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Though the chronic lymphocytic leukaemia (CLL) management options in India are still limited compared to the novel drug options in resource-rich settings, the availability of less costly generics and the government health insurance scheme has enabled many patients to access the newer drugs in India. The current study compared the cost-effectiveness and cost-utility of existing initial management options for the progression-free survival (PFS) time horizon from the patient's perspective. A two-health-state, PFS and progressive disease, Markov model was assumed for three regimens (generics): ibrutinib monotherapy, bendamustine-rituximab (B-R), and rituximab-chlorambucil (RClb) used as the frontline treatment of CLL patients in India. All costs, utilization of services, and consequences data during the PFS period were collected from interviewing patients during follow-up visits. The transition probability (TP) and average PFS information were obtained from landmark published studies. EQ-5D-5L questionnaires were utilized to assess the quality of life (QoL). Quality-adjusted life years (QALY) were measured during the PFS period. The incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR) were studied. Upon analysis, the entire monetary expense during the PFS time was ₹1581964 with ibrutinib, ₹171434 with B-R, and ₹91997 with RClb treatment arm. Pooled PFS and QALY gain was 10.33 and 8.28 years for ibrutinib, 4.08 and 3.53 years for the B-R regimen, and 1.33 and 1.23 years in RClb arms, respectively. Ibrutinib's ICER and ICUR were ₹214587.32 per PFS year gain and ₹282384.86 per QALY gain when assessed against the B-R regimen. Ibrutinib also performed better in ICER and ICUR against the RClb arm with ₹157014.29 per PFS year gain and ₹200413.6 per QALY gain. In conclusion, generic ibrutinib is a cost-effective initial line of management compared to other commonly used treatment regimes in resource-limited settings. [ABSTRACT FROM AUTHOR]

The article discusses the impact of cataract and glaucoma on patients' quality of life in North India, where these conditions are leading causes of blindness. The study conducted a cross-sectional analysis of 541 participants, revealing lower quality of life scores for glaucoma patients compared to cataract patients. Visual acuity in the worse eye and treatment for glaucoma were found to be significant factors affecting quality of life, emphasizing the importance of early detection and comprehensive care. The findings suggest the need for policy initiatives focusing on early detection and management of these eye disorders to improve patients' quality of life. [Extracted from the article]

Background & objectives: The Government of India has initiated a population based screening (PBS) for noncommunicable diseases (NCDs). A health technology assessment agency in India commissioned a study to assess the cost-effectiveness of screening diabetes and hypertension. The present study was undertaken to estimate the cost of PBS for Type II diabetes and hypertension. Second, out-of-pocket expenditure (OOPE) for outpatient care and health-related quality of life (HRQoL) among diabetes and hypertension patients were estimated. Methods: Economic cost of PBS of diabetes and hypertension was assessed using micro-costing methodology from a health system perspective in two States. A total of 165 outpatients with diabetes, 300 with hypertension and 497 with both were recruited to collect data on OOPE and HRQoL. Results: On coverage of 50 per cent, the PBS of diabetes and hypertension incurred a cost of ₹ 45.2 per person screened. The mean OOPE on outpatient consultation for a patient with diabetes, hypertension and both diabetes and hypertension was ₹ 4381 (95% confidence interval [CI]: 3786-4976), ₹ 1427 (95% CI: 1278-1576) and ₹ 3932 (95% CI: 3614-4250), respectively. Catastrophic health expenditure was incurred by 20, 1.3 and 14.8 per cent of patients with diabetes, hypertension and both diabetes and hypertension, respectively. The mean HRQoL score of patients with diabetes, hypertension and both was 0.76 (95% CI: 0.72-0.8), 0.89 (95% CI: 0.87-0.91) and 0.68 (95% CI: 0.66-0.7), respectively. Interpretations & conclusions: The findings of our study are useful for assessing cost-effectiveness of screening strategies for diabetes and hypertension. [ABSTRACT FROM AUTHOR]

Background Environmental influence plays a major role in determining health status of individuals. Punjab has been reported as having a high degree of water pollution due to heavy metals from untreated industrial effluent discharge and high pesticide consumption in agriculture. The present study ascertained the association of heavy metal and pesticide exposure on reproductive and child health outcomes in Punjab, India. Methods A cross-sectional community-based survey was conducted in which 1904 women in reproductive age group and 1762 children below 12??...years of age from 35 villages in three districts of Punjab were interviewed on a semistructured schedule for systemic and general health morbidities. Medical doctors conducted a clinical examination and review of records where relevant. Out of 35 study villages, 25 served as target (exposed) and 10 as non-target (less exposed or reference). Effluent, ground and surface water, fodder, vegetables and milk (bovine and human) samples were tested for chemical composition, heavy metals and pesticides. Results Spontaneous abortion (20.6 per 1000 live births) and premature births (6.7 per 1000 live births) were significantly higher in area affected by heavy metal and pesticide pollution (p<0.05). Stillbirths were about five times higher as compared with a meta-analysis for South Asian countries. A larger proportion of children in target area were reported to have delayed milestones, language delay, blue line in the gums, mottling of teeth and gastrointestinal morbidities (p<0.05). Mercury was found in more than permissible limits (MPL) in 84.4% samples from the target area. Heptachlor, chlorpyriphos, β-endosulfan, dimethoate and aldrin were found to be more than MPL in 23.9%, 21.7%, 19.6%, 6.5% and 6.5% ground water samples respectively. Conclusion Although no direct association could be established in this study, heavy metal and pesticide exposure may be potential risk factors for adverse reproductive and child health outcomes. [ABSTRACT FROM AUTHOR]

Background & objectives: The World Health Organisation recommended immediate initiation of antiretroviral therapy (ART) in all adult human immunodeficiency virus (HIV) patients regardless of their CD4 cell count. This study was undertaken to ascertain the cost-effectiveness of implementation of these guidelines in India. Methods: A Markov model was developed to assess the lifetime costs and health outcomes of three scenarios for initiation of ART treatment at varying CD4 cell count <350/mm³, <500/mm³ and test and treat using health system perspective using life-time horizon. A few input parameters for this model namely, transition probabilities from one stage to another stage of HIV and incidence rates of TB were calculated from the data of Centre of Excellence for HIV treatment and care, Chandigarh; whereas, other parameters were obtained from the published literature. Total HIV-related deaths averted, HIV infections averted and incremental cost-effectiveness ratio per quality adjusted life years (QALYs) gained were calculated. Result: Test and treat intervention slowed down the progression of disease and averted 18,386 HIV-related deaths, over lifetime horizon. It also averted 16,105 new HIV infections and saved 343,172 QALYs as compared to the strategy of starting ART at CD4 cell count of 500/mm³. Incremental cost per QALY gained for the immediate initiation of ART as compared to ART at CD4 cell count of 500/mm³ and 350/mm³ was ₹ 46,599 and 80,050, respectively at reported rates of adherence to the therapy. Interpretation & conclusions: Immediate ART (test and treat) is highly cost-effective strategy over the past criteria of delayed therapy in India. Cost-effectiveness of this policy is largely because of reduction in the transmission of HIV. [ABSTRACT FROM AUTHOR]

Purpose: This study evaluated the health-related quality of life (HRQoL) among breast cancer patients during various phases of treatment and with different treatment modalities, which helps in monitoring treatment outcomes, assessing the well-being of patients, and conducting health technology assessments.Methods: A total of 534 interviews were conducted among the patients of breast cancer recruited at different stages of disease and with different treatment modalities. HRQoL was determined using EuroQoL five dimensions questionnaire with five levels (EQ-5D-5L), EuroQoL Visual Analogue Scale (EQ VAS), and the EORTC QLQ-BR23 instrument. The utility values were determined based on the Indian EQ-5D-5L value set. The socio-demographic and clinico-therapeutic determinants of HRQoL were evaluated using multiple linear regression.Results: The mean utility value of breast cancer patients was 0.602 (SD = 0.311) and mean EQ VAS score was 75 (SD = 12.3). The mean utility value at diagnosis was 0.628, whereas utility value was 0.55, 0.595, and 0.64 for post-surgery, post-chemotherapy, and post-radiotherapy treatment groups, respectively. The most frequently reported problem was pain/discomfort (in 84.3% patients), followed by anxiety/depression (83.5%). On EORTC QLQ-BR23, the maximum symptom scale scores for systemic therapy side effects were reported in the post chemotherapy group. The body image score and future perspective score were better in patients undergoing breast conservative surgery (BCS) compared to patients undergoing modified radical mastectomy. Age, education, and employment status of the patient, type of treatment modality, and use of taxanes are the determinants of HRQoL in breast cancer patients.Conclusion: Clinical interventions should focus upon management of pain and anxiety. BCS should be offered to all eligible patients as it is associated with better HRQoL. Addressing the factors that independently affect the HRQoL will help in improving the treatment compliance and outcomes. [ABSTRACT FROM AUTHOR]

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

Background & objectives: Despite significant resources being spent on National Vector Borne Disease Control Programme (NVBDCP), there are meagre published data on health system cost upon its implementation. Hence, the present study estimated the annual and unit cost of different services delivered under NVBDCP in North India. Methodology: Economic cost of implementing NVBDCP was estimated based on data collected from three North Indian States, i.e. Punjab, Haryana and Himachal Pradesh. Multistage stratified random sampling was used for selecting health facilities across each level [i.e. subcentres (SCs), Primary Health Centres (PHCs), community health centres (CHCs) and district malaria office (DMO)] from the selected States. Data on annual consumption of both capital and recurrent resources were assessed from each of the selected facilities following bottom-up costing approach. Capital items (equipment, vehicles and furniture) were annualized over average life span using a discount rate of 3 per cent. The mean annual cost of implementation of NVBDCP was estimated for each level along with unit cost. Results: The mean annual cost of implementing NVBDCP at the level of SC, PHC and CHC and DMO was ₹ 230,420 (199,523-264,901), 686,962 (482,637-886,313), 1.2 million (0.9-1.5 million) and 9.1 million (4.6-13.5 million), respectively. Per capita cost for the provision of complete package of services under NVBDCP was ₹ 45 (37-54), 48 (29-73), 10 (6-14) and 47 (31-62) at the level of SC, PHC, CHC and DMO level, respectively. The per capita cost was higher in Himachal Pradesh (HP) at SC [₹ 69 (52-85)] and CHC [₹ 20.8 (20.7-20.8)] level and in Punjab at PHC level [₹ 89 (49-132)] as compared to other States. Interpretation & conclusions: The evidence on cost of NVBDCP can be used to undertake future economic evaluations which could serve as a basis for allocating resources efficiently, policy development as well as future planning for scale up of services. [ABSTRACT FROM AUTHOR]

Background The increasing burden of kidney failure (KF) in India necessitates provision of cost-effective kidney replacement therapy (KRT). We assessed the comparative cost-effectiveness of initiating KRT with peritoneal dialysis (PD) or haemodialysis (HD) in the Indian context. Methods The cost and clinical effectiveness of starting KRT with either PD or HD were measured in terms of life years (LYs) and quality-adjusted life years (QALYs) using a mathematical Markov model. Complications such as peritonitis, vascular access–related complications and blood-borne infections were considered. Health system costs, out-of-pocket expenditures borne by patients and indirect costs were included. Two scenarios were considered: Scenario 1 (real-world scenario)—as per the current cost and utilization patterns; Scenario 2 (public programme scenario)—use in the public sector as per Pradhan Mantri National Dialysis Programme (PMNDP) guidelines. The lifetime costs and health outcomes among KF patients were assessed. Results The mean QALYs lived per KF person with PD and HD were estimated to be 3.3 and 1.6, respectively. From a societal perspective, a PD-first policy is cost-saving as compared with an HD-first policy in both Scenarios 1 and 2. If only the costs directly attributable to patient care (direct costs) are considered, the PD-first treatment policy is estimated to be cost-effective only if the price of PD consumables can be brought down to INR70/U. Conclusions PD as initial treatment is a cost-saving option for management of KF in India as compared with HD first. The government should negotiate the price of PD consumables under the PMNDP. [ABSTRACT FROM AUTHOR]

There is no comparative health-related quality of life (HR-QoL) data of transplant eligible (TE) multiple myeloma (MM) patients undergoing early autologous stem cell transplantation (ASCT) and those without in the era of novel drugs. This study prospectively evaluated the serial HR-QoL in TE-MM using the EORTC QLQ-C30 and MY20 questionnaires. Barring the transient worsening in QoL one-month after ASCT, there was a comparable improvement in most QoL domains in both early-ASCT and no-early ASCT cohorts. Post-early-ASCT patients had higher global health scores (71.9 vs. 60.8, p <.05) than no-early ASCT at 12-months. Patients belonging to lower socioeconomic status (SES) were more likely not to undergo ASCT than middle-high SES patients (38.6% vs. 74.5%, p <.05). While age, gender had no impact on QoL, performance status, staging, and induction therapy impacted QoL. This study shows that early ASCT maintains QoL and should be encouraged in all TE-MM patients. [ABSTRACT FROM AUTHOR]

Background: Lack of robust data on economic burden due to enteric fever in India has made decision making on typhoid vaccination a challenge. Surveillance for Enteric Fever network was established to address gaps in typhoid disease and economic burden.Methods: Patients hospitalized with blood culture-confirmed enteric fever and nontraumatic ileal perforation were identified at 14 hospitals. These sites represent urban referral hospitals (tier 3) and smaller hospitals in urban slums, remote rural, and tribal settings (tier 2). Cost of illness and productivity loss data from onset to 28 days after discharge from hospital were collected using a structured questionnaire. The direct and indirect costs of an illness episode were analyzed by type of setting.Results: In total, 274 patients from tier 2 surveillance, 891 patients from tier 3 surveillance, and 110 ileal perforation patients provided the cost of illness data. The mean direct cost of severe enteric fever was US$119.1 (95% confidence interval [CI], US$85.8-152.4) in tier 2 and US$405.7 (95% CI, 366.9-444.4) in tier 3; 16.9% of patients in tier 3 experienced catastrophic expenditure.Conclusions: The cost of treating enteric fever is considerable and likely to increase with emerging antimicrobial resistance. Equitable preventive strategies are urgently needed. [ABSTRACT FROM AUTHOR]

Objectives: Although an increasing number of countries are adopting essential health service packages (EHSPs) and undertaking their cost assessment, standardization of the costing methods and their reporting are imperative to instill confidence in the use of findings of EHSPs as evidence for decision making and resource allocation. This review was conducted to synthesize the EHSP costing reports, focusing on the key costing methods and their reporting standards.Methods: A systematic review of English language literature (peer-reviewed as well as gray) was conducted. PubMed, Embase, Scopus, NHS Economic Evaluation Database, Google Scholar, and websites of key institutions were reviewed (2000-2020). Publication characteristics, costing methods, valuation sources, quality, transparency, and reporting standards were assessed and synthesized.Results: A total of 29 studies from 19 countries were included. Most studies were government reports (69%) and reported the use of "bottom-up" approach (76%), OneHealth tool (38%), had international funding (79%), and reported both normative and empirical cost estimates (41%). Six studies (21%) scored "excellent" in conduct and reporting. Stand-alone costing of EHSP had higher mean quality score (80). The projected increase in government budget to implement EHSP ranged from 17% to 117%. Limited availability of reliable data on resources, prices, and coverage of interventions were identified as major limitations for costing of EHSPs.Conclusions: Substantial differences in the costing methods and reporting standards of EHSPs made comparisons across countries difficult. Existing costing guidelines and checklists should be adapted for EHSPs with more specific methodological guidance to allow harmonization of methods and reporting. [ABSTRACT FROM AUTHOR]

A health system is considered efficient when it provides maximum health gains to the population from the available resources. Newer drugs, diagnostics and treatment strategies aim to improve the health of the population, however, they come at an increased cost. Therefore, for an efficient health system, it needs to be decided if the extra cost being incurred is justified to achieve the extra health gains. In this regard, health technology assessment (HTA) helps to make evidence informed decisions by evaluating relative cost and benefits of the available interventions. Economic evidence generated by HTA can also be used in framing standard treatment guidelines (STGs) for high-cost cancer care. In multi-payer systems like India, the decisions regarding the clinical management of patients are taken based on the patients' ability to pay, which creates inequities in utilization of healthcare. Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (AB PM-JAY) offers an opportunity to ensure equity as it reduces financial barriers, besides having a potential to affect efficiency by including only cost-effective interventions in the benefit package. As a result, informed clinical decisions based upon HTA evidence can make cancer treatment more efficient, equitable and affordable for the patients. [ABSTRACT FROM AUTHOR]

World Health Organization has prequalified the use of typhoid conjugate vaccine (TCV) in children over six months of age in typhoid endemic countries. We assessed the cost-effectiveness of introducing TCV separately for urban and rural areas of India. A decision analytic model was developed, using a societal perspective, to compare long-term costs and outcomes (3% discount rate) in a new-born cohort of 100,000 children immunized with or without TCV. Three vaccination scenarios were modelled, assuming the protective efficacy of TCV to last for 5, 10 and 15 years following immunization. Incidence of typhoid infection estimated under 'National Surveillance System for Enteric Fever' (NSSEFI)' was used. The prices of vaccine and cost of service delivery were included for vaccination arm. Both health system cost and out-of-pocket expenditures for treatment of typhoid illness and its complications was included. TCV introduction in urban areas would result in prevention of 17% to 36% typhoid cases and deaths. With exclusion of indirect costs, the incremental cost per QALY gained was ₹ 151,346 (54,730–307,975), ₹ 61,710 (−5250 to 163,283) and ₹ 45,188 (−17,069 to 141,093) for scenario 1, 2 and 3 respectively. While, with inclusion of indirect costs, all 3 scenarios were cost saving. Further, in rural areas, TCV is estimated to reduce the typhoid cases and deaths by 19% to 36%, with ICER (incremental cost per QALY gained) ranging from ₹ 2340 (1316–4370) to ₹ 3574 (2057 – 6691) thousand (inclusive of indirect costs) among the 3 vaccination scenarios. From a societal perspective, introduction of TCV is a cost saving strategy in urban India. Further, due to low incidence of typhoid infection, introduction of TCV is not cost-effective in rural settings of India. [ABSTRACT FROM AUTHOR]

Background: Unintentional injuries account for 10% of deaths worldwide; the majority due to road traffic injuries, falls, drowning, poisoning and burns. Effective surveillance systems provide evidence for informed injury prevention and treatment and improve recovery outcomes. Our objectives were to review existing sources of unintentional injury data, and quality of the data on the burden, distribution, risk factors and trends of unintentional injuries in India and to describe strengths and limitations of health facility-based data for potential use in injury surveillance systems.Methods: We searched national and international organisations' websites to identify unintentional injury-related mortality and morbidity data sources in India. We reviewed and evaluated data collection methods for surveillance attributes recommended by World Health Organization (WHO). We visited health facilities at all levels from public and private sectors, emergency transport centres, insurance offices and police stations in settings reporting significant number of injuries. In these sites, we interviewed key stakeholders using an explorative approach on current data collection processes and challenges to establishing an injury surveillance system based on WHO guidelines.Results: Major gaps were highlighted in injury mortality and morbidity data in India, including ill-defined causes of injury deaths and lack of standardisation in classification and coding. Site visits revealed that reporting standards of injuries varied, with issues around clarity of definitions, accountability, time points and lack of reporter/coder training. Major challenges were lack of dedicated staff and training.Conclusions: There is an important need to build human resource capacity, integrate data sources, standardise and streamline data collected, ensure accountability and capitalise on digital health information systems including insurance databases. [ABSTRACT FROM AUTHOR]

Aim: This systematic review aimed to ascertain the diagnostic accuracy (sensitivity and specificity) of screening tests for early detection of type 2 diabetes and prediabetes in previously undiagnosed adults. Methods: This systematic review included published studies that included one or more index tests (random and fasting tests, HbA1c) for glucose detection, with 75-gram Oral Glucose Tolerance Test (or 2-hour post load glucose) as a reference standard (PROSPERO ID CRD42018102477). Seven databases were searched electronically (from their inception up to March 9, 2020) accompanied with bibliographic and website searches. Records were manually screened and full text were selected based on inclusion and exclusion criteria. Subsequently, data extraction was done using standardized form and quality assessment of studies using QUADAS-2 tool. Meta-analysis was done using bivariate model using Stata 14.0. Optimal cut offs in terms of sensitivity and specificity for the tests were analysed using R software. Results: Of 7,151 records assessed by title and abstract, a total of 37 peer reviewed articles were included in this systematic review. The pooled sensitivity, specificity, positive (LR+) and negative likelihood ratio (LR-) for diagnosing diabetes with HbA1c (6.5%; venous sample; n = 17 studies) were 50% (95% CI: 42–59%), 97.3% (95% CI: 95.3–98.4), 18.32 (95% CI: 11.06–30.53) and 0.51 (95% CI: 0.43–0.60), respectively. However, the optimal cut-off for diagnosing diabetes in previously undiagnosed adults with HbA1c was estimated as 6.03% with pooled sensitivity of 73.9% (95% CI: 68–79.1%) and specificity of 87.2% (95% CI: 82–91%). The optimal cut-off for Fasting Plasma Glucose (FPG) was estimated as 104 milligram/dL (mg/dL) with a sensitivity of 82.3% (95% CI: 74.6–88.1%) and specificity of 89.4% (95% CI: 85.2–92.5%). Conclusion: Our findings suggest that at present recommended threshold of 6.5%, HbA1c is more specific and less sensitive in diagnosing the newly detected diabetes in undiagnosed population from community settings. Lowering of thresholds for HbA1c and FPG to 6.03% and 104 mg/dL for early detection in previously undiagnosed persons for screening purposes may be considered. [ABSTRACT FROM AUTHOR]

Background: Retinoblastoma is the most common primary intraocular malignancy among children. Despite being curable in early stages, majority of the cases in India present in late stages, when outcomes are very poor. Objectives: The aim of this study was to assess the epidemiological profile, clinical characteristics, and treatment practices among retinoblastoma patients in north India. Materials and Methods: Data on all patients with retinoblastoma, over a 10-year-time period from 2009 to 2018, who were treated in a tertiary care hospital in north India, were assessed. Data were analyzed to describe the demographic characteristics, clinical features in terms of stage at presentation, and management practices in terms of diagnostic investigations and treatment. The statistical significance for difference in percentages was assessed using Fischer's exact test at a 5% significance level. Results: A total of 25 retinoblastoma patients were enlisted, of whom one was excluded as it was adult onset retinoblastoma. The median age at presentation was 3 years, with a male to female ratio of 1:1.4. Bilateral presentation was seen in 16.6% cases. Majority (66.6%) of the patients underwent magnetic resonance imaging of brain and orbit as a part of the diagnostic workup. Intraocular disease was seen in 58.3% patients, whereas 41.6% patients had extraocular disease. Local therapy with vision preservation could be used only in 8.3% patients, whereas 87.5% patients were referred for enucleation. Chemotherapy with combination of vincristine, etoposide, and carboplatin was used extensively both, in neoadjuvant setting (83.3%) and in the adjuvant setting. Conclusion: Despite availability of treatment for eye preservation, its utility is limited due to the advanced stage at presentation. Awareness about the disease and its symptoms for early diagnosis, especially with the Mid-Level Health Provider at Health and Wellness Centers, is likely to improve early reporting and treatment and meeting the Vision 2020 goals. [ABSTRACT FROM AUTHOR]

Cost-effectiveness analysis (CEA) provides information on how much extra do we need to spend per unit gain in health outcomes with introduction of any new healthcare intervention or treatment as compared to the alternative. This information is crucial to make decision regarding funding any new drug, diagnostic test or determining standard treatment protocol. It becomes even more important to consider this evidence in resource constrained low-income and middle-income country settings. Generating evidence on costs and consequences of a treatment or intervention could be performed in the setting of a randomized controlled trial, which is the perfect platform to evaluate efficacy or effectiveness. However, we argue that randomized controlled trial (RCT) offers an incomplete setting to generate comprehensive data on all costs and consequences for the purpose of a CEA. Hence, it is needed to use a decision model, either in combination with the evidence from RCT or alone. In this article, we demonstrate the application of decision model–based economic evaluation using 2 separate techniques – a decision tree and a Markov model. We argue that application of a decision model allows computation of health benefits in terms of utility-based measure such as a quality-adjusted life year or disability-adjusted life year which is preferred for a CEA, measure distal costs and consequences which are much more downstream to the application of intervention, allows comparison with multiple intervention and comparators, and provides opportunity of making use of evidence from multiple sources rather than a single RCT which may have limited generalizability. This makes the use of such evidence much more acceptable for clinical use and policy relevant. [ABSTRACT FROM AUTHOR]

Background: We undertook this study to assess the incremental cost per quality adjusted life year (QALY) gained with the use of pan-genotypic sofosbuvir (SOF) + velpatasvir (VEL) for HCV patients, as compared to the current treatment regimen under the universal free treatment scheme in Punjab state. Methodology: A Markov model depicting natural history of HCV was developed to simulate the progression of disease. Three scenarios were compared: I (Current Regimen)—use of SOF + daclatasvir (DCV) for non-cirrhotic patients and ledipasvir (LDV) or DCV with SOF ± ribavirin (RBV) according to the genotype for cirrhotic patients; II—use of SOF + DCV for non-cirrhotic patients and use of SOF+VEL for compensated cirrhotic patients (with RBV in decompensated cirrhosis patients) and III—use of SOF+VEL for both non-cirrhotic and compensated cirrhotic patients (with RBV in decompensated cirrhosis patients). The lifetime costs, life-years and QALYs were assessed for each scenario, using a societal perspective. All the future costs and health outcomes were discounted at an annual rate of 3%. Finally, the incremental cost per QALY gained was computed for each of scenario II and III, as compared to scenario I and for scenario III as compared to II. In addition, we evaluated the lifetime costs and QALYs among HCV patients for each of scenario I, II and III against the counterfactual of ‘no universal free treatment scheme’ scenario which involves patients purchasing care in routine setting of from public and private sector. Results: Each of the scenarios I, II and III dominate over the no universal free treatment scheme scenario, i.e. have greater QALYs and lesser costs. The use of SOF+VEL only for cirrhotic patients (scenario II) increases QALYs by 0.28 (0.03 to 0.71) per person, and decreases the cost by ₹ 5,946 (₹ 1,198 to ₹ 14,174) per patient, when compared to scenario I. Compared to scenario I, scenario III leads to an increase in QALYs by 0.44 (0.14 to 1.01) per person, and is cost-neutral. While the mean cost difference between scenario III and I is—₹ 2,676 per patient, it ranges from a cost saving of ₹ 14,835 to incurring an extra cost of ₹ 3,456 per patient. For scenario III as compared II, QALYs increase by 0.16 (0.03 to 0.36) per person as well as costs by ₹ 3,086 per patient which ranges from a cost saving of ₹ 1,264 to incurring an extra cost of ₹ 6,344. Shift to scenario II and III increases the program budget by 5.5% and 60% respectively. Conclusion: Overall, the use of SOF+VEL is highly recommended for the treatment of HCV infection. In comparison to the current practice (scenario I), scenario II is a dominant option. Scenario III is cost-effective as compared to scenario II at a threshold of one-time GDP per capita. If budget is an important constraint, velpatasvir should be given to HCV infected cirrhotic patients. However, if no budget constraint, universal use of velpatasvir for HCV treatment is recommended. [ABSTRACT FROM AUTHOR]

Introduction: Public health spending in India has been traditionally one of the lowest globally. Punjab is one of the states with highest proportion of out-of-pocket expenditures for healthcare in India. We undertook this study to produce the sub-national health accounts (SNHA) for Punjab state in India. Methodology: We used System of Health Accounts (SHA) 2011 framework for preparing health accounts for Punjab state. Data on health spending by government was obtained from concerned public sector departments both at state and central level. Estimates on Out-of-Pocket Expenditures (OOPE) expenditure were derived from National Sample Survey (NSS) 71st round data, Consumer Expenditure Survey (CES) data and Pharmatrac. Primary surveys were done for assessing health expenditure data by firms and non-governmental organizations. All estimates of healthcare expenditures reported in our paper pertain to 2013–14, and are reported in both Indian National Rupee (INR) and United States Dollar (US $),using average conversion rate of INR 60.50 per US $. Results: In 2013–14, the current health expenditures (CE) in Punjab was INR 134,680million (US $ 2245 million) which was 4.02% of its gross state domestic product (GSDP).However, public spending on health was 0.95% of GSDP i.e. 21% of the total health expenditure (THE), while 79% was private expenditure. In per capita terms, THE in Punjab was INR 4963 (US $ 82.03). In terms of functions, medical goods (41.6%) and curative care (37%) consumed larger share of expenditure in the Punjab state. Households spent 52% of expenditures for medicines and other pharmaceutical goods. Risk pooling mechanisms are being adopted to a lesser extent in the state. Conclusion: The healthcare in Punjab is largely financed through private OOPE. Currently, public health spending in Punjab is inadequate to meet the healthcare demands of population, which is less than 1% of state’s GSDP. Monitoring public resources is very important for better resource allocations. Health Accounts production is useful in order to assess future trends and impact of health financing policies on goals of universal health coverage and should be made a part of routine monitoring system both at national and sub-national level. [ABSTRACT FROM AUTHOR]

Highlights • HSCT for thalassemia is a long-term value-for-money intervention in a developing country. • The clinical and economic benefits of HSCT far outweigh TC. • The ICER (QALY) with HSCT as compared with TC is Image 16 64,096 (US$986) in MRD transplantation. • The probability of HSCT to be cost effective at the willingness to pay threshold of Indian GDP per capita is 94%. Abstract Hematopoietic stem cell transplantation (HSCT) is the only cure for thalassemia major (TM), which inflicts a significant 1-time cost. Hence, it is important to explore the cost effectiveness of HSCT versus lifelong regular transfusion-chelation (TC) therapy. This study was undertaken to estimate incremental cost per quality-adjusted life-year (QALY) gained with the intervention group HSCT, and the comparator group TC, in TM patients. A combination of decision tree and Markov model was used for analysis. A hospital database, supplemented with a review of published literature, was used to derive input parameters for the model. A lifetime study horizon was used and future costs and consequences were discounted at 3%. Results are presented using societal perspective. Incremental cost per QALY gained with use of HSCT as compared with TC was Image 17 64,096 (US$986) in case of matched related donor (MRD) and Image 18 1,67,657 (US$2579) in case of a matched unrelated donor transplantation. The probability of MRD transplant to be cost effective at the willingness to pay threshold of Indian per capita gross domestic product is 94%. HSCT is a long-term value for money intervention that is highly cost effective and its long-term clinical and economic benefits outweigh those of TC. [ABSTRACT FROM AUTHOR]

Background & objectives: Numerous studies have highlighted the regressive and immiserating impact of out-of-pocket (OOP) health spending in India. However, most of these studies have explored this issue at the national or up to the State level, with an associated risk of overlooking intra-State diversities in the health system and health-seeking behaviour and their implication on the financial burden of healthcare. This study was aimed to address this issue by analyzing district level diversities in inequity, financial burden and impoverishing impact of OOP health spending. Methods: A household survey of 62,335 individuals from 12,134 households, covering eight districts across three States, namely Gujarat, Haryana and Rajasthan was conducted during 2014-2015. Other than general household characteristics, the survey collected information on household OOP [sum total of expenditure on doctor consultation, drugs, diagnostic tests etc. on inpatient depatment (IPD), outpatient depatment (OPD) or chronic ailments] and household monthly consumption expenditure [sum total of monthly expenditure on food, clothing, education, healthcare (OOP) and others]. Gini index of consumption expenditure, concentration index and Kakwani index (KI) of progressivity of OOP, catastrophic burden (at 20% threshold) and poverty impact (using district-level poverty thresholds) were computed, for these eight districts using the survey data. The concentration curve (of OOP expenditure) and Lorenz curve (of consumption expenditure) for the eight districts were also drawn. Results: The distribution of OOP was found to be regressive in all the districts, with significant inter-district variations in equity parameters within a State (KI ranges from −0.062 to −0.353). Chhota Udepur, the only tribal district within the sample was found to have the most regressive distribution (KI of −0.353) of OOP. Furthermore, the economic burden of OOP was more pronounced among the rural sample (CB of 19.2% and IM of 8.9%) compared to the urban sample (CB of 9.4% and IM of 3.7%). Interpretation & conclusions: The results indicate that greater decentralized planning taking into account district-level health financing patterns could be an effective way to tackle inequity and financial vulnerability emerging out of OOP expenses on healthcare. [ABSTRACT FROM AUTHOR]

Verbal autopsy methods have been developed to determine medical causes of deathforprioritizing disease control programs. Additional information on social causesmay facilitate designing of more appropriate prevention strategies. Use of social autopsy in investigations of causes of adult deaths has been limited. Therefore, acommunity-based study was conducted in NandpurKalour Block of Fatehgarh Sahib District in Punjab (India)for finding social causes of adult deaths. An integrated verbal and social autopsy toolwas developed and verbal autopsies of 600 adult deaths, occurring over a reference period of one year, were conducted in 2014. Quantitative analysis described the socio-demographic characteristics of the deceased, number and type of consultations from health care providers, and type of care received during illness. Qualitative data was analyzed to find out social causes of death by thematic analysis. The median duration of illness from symptom onset till death was 9 days (IQR = 1–45 days). At the onset of illness, 72 (12%) deceased utilized home remedies and 424 (70.7%)received care from a clinic/hospital, and 104 (17.3%) died withoutreceiving any care. The number of medical consultations varied from one to six (median = 2). The utilization of government health facilities and qualified allopathic doctor increased with each consultation (p value<0.05). The top five social causes of adult deaths in a rural area of Punjab in India. (1) Non availability of medical practitioner in the vicinity, (2) communication gaps between doctor and patient on regular intake of medication, (3) delayed referral by service provider, (4) poor communication with family on illness, and (5) perception of illness to be ‘mild’ by the family or care taker. To conclude, social autopsy tool should be integrated with verbal autopsy tool for identification of individual, community, and health system level factors associated with adult mortality. [ABSTRACT FROM AUTHOR]

Background The National Health Mission (NHM) was launched in 2005 by the Government of India. As NHM has completed about 15 years (2005-2020), there is a need to review the impact of NHM on health measures. Methods Logic model (input-process-output-outcome-impact) was used to measure the impact of National Health Mission on maternal health outcomes in India. We studied the impact of NHM by comparing the proportion of women who had first-trimester registration, institutional delivery, postnatal check-ups before NHM (NFHS- 3 data) and after NHM (NFHS-4 data) among those who had a delivery in the last five years preceding the date of the survey after adjusting for sociodemographic factors, road density, telephone density and health worker density. Results The Health worker density increased from 32.67 to 50.29 per 10000 population in post NHM period as compared to pre NHM period. Beds per 10,000 population increased from 4.43 in 2005 to 5.96 in 2015. There was a significant increase in the proportion of first-trimester registration from 57.3% to 67.4%, in institutional delivery rate from 41.6% to 87.7% and postnatal check-ups from 42.4% to 72.3% from the year, 2005 to 2015. The Maternal mortality ratio declined from 250 to 130 per lakh childbirths between 2005 and 2015. Conclusions NHM has led to an improvement in maternal health-related outcomes in the country. Key messages The learnings from NHM can be utilized to improve further the outcomes for achieving Universal Health Coverage (UHC) by 2030. [ABSTRACT FROM AUTHOR]

Background and Objectives: Globally, a number of countries have developed guidelines that describe the design and conduct of economic evaluations as part of health technology assessment (HTA) or pharmacoeconomic analysis for decision making. The current scoping review was undertaken with an objective to summarize the recommendations made on methods of economic evaluation by the national healthcare economic evaluation (HEE) guidelines.A comprehensive search was undertaken in the website repositories of the International Society for Pharmacoeconomic and Outcomes Research (ISPOR) and Guide to Economic Analysis and Research (GEAR), and websites of national HTA agencies and ministries of health of individual countries. All guidelines in the English language were included in this review. Data were extracted with respect to general and methodological characteristics, and a descriptive analysis of recommendations made across the countries was undertaken.Overall, our review included 31 national HEE guidelines, published between 1997 and August 2020. Nearly half (45%) of the guidelines targeted the evaluation of pharmaceuticals. The nature of the guidelines was either mandatory (31%), recommendatory (42%), or voluntary (16%). There was a substantial consensus among the guidelines on several key principles, including type of economic evaluation (cost-utility analysis), time horizon of the analysis (long enough), health outcome measure (quality-adjusted life-years) and use of sensitivity analyses. The recommendations on study perspective, comparator, discount rate and type of costs to be included (particularly the inclusion of indirect costs) varied widely.Despite similarity in the overall processes, variation in several recommendations given by various national HEE guidelines was observed. This is perhaps unsurprising given the differences in the health systems and financing mechanisms, capacity of local researchers, and data availability. This review offers important lessons and a starting point for countries that are planning to develop their own HEE guidelines.Methodology: Globally, a number of countries have developed guidelines that describe the design and conduct of economic evaluations as part of health technology assessment (HTA) or pharmacoeconomic analysis for decision making. The current scoping review was undertaken with an objective to summarize the recommendations made on methods of economic evaluation by the national healthcare economic evaluation (HEE) guidelines.A comprehensive search was undertaken in the website repositories of the International Society for Pharmacoeconomic and Outcomes Research (ISPOR) and Guide to Economic Analysis and Research (GEAR), and websites of national HTA agencies and ministries of health of individual countries. All guidelines in the English language were included in this review. Data were extracted with respect to general and methodological characteristics, and a descriptive analysis of recommendations made across the countries was undertaken.Overall, our review included 31 national HEE guidelines, published between 1997 and August 2020. Nearly half (45%) of the guidelines targeted the evaluation of pharmaceuticals. The nature of the guidelines was either mandatory (31%), recommendatory (42%), or voluntary (16%). There was a substantial consensus among the guidelines on several key principles, including type of economic evaluation (cost-utility analysis), time horizon of the analysis (long enough), health outcome measure (quality-adjusted life-years) and use of sensitivity analyses. The recommendations on study perspective, comparator, discount rate and type of costs to be included (particularly the inclusion of indirect costs) varied widely.Despite similarity in the overall processes, variation in several recommendations given by various national HEE guidelines was observed. This is perhaps unsurprising given the differences in the health systems and financing mechanisms, capacity of local researchers, and data availability. This review offers important lessons and a starting point for countries that are planning to develop their own HEE guidelines.Results: Globally, a number of countries have developed guidelines that describe the design and conduct of economic evaluations as part of health technology assessment (HTA) or pharmacoeconomic analysis for decision making. The current scoping review was undertaken with an objective to summarize the recommendations made on methods of economic evaluation by the national healthcare economic evaluation (HEE) guidelines.A comprehensive search was undertaken in the website repositories of the International Society for Pharmacoeconomic and Outcomes Research (ISPOR) and Guide to Economic Analysis and Research (GEAR), and websites of national HTA agencies and ministries of health of individual countries. All guidelines in the English language were included in this review. Data were extracted with respect to general and methodological characteristics, and a descriptive analysis of recommendations made across the countries was undertaken.Overall, our review included 31 national HEE guidelines, published between 1997 and August 2020. Nearly half (45%) of the guidelines targeted the evaluation of pharmaceuticals. The nature of the guidelines was either mandatory (31%), recommendatory (42%), or voluntary (16%). There was a substantial consensus among the guidelines on several key principles, including type of economic evaluation (cost-utility analysis), time horizon of the analysis (long enough), health outcome measure (quality-adjusted life-years) and use of sensitivity analyses. The recommendations on study perspective, comparator, discount rate and type of costs to be included (particularly the inclusion of indirect costs) varied widely.Despite similarity in the overall processes, variation in several recommendations given by various national HEE guidelines was observed. This is perhaps unsurprising given the differences in the health systems and financing mechanisms, capacity of local researchers, and data availability. This review offers important lessons and a starting point for countries that are planning to develop their own HEE guidelines.Conclusion: Globally, a number of countries have developed guidelines that describe the design and conduct of economic evaluations as part of health technology assessment (HTA) or pharmacoeconomic analysis for decision making. The current scoping review was undertaken with an objective to summarize the recommendations made on methods of economic evaluation by the national healthcare economic evaluation (HEE) guidelines.A comprehensive search was undertaken in the website repositories of the International Society for Pharmacoeconomic and Outcomes Research (ISPOR) and Guide to Economic Analysis and Research (GEAR), and websites of national HTA agencies and ministries of health of individual countries. All guidelines in the English language were included in this review. Data were extracted with respect to general and methodological characteristics, and a descriptive analysis of recommendations made across the countries was undertaken.Overall, our review included 31 national HEE guidelines, published between 1997 and August 2020. Nearly half (45%) of the guidelines targeted the evaluation of pharmaceuticals. The nature of the guidelines was either mandatory (31%), recommendatory (42%), or voluntary (16%). There was a substantial consensus among the guidelines on several key principles, including type of economic evaluation (cost-utility analysis), time horizon of the analysis (long enough), health outcome measure (quality-adjusted life-years) and use of sensitivity analyses. The recommendations on study perspective, comparator, discount rate and type of costs to be included (particularly the inclusion of indirect costs) varied widely.Despite similarity in the overall processes, variation in several recommendations given by various national HEE guidelines was observed. This is perhaps unsurprising given the differences in the health systems and financing mechanisms, capacity of local researchers, and data availability. This review offers important lessons and a starting point for countries that are planning to develop their own HEE guidelines. [ABSTRACT FROM AUTHOR]

Background: Resource allocation in health is universally challenging, but especially so in resource-constrained contexts in the Global South. Pursuing a strategy of evidence-based decision-making and using tools such as Health Technology Assessment (HTA), can help address issues relating to both affordability and equity when allocating resources. Three BRICS and Global South countries, China, India and South Africa have committed to strengthening HTA capacity and developing their domestic HTA systems, with the goal of getting evidence translated into policy. Through assessing and comparing the HTA journey of each country it may be possible to identify common problems and shareable insights. Objectives: This collaborative paper aimed to share knowledge on strengthening HTA systems to enable enhanced evidence-based decision-making in the Global South by: Identifying common barriers and enablers in three BRICS countries in the Global South; and Exploring how South-South collaboration can strengthen HTA capacity and utilisation for better healthcare decision-making. Methods: A descriptive and explorative comparative analysis was conducted comprising a Within-Case analysis to produce a narrative of the HTA journey in each country and an Across-Case analysis to explore both knowledge that could be shared and any potential knowledge gaps. Results: Analyses revealed that China, India and South Africa share many barriers to strengthening and developing HTA systems such as: (1) Minimal HTA expertise; (2) Weak health data infrastructure; (3) Rising healthcare costs; (4) Fragmented healthcare systems; and (5) Significant growth in non-communicable diseases. Stakeholder engagement and institutionalisation of HTA were identified as two conducive factors for strengthening HTA systems. Conclusion: China, India and South Africa have all committed to establishing robust HTA systems to inform evidence-based priority setting and have experienced similar challenges. Engagement among countries of the Global South can provide a supportive platform to share knowledge that is more applicable and pragmatic. [ABSTRACT FROM AUTHOR]

A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented.A multi-strategy community intervention known as the National Rural Health Mission (NRHM) was implemented in India from 2005 to 2012 in an attempt to reduce maternal and child mortality.This study examined the extent to which the NRHM’s maternal and child health (MCH) sector plans were implemented. We observed trends in how intergovernmental (use of central government funds by state governments) budgets were allocated and used to implement MCH plans in Haryana, India.We conducted a retrospective assessment of programme implementation plans, MCH budget allocation and expenditure and financial monitoring reports during the NRHM implementation period. The yearly budget utilization rate was calculated for each MCH strategy implemented. On the basis of this budget utilization rate, we classed the extent of MCH strategy implementation as fully, partially or not implemented. The status of MCH indicators before, during and after the NRHM period was obtained from national demographic surveys. The budget utilization rate was correlated with MCH outcomes.The overall budget allocated for MCH plans increased from $US6.6 million during the 2005–2006 period to $US66.7 million in the 2012–2013 period. The rate of budget utilization increased from 20.6% in 2007–2008 to 89% in 2012–2013. Expenditure exceeded the initially allocated budget for patient referral services (111.5%), human resources (110.1%), drugs and logistics (170%), accredited social health activists (133.3%) and immunization (106.4%). Additional budget was obtained from the state health budget. Plans for referral services, human resources, drug provision, accredited social health activists and immunization were fully implemented, few schemes (<1%) were not implemented, and all other schemes were only partially implemented. MCH indicators improved significantly (p < 0.05). The rate of institutional childbirth was highly and positively correlated with rates of budget utilization for implementing accredited social health activists (r = 0.96) and financial incentives for hospital delivery schemes (r = 0.5).The trend for increasing use of the allocated budget for MCH strategies, improvement in MCH indicators and their positive correlation indicate better and more effective implementation of NRHM MCH strategies than in the past in Haryana, India. However, overall, the NRHM was only partially implemented. [ABSTRACT FROM AUTHOR]

Background: Supervised toothbrushing (STB) significantly reduces the incidence and progression of dental caries. School years present a favorable age for introducing such healthy habits for a lifetime., Aim: To estimate the cost-effectiveness of implementing a STB program in India in preventing dental caries incidence., Design: An operational framework of a national STB program was devised. A mathematical model was then developed to evaluate this program's clinical effectiveness and economic impact in the Indian scenario. This study considered a hypothetical cohort of the Indian population aged from 6 to 75 years. Two groups were compared: no intervention and STB in government schools. The health outcomes assessed were a number of tooth caries incidences averted and quality-adjusted life years gained., Results: The STB program in the government schools of India would prevent at least one tooth from developing caries in an individual's lifetime. Considering the current treatment-seeking behavior, the STB program saves INR 153 (US$ 1.95) per carious tooth incidence averted and INR 22 202 (US$ 283) per QALY gained., Conclusion: In India, the school-based STB program is expected to be a cost-effective strategy for reducing the dental caries burden and its associated treatment costs., (© 2024 BSPD, IAPD and John Wiley & Sons Ltd.)

Background: A digital supportive supervision (DiSS) tool was developed and implemented in Rajasthan, India, to enhance the coverage and quality of maternal health, child health and nutrition (MCHN) services. This study aims to assess the impact and cost-effectiveness of DiSS compared to traditional paper-based supportive supervision., Methods and Analysis: A quasi-experimental research design incorporating interrupted time series regression analysis will be employed to evaluate the impact of DiSS. Two districts from the high DiSS intensity group, defined as having at least 25% of the MCHN sessions supervised digitally, will be randomly selected as intervention districts. Two comparator districts will be selected from the low DiSS intensity group (less than 25% of MCHN sessions supervised digitally) after matching with intervention districts based on three indicators-female literacy, proportion of population belonging to scheduled caste or tribe and coverage of four antenatal care visits. District-level monthly data on the number of beneficiaries using MCHN services will be obtained from the state's routine health management information system. Key informants involved in supervising MCHN sessions will also be interviewed to complement the quantitative findings. A mixed micro-costing methodology, incorporating top-down and bottom-up approaches, for assessing the cost of implementing supervision in either scenario. A decision model will estimate long-term health outcomes, in the form of quality-adjusted life years (QALY), in both the intervention and comparator groups. Cost-effectiveness of DiSS will be assessed by computing the incremental cost per QALY gained in the intervention versus comparator group., Ethics and Dissemination: The study has been approved by the Institute Ethics Committee of the PGIMER, Chandigarh, India (IEC No. IEC-03/2023-2671). The study results will be disseminated at research conferences and published in peer-reviewed journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Introduction: Traditional economic evaluations typically focus on direct health effects and costs offset to the healthcare system. However, vaccines offer significant indirect benefits beyond direct health effects, such as herd immunity, reduced force of infection, reduction in antimicrobial resistance, and others. Failure to consider these benefits while evaluating vaccines may undervalue vaccines. Therefore, it is argued that the full value of vaccines should be estimated by incorporating these broader benefits., Areas Covered: This review presents the broader value domains proposed in literature by various frameworks, and their definitions. The review of economic evidence of vaccine use in India to discuss to what extent these broader value domains have been considered in economic evaluations in India has been presented. We also discuss specific considerations that need to be taken care of while developing value frameworks or guidelines for the economic evaluation of vaccines., Expert Opinion: To develop a comprehensive framework tailored to the country needs, prioritize relevant value domains and optimal methodologies based on the country's healthcare context, and data availability. These value domains must align with people's as well as decision-makers preferences to ensure economic assessments are relevant and actionable.

Introduction: The current financing of public-sector district hospitals in India relies on historical budget allocations rather than actual utilization or healthcare needs. We utilized empirical data on healthcare delivery costs to develop the financing framework for these hospitals using a blended payment approach., Methods: The primary data on cost of delivering services in 27 district hospitals across nine states of India was analysed along with indicators influencing the demand and supply of health services. Payment for outpatient, inpatient, and indirect services was assessed using the risk adjusted global budget, case-based bundled payment, and per-bed-global budget, respectively. Risk adjustment weights were computed by regressing the cost of outpatient care with demand and supply side factors which are likely to influence the utilization or the prices. Budget impact analysis was conducted to assess the fiscal implications of this payment approach, accounting for current care standards and two scenarios: upgrading district hospitals to Indian Public Health Standards (IPHS) or medical colleges., Results: The average annual budget for a district hospital in India is estimated at ₹326 million (US$3.35 million), ranging from ₹66 million to ₹2.57 billion (US$0.8-31.13 million). Inpatient care comprises the largest portion (78%) of the budget. Upgrading to IPHS-compliant secondary hospitals or medical colleges would increase average budgets by 131 and 91.5%, respectively., Conclusion: Implementing a blended payment approach would align funding with healthcare needs, enhance provider performance, and support ongoing financing reforms aimed at strategic purchasing and universal health coverage., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Prinja, Jyani, Goyal, Sharma, Kaur and Sundararaman.)

The south Asian region (SAR) is home to 1·74 billion people, corresponding to 22% of the global population. The region faces several challenges pertaining to changing epidemiology, rapid urbanisation, and social and economic concerns, which affect health outcomes. Primary health care (PHC) is a cost-effective strategy to respond to these challenges through integrated service delivery, multi-sectoral action, and empowered communities. The PHC approach has historically been an important cornerstone of health policy in SAR countries. However, the region is yet to fully reap the benefits of PHC-oriented health systems. Our introductory paper in this Lancet Series on PHC in the SAR describes the existing PHC delivery structure in five SAR nations (ie, Bangladesh, India, Nepal, Pakistan, and Sri Lanka) and critically appraises PHC performance to identify its enablers and barriers. The paper proposes investing in a shared culture of innovation and collaboration for revitalisation of PHC in the region., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Only limited information exists regarding the epidemiology of Kawasaki disease (KD) in low-income and middle-income countries. The present study provides the incidence of KD during 2015-2019 in Chandigarh, north India. Our centre follows the largest KD cohort in India., Methods: Children with KD at Chandigarh diagnosed during January 2015-December 2019 were enrolled in the study. Annual incidence rates were determined using decadal growth rates of the National Census 2011. We computed the incidence of KD in children aged <5, and <15 years. We also undertook linear trend analysis using our incidence data from 1994 to 2019., Findings: During 2015-2019, 83 patients (66 males, 17 females) were diagnosed with KD in Chandigarh. Incidence rates during these 5 years were 5.64, 9.25, 9.11, 9.87, and 9.72/100,000 in children aged <5 years, and 2.65, 4.44, 3.86, 5.07, 4.74/100,000 in children aged <15 years. The median age at diagnosis was 48 months (range: 12 days to 15 years). Compared to previous data (2009-2014), there was a 53.1% increase in annual incidence of KD in children aged <5 years, and a 53.7% increase in children aged <15 years. Coronary artery abnormalities during acute phase were noted in 16.9%, and in 7.2% of patients at 6 weeks of follow-up. The trend analysis indicated a monthly rise of 0.002 cases per 100,000 children aged <5 years, and 0.0165 cases per 100,000 children aged <15 years., Interpretation: The incidence of KD has continued to show an upward trend in Chandigarh over the period 2015-2019. This may indicate a true rise in the occurrence of KD or may reflect better disease ascertainment as a result of greater awareness about KD amongst healthcare professionals., Funding: None., Competing Interests: All authors declare that they have no potential conflicts of interest., (© 2024 The Authors.)

Objective: The Indian Government launched Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), the world's largest health insurance scheme, in 2018. To reform pricing and gather evidence on healthcare costs, a hospital cost-surveillance pilot was initiated among PM-JAY empanelled hospitals. We analysed the process and challenges from both healthcare providers and payer agency's perspectives and offer recommendations for implementing similar systems in lower- and middle-income countries., Design: We employed an open-ended, descriptive and qualitative study design using in-depth interviews (IDI) as the data collection strategy., Settings: The interviews were conducted in both virtual and face-to-face modes depending on the convenience of the participants. The IDIs for the National Health Authority (NHA) officials and all providers in Kerala were conducted virtually, while face-to-face interviews were conducted and in Haryana and Chhattisgarh., Participants: Staff from 21 hospitals in three states (Haryana, Chhattisgarh and Kerala), including officials from State Health Agency (n=5) and NHA (n=3) were interviewed., Results: The findings highlight significant challenges in reporting cost data at the hospital level. These include a shortage of trained staff, leading to difficulties in collecting comprehensive and high-quality data. Additionally, the data collection process is resource-intensive and time-consuming, putting strain on limited capacity. Operational issues with transaction management system, such as speed, user-friendliness and frequent page expirations, also pose obstacles. Finally, current patient records data has gaps, in terms of quantity and quality, to be directly put to use for pricing., Conclusion: Accurate cost data is vital for health policy decisions. Capacity building across healthcare levels is needed for precise cost collection. Integration into digital infrastructure is key to avoid burdening providers and ensure quality data capture., Competing Interests: Competing interests: SP has formerly served as the Executive Director of the National Health Authority and BG is currently serving as the Additional Chief Executive Officer of the National Health Authority, Government of India., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: It is important to determine the health-related quality of life (HRQoL) to devise population-based cost-effective service delivery models. The present study aimed to evaluate the HRQoL of patients with refractive errors (RE) using generic and vision-specific instruments, identify the determinants of HRQoL, and examine the validity between the quality-of-life instruments for refractive errors., Methods: Face-to-face interviews were conducted with 515 participants with RE using generic as well as vision-specific HRQoL measures. Mean EuroQol-five dimensions-five levels (EQ-5D-5L) utility value, National Eye Institute-Visual Function Questionnaire-25 (NEI-VFQ-25) composite score, and EuroQol-Visual analogue scale (EQ-VAS) score were computed, and determinants of quality of life were determined using generalized linear regression model. The validity between generic and disease-specific measures was ascertained using Pearson's coefficient., Results: The mean EQ-5D-5L utility score for patients with RE was estimated as 0.72 (95% CI: 0.70-0.75). The mean NEI-VFQ-25 composite score and EQ-VAS score were 71.3 (95% CI: 69.8-73), and 74.7 (95% CI: 73.4-76.1), respectively. Visual acuity, gender, and presence of co-morbidities were significantly associated with quality of life. The concurrence between the generic and vision-specific instruments was found to be low to moderate., Conclusion: The findings of the study indicate the importance of the value of quality of life for patients with RE, which could be taken into account by health administrators, doctors and researchers to carry out economic evaluations, since these measures provide a basis for an evaluation more precisely the impact of RE and guide the determination of efficient ways to alleviate the burden of treatable visual impairment. More research is required to explore the potential integration of a vision component, the sixth dimension, into the EQ-5D-5L instrument, given the moderate agreement observed between the generic and specific assessment tools., (Copyright © 2024. Publicado por Elsevier España, S.L.U.)

Competing Interests: Competing interests: SSK, BSB and SP are the principal investigators of HTAIn Regional Resource Centers. KT, MS and AS previously worked for the HTAIn secretariat.

Competing Interests: None declared.

This series, "Primary health care in South Asia", is an effort to provide region-specific, evidence-based insights for reorienting health systems towards PHC. Led by regional thinkers, this series draws lessons from five countries in South Asia: Bangladesh, India, Nepal, Pakistan, and Sri Lanka. This is the last paper in the series that outlines points for future action. We call for action in three areas. First, the changing context in the region, with respect to epidemiological shifts, urbanisation, and privatisation, presents an important opportunity to appraise existing policies on PHC and reformulate them to meet the evolving needs of communities. Second, reorienting health systems towards PHC requires concrete efforts on three pillars-integrated services, multi-sectoral collaboration, and community empowerment. This paper collates nine action points that cut across these three pillars. These action points encompass contextualising policies on PHC, scaling up innovations, allocating adequate financial resources, strengthening the governance function of health ministries, establishing meaningful public-private engagements, using digital health tools, reorganising service delivery, enabling effective change-management processes, and encouraging practice-oriented research. Finally, we call for more research-policy-practice networks on PHC in South Asia that can generate evidence, bolster advocacy, and provide spaces for cross-learning., Funding: WHO SEARO funded this paper. This source did not play any role in the design, analysis or preparation of the manuscript., Competing Interests: We declare no conflict of interest., (© 2024 The Authors.)

Background: The design of health benefits package (HBP), and its associated payment and pricing system, is central to the performance of government-funded health insurance programmes. We evaluated the impact of revision in HBP within India's Pradhan Mantri Jan Arogya Yojana (PM-JAY) on provider behaviour, manifesting in terms of utilisation of services., Methods: We analysed the data on 1.35 million hospitalisation claims submitted by all the 886 (222 government and 664 private) empanelled hospitals in state of Punjab, from August 2019 to December 2022, to assess the change in utilisation from HBP 1.0 to HBP 2.0. The packages were stratified based on the nature of revision introduced in HBP 2.0, i.e., change in nomenclature, construct, price, or a combination of these. Data from National Health System Cost Database on cost of each of the packages was used to determine the cost-price differential for each package during HBP 1.0 and 2.0 respectively. A dose-response relationship was also evaluated, based on the multiplicity of revision type undertaken, or based on extent of price correction done. Change in the number of monthly claims, and the number of monthly claims per package was computed for each package category using an appropriate seasonal autoregressive integrated moving average (SARIMA) time series model., Findings: Overall, we found that the HBP revision led to a positive impact on utilisation of services. While changes in HBP nomenclature and construct had a positive effect, incorporating price corrections further accentuated the impact. The pricing reforms highly impacted those packages which were originally significantly under-priced. However, we did not find statistically significant dose-response relationship based on extent of price correction. Thirdly, the overall impact of HBP revision was similar in public and private hospitals., Interpretation: Our paper demonstrates the significant positive impact of PM-JAY HBP revisions on utilisation. HBP revisions need to be undertaken with the anticipation of its long-term intended effects., Funding: Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ)., Competing Interests: The present manuscript was written as part of a project funded by ‘The Deutsche Gesellschaft für Internationale Zusammenarbeit’, also known as GIZ. The project funding was made to the institution –Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. We would like to note that the lead author—Shankar Prinja, has formerly served as the Executive Director at the National Health Authority (NHA), while Basant Garg is currently the Additional CEO of the NHA. The authors declare no other conflicts of interest., (© 2024 The Authors.)

Setting reimbursement rates in national insurance schemes requires robust cost data. Collecting provider-generated cost accounting information is a potential mechanism for improving the cost evidence. To inform strategies for obtaining cost data to set reimbursement rates, this analysis aims to describe the role of cost accounting in public and private health sectors in India and describe the importance, perceived barriers and facilitators to improving cost accounting systems. In-depth interviews were conducted with 11 key informants. The interview tool guide was informed by a review of published and grey literature and government websites. The interviews were recorded as both audio and video and transcribed. A thematic coding framework was developed for the analysis. Multiple discussions were held to add, delete, classify or merge the themes. The themes identified were as follows: the status of cost accounting in the Indian hospital sector, legal and regulatory requirements for cost reporting, challenges to implementing cost accounting and recommendations for improving cost reporting by health care providers. The findings indicate that the sector lacks maturity in cost accounting due to a lack of understanding of its benefits, limited capacity and weak enforcement of cost reporting regulations. Providers recognize the value of cost analysis for investment decisions but have mixed opinions on the willingness to gather and report cost information, citing resource constraints and a lack of trust in payers. Additionally, heterogeneity among providers will require tailored approaches in developing cost accounting reporting frameworks and regulations. Health care cost accounting systems in India are rudimentary with a few exceptions, raising questions about how to source these data sustainably. Strengthening cost accounting systems in India will require standardized data formats, integrated into existing data management systems, that both meet the needs of policy makers and are acceptable to hospital providers., (© The Author(s) 2024. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Background: Ventilator-associated pneumonia (VAP) is the commonest healthcare-associated infection (HAI) in intensive care units (ICU), especially in trauma patients. VAP imposes a significant cost burden on the healthcare ecosystem. However, there are few data from the developing world., Methodology: We conducted this study in the trauma ICU (TICU) of PGIMER, Chandigarh, from October 2021 to December 2022. The incidence, incidence density, and average length of stay (ALOS) of both VAP and non-VAP patients were established. The health system cost was assessed using a mixed (top-down and bottom-up) micro-costing approach. We collected data for all the resources (direct and indirect costs) utilized during service delivery and estimated the health system cost per bed per day., Results: In this study, 494 patients were admitted to TICU, of which 484 received Mechanical Ventilation (MV) and 47 developed VAP. We included 41 and 44 patients with and without VAP. The VAP incidence rate was 9.7% and the VAP incidence density was 10.79/1000 MV days. The ALOS for VAP patients was 21 days, and for non- VAP patients was 8.2 days. Our study estimated a total health system cost of INR 25,927 per bed per day. The health system cost of treating a VAP patient was INR 544,467 compared to INR 207,416 for a non-VAP patient., Conclusion: Treatment of VAP poses substantial costs for the health system and patients. There is a need to focus on preventing VAP, which would eventually reduce the length of stay and the resultant financial impact on the health system and the patient., (Copyright © 2024 Copyright: © 2024 Indian Chest Society.)

Background: Survival outcomes for multiple myeloma have improved dramatically since the introduction of novel therapeutic agents. While these drugs are highly effective in improving survival outcomes and quality of life in patients with multiple myeloma, they come at a significant cost. We assessed the cost-effectiveness of bortezomib-based triplet or quadruplet drug regimens in isolation and followed by autologous hematopoietic stem cell transplantation (AHSCT) for the treatment of newly diagnosed multiple myeloma (NDMM) in the Indian context., Methods: A Markov model was developed to assess the health and economic outcomes of novel drug regimens with and without AHSCT for the treatment of NDMM in India. We estimated the lifetime quality-adjusted life-years (QALYs) and costs in each scenario. The incremental cost-effectiveness ratios (ICERs) were computed and compared against the current willingness-to-pay threshold of a one-time per capita gross domestic product of ₹146,890 (US$1,927.70) for India. Parameter uncertainty was assessed through Monte Carlo probabilistic sensitivity analysis., Results: Among seven treatment sequences, the VCd (bortezomib, cyclophosphamide, dexamethasone) alone arm has the lowest cost and health benefits as compared to four treatment sequences, namely VTd (bortezomib, thalidomide, dexamethasone) alone, VRd (bortezomib, lenalidomide, dexamethasone) alone, VRd plus AHSCT and DVRd (Daratumumab, bortezomib, lenalidomide, dexamethasone) plus AHSCT. It was found that VTd plus AHSCT and VCd plus AHSCT arms were extendedly dominated (ED) by combination of two alternative treatments. Among the five non-dominated strategies, VRd has a lowest incremental cost of ₹ 2,20,093 (US$2,888) per QALY gained compared to VTd alone followed by VRd plus AHSCT [₹3,14,530 (US$4,128) per QALY gained] in comparison to VRd alone. None of the novel treatment sequences were found to be cost-effective at the current WTP threshold of ₹1,46,890 (US$1,927.7)., Conclusion: At the current WTP threshold of one-time per capita GDP (₹ 146,890) of India, VRd alone and VRd plus AHSCT has 38.1% and 6.9% probability to be cost-effective, respectively. Reduction in current reimbursement rates of novel drugs, namely VRd, lenalidomide, and pomalidomide plus dexamethasone under national insurance program and societal cost of transplant by 50%, would make VRd plus AHSCT and VTd plus AHSCT cost-effective at an incremental cost of ₹40,671 (US$34) and ₹97,639 (US$1,281) per QALY gained, respectively., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Introduction: Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world's largest tax-funded insurance schemes. The present study was conducted to understand the decision-making process around the evolution (and revision) of health benefit packages (HBPs) and reimbursement rates within PM-JAY, with a specific focus on assessing the extent of use of economic evidence and role of various stakeholders in shaping these policy decisions., Methods: A mixed-methods study was adopted involving in-depth interviews with seven key stakeholders involved in HBP design and reimbursement rates decisions, and a survey of 80 government staff and other relevant stakeholders engaged in the implementation of PM-JAY. The data gathered were thematically analysed, and a coding framework was developed to explore specific themes. Additionally, publicly available documents were reviewed to ensure a comprehensive understanding of the decision-making processes., Results: Findings reveal a progressive transition towards evidence-based practices for policy decisions within PM-JAY. The initial version of HBP relied heavily on key criteria like disease burden, utilisation rates, and out-of-pocket expenditures, along with clinical opinion in shaping decisions around the inclusion of services in the HBP and setting reimbursement rates. Revised HBPs were informed based on evidence from a national-level costing study and broader stakeholder consultations. The use of health economic evidence increased with each additional revision with consideration of health technology assessment (HTA) evidence for some packages and reimbursement rates based on empirical cost evidence in the most recent update. The establishment of the Health Financing and Technology Assessment unit further signifies the use of evidence-based policymaking within PM-JAY. However, challenges persist, notably with regard to staff capacity and understanding of HTA principles, necessitating ongoing education and training initiatives., Conclusion: While substantial progress has been made in transitioning towards evidence-based practices within PM-JAY, sustained efforts and political commitment are required for the ongoing systematisation of processes., Competing Interests: Competing interests: SP formerly served as the executive director of the National Health Authority, Government of India., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background and Objective: Androgen-deprivation therapy is the mainstay of treatment for patients with newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC). However, the intensification of treatment with either docetaxel or novel anti-androgens (abiraterone-acetate plus prednisone [AAP], enzalutamide, and apalutamide) is being recommended based on the improved clinical outcomes and quality of life among patients. This study aimed to determine the most cost-effective drug for treatment intensification for patients with mHSPC in India., Methods: A Markov model was developed with four health states: progression-free survival, progressive disease, best supportive care, and death. Lifetime costs and consequences were estimated for four treatment sequences: AAP-first, enzalutamide-first, apalutamide-first, and docetaxel-first. Incremental cost per quality-adjusted life-year (QALY) gained with a given treatment option was compared against the next best alternative and assessed for cost effectiveness using a willingness to pay threshold of 1 × per capita gross domestic product in India., Results: We estimated that the total lifetime cost per patient was ₹1,367,454 (US$17,487), ₹2,168,885 (US$27,735), ₹7,678,501 (US$98,190), and ₹1,358,746 (US$17,375) in the AAP-first, enzalutamide-first, apalutamide-first, and docetaxel-first treatment sequence, respectively. The mean quality-adjusted life-years lived per patient were 4.78, 5.03, 3.22, and 2.61, respectively. The AAP-first sequence incurs an incremental cost of ₹4014 (US$51) per quality-adjusted life-year gained as compared with the docetaxel-first sequence, with a 87% probability of being cost effective at the willingness-to-pay threshold of 1 × per-capita gross domestic product of India. The use of AAP-first also incurs an incremental net monetary benefit of ₹396,491 (US$5070) as compared with the docetaxel-first treatment sequence. Nearly a 48% reduction in the price of enzalutamide is required to make it a cost-effective treatment sequence as compared with AAP-first in India., Conclusions: We concur with the inclusion of standard-dose AAP in India's publicly financed health insurance scheme for the intensification of treatment in mHSPC as it is the only cost-effective sequence among the various novel anti-androgens when compared with the docetaxel-first treatment sequence. Furthermore, a systematic reduction in the price of enzalutamide would further help to improve clinical outcomes among patients with mHSPC., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Making evidence-based policy decisions is challenging when there is a lack of information, especially when deciding provider payment rates for publicly funded health insurance plans. Therefore, the goal of this study was to estimate the cost of a cochlear implant operation in a tertiary care setting in India. We also looked at the patients' out-of-pocket (OOP) expenses for the cochlear implant surgery. From the perspectives of the patients and the healthcare systems, we assessed the financial costs of the cochlear implantation procedure. A bottom-up pricing model was used to assess the cost that the healthcare system would bear for a cochlear implant procedure. Information on all the resources (both capital and ongoing) required to offer cochlear implantation services for hearing loss was gathered over the course of a year. 120 individuals with hearing loss who had cochlear implantation surgery disclosed their out-of-pocket (OOP) costs, which included both direct medical and non-medical expenses. All costs for the budgetary year 2018-2019 were anticipated. The unit health system spent ₹ 151($2), ₹ 578($7.34) and ₹ 37,449($478) on ear exams, audiological evaluations, and cochlear implant surgeries, respectively. Per bed-day in the otolaryngology ward, hospitalization cost ₹ 202($2.6), or ₹ 1211($15.5). The estimated average out-of-pocket cost for a cochlear implant operation was ₹ 682,230($8710). Our research can be used to establish package rates for publicly funded insurance plans in India, plan the growth of public sector hearing care services, and do cost-effectiveness assessments on various hearing care models., Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04389-7., Competing Interests: Conflict of interestThere is no conflict of interest. I had full access to all of the data in this study and I take complete responsibility for the integrity of the data and the accuracy of the data analysis., (© Association of Otolaryngologists of India 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Purpose: Denosumab is clinically superior to zoledronic acid (ZA) for preventing and delaying time to first and subsequent skeletal-related events (SREs) among patients with breast cancer (BC) with bone metastases. We evaluated the cost and health benefits of denosumab and ZA (once every 4 weeks and once every 12 weeks) among four different molecular subtypes of BC with bone metastases in India., Materials and Methods: A Markov model was developed in Microsoft Excel to estimate lifetime health consequences and resulting costs among cohort of 1,000 patients with BC with bone metastasis, for three intervention scenarios, namely denosumab (once every 4 weeks), ZA (once every 4 weeks), and ZA (once every 12 weeks). The health outcomes were measured in terms of SREs averted and quality-adjusted life-years (QALYs) gained. The cost of each intervention scenario was measured using both the health system and the patient's perspectives. Indirect costs because of lost productivity were not included. The future costs and outcomes were discounted at the standard rate of 3%., Results: Over a lifetime, the incremental number of SREs averted with use of denosumab once every 4 weeks (compared with ZA once every 4 weeks and once every 12 weeks) among patients with luminal A, luminal B, human epidermal growth factor receptor 2-enriched, and triple negative breast cancer were estimated as 0.39, 0.26, 0.25, and 0.19, respectively. The number of QALYs lived were slightly higher in the denosumab arm (1.45-2.80) compared with ZA once every 4 weeks and once every 12 weeks arms (1.44-2.78). However, denosumab once every 4 weeks was not found to be a cost-effective alternative for either of the four molecular subtypes of breast cancer. ZA once every 12 weeks was found to be a cost-effective option with an average cost-effectiveness ratio ranging between ₹68,254 and ₹73,636., Conclusion: ZA once every 12 weeks is the cost-effective treatment option for BC with bone metastases in India. The present study findings hold significance for standard treatment guidelines under India's government-funded health insurance program.