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Background: Resource allocation decisions for disease categories can be informed by proper estimates of the magnitude and distribution of total spending. In the backdrop of a high burden of Non-Communicable Diseases and Injuries (NCDI) in India, and a paucity of estimates on government spending on NCDI, this paper attempts to analyse public sector expenditure on NCDI spending in India. Methods: Various recent budget documents of the Centre and States/Union Territories have been used to extract expenditure on NCDI. The aggregates thus arrived at have been analysed to estimate aggregate and state level per capita spending. State level spending have been compared against disease burden using DALYs. Patterns of spending on NCDI across states were also analysed together with state level poverty to observe possible patterns. Findings: The total spending on NCDI by the government is low at less than 0.5% of GDP. NCDI spending is little more than one-fourth of total health spending of the country and most spending takes place at the state level (80%). The Ministry of Health and Family Welfare’s share in Central spending on NCDI is around 65%, and currently it spends 20% of its total health spending on NCDI. The gap between spending and DALYs is the most for the economically vulnerable states. Also, the states with high poverty levels also have low per capita expenditure on NCDI Interpretation: India does not depend on donor funding for health. It will have to step up domestic funding to address the increasing disease burden of NCDIs and to reduce the high out-of-pocket expenditure on NCDI. Policies on NCDI need to focus on UHC, service integration and personnel gaps. [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: Expenditure on medications for highly prevalent chronic conditions such as diabetes mellitus (DM) can result in financial impoverishment. People in developing countries and in low socioeconomic status groups are particularly vulnerable. China and India currently hold the world's two largest DM populations. Both countries are ageing and undergoing rapid economic development, urbanisation and social change. This paper assesses the determinants of DM medication use and catastrophic expenditure on medications in older adults with DM in China and India.Methods: Using national standardised data collected from adults aged 50 years and above with DM (self-reported) in China (N = 773) and India (N = 463), multivariable logistic regression describes: 1) association between respondents' socio-demographic and health behavioural characteristics and the dependent variable, DM medication use, and 2) association between DM medication use (independent variable) and household catastrophic expenditure on medications (dependent variable) (China: N = 630; India: N = 439). The data source is the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 (2007-2010).Results: Prevalence of DM medication use was 87% in China and 71% in India. Multivariable analysis indicates that people reporting lifestyle modification were more likely to use DM medications in China (OR = 6.22) and India (OR = 8.45). Women were more likely to use DM medications in China (OR = 1.56). Respondents in poorer wealth quintiles in China were more likely to use DM medications whereas the reverse was true in India. Almost 17% of people with DM in China experienced catastrophic healthcare expenditure on medications compared with 7% in India. Diabetes medication use was not a statistically significant predictor of catastrophic healthcare expenditure on medications in either country, although the odds were 33% higher among DM medications users in China (OR = 1.33).Conclusions: The country comparison reflects major public policy differences underpinned by divergent political and ideological frameworks. The DM epidemic poses huge public health challenges for China and India. Ensuring equitable and affordable access to medications for DM is fundamental for healthy ageing cohorts, and is consistent with the global agenda for universal healthcare coverage. [ABSTRACT FROM AUTHOR]

Background: Rates of perinatal depression (antenatal and postnatal depression) in South Asia are among the highest in the world. The delivery of effective psychological treatments for perinatal depression through existing health systems is a challenge due to a lack of human resources. This paper reports on a trial protocol that aims to evaluate the effectiveness and cost-effectiveness of the Thinking Healthy Programme delivered by peers (Thinking Healthy Programme Peer-delivered; THPP), for women with moderate to severe perinatal depression in rural and urban settings in Pakistan and India.Methods/design: THPP is evaluated with two randomised controlled trials: a cluster trial in Rawalpindi, Pakistan, and an individually randomised trial in Goa, India. Trial participants are pregnant women who are registered with the lady health workers in the study area in Pakistan and pregnant women attending outpatient antenatal clinics in India. They will be screened using the patient health questionnaire-9 (PHQ-9) for depression symptoms and will be eligible if their PHQ-9 is equal to or greater than 10 (PHQ-9 ≥ 10). The sample size will be 560 and 280 women in Pakistan and India, respectively. Women in the intervention arm (THPP) will be offered ten individual and four group sessions (Pakistan) or 6-14 individual sessions (India) delivered by a peer (defined as a mother from the same community who is trained and supervised in delivering the intervention). Women in the control arm (enhanced usual care) will receive health care as usual, enhanced by providing the gynaecologist or primary-health facilities with adapted WHO mhGAP guidelines for depression treatment, and providing the woman with her diagnosis and information on how to seek help for herself. The primary outcomes are remission and severity of depression symptoms at the 6-month postnatal follow-up. Secondary outcomes include remission and severity of depression symptoms at the 3-month postnatal follow-up, functional disability, perceived social support, breastfeeding rates, infant height and weight, and costs of health care at the 3- and 6-month postnatal follow-ups. The primary analysis will be intention-to-treat.Discussion: The trials have the potential to strengthen the evidence on the effectiveness and cost-effectiveness of an evidence-based psychological treatment recommended by the World Health Organisation and delivered by peers for perinatal depression. The trials have the unique opportunity to overcome the shortage of human resources in global mental health and may advance our understanding about the use of peers who work in partnership with the existing health systems in low-resource settings.Trial Registration: Pakistan Trial: ClinicalTrials.gov Identifier: NCT02111915 (9 April 2014) India Trial: ClinicalTrials.gov Identifier: NCT02104232 (1 April 2014). [ABSTRACT FROM AUTHOR]

Background: India launched a national conditional cash transfer program, Janani Suraksha Yojana (JSY), aimed at reducing maternal mortality by promoting institutional delivery in 2005. It provides a cash incentive to women who give birth in public health facilities. This paper studies the extent of program uptake, reasons for participation/ non participation, factors associated with non uptake of the program, and the role played by a program volunteer, accredited social health activist (ASHA), among mothers in Ujjain district in Madhya Pradesh, India. Methods: A cross-sectional study was conducted from January to May 2011 among women giving birth in 30 villages in Ujjain district. A semi-structured questionnaire was administered to 418 women who delivered in 2009. Socio-demographic and pregnancy related characteristics, role of the ASHA during delivery, receipt of the incentive, and reasons for place of delivery were collected. Multinomial regression analysis was used to identify predictors for the outcome variables; program delivery, private facility delivery, or a home delivery. Results: The majority of deliveries (318/418; 76%) took place within the JSY program; 81% of all mothers below poverty line delivered in the program. Ninety percent of the women had prior knowledge of the program. Most program mothers reported receiving the cash incentive within two weeks of delivery. The ASHA's influence on the mother's decision on where to deliver appeared limited. Women who were uneducated, multiparious or lacked prior knowledge of the JSY program were significantly more likely to deliver at home. Conclusion: In this study, a large proportion of women delivered under the program. Most mothers reporting timely receipt of the cash transfer. Nevertheless, there is still a subset of mothers delivering at home, who do not or cannot access emergency obstetric care under the program and remain at risk of maternal death. [ABSTRACT FROM AUTHOR]

Background Bidis, the most common smoking tobacco product in India, remain largely untaxed and are subject to very few regulations to discourage their use. A major argument against tax increases is the large potential loss of economic activity and employment in the bidi industry from reduced consumption. Methods We used a nationally representative survey of unorganised bidi manufacturing firms (n=2841) in India to estimate the economic contribution of the industry. Results We find that of the 35 states and union territories of India, the bidi industry operated across 17 states, with over 95% of its production concentrated in 10 states. Bidi manufacturing firms contributed 0.50% of total sales and 0.6% of the gross value added by the manufacturing economy in 2005-2006. The industry employed approximately 3.4 million full-time workers, which comprise about 0.7% of employment in all sectors. A further 0.7 million were part-time workers. Bidi workers were also among the lowest paid employees in India. The industry offered only 0.09% of all compensation provided in the manufacturing sector (organised and unorganised). Conclusions Considering the relatively small economic footprint of the bidi industry in India, higher excise taxes and regulations on bidis are unlikely to disrupt economic growth at an aggregate level, or lead to mass unemployment and economic hardship among small bidi workers. On average, the economic annual output per bidi worker is about US$143, which is an order of magnitude smaller than the large economic losses from the several hundred thousand deaths due to bidi smoking per year. [ABSTRACT FROM AUTHOR]

Context: Out-of-pocket expenditure on health in India is high. Many people including persons with disability (PwD) face catastrophic health expenditure. Health insurance is a promising strategy to overcome this burden. Swavlamban was the first health insurance for PwD which also covered mental illness. We conducted regular camps at the National Institute of Mental Health and Neurosciences (NIMHANS) for enrollment in the scheme. In this study, we present the features of the scheme and the sociodemographic profile of beneficiaries enrolled. Aims: To describe the experience of conducting enrollment camps for the Swavlamban Health Insurance scheme at NIMHANS and the sociodemographic profile of beneficiaries enrolled. Settings and Design: The study comprised all PwD and their family members enrolled in the Swavlamban through the camps conducted at NIMHANS from May 2016 to April 2017. Results: A total of 1248 persons were enrolled, of which 643 were PwD. The beneficiaries (PwD) were predominantly male (69%), with a mean age of 31 years, from Bengaluru (84%), and majority had disability due to mental retardation (43%). Although camps were conducted in mental hospital and publicized among mental health professionals, only 135 persons disabled with mental illness (21% of PwD beneficiaries) were enrolled. Conclusions: Mental health professionals need to take the lead in coordinating with various stakeholders so that the PwD can avail health insurance and other welfare benefits. There is a need to lobby and advocate for making these schemes easily accessible. [ABSTRACT FROM AUTHOR]

Background: Operational/implementation research (OR/IR) is a key activity to improve disease control programme performance. We assessed the extent to which malaria and tuberculosis (TB) grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria ("Global Fund") include support for OR/IR, and discuss the implications of the current Global Fund operating mechanisms for OR/IR support.Methods: The situation analysis focussed on malaria and TB, while HIV was excluded. Stakeholder interviews were conducted at the Global Fund secretariat and in six purposefully selected high disease burden countries, namely the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Myanmar and Zimbabwe. Interviewed in-country stakeholders included the relevant disease control programme managers, project implementation partners, representatives from international organisations with a stake in global health, academic and governmental research institutions, and other relevant individuals such as members of the country coordination mechanism. Additionally, documentation of grants and OR/IR obtained from the Global Fund was reviewed.Results: The Global Fund provides substantial resources for malaria and TB surveys, and supports OR/IR if such support is requested and the application is well justified. We observed considerable variations from one country to another and between programmes with regards to need, demand, absorption capacity and funding for OR/IR related to malaria and TB. Important determinants for the extent of such funding are the involvement of national research coordination bodies, established research agendas and priorities, human and technical research capacity, and involvement of relevant stakeholders in concept note development. Efforts to disseminate OR/IR findings were generally weak, and the Global Fund does not maintain a central OR/IR database. When faced with a need to choose between procurement of commodities for disease control and supporting research, countries tend to seek research funding from other donors. The Global Fund is expected to issue more specific guidance on the conditions under which it supports OR/IR, and to adapt administrative procedures to facilitate research.Conclusions: The importance of OR/IR for optimising disease control programmes is generally accepted but countries vary in their capacity to demand and implement studies. Countries expect guidance on OR/IR from the Global Fund. Administrative procedures specifically related to the budget planning should be modified to facilitate ad-hoc OR/IR funding. More generally, several countries expressed a need to strengthen capacity for planning, negotiating and implementing research. [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]

Background: With the critical shortage of government doctors serving in rural health centers in India, understanding the initial posting policies, processes, and practices become important from a retention point of view. The initial posting is a very critical stage of an employment cycle and could play an important role in influencing the key human resource for health outcomes such as turnover and performance. The current study aimed at exploring a rather unknown phenomenon of the initial posting-related processes, practices, and perceptions of Medical Officers working with the Public Health Department in Gujarat, India.Methods: This was an exploratory study carried out in the state of Gujarat, India, that used qualitative methods first to document the extant initial posting policy with the help of document review and five Key Informant interviews; next, 19 in-depth interviews were carried out with Medical Officers to assess implementation of policies as well as processes and systems related to the initial posting of Medical Officers. A thematic framework approach was used to analyze qualitative data using NVIVO.Results: The results indicate that there is no formal published or written initial posting policy in the state, and in the absence of a written and formal policy, the overall posting systems were perceived to be arbitrary by the study respondents. In the absence of any policy, the state has some unwritten informal practices such as posting the Medical Officers at their native places. Although this practice reflects a concern towards the Medical Officer's needs, such practices are not consistently applied indicating some inequity and possible implications over Medical Officers' retention and motivation.Conclusions: Initial posting is a critical aspect of an employment cycle, and the perceptions and experiences of MOs regarding the processes and practices involved in their initial posting can be crucial in influencing their performance and turnover rates. If long-term solutions are to be sought in addressing the availability and distribution of Medical Officers in the state, then there is a need to have clearly laid down initial posting-related policies that reflect the equity and consideration towards Medical Officers in placement-related matters. [ABSTRACT FROM AUTHOR]

Introduction: In high-income countries, secondhand smoke (SHS) exposure is higher among disadvantaged groups. We examine socioeconomic inequalities in SHS exposure at home and at workplace in 15 low- and middle-income countries (LMICs).Methods: Secondary analyses of cross-sectional data from 15 LMICs participating in Global Adult Tobacco Survey (participants ≥ 15 years; 2008-2011) were used. Country-specific analyses using regression-based methods were used to estimate the magnitude of socioeconomic inequalities in SHS exposure: (1) Relative Index of Inequality and (2) Slope Index of Inequality.Results: SHS exposure at home ranged from 17.4% in Mexico to 73.1% in Vietnam; exposure at workplace ranged from 16.9% in Uruguay to 65.8% in Bangladesh. In India, Bangladesh, Thailand, Malaysia, Philippines, Vietnam, Uruguay, Poland, Turkey, Ukraine, and Egypt, SHS exposure at home reduced with increasing wealth (Relative Index of Inequality range: 1.13 [95% confidence interval [CI] 1.04-1.22] in Turkey to 3.31 [95% CI 2.91-3.77] in Thailand; Slope Index of Inequality range: 0.06 [95% CI 0.02-0.11] in Turkey to 0.43 [95% CI 0.38-0.48] in Philippines). In these 11 countries, and in China, SHS exposure at home reduced with increasing education. In India, Bangladesh, Thailand, and Philippines, SHS exposure at workplace reduced with increasing wealth. In India, Bangladesh, Thailand, Philippines, Vietnam, Poland, Russian Federation, Turkey, Ukraine, and Egypt, SHS exposure at workplace reduced with increasing education.Conclusion: SHS exposure at homes is higher among the socioeconomically disadvantaged in the majority of LMICs studied; at workplaces, exposure is higher among the less educated. Pro-equity tobacco control interventions alongside targeted efforts in these groups are recommended to reduce inequalities in SHS exposure.Implications: SHS exposure is higher among the socioeconomically disadvantaged groups in high-income countries. Comprehensive smoke-free policies are pro-equity for certain health outcomes that are strongly influenced by SHS exposure. Using nationally representative Global Adult Tobacco Survey (2008-2011) data from 15 LMICs, we studied socioeconomic inequalities in SHS exposure at homes and at workplaces. The study showed that in most LMICs, SHS exposure at homes is higher among the poor and the less educated. At workplaces, SHS exposure is higher among the less educated groups. Accelerating implementation of pro-equity tobacco control interventions and strengthening of efforts targeted at the socioeconomically disadvantaged groups are needed to reduce inequalities in SHS exposure in LMICs. [ABSTRACT FROM AUTHOR]

Background: An essential element of mental health service scale up relates to an assessment of resource requirements and cost implications.Aims: To assess the expected resource needs of scaling up services in five districts in sub-Saharan Africa and south Asia.Method: The resource quantities associated with each site's specified care package were identified and subsequently costed, both at current and target levels of coverage.Results: The cost of the care package at target coverage ranged from US$0.21 to 0.56 per head of population in four of the districts (in the higher-income context of South Africa, it was US$1.86). In all districts, the additional amount needed each year to reach target coverage goals after 10 years was below $0.10 per head of population.Conclusions: Estimation of resource needs and costs for district-level mental health services provides relevant information concerning the financial feasibility of locally developed plans for successful scale up. [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]

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]

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]

Background: Pay-for-performance rewards health-care providers by paying them more if they succeed in meeting performance targets. A new contract for general practitioners in the United Kingdom represents the most radical shift towards pay-for-performance seen in any health-care system. The contract provides an important opportunity to address disparities in chronic disease management between ethnic and socioeconomic groups. We examined disparities in management of people with diabetes and intermediate clinical outcomes within a multiethnic population in primary care before and after the introduction of the new contract in April 2004.Methods and Findings: We conducted a population-based longitudinal survey, using electronic general practice records, in an ethnically diverse part of southwest London. Outcome measures were prescribing levels and achievement of national treatment targets (HbA1c < or = 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol < or = 5 mmol/l or 193 mg/dl). The proportion of patients reaching treatment targets for HbA1c, BP, and total cholesterol increased significantly after the implementation of the new contract. The extents of these increases were broadly uniform across ethnic groups, with the exception of the black Caribbean patient group, which had a significantly lower improvement in HbA1c (adjusted odds ratio [AOR] 0.75, 95% confidence interval [CI] 0.57-0.97) and BP control (AOR 0.65, 95% CI 0.53-0.81) relative to the white British patient group. Variations in prescribing and achievement of treatment targets between ethnic groups present in 2003 were not attenuated in 2005.Conclusions: Pay-for-performance incentives have not addressed disparities in the management and control of diabetes between ethnic groups. Quality improvement initiatives must place greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes. [ABSTRACT FROM AUTHOR]