Cost effectiveness of strategies for cervical cancer prevention in India

The establishment of link between high-risk human papillomavirus (HPV) infection and occurrence of cervical cancer has resulted in development of various HPV related control strategies for the prevention of cervical cancer. The objective of the present study was to assess the cost effectiveness of various screening strategies for cervical cancer and human papilloma virus (HPV) vaccination in India. A Markov model based on societal perspective was designed to estimate the lifetime costs and consequences of screening (with either visual inspect with acetic acid (VIA), Papanicolaou test or HPV DNA test at various time intervals) in a hypothetical cohort of 30-65 years age women or vaccination among adolescent girls. Diagnostic accuracy of the screening strategies, efficacy of HPV vaccination and data on transition probabilities was based on the results of the existing meta-analyses. Primary data was collected for assessing per person cost of screening, cost of treating cervical cancer and quality of life. We found that introduction of different screening strategies leads to reduction in lifetime occurrence of cervical cancer cases caused by HPV 16/18 from 20% to 61%, and cervical cancer deaths from 28% to 70%, as compared to no screening. Among various screening strategies, screening with both VIA 5 yearly and VIA 10 yearly came out to be cost effective at 1-time per capita GDP, with VIA every 5 years providing greater health benefits as compared to VIA 10 years. Hence, screening with VIA 5 years at an incremental cost of US$ 829 (INR 54,881) per QALY gained is the recommended strategy for India. Further, with regards to HPV vaccination, it leads to 60% reduction in cancer cases and mortality caused by HPV 16/18 as compared to no vaccination. Moreover, when this vaccinated cohort of adolescent girls is also screened later in their life (with VIA every 10 years and VIA 5 years), it leads to 69%-76% reduction in cancer cases and 71%-81% reduction in cancer deaths. As compared to no vaccination and no screening, both HPV vaccination alone and vaccination plus screening (with VIA every 5 yearly and VIA 10 yearly) appears to be cost effective with ICERs in the range of US$ 86 (INR 5,693) to US$ 476 (INR 31,511) per QALY gained. In the long run, when the cohort of adolescent girls, who were immunized for HPV, reach the age of 30 years, the screening frequency using VIA should be determined based on the coverage of HPV vaccination in that cohort.

Cost of Treatment for Cervical Cancer in India

INTRODUCTION

Cervical cancer is a major public health problem in India leading to high economic burden, which is disproportionately borne by the patients as out-of-pocket expenditure (OOPE). Several publicly financed health insurance schemes (PFHIs) in India cover the treatment for cervical cancer. However, the provider payment rates for health benefit packages (HBP) under these PFHIs are not based on scientific evidence. We undertook this study to estimate the cost of services provided for treatment of cervical cancer and  cost of the package of care for cervical cancer in India.

METHODS

The study was undertaken at a large public tertiary hospital in North India. The health system cost was assessed using a mixed micro-costing approach. The data were collected for all the resources utilized during service delivery for cervical cancer patients. To evaluate the OOPE, randomly selected 248 patients were interviewed following the cost of illness approach. Logistic regression was used to assess the factors associated with catastrophic health expenditure (CHE).

RESULTS

Health system cost for different cervical cancer treatment modalities i.e. radiotherapy, brachytherapy, chemotherapy and surgery, ranges from INR 19,494 to 41,388 (USD 291 - 617). Furthermore, patients spent INR 4,042 to 23,453 ( USD 60 - 350) as OOPE. Nearly 62% patients incurred CHE, and 30% reported distress financing. The odds of CHE (OR: 25.39, p-value: <0.001) and distress financing (OR: 15.37, p-value: 0.001) were significantly higher in poorest-income quintile. The HBP cost varies from INR 45,364 to 64,422 (USD 676 - 960) for brachytherapy and radiotherapy respectively.

CONCLUSION

Cervical cancer treatment leads to high OOPE in India, which imposes financial hardship, especially for the poorest. The coverage of risk pooling mechanisms like PHFIs should be enhanced. The findings of our study should be used to set the reimbursement rates of providing cervical cancer treatment under PFHI schemes.

Health-related quality of life among cervical cancer patients in India

INTRODUCTION

Estimation of health-related quality of life of cervical cancer patients in India is important in assessing the well-being of patients, monitor treatment outcomes, and conduct health technology assessments. However, health-related quality of life estimates for different stages of cervical cancer are not available for the Indian population. This study aims to generate stage-specific quality of life scores for cervical cancer patients in India.

METHODS

A cross-sectional study using the EQ-5D (EuroQol 5-dimensions) instrument, that consists of the EQ-5D-5L descriptive system and the EuroQol Visual Analog Scale (EQ-VAS) was conducted. A total of 159 cervical cancer patients were interviewed. Mean EQ-5D-5L quality of life scores (utility scores) were calculated using the EQ-5D-5L index value calculator across different stages of cervical cancer. The proportion of patients reporting problems in different attributes of EQ-5D-5L was assessed. The impact of socio-economic determinants on health-related quality of life was evaluated using multiple linear regression.

RESULTS

The mean EQ-5D-5L and EQ-VAS utility scores among patients of cervical cancer were 0.64 [95% CI=0.61-0.67] and 67.6 [95% CI=65.17-70.03], respectively. The most frequently reported problem among cervical cancer patients was pain/discomfort (61.88%), followed by difficulty in performing usual activities (53.81%), and anxiety/depression (41.26%).

CONCLUSION

Cervical cancer significantly impacts the health-related quality of life of the patients in India. Clinical interventions should focus on the control of pain and relief of anxiety. The measurement of health-related quality of life should be an integral component of the effectiveness of interventions as well as health technology assessment.

Establishing reference costs for the health benefit packages under universal health coverage in India: cost of health services in India (CHSI) protocol

INTRODUCTION

To achieve universal health coverage, the Government of India has introduced Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB - PMJAY), a large tax-funded national health insurance scheme for the provision of secondary and tertiary care services in public and private hospitals. AB - PMJAY reimburses care for 1573 health benefit packages (HBPs). HBPs are designed to cover the treatment of diseases/conditions with high incidence/prevalence or which contribute to high out-of-pocket expenditure. However, there is a dearth of reference cost data against which provider payment rates can be assessed.

METHODS AND ANALYSIS

The CHSI (Cost of Health Services in India) study will collect cost data from 13 Indian states covering 52 public and 40 private hospitals, using a mixed economic costing methodology (top-down and bottom-up), to generate unit costs for the HBPs. States will be sampled to capture economic status, development indicators and health service utilisation heterogeneity. The public sector hospitals will be chosen at secondary and tertiary care level. One tertiary facility will be selected from each state. At secondary level, three districts per state will be selected randomly from the district composite development score ranking. The private sector hospital sample will be stratified by nature of ownership (for-profit and not-for-profit), type of city (tier 1, 2 or 3) and size of the hospital (number of beds). Average costs for each HBP will be calculated across the different facility types. Multiple scenarios will be used to suggest rates which could be negotiated with the providers. Overall, the study will provide economic cost data for price setting, strategic purchasing, health technology assessment and a national cost database of India.

ETHICS AND DISSEMINATION

The approval has been obtained from the Institutional Ethics Committee and Institutional Collaborative Committee of the Post Graduate Institute of Medical Education and Research, Chandigarh, India. The results shall be disseminated in conferences and peer-reviewed articles.

Epidemiological profile of retinoblastoma in North India: Implications for primary care and family physicians

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.

A systematic review of economic evaluations of treatment regimens in multiple myeloma

BACKGROUND

The expansion of advanced expensive therapeutic innovations for Multiple Myeloma (MM) led to increased disclosure of economic evaluations. The present analysis systematically reviewed and appraised the reporting quality of economic evaluations in MM.

METHODOLOGY

A comprehensive literature search in Ovid, MEDLINE(R), PubMed, and Cochrane libraries was conducted for studies published in the past decade. Two independent authors performed study selection and data extraction in a standardized form. Study methodological quality assessment was performed using 10-item Drummond's tool.

RESULTS

Of potentially eligible 1150 retrieved studies, 17 met eligibility criteria. Six evaluations (35%) were in newly diagnosed MM and 11 (65%) in relapse refractory (RR) MM. Nine studies (53%) embraced the payer's perspective, five (29%) adopted health care system, one (6%) societal and two did not report. Six (35%) employed partitioned survival model, 4(24%) discrete event simulation, 4(24%) Markov model and 2(12%) used decision tree model. The methodological quality has improved significantly; 16 (94%) studies comprehended a well-defined question by affirming the analysis perspective and examined both costs and outcomes while 13 (71%) provided a comprehensive description of competing alternatives.

CONCLUSION

The addition of novel drugs to the treatment armamentarium of MM is considerably cost-effective. The evaluations became more frequent, methodological quality has improved in the last decade.

Economics of COVID-19: challenges and the way forward for health policy during and after the pandemic

The emergence of novel coronavirus disease 2019 (COVID-19) pandemic provides unique challenges for health system. While on the one hand, the government has to struggle with the strategies for control of COVID-19, on the other hand, other routine health services also need to be managed. Second, the infrastructure needs to be augmented to meet the potential epidemic surge of cases. Third, economic welfare and household income need to be guaranteed. All of these have complicated the routine ways in which the governments have dealt with various trade-offs to determine the health and public policies. In this paper, we outline key economic principles for the government to consider for policymaking, during, and after the COVID-19 pandemic. The pandemic rightfully places long due attention of policymakers for investing in health sector. The policy entrepreneurs and public health community should not miss this once-in-a-lifetime "policy window" to raise the level of advocacy for appropriate investment in health sector.

Protocol for a systematic review of reviews evaluating effectiveness of mass media interventions for prevention and control of non-communicable diseases

INTRODUCTION

Timely interventions are required in order to change unhealthy lifestyles because if continued for a prolonged period of time, these become risk factors for non-communicable diseases (NCDs). Education through mass media is an important factor in bringing out the behavioural change which may get missed in community-based interventions due to their limited reach. Many countries engage in mass media interventions, however, the nature of interventions and their effectiveness differs. We, therefore, describe the protocol of a systematic review to evaluate the effectiveness of the mass media interventions to reduce the risk of NCDs in the general population and compare the differences in effectiveness estimates across low/middle-income countries and developed countries.

METHODS AND ANALYSIS

We will search The Cochrane Library, Database of Abstracts of Reviews of Effectiveness, PubMed, Excerpta Medica Database limited to publications since 2000 to October 2019. Specific terms for the search strategy will be piloted as database-controlled vocabulary in the databases searched. The searches will include variations of the following terms: mass media, mass communication, campaign, publicity and terms for types of media, that is, print media, mobile, digital media, social media and broadcast. Study designs to be included will be systematic reviews followed by grey literature and other good quality reviews identified. The primary outcome of effectiveness will be the percentage change in population having different behavioural risk factors. In addition, mean overall change in levels of several physical or biochemical parameters will be studied as secondary outcomes.

ETHICS AND DISSEMINATION

The review is being done under the doctoral research which has been approved by the Institute Ethics Committee of the Post Graduate Institute of Medical Education and Research Dissemination will be done by submitting scientific articles to academic peer-reviewed journals. We will present the results at relevant conferences and meetings.

PROSPERO REGISTRATION NUMBER

CRD42016048013.

Cost of Delivering Secondary Healthcare Through the Public Sector in India

BACKGROUND

Government spending on provision of secondary healthcare has increased four-fold (in real terms) over the last decade in India. The evidence on the cost of secondary care to the health system is limited. The present study estimates the total and unit cost of services at community health centres (CHCs) and district hospitals (DHs) across India.

METHODS

The present study was undertaken in 19 CHCs and ten DHs across the four Indian states of Himachal Pradesh, Tamil Nadu, Kerala and Odisha to assess the economic cost of health services using a bottom-up methodology. Data on annual consumption of both capital and recurrent resources, spent in the provision of health services during the financial year of 2014-2015, were collected. Capital expenditure was annualised and shared resources were allocated to each of the shared activities using appropriate statistics.

RESULTS

The mean annual costs of providing services at the CHC and DH level were 17 million Indian rupees (₹) ($US0.27 million) and ₹147 million ($US2.3 million), respectively. More than half of this annual cost was attributed to salaries (57% and 62% for CHC and DH level, respectively) and curative care (60% and 65%, respectively). At CHCs, the unit cost ranged from ₹134 (95% confidence interval [CI] 104-160) for an outpatient consultation to ₹3833 (95% CI 2668-5839) for institutional delivery. Similarly, at DH level, the unit cost varied from ₹183 (95% CI 124-248) for an outpatient consultation in an orthopaedics department to ₹4764 (95% CI 3268-6960) for an operation.

CONCLUSION

The estimates from the present study may help generate benchmarks to aid in setting up provider payment rates and be used in future economic evaluations.

Cost-Effectiveness of Therapeutic Use of Safety-Engineered Syringes in Healthcare Facilities in India

BACKGROUND

Globally, 16 billion injections are administered each year of which 95% are for curative care. India contributes 25-30% of the global injection load. Over 63% of these injections are reportedly unsafe or deemed unnecessary.

OBJECTIVES

To assess the incremental cost per quality-adjusted life-year (QALY) gained with the introduction of safety-engineered syringes (SES) as compared to disposable syringes for therapeutic care in India.

METHODS

A decision tree was used to compute the volume of needle-stick injuries (NSIs) and reuse episodes among healthcare professionals and the patient population. Subsequently, three separate Markov models were used to compute lifetime costs and QALYs for individuals infected with hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Three SES were evaluated-reuse prevention syringe (RUP), sharp injury prevention (SIP) syringe, and syringes with features of both RUP and SIP. A lifetime study horizon starting from a base year of 2017 was considered appropriate to cover all costs and consequences comprehensively. A systematic review was undertaken to assess the SES effects in terms of reduction in NSIs and reuse episodes. These were then modelled in terms of reduction in transmission of blood-borne infections, life-years and QALYs gained. Future costs and consequences were discounted at the rate of 3%. Incremental cost per QALY gained was computed to assess the cost-effectiveness. A probabilistic sensitivity analysis was undertaken to account for parameter uncertainties.

RESULTS

The introduction of RUP, SIP and RUP + SIP syringes in India is estimated to incur an incremental cost of Indian National Rupee (INR) 61,028 (US$939), INR 7,768,215 (US$119,511) and INR 196,135 (US$3017) per QALY gained, respectively. A total of 96,296 HBV, 44,082 HCV and 5632 HIV deaths are estimated to be averted due to RUP in 20 years. RUP has an 84% probability to be cost-effective at a threshold of per capita gross domestic product (GDP). The RUP syringe can become cost saving at a unit price of INR 1.9. Similarly, SIP and RUP + SIP syringes can be cost-effective at a unit price of less than INR 1.2 and INR 5.9, respectively.

CONCLUSION

RUP syringes are estimated to be cost-effective in the Indian context. SIP and RUP + SIP syringes are not cost-effective at the current unit prices. Efforts should be made to bring down the price of SES to improve its cost-effectiveness.

Process evaluation of health system costing - Experience from CHSI study in India

Background

A national study, ‘Costing of healthcare services in India’ (CHSI) aimed at generating reliable healthcare cost estimates for health technology assessment and price-setting is being undertaken in India. CHSI sampled 52 public and 40 private hospitals in 13 states and used a mixed micro-costing approach. This paper aims to outline the process, challenges and critical lessons of cost data collection to feed methodological and quality improvement of data collection.

Methods

An exploratory survey with 3 components–an online semi-structured questionnaire, group discussion and review of monitoring data, was conducted amongst CHSI data collection teams. There were qualitative and quantitative components. Difficulty in obtaining individual data was rated on a Likert scale.

Results

Mean time taken to complete cost data collection in one department/speciality was 7.86(±0.51) months, majority of which was spent on data entry and data issues resolution. Data collection was most difficult for determination of equipment usage (mean difficulty score 6.59±0.52), consumables prices (6.09±0.58), equipment price(6.05±0.72), and furniture price(5.64±0.68). Human resources, drugs & consumables contributed to 78% of total cost and 31% of data collection time. However, furniture, overheads and equipment consumed 51% of time contributing only 9% of total cost. Seeking multiple permissions, absence of electronic records, multiple sources of data were key challenges causing delays.

Conclusions

Micro-costing is time and resource intensive. Addressing key issues prior to data collection would ease the process of data collection, improve quality of estimates and aid priority setting. Electronic health records and availability of national cost data base would facilitate conducting costing studies.

Cost Effectiveness of Trastuzumab for Management of Breast Cancer in India

PURPOSE

We undertook this study to evaluate the incremental cost per quality-adjusted life-year (QALY) gained with use of adjuvant trastuzumab as compared with chemotherapy alone among patients with nonmetastatic breast cancer in India.

METHODS

We used a Markov model to estimate the incremental cost of using trastuzumab (for 1 year, 6 months, or 9 weeks) as compared with chemotherapy alone using a societal perspective, excluding indirect productivity losses. Although the outcomes (QALYs) in the standard chemotherapy arm were estimated after calibrating the model as per survival data from 2 Indian cancer registries, effectiveness estimates from the HERA trial and a joint analysis of the NSABP B-31 and NCCTG N9831 trials were used to estimate the consequences of 1-year trastuzumab use. The cost of treatment was estimated using national standard treatment guidelines and real-world use estimates for different treatment modalities as per data from Indian cancer registries. Probabilistic sensitivity analysis was undertaken to evaluate parameter uncertainty.

RESULTS

For 1 year of trastuzumab use, the incremental benefit per patient, incremental cost per QALY gained, and probability of being cost effective using HERA trial estimates were 1.29 QALYs, 178,877 Indian national rupees (INRs; US$2,558), and 4%, respectively, whereas the corresponding figures using joint analysis estimates were 1.69 QALYs, INR 134,413 (US$1,922), and 57.3%, respectively.

CONCLUSION

Use of trastuzumab for 1 year is not cost effective in India at the current price. However, trastuzumab use for 9 weeks is cost effective and should be included in clinical guidelines and reimbursement policies. A price reduction of 15% to 35% increases the probability of 1-year trastuzumab use being cost effective, to 90%.

Cost-Effectiveness Analysis and Decision Modelling: A Tutorial for Clinicians

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.

Geographic Inequities in Coverage of Maternal and Child health Services in Haryana State of India

Introduction India aims to achieve universal health coverage, with a focus on equitable delivery of services. There is significant evidence on extent of inequities by income status, gender and caste. In this paper, we report geographic inequities in coverage of reproductive, maternal and child health (MCH) services in Haryana state of India. Methods Cross-sectional data on utilization of maternal, child health and family planning services were collected from 12,191 women who had delivered a child in the last one year, 10314 women with 12-23 months old child, and 45864 eligible couples across all districts in Haryana state. Service coverage was assessed based on eight indicators - 6 for maternal health, one for child health and one for family planning. Inter- and intra-district inequalities were compared based on four and three indicators respectively. Results Difference in coverage of full ante-natal care, full immunization and contraceptive prevalence rate between districts performing best and worst was found to be 54%, 65% and 63% respectively. More than one-thirds of the sub-centres (SCs) in Panchkula, Ambala, Gurgaon and Mewat districts had their ante-natal care coverage less than 50% of the respective district average. Similarly, a significant proportion of SCs in Mewat, Panipat and Hisar districts had full immunization rate below 50% of the district average. Conclusion Widespread inter- and intra-district inequities in utilization of MCH services exist. A comprehensive geographical targeting to identify poor performing districts, community development blocks and SCs could result in significant equity gains, besides contributing to quick achievement of sustainable development goals.

Out-of-pocket expenditure and catastrophic health expenditure for hospitalization due to injuries in public sector hospitals in North India

Background

Injuries are a major public health problem, resulting in high health care demand and economic burden. They result in loss of disability adjusted life years (DALYs) and high out-of-pocket expenditure. However, there is little evidence on the economic burden of injuries in India. We undertook this study to report out-of-pocket expenditure and the prevalence of catastrophic health expenditure for injuries related hospitalizations in public sector hospitals in North India. Further, we also evaluate the determinants of catastrophic health expenditure.

Methods and analysis

A prospective observational study was conducted. Participants were recruited from three hospitals for all injury cases. Data were collected via face-to-face baseline interviews and follow-up interviews over the phone at 1, 2, 4 and 12 months post-injury. Prevalence of catastrophic health expenditure (more than 30% of consumption expenditure) and impoverishment (International dollar 1.90) were estimated.

Results

Road traffic injuries (57%) were the leading cause of injury. Direct out-of-pocket expenditure for hospitalizations was INR 16,768 (USD 263) while indirect productivity loss was INR 8,164 (USD 128). The prevalence of catastrophic expenditure was 22.2% with 12.2% slipping below poverty line. Prevalence of catastrophic health expenditure and impoverishment was higher and significantly associated with poorest quintile, tertiary care hospital and increased duration of hospitalization (p< 0.001).

Conclusion

The economic impact of injuries is notably high both in terms of out-of-pocket expenditure and productivity loss. A high proportion of households experienced catastrophic expenditure and impoverishment following an injury, highlighting need for programs to prevent injuries.

Study to Test and Operationalize Preventive Approaches for CKD of Undetermined Etiology in Andhra Pradesh, India

INTRODUCTION

High prevalence of chronic kidney disease (CKD) not associated with known risk factors has been reported from coastal districts of Andhra Pradesh. The Study to Test and Operationalize Preventive Approaches for Chronic Kidney Disease of Undetermined Etiology in Andhra Pradesh (STOP CKDu AP) aims to ascertain the burden (prevalence and incidence) of CKD, the risk factor profile, and the community perceptions about the disease in the Uddanam area of Andhra Pradesh.

METHODS

Study participants will be sampled from the Uddanam area using multistage cluster random sampling. Information will be collected on the demographic profile, occupational history, and presence of conventional as well as nonconventional risk factors. Glomerular filtration rate (GFR) will be estimated using the Chronic Kidney Disease Epidemiology Collaboration equation, and proteinuria will be measured. All abnormal values will be confirmed by repeat testing after 3 months. Cases of CKD not associated with identified etiologies will be identified. Biospecimens will be stored to explore future hypotheses. The entire cohort will be followed up every 6 months to determine the incidence of CKD and to identify risk factors for decline in kidney function. Qualitative studies will be performed to understand the community perceptions and expectations with respect to the interventions.

IMPLICATIONS

CKD is an important public health challenge in low- and middle-income countries. This study will establish the prevalence and determine the incidence of CKD not associated with known risk factors in a reported high-burden region, and will provide insights to help design targeted health systems responses. The findings will contribute to the policy development to tackle CKD in the region and will permit international comparisons with other regions with similar high prevalence.

Cost of Treatment of Valvular Heart Disease at a Tertiary Hospital in North India: Policy Implications

BACKGROUND

Lack of data on the cost of cardiac care is an impediment to evidence-based planning, especially for determining provider payment rates under publically financed health insurance schemes.

OBJECTIVE

This study estimates the unit costs of outpatient consultation, hospitalization, intensive care, selected surgical procedures and diagnostics for providing cardiac care for valvular heart disease at a tertiary hospital in India.

METHODS

We undertook an economic costing of cardiac care using both patient and health system perspectives. For the health system costs, a bottom-up costing methodology was used. Data on all resources (capital and recurrent) utilized for the delivery of cardiac care services for valvular heart disease for 1 year were collected. Data on out-of-pocket expenditures was collected from 100 cardiac patients who underwent valve replacement and balloon valvotomy procedures. All estimated costs represent the year 2016-2017.

RESULTS

The health system cost of an outpatient cardiac consultation was estimated as 182.4 Indian rupees (INR) (US$2.8) and INR334.8 (US$5.2) in the cardiology, and cardio-thoracic and vascular surgery (CTVS) departments, respectively. The cost of hospitalization per bed-day in cardiology, CTVS and the intensive care unit (ICU) was INR1040 (US$16), INR3853 (US$60) and INR12,635 (US$197), respectively. The median out-of-pocket expenditure for valve replacement surgery using mechanical and bio-prosthetic valves was estimated to be INR107,800 (US$1684) and INR154,000 (US$2406), respectively, and for balloon valvotomy was estimated to be INR14,456 (US$367). Overall package cost per mechanical and bio-prosthetic single valve replacement surgery and balloon valvotomy procedure was estimated as INR127,919 (US$1999), INR148,919 (US$2372) and INR14,456 (US$226), respectively.

CONCLUSION

Our findings are useful for planning expansion of public sector cardiac care services, developing package rates for publically financed insurance schemes in India and for undertaking research on cost effectiveness of various models of cardiac care.

Real-world cost-effectiveness of pan-genotypic Sofosbuvir-Velpatasvir combination versus genotype dependent directly acting anti-viral drugs for treatment of hepatitis C patients in the universal coverage scheme of Punjab state in India

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.

Comprehensive measurement of health system performance at district level in India: Generation of a composite index

There have been limited attempts at measurement of health system performance at decentralized levels in low- and middle-income countries. This study was undertaken to develop a composite indicator to measure health system performance at district level in India. Primary data were collected from 377 public health facilities in 21 districts of Haryana state in India using health facility surveys. In addition, 1700 health care providers and 800 clients visiting health facilities were interviewed. Routine health management information system data at district and state level were also analyzed. These data were used for computing 67 input and process indicators covering six health system building blocks. Indicators were normalized and aggregated to generate domain-specific and overall composite health system performance index (HSPI) for each district. Several sensitivity analyses were performed to assess robustness of results. Overall, Panchkula and Ambala districts were found to be the best performing in the state (with HSPI scores of 0.64 and 0.62 out of 1), while Mewat, Faridabad, and Palwal districts had the poorest performance (with HSPI scores of 0.46, 0.49, and 0.48 out of 1). Significant variation in performance was observed for each health system building block. Sensitivity analyses results showed that study findings were robust to variations in methods of aggregation of indicators. Our study provides a framework and methods to measure health system performance at district level in a comprehensive manner. The composite indicator provides a summary snapshot to benchmark performance, while building block and domain scores provide critical information for programmatic action.

Primary health care financing interventions: a systematic review and stakeholder-driven research agenda for the Asia-Pacific region

INTRODUCTION

Interventions targeting the financing of primary health care (PHC) systems could accelerate progress towards universal health coverage; however, there is limited evidence to guide best-practice implementation of these interventions. This study aimed to generate a stakeholder-led research agenda in the area of PHC financing interventions in the Asia-Pacific region.

METHODS

We adopted a two-stage process: (1) a systematic review of financing interventions targeting PHC service delivery in the Asia-Pacific region was conducted to develop an evidence gap map and (2) an electronic-Delphi (e-Delphi) exercise with key national PHC stakeholders was undertaken to prioritise these evidence needs.

RESULTS

Thirty-one peer-reviewed articles (including 10 systematic reviews) and 10 grey literature reports were included in the review. There was limited consistency in results across studies but there was evidence that some interventions (removal of user fees, ownership models of providers and contracting arrangements) could impact PHC service access, efficiency and out-of-pocket cost outcomes. The e-Delphi exercise highlighted the importance of contextual factors and prioritised research in the areas of: (1) interventions to limit out-of-pocket costs; (2) financing models to enhance health system performance and maintain PHC budgets; (3) the design of incentives to promote optimal care without unintended consequences and (4) the comparative effectiveness of different PHC service delivery strategies using local data.

CONCLUSION

The research questions which were deemed most important by stakeholders are not addressed in the literature. There is a need for more research on how financing interventions can be implemented at scale across health systems. Such research needs to be pragmatic and balance academic rigour with practical considerations.

Cost analysis of a simulation-based training for health workforce in India

BACKGROUND

Training of health-care workforce including doctors, staff nurses, and Auxiliary Nurse Midwives using simulation techniques for skill enhancement have been used in a variety of clinical settings to improve the quality of training. India adopted the skills laboratories model for capacity building of health workers in maternal and child health in Bihar state.

OBJECTIVE

Current economic evaluation was performed with the objective of assessing the financial and economic cost of implementing skills laboratories.

METHODS

Data on all resources spent for the development of skill laboratory and implementing training during financial year 2011 were collected from Patna district in Bihar state. We used standard methods to estimate the full financial and economic costs of implementing the skills laboratories from a health system perspective.

RESULTS

Overall cost of implementing 20 permanent and 10 mobile skills laboratory training in Bihar was Indian Rupee (INR) 8849895 from a financial perspective. The cost was nearly two times higher when using an economic perspective to account for opportunity cost of all resources used. The unit cost of training a participant using permanent and mobile laboratory was INR 6856 and INR 7474, respectively assuming an annual volume of 90 training. The optimum number of training which should be operated annually in a skills laboratory to make it most efficient is about 70-80 training per annum.

CONCLUSIONS

Economic implications of skills laboratory organization should be borne while planning scale up in Bihar and other states. Further research on the effectiveness of two models of skill laboratory, that is, permanent and mobile and their cost is recommended.

Mortality and health-related quality of life following injuries and associated factors: a cohort study in Chandigarh, North India

INTRODUCTION

Injuries are among the 10 leading causes of deaths worldwide. In recent years, the quality and reporting of injury mortality has improved but little or no data are available on the morbidity burden and impact of non-fatal injuries in India. This study evaluates health recovery status postinjury, identifying predictors of recovery in North India.

METHODS

Prospective cohort study recruiting patients from one tertiary-level and two secondary-level hospitals in North India between April and June 2014 hospitalised due to any injury. Health-related quality of life was assessed at baseline and at 1-month, 2-month, 4-month and 12-month postinjury using the EuroQol five-dimensional (EQ-5D-5L) questionnaire. Multivariable linear regressions with generalised estimating equations were used to examine the relationship between sociodemographic and injury-related factors with the EQ-5D-5L single utility score and the visual analogue scale (VAS) score.

RESULTS

A total of 2416 eligible patients aged ≥18 years were enrolled in the study. Of these, 2150 (74%) completed baseline and all four follow-up EQ-5D-5L questionnaires. Almost 7% (n=172) patients died by the first follow-up and the overall mortality at 12 months was 9% (n=176). Both EQ-5D-5L utility and VAS scores dropped significantly at 1-month postinjury but gradually improved at 2, 4 and 12 months. Severe injuries, defined as those requiring a hospital stay of ≥7 days, were associated with lower utility scores at 1-month, 2-month and 4-month follow-ups (p<0.001).

CONCLUSION

This is the first study to examine health outcomes following injuries in India. The findings highlight the need to understand the social, psychological and biological factors influencing recovery outcomes. High mortality following discharge emphasises the need to invest in secondary and tertiary injury prevention in India.

Cost of antiretroviral treatment for HIV patients in two centres of North India

There is paucity of evidence on cost of antiretroviral therapy (ART) delivered through the public sector in India. Moreover, the Government of India is considering changing the criteria for introduction of ART to HIV patients, which is likely to have significant economic implications. In this paper, we assess the health system cost of ART services at two levels of health care delivery. Bottom-up costing was used to collect data on capital and recurrent resources consumed over a period of one year (April 2014–March 2015). Capital costs were annualized and shared costs apportioned to calculate annual and unit costs of providing ART care. Sensitivity analysis was undertaken to measure the extent of uncertainty in input prices. The annual per capita cost of ART therapy was INR 48,975 (USD738) in the Centre of Excellence (COE) and INR 24,954 (USD376) in the ART centre. Drugs contributed around 70% and 65% of total annual cost, followed by human resource (19% each) and capital cost (7%; 12%) in COE and ART centres, respectively. These provide a comprehensive assessment of the cost of ART care in India. The study estimates could be used for planning of services, as well as undertaking further cost-effectiveness studies.