher than that of survivors. The differential is significantly higher for those residing in rural areas, staying longer in hospitals, utilizing private health facilities and suffering from non-communicable and other serious diseases. There is significant differential in OOP inpatient care cost between individuals and between episodes of hospitalization of individuals. Conclusion: The findings of this study can be used to assess the economic burden of inpatient care induced by increasing life expectancy and epidemiological transition in India. Social security and other social assistance programs in India should be made sensitive to the high cost of inpatient care at the end of life. There is an urgent need to expand the outreach of the public health system in India to rural areas. [ABSTRACT FROM AUTHOR]

Antiretroviral therapy (ART) access in the developing world has improved, but whether increased access has translated to more rapid treatment initiation among those who need it is unknown. We characterize time to ART initiation across three eras of ART availability in Chennai, India (1996–1999: pregeneric; 2000–2003: generic; 2004–2007: free rollout). Between 1996 and 2007, 11,171 patients registered for care at the YR Gaitonde Centre for AIDS Research and Education (YRGCARE), a tertiary HIV referral center in southern India. Of these, 5726 patients became eligible for ART during this period as per Indian guidelines for initiation of ART. Generalized gamma survival models were used to estimate relative times (RT) to ART initiation by calendar periods of eligibility. Time to initiation of ART among patients in Chennai, India was also compared to an HIV clinical cohort in Baltimore, USA. Median age of the YRGCARE patients was 34 years; 77% were male. The median CD4 at presentation was 140 cells/µl. After adjustment for demographics, CD4 and WHO stage, persons in the pregeneric era took 3.25 times longer (95% confidence interval [CI]: 2.53–4.17) to initiate ART versus the generic era and persons in the free rollout era initiated ART more rapidly than the generic era (RT: 0.73; 95% CI: 0.63–0.83). Adjusting for differences across centers, patients at YRGCARE took longer than patients in the Johns Hopkins Clinical Cohort (JHCC) to initiate ART in the pregeneric era (RT: 4.90; 95% CI: 3.37–7.13) but in the free rollout era, YRGCARE patients took only about a quarter of the time (RT: 0.31; 95% CI: 0.22–0.44). These data demonstrate the benefits of generic ART and government rollouts on time to initiation of ART in one developing country setting and suggests that access to ART may be comparable to developed country settings. [ABSTRACT FROM AUTHOR]

Background: Policy-makers who are making decisions on sexuality education programs face important economic questions: what are the costs of developing sexuality education programs; and what are the costs of implementing and scaling them up? This study responds to these questions by assessing the costs of six school-based sexuality education programs (Nigeria, Kenya, Indonesia, India, Estonia and the Netherlands). Methods: Cost analyses were carried out in schools that were fully implementing a SE program, as this best reflects the resources needed to run an effective program. The costs were analyzed from the program perspective, meaning that all costs borne by the governmental and (international) non-governmental organizations supporting the program were included. Cost analyses were based on financial records, interviews and school surveys. We distinguished costs in three consecutive program phases: development, update and implementation. Recommendations on the most efficient program characteristics and scale-up pathways were drawn from results of three fully scaled up programs (Estonia, Nigeria and the Netherlands), scale-up scenarios of two pilot programs (Kenya and Indonesia), and an implementation plan (India), The costs of the programs were compared by converting cost per student reached in US dollars (US$) to international dollars (I$). Results: Findings revealed a range of costs and coverage of sexuality education programs. Costs per student reached were; US$7 in Nigeria, US$13.50 in India, US$33 in Estonia and the Netherlands, US$50 in Kenya, and US$160 in Indonesia. Conclusions: Intra-curricular sexuality education programs have, because of their compulsory nature, the most potential to be scaled up and are therefore most efficient. Extra-curricular sexuality education programs have lower potential to be scaled up and are therefore less efficient. In terms of class size and number of lessons, countries need to strike a balance between the quality (demanding smaller classes and many lessons) and the costs (demanding larger classes and fewer lessons). Advocacy was a significant cost component. [ABSTRACT FROM AUTHOR]

Background: There is limited evidence on whether active case finding (ACF) among marginalised and vulnerable populations mitigates the financial burden during tuberculosis (TB) diagnosis. Objectives: To determine the effect of ACF among marginalised and vulnerable populations on prevalence and inequity of catastrophic costs due to TB diagnosis among TB-affected households when compared with passive case finding (PCF). Methods: In 18 randomly sampled ACF districts in India, during March 2016 to February 2017, we enrolled all new sputum-smear-positive TB patients detected through ACF and an equal number of randomly selected patients detected through PCF. Direct (medical and non-medical) and indirect costs due to TB diagnosis were collected through patient interviews at their residence. We defined costs due to TB diagnosis as 'catastrophic' if the total costs (direct and indirect) due to TB diagnosis exceeded 20% of annual pre-TB household income. We used concentration curves and indices to assess the extent of inequity. Results: When compared with patients detected through PCF (n = 231), ACF patients (n = 234) incurred lower median total costs (US$ 4.6 and 20.4, p < 0.001). The prevalence of catastrophic costs in ACF and PCF was 10.3 and 11.5% respectively. Adjusted analysis showed that patients detected through ACF had a 32% lower prevalence of catastrophic costs relative to PCF [adjusted prevalence ratio (95% CI): 0.68 (0.69, 0.97)]. The concentration indices (95% CI) for total costs in both ACF [−0.15 (−0.32, 0.11)] and PCF [−0.06 (−0.20, 0.08)] were not significantly different from the line of equality and each other. The concentration indices (95% CI) for catastrophic costs in both ACF [−0.60 (−0.81, -0.39)] and PCF [−0.58 (−0.78, -0.38)] were not significantly different from each other: however, both the curves had a significant distribution among the poorest quintiles. Conclusion: ACF among marginalised and vulnerable populations reduced total costs and prevalence of catastrophic costs due to TB diagnosis, but could not address inequity. [ABSTRACT FROM AUTHOR]

Introduction. Health needs assessment (HNA) targets health resources to needs yet is rarely used in low-resource contexts such as the Indian villages. Methods. The authors combined rapid participatory appraisal (RPA) and HNA tools into 4 steps: (a) define HNA parameters, objectives, and community; (b) describe community demographics, health status, felt needs, assets, and health services; (c) analysis; and (d) design interventions considering felt needs, assets, impact potential, and organizational resources. Results. Community felt needs focused on lack of access to personal health services. Major morbidities included respiratory and diarrheal disease and maternal/child health problems. Formal anthropometry revealed high prevalence of underweight and stunting. Community assets included high land ownership, educated unmarried women, and operational government services. Conclusions. In low-resource developing country contexts with poor information systems, HNA is possible and useful. Including RPA and community participation to also assess assets resulted in programs responding to communities’ needs using existing resources. [ABSTRACT FROM PUBLISHER]