Sex-specific Trends in Under-five Mortality in Rural Ballabgarh.

Objectives: To assess sex-specific differentials in child survival from 1992-2011. Methods: We analyzed data from the electronic database of Health and Demographic Surveillance System (HDSS) site in Ballabgarh in North India. Results: Sex ratio at birth was adverse for girls throughout the study period (821 to 866 girls per 1,000 boys) and was lowest in the period 2004-2006 at 821 girls per 1,000 boys. Overall, under-five mortality rates during the period 1992-2011 remained stagnant due to increasing neonatal mortality rate (9.2 to 27.7 P< 0.001). Mortality rates among girls were consistently and significantly higher than boys during the post-neonatal period (160% to 200% higher) as well as in childhood (160% to 230% higher). Conclusions: Strategies to address the neonatal mortality and gender differences are required for further reductions in child mortality in India.

Performance of cause-specific childhood mortality surveillance by health workers using a short verbal autopsy tool.

Background: The routine use of verbal autopsy in health-care delivery settings has been limited. Hence, the performance of neonatal and postneonatal verbal autopsy (VA) tools developed at the Comprehensive Rural Health Services Project (CRHSP), Ballabgarh (India), were assessed. Methods: Short VA tools developed by CRHSP were filled by health workers during their routine house visits while standard VA tools of the International Network of Field Sites with continuous Demographic Evaluation (INDEPTH) were filled by trained research workers for all 143 under-fivechildren deaths that occurred in 2008. The level of agreement in the cause of death assigned by the two VA tools was assessed by kappa and by comparison of the cause-specific mortality fractions. Results: Among 65 neonatal deaths, the cause specific mortality fraction (CSMF) was 43.1% and 40% for low birthweight, 15.4% and 26.2% for birth asphyxia, and 7.7% and 10.8% for pneumonia by INDEPTH and CRHSP VA tools respectively. In 78 deaths among 29-days to <5-year olds, the CSMF was 29.4% and 26.9% for diarrhoea, and 16.6% each for pneumonia using the INDEPTH and CRHSP VA tools respectively. Kappa for most causes of death was more than 0.8, except for birth asphyxia, which had a kappa of 0.678. Conclusions: Short VA tools have a satisfactory performance in field settings, which can be used routinely by health workers for filling the gaps in the cause-of-death information in places where medical certification of cause of death is deficient.

Cost of curative pediatric services in a public sector setting.

OBJECTIVE: To estimate the cost of ambulatory (out-patient) and in-patient pediatric health services for the year 1999 provided by All India Institute of Medical Sciences (AIIMS) at all the three levels-primary, secondary and tertiary level. METHODS: The costing module developed by Children's Vaccines Initiative (CVI) was used. This rapid assessment tool focuses on collection of data at macro level by using key informants like doctors, nursing staff, accountant, store keeper, engineer etc. Cost per beneficiary was estimated separately for in-patients and out-patients and was calculated by dividing the total cost of the services by the number of beneficiaries for the year 1999. For the out-patient, the beneficiaries were the total out-patient attendees and for the in-patient, it was the total pediatric admissions multiplied by mean duration of stay in days. RESULTS: The cost per out-patient visit was INR.20.2 (US0.44 dollars@1US dollars=INR.46) at primary level, higher than INR14.5 (US0.31 dollars) at the secondary level, while at tertiary level it was INR 33.8 (US 0.73 dollars). At the primary and secondary level, non-physician cost was more than the physician cost, and for tertiary level, physician cost was much higher than the other costs. There were no in-patient services at primary level. The cost of in-patient services at secondary level was estimated as INR 419.30 (US 9.1 dollars) per patient per day with a bed occupancy rate of 60%. Two-fifths of the cost was due to nursing and other supportive staff and one fifth due to the doctor costs and overhead costs. The unit cost of INR 928 (US 20.2 dollars) per patient per day incurred at AIIMS with a bed occupancy rate of 100% was almost twice that of secondary level. In contrast to the secondary level, almost half the total costs at tertiary level was due to the doctors costs. CONCLUSIONS: Effective use of resources at lower level of care especially ambulatory care at primary level and inpatient care at secondary level can result in much higher savings for the system and also, the society. These would need to be appropriately strengthened.