Effectiveness of the health and wellness centers in improving identification and primary care of non-communicable diseases in Chhattisgarh State of India.

Introduction: India launched a national initiative named Health and Wellness Centres (HWCs) in 2018 to provide population-based primary care including for the non-communicable diseases (NCDs) in rural areas. The current study assesses whether operationalization of HWCs improved the detection of NCDs and increased the share of public sector facilities in providing NCD services. Methods: Two rounds of household surveys were conducted in rural Chhattisgarh in 2019 and 2022. With a focus on NCDs, the household survey covered a representative sample of individuals above the age of 30 years - 2760 individuals in 2019 and 2638 in 2022. Multi-variate regression analysis was carried out to determine effects of HWCs on identification of NCDs and utilization of public sector services. Results: The population covered by HWCs had 25% greater chance of being identified with NCDs as compared to the population without HWCs (AOR = 1.25, P = 0.03). The NCD patients living in areas covered by HWCs had 70% greater chance of utilizing the public healthcare facilities (AOR = 1.70, P = 0.01). In the population covered by HWCs, the share of the public sector in NCD care increased from 41.2% in 2019 to 62.1% in 2022, whereas the share of informal private providers dropped from 23.5% in 2019 to 8.4% in 2022. Conclusion: The HWCs showed effectiveness in increasing detection of NCDs at the population level and bringing a larger share of NCD patients to utilize public sector services. They can prove to be a crucial architectural correction for improving primary care service delivery for NCDs and other population health needs in India.

Cost of Care for Non-communicable Diseases: Which Types of Healthcare Providers are the Most Economical in India's Chhattisgarh State?

BACKGROUND: Non-communicable diseases (NCDs) affect a large number of people globally and their burden has been growing. Healthcare for NCDs often involves high out-of-pocket expenditure and rising costs of providing services. Financing and providing care for NCDs have become a major challenge for health systems. Despite the high burden of NCDs in India, there is little information available on the costs involved in NCD care. METHODS: The study was aimed at finding out the average monthly cost of outpatient care per NCD patient. The average cost was defined as all resources spent directly by government and citizens to get a month of care for a NCD patient. The cost borne by the government on public facilities was taken into account and activity-based costing was used to apportion it to the function of providing outpatient NCD care. For robustness, time-driven activity-based costing and sensitivity analyses were also performed. The study was conducted in Chhattisgarh State and involved a household survey and a facility survey, conducted simultaneously at the end of 2022. The surveys had a sample representative of the state, covering 3500 individuals above age of 30 years and 108 health facilities. RESULTS: The average monthly cost per NCD patient was Indian Rupees (INR) 688 for public providers, INR 1389 for formal for-profit providers and INR 408 for informal private providers and they managed 53.5, 34.3 and 12.0% of NCD patients respectively. The disease profile of patients handled by different types of providers was similar. The average cost per patient was lowest for the primary care facilities in the public sector. CONCLUSIONS: The average direct cost of NCD care for government and citizens put together was substantially higher in case of formal for-profit providers compared with public facilities, even after taking into account the government subsidies to public sector. This has implications for allocative efficiency and the desired public-private provider mix in health systems.

Does government health insurance protect households from out of pocket expenditure and distress financing for caesarean and non-caesarean institutional deliveries in India? Findings from the national family health survey (2019-21).

OBJECTIVE: Institutional deliveries have been promoted in India to reduce maternal and neonatal mortality. While the institutional deliveries have increased, they tend to involve large out of pocket expenditure (OOPE) and distress financing for households. In order to protect the families from financial hardship, publicly funded health insurance (PFHI) schemes have been implemented in India. An expanded national health insurance scheme called the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched in 2018. The current study was aimed at evaluating the performance of PFHI in reducing the OOPE and distress financing for the caesarean and non-caesarean institutional deliveries after the launch of PMJAY. This study analysed the nationally representative dataset of the National Family Health Survey (NFHS-5) conducted in 2019-21. RESULTS: Enrollment under PMJAY or other PFHI was not associated with any reduction in out of pocket expenditure or distress financing for caesarean or non-caesarean institutional deliveries across India. Irrespective of the PFHI coverage, the average OOPE in private hospitals was five times larger than public hospitals. Private hospitals showed an excessive rate of using caesarean-section. Utilization of private hospitals was significantly associated with incurring larger OOPE and occurrence of distress financing.

Role of publicly funded health insurance in financial protection of the elderly from hospitalisation expenditure in India-findings from the longitudinal aging study.

BACKGROUND: The elderly face a greater burden of illnesses than other age groups and have a more frequent need of healthcare, including in-patient hospitalisations. Catastrophic expenditure on hospitalisation of the elderly poses a significant challenge to India's aim of achieving Universal Health Coverage (UHC). India has implemented a policy of Publicly Funded Health Insurance (PFHI) to provide free inpatient care by empanelling private and public hospitals. The existing studies have examined the performance of PFHI in financial protection of the elderly. METHODS: This study utilised the Longitudinal Ageing Study in India (LASI) Wave 1, conducted in 2017-18. LASI is a large-scale nationally representative survey collecting data on elderly health including illness burden, healthcare use and out of pocket expenditure (OOPE). It covered a sample 72,250 individuals aged 45 or above. Financial Protection was measured in terms of Catastrophic Health Expenditure (CHE). Multivariate analysis was conducted to find effect of PFHI on OOPE-quantile and logistic models were applied for OOPE and CHE respectively. For robustness, Propensity Score Matching (PSM) model was applied. RESULTS: Of the hospitalisations, 35% had taken place in public hospitals. The mean OOPE for a hospitalisation in public sector was Indian Rupees (INR) 8276, whereas it was INR 49,700 in private facilities. Incidence of CHE was several times greater for using private hospitals as compared to public hospitals. Multi-variate analyses showed that enrolment under PFHI was not associated with lower OOPE or CHE. PSM model also confirmed that PFHI-enrolment had no effect on OOPE or CHE. Use of private facilities was a key determinant of OOPE, irrespective of enrolment under PFHI. CONCLUSIONS: This was the first study in India to examine the performance of PFHI in the context of catastrophic hospitalisation expenditure faced by the elderly. It found that PFHI was not effective in financial protection of the elderly. The ongoing reliance on a poorly regulated private sector seems to be a key limitation of PFHI policy. Governments need to find more effective ways of protecting the elderly from catastrophic health expenditure if the goal of UHC has to be realized.

What is the out-of-pocket expenditure on medicines in India? An empirical assessment using a novel methodology.

The share of expenditure on medicines as part of the total out-of-pocket (OOP) expenditure on healthcare services has been reported to be much higher in India than in other countries. This study was conducted to ascertain the extent of this share of medicine expenditure using a novel methodology. OOP expenditure data were collected through exit interviews with 5252 out-patient department patients in three states of India. Follow-up interviews were conducted after Days 1 and 15 of the baseline to identify any additional expenditure incurred. In addition, medicine prescription data were collected from the patients through prescription audits. Self-reported expenditure on medicines was compared with the amount imputed using local market prices based on prescription data. The results were also compared with the mean expenditure on medicines per spell of ailment among non-hospitalized cases from the National Sample Survey (NSS) 75th round for the corresponding states and districts, which is based on household survey methodology. The share of medicines in OOP expenditure did not change significantly for organized private hospitals using the patient-reported vs imputation-based methods (30.74-29.61%). Large reductions were observed for single-doctor clinics, especially in the case of 'Ayurvedic' (64.51-36.51%) and homeopathic (57.53-42.74%) practitioners. After adjustment for socio-demographic factors and types of ailments, we found that household data collection as per NSS methodology leads to an increase of 25% and 26% in the reported share of medicines for public- and private-sector out-patient consultations respectively, as compared with facility-based exit interviews with the imputation of expenditure for medicines as per actual quantity and price data. The nature of healthcare transactions at single-doctor clinics in rural India leads to an over-reporting of expenditure on medicines by patients. While household surveys are valid to provide total expenditure, these are less likely to correctly estimate the share of medicine expenditure.

Implementing a health labour market analysis to address health workforce gaps in a rural region of India.

BACKGROUND: Human Resources for Health (HRH) are essential for making meaningful progress towards universal health coverage (UHC), but health systems in most of the developing countries continue to suffer from serious gaps in health workforce. The Global Strategy on Human Resources for Health-Workforce 2030, adopted in 2016, includes Health Labor Market Analysis (HLMA) as a tool for evidence based health workforce improvements. HLMA offers certain advantages over the traditional approach of workforce planning. In 2018, WHO supported a HLMA exercise in Chhattisgarh, one of the predominantly rural states of India. METHODS: The HLMA included a stakeholder consultation for identifying policy questions relevant to the context. The HLMA focused on state HRH at district-level and below. Mixed methods were used for data collection and analysis. Detailed district-wise data on HRH availability were collected from state's health department. Data were also collected on policies implemented on HRH during the 3 year period after the start of HLMA and changes in health workforce. RESULTS: The state had increased the production of doctors but vacancies persisted until 2018. The availability of doctors and other qualified health workers was uneven with severe shortages of private as well as public HRH in rural areas. In case of nurses, there was a substantial production of nurses, particularly from private schools, however there was a lack of trusted accreditation mechanism and vacancies in public sector persisted alongside unemployment among nurses. Based on the HLMA, pragmatic recommendations were decided and followed up. Over the past 3 years since the HLMA began an additional 4547 health workers including 1141 doctors have been absorbed by the public sector. The vacancies in most of the clinical cadres were brought below 20%. CONCLUSION: The HLMA played an important role in identifying the key HRH gaps and clarifying the underlying issues. The HLMA and the pursuant recommendations were instrumental in development and implementation of appropriate policies to improve rural HRH in Chhattisgarh. This demonstrates important progress on key 2030 Global Strategy milestones of reducing inequalities in access to health workers and improving financing, retention and training of HRH.

How much do government and households spend on an episode of hospitalisation in India? A comparison for public and private hospitals in Chhattisgarh state.

BACKGROUND: Improvements in the financing of healthcare services are important for developing countries like India to make progress towards universal health coverage. Inpatient-care contributes to a big share of total health expenditure in India. India has a mixed health-system with a sizeable presence of private hospitals. Existing studies show that out-of-pocket expenditure (OOPE) incurred per hospitalisation in private hospitals was greater than public facilities. But, such comparisons have not taken into account the healthcare spending by government. METHODS: For a valid comparison between public and for-profit private providers, this study in Indian state of Chhattisgarh assessed the combined spending by government and households per episode of hospitalisation. The supply-side and demand-side spending from public and private sources was taken into account. The study used two datasets: a) household survey for data on hospital utilisation, OOPE, cash incentives received by patients and claims raised under publicly funded health insurance (PFHI) schemes (n = 903 hospitalisation episodes) b) survey of public facilities to find supply-side government spending per hospitalisation (n = 64 facilities). RESULTS: Taking into account all relevant demand and supply side expenditures, the average total spending per day of hospitalisation was INR 2833 for public hospitals and INR 6788 for private hospitals. Adjusted model for logarithmic transformation of OOPE while controlling for variables including case-mix showed that a hospitalisation in private hospitals was significantly more expensive than public hospitals (coefficient = 2.9, p < 0.001). Hospitalisations in private hospitals were more likely to result in a PFHI claim (adjusted-odds-ratio = 1.45, p = 0.02) and involve a greater amount than public hospitals (coefficient = 0.27, p < 0.001). Propensity-score matching models confirmed the above results. Overall, supply-side public spending contributed to 16% of total spending, demand-side spending through PFHI to 16%, cash incentives to 1% and OOPE to 67%. OOPE constituted 31% of total spending per episode in public and 86% in private hospitals. CONCLUSIONS: Government and households put together spent substantially more per hospitalisation in private hospitals than public hospitals in Chhattisgarh. This has important implications for the allocative efficiency and the desired public-private provider-mix. Using public resources for purchasing inpatient care services from private providers may not be a suitable strategy for such contexts.

Assessing competence of mid-level providers delivering primary health care in India: a clinical vignette-based study in Chhattisgarh state.

BACKGROUND: The global commitment to primary health care (PHC) has been reconfirmed in the declaration of Astana, 2018. India has also seen an upswing in national commitment to implement PHC. Health and wellness centres (HWCs) have been introduced, one at every 5000 population, with the fundamental purpose of bringing a comprehensive range of primary care services closer to where people live. The key addition in each HWC is of a mid-level healthcare provider (MLHP). Nurses were provided a 6-month training to play this role as community health officers (CHOs). But no assessments are available of the clinical competence of this newly inducted cadre for delivering primary care. The current study was aimed at providing an assessment of competence of CHOs in the Indian state of Chhattisgarh. METHODS: The assessment involved a comparison of CHOs with rural medical assistants (RMAs) and medical officers (MO), the two main existing clinical cadres providing primary care in Chhattisgarh. Standardized clinical vignettes were used to measure knowledge and clinical reasoning of providers. Ten ailments were included, based on primary care needs in Chhattisgarh. Each part of clinical vignettes was standardized using expert consultations and standard treatment guidelines. Sample size was adequate to detect 15% difference between scores of different cadres and the assessment covered 132 CHOs, 129 RMAs and 50 MOs. RESULTS: The overall mean scores of CHOs, RMAs and MOs were 50.1%, 63.1% and 68.1%, respectively. They were statistically different (p < 0.05). The adjusted model also confirmed the above pattern. CHOs performed well in clinical management of non-communicable diseases and malaria. CHOs also scored well in clinical knowledge for diagnosis. Around 80% of prescriptions written by CHOs for hypertension and diabetes were found correct. CONCLUSION: The non-physician MLHP cadre of CHOs deployed in rural facilities under the current PHC initiative in India exhibited the potential to manage ambulatory care for illnesses. Continuous training inputs, treatment protocols and medicines are needed to improve performance of MLHPs. Making comprehensive primary care services available close to people is essential to PHC and well-trained mid-level providers will be crucial for making it a reality in developing countries.

Household expenditure on non-Covid hospitalisation care during the Covid-19 pandemic and the role of financial protection policies in India.

BACKGROUND: Despite global guidance for maintaining essential non-Covid health services during the pandemic, there is a concern that existing services faced a major disruption. The access as well as affordability of healthcare could have suffered during the pandemic, especially in developing countries including India. There are no population based studies available in India on changes in access and financial risk for non-Covid hospitalisation during the pandemic. India has a policy of Publicly Funded Health Insurance (PFHI) to ensure access and financial protection for hospital care but no information is available on its performance during the pandemic. The current study was aimed to find out the change in access and financial protection for non-Covid hospitalisations during the Covid-19 pandemic and to examine the performance of PFHI in this context. METHODS: Panel data was analyzed, from two rounds of annual household surveys conducted in Chhattisgarh state for year 2019 and 2020. The survey followed a two-stage population based sample of around 3000 households, representative for the state. Two kinds of measures of catastrophic health expenditure were used - based on annual household consumption expenditure and on non-food consumption expenditure. Multivariate analysis was carried out to find determinants of utilisation and spending. In addition, Propensity Score Matching method was applied to find effect of PFHI schemes. RESULTS: Utilisation of hospital care per 1000 population reduced from 58.2 in 2019 to 36.6 during the pandemic i.e. in 2020. The share of public hospitals in utilisation increased from 60.1% in 2019 to 67.0% in 2020. Incidence of catastrophic expenditure was significantly greater during the pandemic. The median Out of Pocket Expenditure (OOPE) in private hospitals doubled from 2019 to 2020. The size of OOPE and occurrence of catastrophic expenditure were significantly associated with utilisation in private hospitals. Enrolment under PFHI schemes including the Ayushman Bharat-Pradhan Mantri Jan Arogaya Yojana (PMJAY) was not effective in reducing OOPE or catastrophic expenditure. CONCLUSION: While the utilisation of hospital care dropped during the pandemic, the private hospitals became further unaffordable. The government policy for financial protection through health insurance remained ineffective during the pandemic.

Catastrophic health expenditure due to hospitalisation for COVID-19 treatment in India: findings from a primary survey.

OBJECTIVE: The COVID-19 pandemic has caused widespread illness and a significant proportion of the infected required hospitalisation for treatment. People in developing countries like India were vulnerable to high hospitalisation costs. Despite its crucial importance, few primary studies are available on this aspect of the pandemic. This study was aimed at finding out the out of pocket expenditure (OOPE) and incidence of catastrophic expenditure on hospitalisation of persons infected with COVID-19. A primary survey of 492 randomly selected hospitalisations of individuals tested positive for COVID-19 in high-burden districts during August to November 2020 was carried out telephonically in Chhattisgarh state of India. RESULTS: Public hospitals accounted for 69% of the hospitalisations for COVID-19 treatment. Mean OOPE per hospitalisation was Indian Rupees (INR) 4871 in public hospitals and INR 169,504 in private hospitals. Around 3% of hospitalisations in public hospitals and 59% in private hospitals resulted in catastrophic expenditure, at a threshold of 40% of non-food annual household expenditure. Enrolment under publicly or privately funded health insurance was not effective in curtailing OOPE. Multivariate analysis showed that utilisation of private hospitals was a key determinant of incurring catastrophic expenditure.

Determinants of condom use during last sexual intercourse among male college youth of Kaski, Nepal: A cross-sectional survey.

BACKGROUND: The National Family Planning program of Nepal has introduced the condom as an important family planning method. Despite the continuous effort from the public and private sectors at various levels, its use among youth remains low. Therefore, this study aimed to assess the factors associated with condom use during the last sexual intercourse among male college youth. METHODS: We conducted a cross-sectional study and analyzed the responses of 361 male college youth (aged 19 to 24 years who reported being sexually active preceding six months of the survey), among the 903 participants who reported being involved in vaginal and anal sexual intercourse. The chi-square test was primarily used to find the associated factors and then, stepwise logistic regression was performed by selecting the covariates after the multicollinearity test followed by adjustment of confounders. RESULTS: We found that more than one-fourth (27.4%) of the sexually active male youth had used the condoms during their last sexual intercourse. Postgraduate male youth were four times more likely to use the condoms during the last sexual intercourse than undergraduate male youth (AOR = 4.09, 95% CI; 2.08-8.06). Similarly, married youth were less likely to use the condoms during the last sexual intercourse with 95% lower odds than their counterparts (AOR = 0.05, 95% CI; 0.01-0.38). Male youth with adequate knowledge about the condoms were 8 times more likely to use them compared to those with inadequate knowledge (AOR = 8.42, 95% CI; 4.34-16.33). Likewise, male youth with favorable attitude towards the condoms were 2.5 times more likely to use them compared to their counterparts (AOR = 2.58, 95% CI; 1.23-5.42). Similarly, male youth having two or more sex partners were 4.5 times more likely to use the condoms than the youth having only a sex partner (AOR = 4.57, 95% CI; 2.38-8.76). CONCLUSION: The study concluded that slightly more than one-fourth (27.4%) of male college youth in Kaski district used the condoms during their last sexual intercourse. Level of education, marital status, knowledge about condoms, attitude toward condoms, and number of sex partners are the determinants of condom use among male college youth so recommended for early behavioral interventions, especially in knowledge and attitude. Further studies focusing on including the rural youth and larger geography may help to reach a firmer conclusion.

Comparing the average cost of outpatient care of public and for-profit private providers in India.

INTRODUCTION: Understanding the cost of care associated with different kinds of healthcare providers is necessary for informing the policy debates in mixed health-systems like India's. Existing studies reporting Out of Pocket Expenditure (OOPE) per episode of outpatient care in public and private providers in India do not provide a fair comparison because they have not taken into account the government subsidies received by public facilities. Public and private health insurance in India do not cover outpatient care and for-profit providers have to meet all their costs out of the payments they take from patients. METHODS: The average direct cost per acute episode of outpatient care was compared for public providers, for-profit formal providers and informal private providers in Chhattisgarh state of India. For public facilities, government subsidies for various inputs were taken into account. Resources used were apportioned using Activity Based Costing. Land provided free to public facilities was counted at market prices. The study used two datasets: a) household survey on outpatient utilisation and OOPE b) facility survey of public providers to find the input costs borne by government per outpatient-episode. RESULTS: The average cost per episode of outpatient care was Indian Rupees (INR) 400 for public providers, INR 586 for informal private providers and INR 2643 for formal for-profit providers and they managed 39.3, 37.9 and 22.9% of episodes respectively. The average cost for government and households put together was greater for using formal for-profit providers than the public providers. The disease profile of care handled by different types of providers was similar. Volume of patients and human-resources were key cost drivers in public facilities. Close to community providers involved less cost than others. CONCLUSIONS AND RECOMMENDATIONS: The findings have implications for the desired mix of public and private providers in India's health-system. Poor regulation of for-profit providers was an important structural cost driver. Purchasing outpatient care from private providers may not reduce average cost. Policies to strengthen public provisioning of curative primary care close to communities can help in reducing cost.

Performance of India's national publicly funded health insurance scheme, Pradhan Mantri Jan Arogaya Yojana (PMJAY), in improving access and financial protection for hospital care: findings from household surveys in Chhattisgarh state.

BACKGROUND: A national Publicly Funded Health Insurance (PFHI) scheme called Pradhan Mantri Jan Arogaya Yojana (PMJAY) was launched by government of India in 2018. PMJAY seeks to cover 500 million persons with an annual cover of around 7000 USD per household. PMJAY claims to be the largest government funded health scheme globally and has attracted an international debate as a policy for Universal Health Coverage. India's decade-long experience of the earlier national and state-specific PFHI schemes had shown poor effectiveness in financial protection. Most states in India have completed a year of implementation of PMJAY but no evaluations are available of this important scheme. METHODS: The study was designed to find out the effect of enrolment under PMJAY in improving utilisation of hospital services and financial protection in Chhattisgarh which has been a leading state in implementing PFHI in terms of enrolment and claims. The study analyses three repeated cross-sections. Two of the cross-sections are from National Sample Survey (NSS) health rounds - year 2004 when there was no PFHI and 2014 when the older PFHI scheme was in operation. Primary data was collected in 2019-end to cover the first year of PMJAY implementation and it formed the third cross-section. Multivariate analysis was carried out. In addition, Propensity Score Matching and Instrumental Variable method were applied to address the selection problem in insurance. RESULTS: Enrollment under PMJAY or other PFHI schemes did not increase utilisation of hospital-care in Chhattisgarh. Out of Pocket Expenditure (OOPE) and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PMJAY or other PFHI schemes. The size of OOPE was significantly greater for utilisation in private sector, irrespective of enrollment under PMJAY. CONCLUSION: PMJAY provided substantially larger vertical cover than earlier PFHI schemes in India but it has not been able to improve access or financial protection so far in the state. Though PMJAY is a relatively new scheme, the persistent failure of PFHI schemes over a decade raises doubts about suitability of publicly funded purchasing from private providers in the Indian context. Further research is recommended on such policies in LMIC contexts.

Access and availability of essential medicines in Chhattisgarh: Situation in public health facilities.

BACKGROUND: In 2013, the Government of Chhattisgarh announced a policy guaranteeing access to free generic medicines in all the public health facilities. This study was conducted with the objectives of evaluating the prescribing patterns of physicians in public health facilities with regard to generic medicines, and whether the prescribed generic medicines were made available to patients. MATERIALS AND METHODS: This cross-sectional study was conducting from December 2013-October 2014, using exit interviews of patients. Out of the total 27 districts of the state, 15 districts were selected, and one district hospital, three community health centers, and three primary health centers were selected from each of these districts, as per logistics feasibility. Descriptive statistics in the form of frequencies and percentages were calculated. RESULTS: During the data collection period, a total of 1290 prescriptions were reviewed from 100 public health facilities. Around 68.89% of the medicines prescribed were generic and were from the 2013 generic drugs list. Around 58.28% of the prescribed generic medicines were available to the patients from these public health facilities, and the rest of the medicines were procured from private pharmacies. CONCLUSION: Chhattisgarh has made considerable progress in increasing access of generic medicines to patients in public health facilities. Our study shows that for the year 2013-14, about 58% of the prescribed medicines were available in various public health facilities. There is opportunity to further improve the state financial allocation for generic medicines, to improve supply chain and logistics for better distribution, and to mandate that physicians in these facilities prescribe generic medicines.