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The Government of India launched a nationwide programme to save and educate the girl child, Beti Bachao Beti Padhao (B3P), by stringent prohibition of sex-selective abortion, enforcement of Preconception and Prenatal Diagnostic Technique (PC-PNDT) and Medical Termination of Pregnancy (MTP) Acts, and social mobilization. We undertook this study to assess the effectiveness of intervention in Haryana state to improve sex ratio at birth (SRB). The monthly data on SRB (represented as girls per 1000 boys) were collected from civil registration system for the entire state of Haryana to evaluate the impact of B3P programme. The segmented time-series regression analysis was used to estimate the change in SRB after B3P programme. In this process, the seasonal auto regressive integrated moving average model was used to control the seasonality, autocorrelation and secular trend imbibed in the data before calculating the estimate of change in slope using regression equation. Overall, the sex ratio at birth in Haryana increased from 827 girls per 1000 boys in January 2005 to 900 girls per 1000 boys in September 2016. The estimates from segmented time-series regression analysis show that there was an insignificant change in SRB of -0.012 units before the intervention. Post slope was estimated to be 1.684, which suggested an increase in SRB of 1.696 [(confidence interval: 0.23, 3.15), P = 0.025] in terms of the difference between pre- and post-slope. This indicates a statistically significant increase of SRB by 1.696 per month attributable to B3P programme. B3P programme has resulted in an improvement of SRB in Haryana. [ABSTRACT FROM AUTHOR]

Background & objectives: India aspires to achieve universal health coverage, which requires ensuring financial risk protection (FRP). This study was done to assess the extent of out-of-pocket (OOP) expenditure and FRP for hospitalization in Haryana State, India. Further, the determinants for FRP were also evaluated. Methods: Data collected as a part of a household level survey conducted in Haryana 'Concurrent Evaluation of National Rural Health Mission: Haryana Health Survey' were analyzed. Descriptive analysis was undertaken to assess socio-demographic characteristics, hospitalization rate, extent and determinants of OOP expenditure and FRP. Prevalence of catastrophic health expenditure (CHE) (more than 40% of non-food expenditure) and impoverishment (Int$ 1.25) were estimated. Multivariate logistic regression was used to assess determinants of FRP. Results: Hospitalization rate was found to be 3106 persons or 3307 episodes per 100,000 population. Median OOP expenditure on hospitalization was ₹ 8000 (USD 133), which was predominantly attributed to medicines (37%). Prevalence of CHE was 25.2 per cent with higher prevalence amongst males [odds ratio (OR)=1.30], those belonging to scheduled caste and scheduled tribes (OR=1.35), poorest 20 per cent households (OR=3.05), having injuries (OR=4.03) and non-communicable diseases (OR=3.13) admitted in a private hospital (OR=2.69) and those who were insured (OR=1.74). There was a 12 per cent relative increase in poverty head count due to OOP payments on healthcare. Interpretation & conclusions: Our findings showed that hospitalization resulted in significant OOP expenditure, leading to CHEs and impoverishment of households. Impact of OOP expenditures was inequitably more on the vulnerable groups. OOP expenditure may be curtailed through provision of free medicines and diagnostics and removal of any form of user charges. [ABSTRACT FROM AUTHOR]

Objective: The implemented multiple-strategy community intervention National Rural Health Mission (NRHM) between 2005 and 2012 aimed to reduce maternal and child health (MCH) inequalities across geographical, socioeconomic and gender categories in India. The objective of this study is to quantify the extent of reduction in these inequalities pre- and post-NRHM in Haryana, North India. Methods: Data of district-level household surveys (DLHS) held before (2002–04), during (2007–08), and after (2012–13) the implementation of NRHM has been used. Geographical, socioeconomic and gender inequalities in maternal and child health were assessed by estimating the absolute differences in MCH indicators between urban and rural areas, between the most advantaged and least advantaged socioeconomic groups and between male and female children. Logistic regression analyses were done to observe significant differences in these inequalities between 2005 and 2012. Results: There were significant improvements in all MCH indicators (p<0.05). The geographical and socioeconomic differences between urban and rural areas, and between rich and poor were significantly (p<0.05) reduced for pregnant women who had an institutional delivery (geographical difference declining from 22% to 7.6%; socioeconomic from 48.2% to 13%), post-natal care within 2 weeks of delivery (2.8% to 1.5%; 30.3% to 7%); and for children with full vaccination (10% to 3.5%, 48.3% to 14%) and who received oral rehydration solution (ORS) for diarrhea (11% to -2.2%; 41% to 5%). Inequalities between male and female children were significantly (p<0.05) reversed for full immunization (5.7% to -0.6%) and BCG immunization (1.9 to -0.9 points), and a significant (p<0.05) decrease was observed for oral polio vaccine (4.0% to 0%) and measles vaccine (4.2% to 0.1%). Conclusions: The implemented multiple-strategy community intervention National Rural Health Mission (NRHM) between 2005 and 2012 might have resulted in significant reductions in geographical, socioeconomic and gender inequalities in MCH in Haryana, as causal relationships cannot be established with descriptive research. [ABSTRACT FROM AUTHOR]

Background: Despite increasing importance being laid on use of routine data for decision making in India, it has frequently been reported to be riddled with problems. Evidence suggests lack of quality in the health management information system (HMIS), however there is no robust analysis to assess the extent of its inaccuracy. We aim to bridge this gap in evidence by assessing the extent of completeness and quality of HMIS in Haryana state of India. Methods: Data on utilization of key maternal and child health (MCH) services were collected using a cross-sectional household survey from 4807 women in 209 Sub-Centre (SC) areas across all 21 districts of Haryana state. Information for same services was also recorded from HMIS records maintained by auxiliary nurse midwives (ANMs) at SCs to check under- or over-recording (Level 1 discordance). Data on utilisation of MCH services from SC ANM records, for a subset of the total women covered in the household survey, were also collected and compared with monthly reports submitted by ANMs to assess over-reporting while report preparation (Level 2 discordance) to paint the complete picture for quality and completeness of routine HMIS. Results: Completeness of ANM records for various MCH services ranged from 73% for DPT1 vaccination dates to 94.6% for dates of delivery. Average completeness level for information recorded in HMIS was 88.5%. Extent of Level 1 discordance for iron-folic acid (IFA) supplementation, 3 or more ante-natal care (ANC) visits and 2 Tetanus toxoid (TT) injections was 41%, 16% and 2% respectively. In 48.2% cases, respondents from community as well as HMIS records reported at least one post-natal care (PNC) home visit by ANM. Extent of Level 2 discordance ranged from 1.6% to 6%. These figures were highest for number of women who completed IFA supplementation, contraceptive intra-uterine device insertion and provision of 2nd TT injection during ANC. Conclusions: HMIS records for MCH services at sub-centre level in Haryana state were satisfactory in terms of completeness. However, there were significant differences in terms of reported and evaluated coverage of MCH services. Quality of HMIS needs to be improved in order to make it relevant for public health program planning and research. [ABSTRACT FROM AUTHOR]

Background: India aims to achieve universal access to institutional delivery. We undertook this study to estimate the universality of institutional delivery care for pregnant women in Haryana state in India. To assess the coverage of institutional delivery, we analyze service coverage (coverage of public sector institutional delivery), population coverage (coverage among different districts and wealth quintiles of the population) and financial risk protection (catastrophic health expenditure and impoverishment as a result of out-of-pocket expenditure for delivery). Methods: We analyzed cross-sectional data collected from a randomly selected sample of 12,191 women who had delivered a child in the last one year from the date of data collection in Haryana state. Five indicators were calculated to evaluate coverage and financial risk protection for institutional delivery—proportion of public sector deliveries, out-of-pocket expenditure, percentage of women who incurred no expenses, prevalence of catastrophic expenditure for institutional delivery and incidence of impoverishment due to out-of-pocket expenditure for delivery. These indicators were calculated for the public and private sectors for 5 wealth quintiles and 21 districts of the state. Results: The coverage of institutional delivery in Haryana state was 82%, of which 65% took place in public sector facilities. Approximately 63% of the women reported no expenditure on delivery in the public sector. The mean out-of-pocket expenditures for delivery in the public and private sectors in Haryana were INR 771 (USD 14.2) and INR 12,479 (USD 229), respectively, which were catastrophic for 1.6% and 22% of households, respectively. Conclusion: Our findings suggest that there is considerably high coverage of institutional delivery care in Haryana state, with significant financial risk protection in the public sector. However, coverage and financial risk protection for institutional delivery vary substantially across districts and among different socio-economic groups and must be strengthened. The success of the public sector in providing high coverage and financial risk protection in maternal health provides encouragement for the role that the public sector can play in universalizing health care. [ABSTRACT FROM AUTHOR]

Background: Generation of resources for providing health care services is an important issue in developing countries. User charges in the form of Surgical Package Program (SPP) were introduced in all district hospitals of Haryana to address this problem. We evaluate the effect of this SPP program on surgical care utilization and out-of-pocket (OOP) expenditures. Methods: Data on 25437 surgeries, from July 2006 to June 2013 in 3 districts of Haryana state, was analyzed using interrupted time series analysis to assess the impact of SPP on utilization of services. Adjustment was made for presence of any autocorrelation and seasonality effects. A cross sectional survey was undertaken among 180 patients in District hospital, Panchkula during June 2013 to assess the extent of out of pocket (OOP) expenditure incurred, financial risk protection and methods to cope with OOP expenditure. Catastrophic health expenditure, estimated as any expenditure in excess of 10% of the household consumption expenditure, was used to assess the extent of financial risk protection. Results: User charges had a negative effect on the number of surgeries in public sector district hospitals in all the 3 districts. The mean out-of-pocket expenditure incurred by the patients was Rs.4564 (USD 74.6). The prevalence of catastrophic expenditure was 5.6%. A higher proportion among the poorest 20% population coped through borrowing money (47.2%), while majority (86.1%) of those belonging to richest quintile paid from their monthly income or savings, or had insurance. Conclusion: There is a need to increase the public financing for curative services and it should be based on the needs of population. Any form of user charge in public sector hospitals should be removed. [ABSTRACT FROM AUTHOR]

Background & objectives: Creation of a strong referral transport network across the country is necessary for improving physical access to public sector health facilities. In this study we evaluated the referral transport services in Haryana, i.e. Haryana Swasthya Vaahan Sewa (HSVS), now known as National Ambulance Service (NAS), to assess the extent and pattern of utilization, and to ascertain its effect on public sector institutional deliveries. Methods: Secondary data on 116,562 patients transported during April to July 2011 in Haryana state were analysed to assess extent and pattern of NAS utilization. Exit interviews were conducted with 270 consecutively selected users and non- users of referral services respectively in Ambala (High NAS utilization), Hisar (medium utilization) and Narnaul (low utilization) districts. Month-wise data on institutional deliveries in public facilities during 2005-2012 were collected in these three districts, and analysed using interrupted time series analysis to assess the impact of NAS on institutional deliveries. Results: Female gender (OR = 77.7), rural place of residence (OR = 5.96) and poor socio-economic status (poorest wealth quintile OR = 2.64) were significantly associated with NAS ambulance service usage. Institutional deliveries in Haryana rose significantly after the introduction of NAS service in Ambala (OR=137.4, 95% CI=22.4-252.4) and Hisar (OR=215, 95% CI=88.5-341.3) districts. No significant increase was observed in Narnaul (OR=4.5, 95% CI= -137.4 to 146.4) district. Interpretation & conclusions: The findings of the present study showed a positive effect of referral transport service on increasing institutional deliveries. However, this needs to be backed up with adequate supply of basic and emergency obstetric care at hospitals and health centres. [ABSTRACT FROM AUTHOR]

Objective In India, Haemophilus influenzae type b (Hib) vaccine introduction in the universal immunization programme requires evidence of its potential health impact and cost-effectiveness, as it is a costly vaccine. Since childhood mortality, vaccination coverage and health service utilization vary across states, the cost-effectiveness of introducing Hib vaccine was studied in Haryana state.Methodology A mathematical model was used to compare scenarios with and without Hib vaccination to estimate the cost-effectiveness of Hib vaccine in Haryana from 2010 to 2024. Demographic and National Family Health Surveys were used to estimate vaccination coverage and mortality rates among children under 5. Hib pneumonia, Hib meningitis and invasive Hib disease incidence were based on Indian studies. Vaccine and syringe prices of the UNICEF supply division were used. Cost-effectiveness from government and societal perspectives was calculated as the net incremental cost per unit of health benefit gained [disability-adjusted life years (DALYs) averted, life years saved, Hib cases averted, Hib deaths averted]. Sensitivity analysis was done using variation in parameter estimates among different states of India.Findings The incremental cost of Hib vaccine introduction from a government and a societal perspective was estimated to be US$81.4 and US$27.5 million, respectively, from 2010 to 2024. Vaccination of 73.3, 71.6 and 67.4 million children with first, second and third dose of pentavalent vaccine, respectively, would avert 7 067 817 cases, 31 331 deaths and 994 564 DALYs. Incremental cost per DALY averted from a government (US$819) and a societal perspective (US$277) was found to be less than the per capita gross national income of India in 2009. In sensitivity analysis, Hib vaccine introduction remained cost-effective for India.Conclusion Hib vaccine introduction is a cost-effective strategy in India. [ABSTRACT FROM AUTHOR]

Background & objectives: User charges have been advocated on efficiency grounds despite the widespread criticism about their adverse effect on equity. We assessed the effect of user charges on inpatient hospitalizations rate and equity in Haryana State. Methods: The inpatient department (IPD) statistics of the public sector facilities in Yamuna Nagar district where user charges had been introduced were analysed and compared with Rohtak district which did not have user charge between 2000 and 2006. National Sample Survey data of Haryana for the 2004- 2005 period were analyzed to compare utilization of public sector facilities for hospitalization, cost of hospitalization, and prevalence of catastrophic out-of-pocket (OOP) expenditure by income quintiles in three districts which had user charges and 17 districts of Haryana which did not levy user charges. Results: During 2000 and 2006, hospital admissions declined by 23.8 per cent in Yamuna Nagar district where user charges had been introduced compared to an almost static hospitalization rate in Rohtak district which did not have user charges (P<0.01). Public sector hospital utilization for inpatient services had a pro-rich (concentration index 0.144) distribution in the three districts with user charges and pro- poor (concentration index -0.047) in the 17 districts without user charges. Significantly higher prevalence of catastrophic health expenditure was observed in public sector institutions with user charges (48%) compared to those without user charges (35.4%) (P<0.001). Interpretation & conclusions: The findings of our study showed that user charges had a negative influence on hospitalizations in Haryana especially among the poor. Public policies for revenue generation should avoid user charges. [ABSTRACT FROM AUTHOR]

Tobacco use is one of the major preventable causes of death and disability worldwide. WHO estimates that 4.9 million deaths annually are attributable to tobacco use. Research questions: What is the magnitude of problem of tobacco users among school going adolescents in a rural block of Haryana? Objectives: 1.To study the prevalence of tobacco use and 2. To assess the correlate factors of tobacco use. Study design: A cross-sectional descriptive type of study. Setting: Schools of Beri block, District Jhajjar. Participants: School going adolescents (10-19 years). Simple size: Total sample size was 1260. Study variables: Age, Sex, Type of tobacco products, Influencing factors, Awareness about health problems. Results: Overall prevalence of 'ever users' of tobacco products was 203 (17.4%). Prevalence of ever users among boys and girls was 197 (27%) and 7 (1.6%) respectively. Prevalence of 'current users' of tobacco products was 169 (14.5%). Majority 89.6% of current users had initiated smoking between the age 10 and 14 years (median age 12 years). The differences in prevalence according to age (p < 0.001) was statistically significant while in relation to caste was found non-significant (p>.067). [ABSTRACT FROM AUTHOR]

Tobacco use is one of the major preventable causes of death and disability worldwide. WHO estimates that 4.9 million deaths annually are attributable to tobacco use. Research questions: What is the magnitude of problem of tobacco users among school going adolescents in a rural block of Haryana? Objectives: 1. To study the prevalence of tobacco use 2. To assess the correlate factors of tobacco use. Study Design: A cross-sectional descriptive type of study. Setting: Schools of Beri block, District Jhajjar. Participants: School going adolescents (10-19 years). Simple size: Total sample size was 1260. Results: Overall prevalence of 'ever users' of tobacco products was 203 (17.4%). Prevalence of ever users among boys and girls was 197 (27%) and 7 (1.6%) respectively. Prevalence of 'current users' of tobacco products was 169 (14.5%). Majority 89.6% of current users had initiated smoking between the age 10 and 14 years (median age 12 years). The differences in prevalence according to age (p < 0.001) was statistically significant while in relation to caste was found non-significant (p>.067). [ABSTRACT FROM AUTHOR]