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Rao KD, Mehta A, Noonan C, Peters MA, Perry H. Voting with their feet: Primary care provider choice and its implications for public sector primary care services in India. Soc Sci Med 2024; 340:116414. [PMID: 38039764 PMCID: PMC10828545 DOI: 10.1016/j.socscimed.2023.116414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/26/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023]
Abstract
Expanding networks of government primary health centers (PHCs) to bring health services closer to communities is a longstanding policy objective in LMICs. In pluralistic health systems, where public and private providers compete for patients, PHCs are often not the preferred source for care. This study analyzes the market for primary care services in the Indian state of Bihar to understand how choice of primary care provider is influenced by distance, cost and quality of care. This study is based on linked surveys of rural households, PHCs, and private primary care providers conducted in 2019 and 2020. Most rural residents lived in proximity to a primary care provider, though not a qualified one. Within a 5-km distance, 60% of villages had a PHC, 90% had an informal provider, 35% an Indian systems of medicine practitioner, and 10% a private MBBS doctor. Most patients sought care from informal providers irrespective of PHC distance; only 25% of patients living in the PHC's vicinity sought care there. Reducing distance to the PHC by 1 km marginally increased the likehood of the PHC being selected, and reduced the likelihood of private clinics being selected. Reducing patient's costs at PHCs increased the likelihood of the PHC being selected and reduced the likelihood of private clinics and private hospitals being selected. Improved clinical quality at PHCs had no effect on patient selection of PHCs, private clinics, or hospitals. Illness severity reduced the likelihood of PHCs or private clinics being selected, and increased the likelihood of private hospitals selected. Wealthier patients were marginally more likely to use PHCs, substantially more likely to use private hospitals, and less likely to use private clinics. Expanding PHC network coverage or improving their quality of care is not sufficient to make PHCs more relevant to local health needs. An orientation towards essential public health functions, as well as, a community-centered approach to the organization of primary health care system is necessary.
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Affiliation(s)
- Krishna D Rao
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Akriti Mehta
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Caitlin Noonan
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Michael A Peters
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Henry Perry
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA.
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Rao KD, Mehta A, Kautsar H, Kak M, Karem G, Misra M, Joshi H, Herbst CH, Perry HB. Improving quality of non-communicable disease services at primary care facilities in middle-income countries: A scoping review. Soc Sci Med 2023; 320:115679. [PMID: 36731302 DOI: 10.1016/j.socscimed.2023.115679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/02/2022] [Accepted: 01/13/2023] [Indexed: 01/22/2023]
Abstract
Health systems in middle-income countries face important challenges in managing the high burden of Non-Communicable Diseases (NCD). Primary health care is widely recognized as key to managing NCDs in communities. However, the effectiveness of this approach is limited by poor quality of care (QoC), among others. This scoping review identifies the types of interventions that have been used in middle-income countries to improve the quality of NCD services at primary care facilities. Further, it identifies the range of outcomes these quality interventions have influenced. This scoping review covered both the grey and peer-reviewed literature. The 149 articles reviewed were classified into four domains - governance, service-delivery systems, health workforce, and patients and communities. There was a remarkable unevenness in the geographic distribution of studies - lower middle-income countries and some regions (Middle East, North Africa, and South East Asia) had a scarcity of published studies. NCDs such as stroke and cardiovascular disease, mental health, cancer, and respiratory disorders received less attention. The thrust of quality interventions was directed at the practice of NCD care by clinicians, facilities, or patients. Few studies provided evidence from interventions at the organizations or policy levels. Overall, effectiveness of quality interventions was mixed across domains. In general, positive or mixed effects on provider clinical skills and behavior, as well as, improvements in patient outcomes were found across interventions. Access to care and coverage of screening services were positively influenced by the interventions reviewed. This review shows that quality improvement interventions tried in middle-income countries mostly focused at the provider and facility level, with few focusing on the organizational and policy level. There is a need to further study the effectiveness of organizational and policy level interventions on the practice and outcomes of NCD care.
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Affiliation(s)
- Krishna D Rao
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Akriti Mehta
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Hunied Kautsar
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | | | - Madhavi Misra
- Johns Hopkins India Private Limited, New Delhi, India
| | - Harsha Joshi
- Johns Hopkins India Private Limited, New Delhi, India
| | | | - Henry B Perry
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Moran AE, Farrell M, Cazabon D, Sahoo SK, Mugrditchian D, Pidugu A, Chivardi C, Walbaum M, Alemayehu S, Isaranuwatchai W, Ankurawaranon C, Choudhury SR, Pickersgill SJ, Watkins DA, Husain MJ, Rao KD, Matsushita K, Marklund M, Hutchinson B, Nugent R, Kostova D, Garg R. Building the health-economic case for scaling up the WHO-HEARTS hypertension control package in low- and middle-income countries. Rev Panam Salud Publica 2022; 46:e140. [PMID: 36071923 PMCID: PMC9440739 DOI: 10.26633/rpsp.2022.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/11/2022] [Indexed: 11/24/2022] Open
Abstract
ABSTRACT
Generally, hypertension control programs are cost-effective, including in low- and middle-income countries, but country governments and civil society are not likely to support hypertension control programs unless value is demonstrated in terms of public health benefits, budget impact, and value-for-investment for the individual country context. The World Health Organization (WHO) and the Pan American Health Organization (PAHO) established a standard, simplified Global HEARTS approach to hypertension control, including preferred antihypertensive medicines and blood pressure measurement devices. The objective of this study is to report on health economic studies of HEARTS hypertension control package cost (especially medication costs), cost-effectiveness, and budget impact and describe mathematical models designed to translate hypertension control program data into the optimal approach to hypertension care service delivery and financing, especially in low- and middle-income countries. Early results suggest that HEARTS hypertension control interventions are either cost-saving or cost-effective, that the HEARTS package is affordable at between US$ 18-44 per person treated per year, and that antihypertensive medicines could be priced low enough to reach a global standard of an average <US$ 5 per patient per year in the public sector. This health economic evidence will make a compelling case for government ownership and financial support for national scale hypertension control programs.
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Affiliation(s)
- Andrew E. Moran
- Resolve to Save Lives, New York, United States of America
- Columbia University Irving Medical Center, New York, United States of America
| | | | | | | | | | - Anirudh Pidugu
- Columbia University Irving Medical Center, New York, United States of America
| | - Carlos Chivardi
- Center for Health Economics, University of York, York, United Kingdom
| | | | | | - Wanrudee Isaranuwatchai
- Health Intervention and Technology Assessment Program, Ministry of Public Health of Thailand, Bangkok, Thailand
| | | | | | | | | | - Muhammad Jami Husain
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, United States of America
| | - Krishna D. Rao
- Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Kunihiro Matsushita
- Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Matti Marklund
- Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Brian Hutchinson
- Center for Global Noncommunicable Diseases, RTI International, Seattle, United States of America
| | - Rachel Nugent
- Center for Global Noncommunicable Diseases, RTI International, Seattle, United States of America
| | - Deliana Kostova
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, United States of America
| | - Renu Garg
- Resolve to Save Lives, New York, United States of America
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Peters MA, Noonan CM, Rao KD, Edward A, Alonge OO. Evidence for an expanded hypertension care cascade in low- and middle-income countries: a scoping review. BMC Health Serv Res 2022; 22:827. [PMID: 35761254 PMCID: PMC9235242 DOI: 10.1186/s12913-022-08190-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 06/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background With nearly 90% of annual hypertension-related deaths occurring in low- and middle-income countries (LMICs), there is an urgent need to measure the coverage of health services that effectively manage hypertension. However, there is little agreement on how to define effective coverage and the existing hypertension care cascade (hypertension prevalence, percent aware, percent treated, and percent controlled) does not account for the quality of care received by patients. This study reviews definitions of effective coverage and service quality for hypertension management services and proposes an expanded hypertension care cascade to improve measurement of health systems performance. Methods A systematic scoping review of literature published in six electronic databases between January 2000 and October 2020 identified studies that defined effective coverage of hypertension management services or integrated dimensions of service quality into population-based estimates of hypertension management in LMICs. Findings informed an expanded hypertension care cascade from which quality-adjusted service coverage can be calculated to approximate effective coverage. Results The review identified 18 relevant studies, including 6 that defined effective coverage for hypertension management services and 12 that reported a measure of service quality in a population-based study. Based on commonly reported barriers to hypertension management, new steps on the proposed expanded care cascade include (i) population screened, (ii) population linked to quality care, and (iii) population adhering to prescribed treatment. Conclusion There is little consensus on the definition of effective coverage of hypertension management services, and most studies do not describe the quality of hypertension management services provided to populations. Incorporating aspects of service quality to the hypertension care cascade allows for the calculation of quality-adjusted coverage of relevant services, enabling an appropriate measurement of health systems performance through effective coverage. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08190-0.
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Affiliation(s)
- Michael A Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Caitlin M Noonan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Anbrasi Edward
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Olakunle O Alonge
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Abstract
INTRODUCTION In response to the ongoing COVID-19 pandemic, countries have adopted various degrees of restrictive measures on people to reduce COVID-19 transmission. These measures have had significant social and economic costs. In the absence of therapeutics, and low vaccination coverage, strategies for a safe exit plan from a lockdown are required to mitigate the transmission and simultaneously re-open societies. Most countries have outlined or have implemented lockdown exit plans. The objective of this scoping review is to (a) identify and map the different strategies for exit from lockdowns, (b) document the effects of these exit strategies, and (c) discuss features of successful exit strategies based on the evidence. METHODS A five-step approach was used in this scoping review: (a) identifying the research question and inclusion/exclusion criteria; (b) searching the literature using keywords within PubMed and WHO databases; (c) study selection; (d) data extraction; (e) collating results and qualitative synthesis of findings. RESULTS Of the 406 unique studies found, 107 were kept for full-text review. Studies suggest the post-peak period as optimal timing for an exit, supplemented by other triggers such as sufficient health system capacity, and increased testing rate. A controlled and step-wise exit plan which is flexible and guided by information from surveillance systems is optimal. Studies recommend continued use of non-pharmaceutical interventions such as physical distancing, use of facemasks, and hygiene measures, in different combinations when exiting from a lockdown, even after optimal vaccination coverage has been attained. CONCLUSION Reviewed studies have suggested adopting a multi-pronged strategy consisting of different approaches depending on the context. Among the different exit strategies reviewed (phase-wise exit, hard exit, and constant cyclic patterns of lockdown), phase-wise exit appears to be the optimal exit strategy.
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Affiliation(s)
- Madhavi Misra
- Johns Hopkins India Private Ltd, Flat 57, India International Centre, 40, Max Muller Marg, New Delhi, 110003, India.
| | - Harsha Joshi
- Johns Hopkins India Private Ltd, Flat 57, India International Centre, 40, Max Muller Marg, New Delhi, 110003, India
| | - Rakesh Sarwal
- National Institution for Transforming India Aayog, Delhi, India
| | - Krishna D Rao
- Johns Hopkins School of Public Health, Johns Hopkins University, Baltimore, USA
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Peters MA, Alonge O, Edward A, Commodore-Mensah Y, Kaur J, Kumar N, Rao KD. Barriers to effective hypertension management in rural Bihar, India: A cross-sectional, linked supply- and demand-side study. PLOS Glob Public Health 2022; 2:e0000513. [PMID: 36962585 PMCID: PMC10021531 DOI: 10.1371/journal.pgph.0000513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 09/13/2022] [Indexed: 11/07/2022]
Abstract
Effective management of hypertension in low- and middle-income settings is a persistent public health challenge. This study examined supply- and demand-side barriers to receiving quality care and achieving effective hypertension management in rural Bihar, India. A state-representative household survey collected information from adults over 30 years of age on characteristics of the hypertension screening, diagnosis, and management services they received. A linked provider assessment determined the percent of providers who provided quality hypertension care (i.e., had a functioning BP measurement device, measured a patient's BP, could correctly diagnose hypertension, had at least one first-line antihypertension medication, and could prescribe correctly based on standard guidelines). Patients were linked with their provider to determine the quality-adjusted coverage of hypertension management and logistic regression analysis was conducted to determine characteristics associated with receiving quality care. A total of 14,386 patients and 390 providers were studied. Nearly a quarter (22.5%) of adults had never had their BP measured before and 8.1% of adults reported a previous hypertension diagnosis. Less than one third (31.0%) of all interviewed providers demonstrated ability to provide quality hypertension care, and quality varied between provider types (14.8% of private homeopathic, 25.2% of informal, 40.0% of private modern medicine, and 60.0% of public providers gave quality care). While 95.8% of diagnosed individuals received some treatment, only 10.9% of patients received care from quality local providers. Nearly 45% of individuals with hypertension received care from non-local providers. Individuals from the general caste with comorbidities living in villages with more high-quality providers were most likely to receive quality care from a local provider. Whereas the coverage of services for individuals diagnosed with hypertension is high, the quality of these services is suboptimal for economically and socially vulnerable populations, which limits effective management and control of hypertension in rural Bihar. Efforts should be targeted towards providers to initiate quality treatment upon diagnosis, including correct prescription of antihypertensives.
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Affiliation(s)
- Michael A Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Olakunle Alonge
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Anbrasi Edward
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | | - Japneet Kaur
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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Hasan MZ, Story WT, Bishai DM, Ahuja A, Rao KD, Gupta S. Does social capital increase healthcare financing's projection? Results from the rural household of Uttar Pradesh, India. SSM Popul Health 2021; 15:100901. [PMID: 34466652 PMCID: PMC8383105 DOI: 10.1016/j.ssmph.2021.100901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/23/2021] [Accepted: 08/19/2021] [Indexed: 11/19/2022] Open
Abstract
In the absence of adequate social security, out-of-pocket health expenditure compels households to adopt coping strategies, such as utilizing savings, selling assets, or acquiring external financial support (EFS) by borrowing with interest. Households' probability of acquiring EFS and its amount (intensity) depends on its social capital – the nature of social relationships and resources embedded within social networks. This study examines the effect of social capital on the probability and intensity of EFS during health events in Uttar Pradesh (UP), India. The analysis used data from a cross-sectional survey of 6218 households, reporting 3066 healthcare events, from two districts of UP. Household heads (HH) reported demographic, socioeconomic, and health-related information, including EFS, for each household member. Self-reported data from Shortened and Adapted Social Capital Assessment Tool in India (SASCAT-I) was used to generate four unique social capital measures (organizational participation, social support, trust, and social cohesion) at HH and community-level, using multilevel confirmatory factor analysis. After descriptive analysis, two-part mixed-effect models were implemented to estimate the probability and intensity of EFS as a function of social capital measures, where multilevel mixed-effects probit regression was used as the first-part and multilevel mixed-effects linear model with log link and gamma distribution as the second-part. Controlling for all covariates, the probability of acquiring EFS significantly increased (p = 0.04) with higher social support of the HH and significantly decreased (p = 0.02) with higher community social cohesion. Conditional to receiving any EFS, higher social trust of the HH resulted in higher intensity of EFS (p = 0.09). Social support and trust may enable households to cope up with financial stress. However, controlling for the other dimensions of social capital, high cohesiveness with the community might restrict a household's access to external resources demonstrating the unintended effect of social capital exerted by formal or informal social control. Social support assists household head to acquire external financing for healthcare payment. But higher social support may not secure higher intensity of receiving external financing. However, trust is a catalyst to acquire more financing conditional of any external financing was acquire in the first place. Living in a cohesive community may restrict access to external financial resources.
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Affiliation(s)
- Md Zabir Hasan
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Corresponding author. 2206 E Mall, Vancouver, BC V6T 1Z3, Canada.
| | - William T. Story
- Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, USA
| | - David M. Bishai
- Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Krishna D. Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shivam Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Patenaude B, Rao KD, Peters DH. An Empirical Examination of the Inequality of Forgone Care in India. Health Syst Reform 2021; 7:e1894761. [PMID: 34464230 DOI: 10.1080/23288604.2021.1894761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Understanding how well a health system is meeting the needs of the population is critical to achieving the policy aspirations of universal health coverage. This study focuses on assessing the inequity of forgone care for priority maternal and child health services across India. We utilize data from the 4th round of the Indian National Family Health Survey (NFHS-4) to examine inequality of forgone care. Our outcomes include forgone institutional delivery, antenatal care, medical care for a child with fever or cough, and medical care for a child with diarrhea. Wagstaff's standardized concentration indices (CIs) are computed at the national level, over urban and rural sub-populations, and by state. Regression decomposition is performed to determine the influence of specific drivers on overall inequality. There was significant variation in the national-level prevalence and CIs for forgone antenatal care (17.8%, CI: -0.423), forgone medical care for a child with fever or cough (32.4%, CI: -0.199), forgone medical care for a child with diarrhea (33.8%, CI: -0.172), and forgone institutional delivery (24.5%, CI: -0.436). For all outcomes, forgone care is disproportionately concentrated among the poor, particularly in rural areas. There is also significant heterogeneity in state-level inequalities. Decomposition analyses show that socioeconomic status, maternal education, rural status, and state-level per capita health spending are the leading drivers of observed inequalities in forgone care. Results suggest attending to both the operation and financing of India's health care system as well as the social determinants that make poor women more likely to forgo maternal health care.
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Affiliation(s)
- Bryan Patenaude
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Rao KD, Kachwaha S, Kaplan A, Bishai D. Not just money: what mothers value in conditional cash transfer programs in India. BMJ Glob Health 2021; 5:bmjgh-2020-003033. [PMID: 33087391 PMCID: PMC7580051 DOI: 10.1136/bmjgh-2020-003033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/20/2020] [Accepted: 09/03/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction Conditional cash transfers (CCTs) have become an important policy tool for increasing demand for key maternal and child health services in low/middle-income countries. Yet, these programs have had variable success in increasing service use. Understanding beneficiary preferences for design features of CCTs can increase program effectiveness. Methods We conducted a Discrete choice experiment in two districts of Uttar Pradesh, India in 2018 with 405 mothers with young children (<3 years). Respondents were asked to choose between hypothetical CCT programme profiles described in terms of five attribute levels (cash, antenatal care visits, growth-monitoring and immunisation visits, visit duration and health benefit received) and responses were analysed using mixed logit regression. Results Mothers most valued the cash transfer amount, followed by the health benefit received from services. Mothers did not have a strong preference for conditionalities related to the number of health centre visits or for time spent seeking care; however, service delivery points were in close proximity to households. Mothers were willing to accept lower cash rewards for better perceived health benefits—they were willing to accept 2854 Indian rupees ($41) less for a programme that produced good health, which is about half the amount currently offered by India’s Maternal Benefits Program. Mothers who had low utilisation of health services, and those from poor households, valued the cash transfer and the health benefit significantly more than others. Conclusion Both cash transfers and the perceived health benefit from services are highly valued, particularly by infrequent service users. In CCTs, this highlights the importance of communicating value of services to beneficiaries by informing about health benefits of services and providing quality care. Conditionalities requiring frequent health centre visits or time taken for seeking care may not have large negative effects on CCT participation in contexts of good service coverage.
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Affiliation(s)
- Krishna D Rao
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shivani Kachwaha
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Avril Kaplan
- International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Bishai
- Family and Population Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Ghazaryan E, Delarmente BA, Garber K, Gross M, Sriudomporn S, Rao KD. Effectiveness of hospital payment reforms in low- and middle-income countries: a systematic review. Health Policy Plan 2021; 36:1344-1356. [PMID: 33954776 DOI: 10.1093/heapol/czab050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/31/2021] [Accepted: 04/15/2021] [Indexed: 01/02/2023] Open
Abstract
Payment mechanisms have attracted substantial research interest because of their consequent effect on care outcomes, including treatment costs, admission and readmission rates and patient satisfaction. Those mechanisms create the incentive environment within which health workers operate and can influence provider behaviour in ways that can facilitate achievement of national health policy goals. This systematic review aims to understand the effects of changes in hospital payment mechanisms introduced in low- and middle-income countries (LMICs) on hospital- and patient-level outcomes. A standardised search of seven databases and a manual search of the grey literature and reference lists of existing reviews were performed to identify relevant articles published between January 2000 and July 2019. We included original studies focused on hospital payment reforms and their effect on hospital and patient outcomes in LMICs. Narrative descriptions or studies focusing only on provider payments or primary care settings were excluded. The authors used the Risk of Bias in Non-Randomized Studies of Interventions tool to assess the risk of bias and quality. Results were synthesized in a narrative description due to methodological heterogeneity. A total of 24 articles from seven middle-income countries were included, the majority of which are from Asia. In most cases, hospital payment reforms included shifts from passive (fee-for-service) to active payment models-the most common being diagnosis-related group payments, capitation and global budget. In general, hospital payment reforms were associated with decreases in hospital expenditures, out-of-pocket payments, length of hospital stay and readmission rates. The majority of the articles scored low on quality due to weak study design. A shift from passive to active hospital payment methods in LMICs has been associated with lower hospital and patient costs as well as increased efficiency without any apparent compromise on quality. However, there is an important need for high-quality studies in this area.
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Affiliation(s)
- Emma Ghazaryan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 W Wolfe St, Baltimore, MD 21205, USA
| | - Benjo A Delarmente
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615 W Wolfe St, Baltimore, MD 21205, USA.,Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, 615 W Wolfe St, Baltimore, MD 21205, USA
| | - Kent Garber
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 W Wolfe St, Baltimore, MD 21205, USA.,Department of Surgery, University of California, 405 Hilgard Ave, Los Angeles, CA 90095, USA
| | - Margaret Gross
- Welch Medical Library, Johns Hopkins School of Medicine, 1900 E Monument St, Baltimore, MD 21205, USA.,William Rand Kenan, Jr. Library of Veterinary Medicine, North Carolina State University, 1060 William Moore Dr., Raleigh, NC 27607, USA
| | - Salin Sriudomporn
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 W Wolfe St, Baltimore, MD 21205, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, 615 W Wolfe St, Baltimore, MD 21205, USA
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 W Wolfe St, Baltimore, MD 21205, USA
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Rao KD, Kaur J, Peters MA, Kumar N, Nanda P. Pandemic response in pluralistic health systems: a cross-sectional study of COVID-19 knowledge and practices among informal and formal primary care providers in Bihar, India. BMJ Open 2021; 11:e047334. [PMID: 33931411 PMCID: PMC8098292 DOI: 10.1136/bmjopen-2020-047334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Responding to pandemics is challenging in pluralistic health systems. This study assesses COVID-19 knowledge and case management of informal providers (IPs), trained practitioners of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) and Bachelor of Medicine, Bachelor of Surgery (MBBS) medical doctors providing primary care services in rural Bihar, India. DESIGN This was a cross-sectional study of primary care providers conducted via telephone between 1 and 15 July 2020. SETTING Primary care providers from 224 villages in 34 districts across Bihar, India. PARTICIPANTS 452 IPs, 57 AYUSH practitioners and 38 doctors (including 23 government doctors) were interviewed from a census of 1138 primary care providers used by community members that could be reached by telephone. PRIMARY OUTCOME MEASURES Providers were interviewed using a structured questionnaire with choice-based answers to gather information on (1) change in patient care seeking, (2) source of COVID-19 information, (3) knowledge on COVID-19 spread, symptoms and methods for prevention and (4) clinical management of COVID-19. RESULTS During the early days of the COVID-19 pandemic, 72% of providers reported a decrease in patient visits. Most IPs and other private primary care providers reported receiving no COVID-19 related engagement with government or civil society agencies. For them, the principal source of COVID-19 information was television and newspapers. IPs had reasonably good knowledge of typical COVID-19 symptoms and prevention, and at levels similar to doctors. However, there was low stated compliance among IPs (16%) and qualified primary care providers (15% of MBBS doctors and 12% of AYUSH practitioners) with all WHO recommended management practices for suspect COVID-19 cases. Nearly half of IPs and other providers intended to treat COVID-19 suspects without referral. CONCLUSIONS Poor management practices of COVID-19 suspects by rural primary care providers weakens government pandemic control efforts. Government action of providing information to IPs, as well as engaging them in contact tracing or public health messaging can strengthen pandemic control efforts.
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Affiliation(s)
- Krishna D Rao
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Japneet Kaur
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Michael A Peters
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Priya Nanda
- Bill and Melinda Gates Foundation India, New Delhi, Delhi, India
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12
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Koon AD, Hoover J, Sonthalia S, Rosser E, Gore A, Rao KD. In-service nurse mentoring in 2020, the year of the nurse and the midwife: learning from Bihar, India. Glob Health Action 2020; 13:1823101. [PMID: 33023408 PMCID: PMC7580717 DOI: 10.1080/16549716.2020.1823101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
In-service nurse mentoring is increasingly seen as a way to strengthen the quality of health care in rural areas, where healthworkers are scarce. Despite this, the evidence base for designing large-scale programs remains relatively thin. In this capacity-building article, we reflect on the limited evidence that exists and introduce features of the world’s largest program, run by CARE-India since 2015. Detail on the mechanics of large-scale programs is often missing from empirical research studies, but is a crucial aspect of organizational learning and development. Moreover, by focusing on the complex ways in which capacity-building is being institutionalized through an embedded model of in-service mentorship, this article bridges research and practice. We point to a number of areas that require further research as well as considerations for program managers designing comparable workforce strengthening programs. With careful planning and cross-national policy learning, we propose that in-service nurse mentoring may offer a cost-effective and appropriate workforce development approach in a variety of settings.
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Affiliation(s)
- Adam D Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health , Baltimore, MD, USA
| | - Jerilyn Hoover
- Department of International Health, Johns Hopkins Bloomberg School of Public Health , Baltimore, MD, USA
| | | | - Erica Rosser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health , Baltimore, MD, USA
| | - Aboli Gore
- Bihar Technical Support Program, CARE India , Patna, India
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health , Baltimore, MD, USA
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13
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Abstract
BACKGROUND Mentoring programs for nurses already in the health workforce are growing in importance. Yet, the settings, goals, scale, and key features of these programs are not widely known. OBJECTIVE To identify and synthesize research on in-service nurse mentoring programs. METHODS We reviewed nurse mentoring research from six databases. Studies either referred explicitly to in-service nurse mentoring programs, were reviews of such programs, or concerned nurse training/education in which mentoring was an essential component. RESULTS We included 69 articles from 11 countries, published from 1995 to 2019. Most articles were from high-income countries (n = 46) and in rural areas (n = 22). Programs were developed to strengthen clinical care (particularly maternal and neonatal care), promote evidence-based practice, promote retention, support new graduate nurses, and develop nurse leaders. Of the articles with sufficient data, they typically described small programs implemented in one facility (n = 23), with up to ten mentors (n = 13), with less than 50 mentees (n = 25), meeting at least once a month (n = 27), and lasting at least a year (n = 24). While over half of the studies (n = 36) described programs focused almost exclusively on clinical skills acquisition, many (n = 33) specified non-clinical professional development activities. Reflective practice featured to a varying extent in many articles (n = 29). Very few (n = 6) explicitly identified the theoretical basis of their programs. CONCLUSIONS Although the literature about in-service nurse mentoring comes mostly from small programs in high-income countries, the largest nurse mentoring programs in the world are in low- and middle-income countries. Much can be learned from studying these programs in greater detail. Future research should analyze key features of programs to make models of mentoring more transparent and translatable. If carefully designed and flexibly implemented, in-service nurse mentoring represents an exciting avenue for enhancing the role of nurses and midwives in people-centered health system strengthening. The contents in this article are those of the authors and do not necessarily reflect the view of the U.S. President's Emergency Plan for AIDS Relief, the U.S. Agency for International Development or the U.S. Government.
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Affiliation(s)
- Jerilyn Hoover
- Credence Management Solutions, LLC, the Global Health Technical Professionals, USAID, 8609 Westwood Center Drive, Suite 300, Vienna, VA 22192 USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
| | - Adam D. Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
| | - Erica N. Rosser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
| | - Krishna D. Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
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14
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Gupta M, Wahl B, Adhikari B, Bar-Zeev N, Bhandari S, Coria A, Erchick DJ, Gupta N, Hariyani S, Kagucia EW, Killewo J, Limaye RJ, McCollum ED, Pandey R, Pomat WS, Rao KD, Santosham M, Sauer M, Wanyenze RK, Peters DH. The need for COVID-19 research in low- and middle-income countries. Glob Health Res Policy 2020; 5:33. [PMID: 32617414 PMCID: PMC7326528 DOI: 10.1186/s41256-020-00159-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/11/2020] [Indexed: 12/21/2022] Open
Abstract
In the early months of the pandemic, most reported cases and deaths due to COVID-19 occurred in high-income countries. However, insufficient testing could have led to an underestimation of true infections in many low- and middle-income countries. As confirmed cases increase, the ultimate impact of the pandemic on individuals and communities in low- and middle-income countries is uncertain. We therefore propose research in three broad areas as urgently needed to inform responses in low- and middle-income countries: transmission patterns of SARS-CoV-2, the clinical characteristics of the disease, and the impact of pandemic prevention and response measures. Answering these questions will require a multidisciplinary approach led by local investigators and in some cases additional resources. Targeted research activities should be done to help mitigate the potential burden of COVID-19 in low- and middle-income countries without diverting the limited human resources, funding, or medical supplies from response activities.
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Affiliation(s)
- Madhu Gupta
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Madhya Marg, Sector 12, Chandigarh, 160012 India
| | - Brian Wahl
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Binita Adhikari
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,Health Foundation Nepal, Kathmandu, Nepal
| | - Naor Bar-Zeev
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Sudip Bhandari
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | - Daniel J Erchick
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Nidhi Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Shreya Hariyani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - E Wangeci Kagucia
- Epidemiology and Demography Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Japhet Killewo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rupali Jayant Limaye
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Eric D McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, USA
| | - Raghukul Pandey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - William S Pomat
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Mathuram Santosham
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Molly Sauer
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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15
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Hasan MZ, Cohen JE, Bishai D, Kennedy CE, Rao KD, Ahuja A, Gupta S. Social capital and peer influence of tobacco consumption: a cross-sectional study among household heads in rural Uttar Pradesh, India. BMJ Open 2020; 10:e037202. [PMID: 32606063 PMCID: PMC7328809 DOI: 10.1136/bmjopen-2020-037202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Having the world's second-largest tobacco-consuming population, tobacco control is a priority agenda of the Indian Government. Yet, there is no evidence of how peer influence and nature of social relationships-defined as social capital-affect tobacco use. This study aimed to explore the role of social capital and peer influence on tobacco consumption among household heads in rural Uttar Pradesh (UP), India. DESIGN AND SETTING This study was embedded within the baseline evaluation of Project Samuday. A cross-sectional multistage cluster survey was implemented in six census blocks of Hardoi and Sitapur districts of UP from June to August 2017. Self-reported tobacco consumption status of randomly selected 6218 household heads (≥18 years; men vs women=5312 vs 906) was assessed from 346 rural communities. Peer influence of tobacco use was measured by the non-self cluster proportion of tobacco consumption among respondents. Community engagement, social support, trust and social cohesion were separately measured as unique facets of social capital both at individual and community levels using the Shortened Adapted Social Capital Assessment Tool in India (SASCAT-I). The explanatory power of covariates was assessed using gender-stratified generalised estimating equations (GEE) with robust-variance estimator. RESULT Tobacco consumption patterns were starkly different for men and women (71% vs 14%). The peer influence only affected men (adjusted odds ratio (AOR)=1.10, 95% CI: 1.05 to 1.16, p<0.01), whereas women were more likely to consume tobacco if they were more engaged with community organisations (AOR=1.33, 95% CI=1.07 to 1.66, p<0.01). CONCLUSION Gender alters the way social engagement affects tobacco use in rural India. Countering peer influence on Indian men should be prioritised as a tobacco control strategy. Moreover, as gender mainstreaming is a critical egalitarian agenda in India, further research is needed to understand how social engagement affects tobacco consumption behaviours among women.
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Affiliation(s)
- Md Zabir Hasan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Joanna E Cohen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
- Institute for Global Tobacco Control (IGTC), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - David Bishai
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Akshay Ahuja
- School of Public Policy, Central European University, Budapest, Hungary
| | - Shivam Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
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16
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Shadmi E, Chen Y, Dourado I, Faran-Perach I, Furler J, Hangoma P, Hanvoravongchai P, Obando C, Petrosyan V, Rao KD, Ruano AL, Shi L, de Souza LE, Spitzer-Shohat S, Sturgiss E, Suphanchaimat R, Uribe MV, Willems S. Health equity and COVID-19: global perspectives. Int J Equity Health 2020; 19:104. [PMID: 32586388 PMCID: PMC7316580 DOI: 10.1186/s12939-020-01218-z] [Citation(s) in RCA: 322] [Impact Index Per Article: 80.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/10/2020] [Indexed: 12/11/2022] Open
Abstract
The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field.
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Affiliation(s)
- Efrat Shadmi
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, 31905, Mount Carmel, Israel.
| | - Yingyao Chen
- School of Public Health, Fudan University, Shanghai, PR China
| | - Inês Dourado
- Health Collective Institute, Federal University of Bahia, Salvador, Brazil
| | - Inbal Faran-Perach
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, 31905, Mount Carmel, Israel
- The mobile clinic for minimizing prostitution damages, Ministry of Health, Haifa, Israel
- "Ve'ahavta" clinic, for refugees and non-citizenship people, Nesher, Israel
| | - John Furler
- Department of General Practice, Faculty of Medicine, Dentistry and Health Science, The University of Melbourne, Melbourne, Australia
| | - Peter Hangoma
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia
- Chr. Michelsen Institute, Bergen, Norway
- Bergen Centre for Ethics in Priority Setting (BCEP), University of Bergen, Bergen, Norway
| | - Piya Hanvoravongchai
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- National Health Foundation, Bangkok, Thailand
- The Equity Initiative, CMB Foundation, Bangkok, Thailand
| | | | - Varduhi Petrosyan
- Gerald and Patricia Turpanjian School of Public Health, American University of Armenia, Yerevan, Armenia
| | - Krishna D Rao
- Department of International Health, Johns Hopkins University, Baltimore, USA
| | - Ana Lorena Ruano
- Center for the Study of Equity and Governance in Health Systems, CEGSS, Guatemala City, Guatemala
- Center for International Health, University of Bergen, Bergen, Norway
| | - Leiyu Shi
- Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | | | | | | | - Rapeepong Suphanchaimat
- International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand
- Division of Epidemiology, Department of Disease Control, Ministry of Public Health, Bangkok, Thailand
| | | | - Sara Willems
- Faculty of Medicine and Health Sciences, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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17
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Hasan MZ, Dean LT, Kennedy CE, Ahuja A, Rao KD, Gupta S. Social capital and utilization of immunization service: A multilevel analysis in rural Uttar Pradesh, India. SSM Popul Health 2020; 10:100545. [PMID: 32405528 PMCID: PMC7211897 DOI: 10.1016/j.ssmph.2020.100545] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/16/2020] [Accepted: 01/17/2020] [Indexed: 11/25/2022] Open
Abstract
The National Health Policy (2017) of India advocates Universal Health Coverage through inclusive growth, decentralization, and rebuilding a cohesive community through a participatory process. To achieve this goal, understanding social organization, and community relationships - defined as social capital - is critical. This study aimed to explore the influence of individual and community-level social capital on a critical health system performance indicator, three-doses of diphtheria-pertussis-tetanus (DPT3) immunization among 12-59 month children, in rural Uttar Pradesh (UP), India. The analysis is based on a cross-sectional survey from two districts of UP, which included 2239 children 12-59 months of age (level 1) from 1749 households (level 2) nested within 346 communities (level 3). We used multilevel confirmatory factor analysis to generate standardized factor scores of social capital constructs (Organizational Participation, Social Support, Trust and Social Cohesion) of the household heads and mothers both at individual and community level, which were then used in the multilevel logistic regressions to explore the independent and contextual effect of social capital on a child's DPT3 immunization status. The result showed only community-level Social Cohesion of the mothers was associated with a child's DPT3 immunization status (Adjusted odds ratio = 1.25, 95% confidence interval = 1.12-1.54; p = 0.04). Beyond its independent effect on utilization of immunization service, the collective Social Cohesion of the mothers significantly modified the relationship of child age, mother's knowledge of immunization, community wealth, and communities' contact with frontline workers with immunization status of the child. With a strong theoretical underpinning, the result substantially contributes to understanding the individual and contextual predictors of immunization service utilization and further advancing the literature of social capital in India. This study can serve as a starting point to catalyze social capital within the health interventions for achieving wellbeing and the collective development of society.
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Affiliation(s)
- Md Zabir Hasan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lorraine T. Dean
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Akshay Ahuja
- School of Public Policy at Central European University, Budapest, Hungary
| | - Krishna D. Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shivam Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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18
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Ahmed S, Srivastava S, Warren N, Mayra K, Misra M, Mahapatra T, Rao KD. The impact of a nurse mentoring program on the quality of labour and delivery care at primary health care facilities in Bihar, India. BMJ Glob Health 2020; 4:e001767. [PMID: 31908856 PMCID: PMC6936590 DOI: 10.1136/bmjgh-2019-001767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/04/2019] [Accepted: 11/10/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Although the number of women who deliver with a skilled birth attendant in India has almost doubled between 2006 and 2016, the country still has the second highest number of maternal deaths and the highest number of neonatal deaths globally. This study examines the impact of a nurse mentoring programme intended to improve the quality of intrapartum care at primary healthcare centre (PHC) facilities in Bihar, India. Method We conducted an evaluation study in 319 public PHCs in Bihar, where nurses participated in a mentoring programme. Using a quasi-experimental trial design, we compared the intrapartum quality of care between the mentored (n=179) and non-mentored PHCs (n=80). Based on direct observation of 847 women, we examined percent differences in 39 labour, delivery and postpartum care-related recommended tasks on five domains: vital sign and labour progress monitoring after admission, second and third stages of labour management, postpartum counselling, infection prevention and essential newborn care practices. Results A significantly higher proportion of women at mentored PHCs received the recommended clinical care, compared with women at non-mentored PHCs. The overall total score of quality of care, expressed in percent of tasks performed, was 30.2% (95% CI: 28.3 to 32.2) in the control PHCs, suggesting that less than one-third of the expected tasks during labour and delivery were performed by nurses in these facilities; the score was 44.2% (95% CI: 42.1 to 46.4) among the facilities where the nurses were trained within last 3 months. The task completion score was slightly attenuated when observed 1 year after mentoring (score 39.1% [37.7–40.5]). Conclusion Mentoring improved intrapartum care by nurses at PHCs in Bihar. However, less than half of the recommended normal delivery intrapartum tasks were completed by the nurse providers. This suggests the need for further improvement in the provision of quality of intrapartum care when risks to maternal and perinatal mortality are highest.
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Affiliation(s)
- Saifuddin Ahmed
- Population, Family and Reproductive Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Swati Srivastava
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nicole Warren
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | | | | | | | - K D Rao
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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19
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Hasan MZ, Leoutsakos JM, Story WT, Dean LT, Rao KD, Gupta S. Exploration of Factor Structure and Measurement Invariance by Gender for a Modified Shortened Adapted Social Capital Assessment Tool in India. Front Psychol 2019; 10:2641. [PMID: 31920771 PMCID: PMC6918543 DOI: 10.3389/fpsyg.2019.02641] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/08/2019] [Indexed: 11/23/2022] Open
Abstract
Social capital is defined as the nature of the social relationship between individuals or groups and the embedded resources available through their social network. It is considered as a critical determinant of health and well-being. Thus, it is essential to assess the performance of any tool when meaningfully comparing social capital between specific groups. Using measurement invariance (MI) analysis, this paper explored the factor structure of the social capital of men and women measured by a modified Shortened Adapted Social Capital Assessment Tool (SASCAT-I) in rural Uttar Pradesh (UP), India. The study sample comprised 5,287 men (18-101 years) and 7,186 women (15-45 years) from 6,218 randomly selected households who responded to SASCAT-I during a community-level cross-sectional survey. Social capital factor structure was examined by both exploratory and confirmatory factor analysis (CFA), and MI across genders was investigated using multigroup CFA. While disregarding gender, four unique factors (Organizational Participation, Social Support, Trust, and Social Cohesion) represented the structure of social capital. The MI analysis presented a partial metric-invariance indicating factor loadings for Organizational Participation and Social Support were the same across genders. The gender-stratified analysis demonstrated that a four-factor solution was best fitted for both men and women. Men and women of rural UP interpreted social capital differently as the perception of Trust and Social Cohesion varied across genders. For any future applications of SASCAT-I, we recommend gender-stratified factor analysis to quantify social capital's measure, acknowledging its multidimensionality.
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Affiliation(s)
- Md Zabir Hasan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - William T. Story
- Department of Community and Behavioral Health, The University of Iowa, Iowa City, IA, United States
| | - Lorraine T. Dean
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Krishna D. Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Shivam Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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20
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Rao KD, Srivastava S, Warren N, Mayra K, Gore A, Das A, Ahmed S. Where there is no nurse: an observational study of large-scale mentoring of auxiliary nurses to improve quality of care during childbirth at primary health centres in India. BMJ Open 2019; 9:e027147. [PMID: 31289071 PMCID: PMC6615817 DOI: 10.1136/bmjopen-2018-027147] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Clinician scarcity in Low and Middle-Income Countries (LMIC) often results in de facto task shifting; this raises concerns about the quality of care. This study examines if a long-term mentoring programme improved the ability of auxiliary nurse-midwives (ANMs), who function as paramedical community health workers, to provide quality care during childbirth, and how they compared with staff nurses. DESIGN Quasi-experimental post-test with matched comparison group. SETTING Primary health centres (PHC) in the state of Bihar, India; a total of 239 PHCs surveyed and matched analysis based on 190 (134 intervention and 56 comparison) facilities. PARTICIPANTS Analysis based on 335 ANMs (237 mentored and 98 comparison) and 42 staff nurses (28 mentored and 14 comparison). INTERVENTION Mentoring for a duration of 6-9 months focused on nurses at PHCs to improve the quality of basic emergency obstetric and newborn care. PRIMARY OUTCOME MEASURES Nurse ability to provide correct actions in managing cases of normal delivery, postpartum haemorrhage and neonatal resuscitation assessed using a combination of clinical vignettes and Objective Structured Clinical Examinations. RESULTS Mentoring increased correct actions taken by ANMs to manage normal deliveries by 17.5 (95% CI 14.8 to 20.2), postpartum haemorrhage by 25.9 (95% CI 22.4 to 29.4) and neonatal resuscitation 28.4 (95% CI 23.2 to 33.7) percentage points. There was no significant difference between the average ability of mentored ANMs and staff nurses. However, they provided only half the required correct actions. There was substantial variation in ability; 41% of nurses for normal delivery, 60% for postpartum haemorrhage and 45% for neonatal resuscitation provided less than half the correct actions. Ability declined with time after mentoring was completed. DISCUSSION Mentoring improved the ability of ANMs to levels comparable with trained nurses. However, only some mentored nurses have the ability to conduct quality deliveries. Continuing education programmes are critical to sustain quality gains.
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Affiliation(s)
- Krishna D Rao
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Swati Srivastava
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division Health Economics Health Financing, Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Nicole Warren
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | | | - Aboli Gore
- CARE India Solutions for Sustainable Development, Patna, India
| | - Aritra Das
- CARE India Solutions for Sustainable Development, Patna, India
| | - Saifuddin Ahmed
- Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Abstract
Gerald Bloom and colleagues argue that the G20 is uniquely placed to facilitate crucial actions to accelerate progress towards universal health coverage
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Affiliation(s)
| | - Yasushi Katsuma
- Waseda University, Tokyo, Japan
- Institute for Global Health Policy Research, National Center for Global Health and Medicine, Tokyo, Japan
| | - Krishna D Rao
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Rao KD, Paina L, Ingabire MG, Shroff ZC. Contracting non-state providers for universal health coverage: learnings from Africa, Asia, and Eastern Europe. Int J Equity Health 2018; 17:127. [PMID: 30286771 PMCID: PMC6172768 DOI: 10.1186/s12939-018-0846-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Formal engagement with non-state providers (NSP) is an important strategy in many low-and-middle-income countries for extending coverage of publicly financed health services. The series of country studies reviewed in this paper - from Afghanistan, Bangladesh, Bosnia & Herzegovina, Ghana, South Africa, Tanzania and Uganda - provide a unique opportunity to understand the dynamics of NSP engagement in different contexts. METHODS A standard template was developed and used to summarize the main findings from the country studies. The summaries were then organized according to emergent themes and a narrative built around these themes. RESULTS Governments contracted NSPs for a variety of reasons - limited public sector capacity, inability of public sector services to reach certain populations or geographic areas, and the widespread presence of NSPs in the health sector. Underlying these reasons was a recognition that purchasing services from NSPs was necessary to increase coverage of health services. Yet, institutional NSPs faced many service delivery challenges. Like the public sector, institutional NSPs faced challenges in recruiting and retaining health workers, and ensuring service quality. Properly managing relationships between all actors involved was critical to contracting success and the role of NSPs as strategic partners in achieving national health goals. Further, the relationship between the central and lower administrative levels in contract management, as well as government stewardship capacity for monitoring contractual performance were vital for NSP performance. CONCLUSION For countries with a sizeable NSP sector, making full use of the available human and other resources by contracting NSPs and appropriately managing them, offers an important way for expanding coverage of publicly financed health services and moving towards universal health coverage.
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Affiliation(s)
- Krishna D. Rao
- Department of International Health, Johns Hopkins University, Suite E-8148 315 N. Wolfe Street, Baltimore, MD 21215 USA
| | - Ligia Paina
- Department of International Health, Johns Hopkins University, Suite E-8148 315 N. Wolfe Street, Baltimore, MD 21215 USA
| | | | - Zubin C. Shroff
- Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland
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Scott K, Beckham SW, Gross M, Pariyo G, Rao KD, Cometto G, Perry HB. What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers. Hum Resour Health 2018; 16:39. [PMID: 30115074 PMCID: PMC6097220 DOI: 10.1186/s12960-018-0304-x] [Citation(s) in RCA: 284] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 07/30/2018] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems. METHODS We searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards. FINDINGS We identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance. CONCLUSION Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential.
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Affiliation(s)
- Kerry Scott
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205 United States of America
| | - S. W. Beckham
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, 21205 United States of America
| | - Margaret Gross
- Welch Medical Library, Johns Hopkins Medical Institutions, 1900 E Monument Street, Baltimore, 21205 United States of America
| | - George Pariyo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205 United States of America
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205 United States of America
| | - Giorgio Cometto
- Health Workforce Department, World Health Organization, Avenue Appia 20, 1202 Geneva, Switzerland
| | - Henry B. Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205 United States of America
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Rajbangshi PR, Nambiar D, Choudhury N, Rao KD. Rural recruitment and retention of health workers across cadres and types of contract in north-east India: A qualitative study. WHO South East Asia J Public Health 2018; 6:51-59. [PMID: 28857063 DOI: 10.4103/2224-3151.213792] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Like many other low- and middle-income countries, India faces challenges of recruiting and retaining health workers in rural areas. Efforts have been made to address this through contractual appointment of health workers in rural areas. While this has helped to temporarily bridge the gaps in human resources, the overall impact on the experience of rural services across cadres has yet to be understood. This study sought to identify motivations for, and the challenges of, rural recruitment and retention of nurses, doctors and specialists across types of contract in rural and remote areas in India's largely rural north-eastern states of Meghalaya and Nagaland. Methods A qualitative study was undertaken, in which 71 semi-structured interviews were carried out with doctors (n = 32), nurses (n = 28) and specialists (n = 11). In addition, unstructured key informant interviews (n = 11) were undertaken, along with observations at health facilities and review of state policies. Data were analysed using Ritchie and Spencer's framework method and the World Health Organization's 2010 framework of factors affecting decisions to relocate to, stay in or leave rural areas. Results It was found that rural background and community attachment were strongly associated with health workers' decision to join rural service, regardless of cadre or contract. However, this aspiration was challenged by health-systems factors of poor working and living conditions; low salary and incentives; and lack of professional growth and recognition. Contractual health workers faced unique challenges (lack of pay parity, job insecurity), as did those with permanent positions (irrational postings and political interference). Conclusion This study establishes that the crisis in recruiting and retaining health workers in rural areas will persist until and unless health systems address the core basic requirements of health workers in rural areas, which are related to health-sector policies. Concerted attention and long-term political commitment to overcome system-level barriers and governance may yield sustainable gains in rural recruitment and retention across cadres and contract types.
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Affiliation(s)
| | | | - Nandini Choudhury
- Public Health Foundation of India, Gurgaon (Haryana), India; Possible, New York, United States of America
| | - Krishna D Rao
- Public Health Foundation of India, Gurgaon (Haryana), India; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Abstract
In many low and middle-income countries patients often bypass the nearest government health center offering free or subsidized services and seek more expensive care elsewhere. This study examines the role of quality of care, in particular clinician competence and structural quality of the health center, on bypassing behavior. Data for this study comes from a survey of 136 primary health centers (PHCs) and 3517 individuals living in the PHC's immediate vicinity in rural Chhattisgarh, India. Overall, the majority (67%) of patients bypassed the local PHC when seeking treatment. Bypassing decreased as provider competence increased, up to a point, after which, improvements in competency did not reduce bypassing. The clinical competence of the health care provider had a greater effect on reducing bypassing compared to PHC structural quality such as the building condition and drug stock-outs. However, the regular presence of clinical providers in the PHC was associated with lower bypassing. Patients that visited the local PHC spent half as much out-of-pocket as those that were treated at private clinics. Poor patients were less likely to bypass the local PHC compared to non-poor patients. These findings suggest that improving structural quality is not sufficient to reduce bypassing of PHCs. While better provider competency can substantially reduce bypassing, beyond a threshold competency level there is little effect. Efforts to strengthen facility-based primary care services need to go beyond simply focusing on improving infrastructure or quality of clinical care. There is a need to rethink how PHCs can be made more relevant to the health care needs of the communities they serve.
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Affiliation(s)
- Krishna D Rao
- Johns Hopkins Bloomberg School of Public Health, USA
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26
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Rao KD, Shahrawat R, Bhatnagar A. Composition and distribution of the health workforce in India: estimates based on data from the National Sample Survey. WHO South East Asia J Public Health 2018; 5:133-140. [PMID: 28607241 DOI: 10.4103/2224-3151.206250] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The availability of reliable and comprehensive information on the health workforce is crucial for workforce planning. In India, routine information sources on the health workforce are incomplete and unreliable. This paper addresses this issue and provides a comprehensive picture of India's health workforce. METHODS Data from the 68th round (July 2011 to June 2012) of the National Sample Survey on the Employment and unemployment situation in India were analysed to produce estimates of the health workforce in India. The estimates were based on self-reported occupations, categorized using a combination of both National Classification of Occupations (2004) and National Industrial Classification (2008) codes. RESULTS Findings suggest that in 2011-2012, there were 2.5 million health workers (density of 20.9 workers per 10 000 population) in India. However, 56.4% of all health workers were unqualified, including 42.3% of allopathic doctors, 27.5% of dentists, 56.1% of Ayurveda, yoga and naturopathy, Unani, Siddha and homoeopathy (AYUSH) practitioners, 58.4% of nurses and midwives and 69.2% of health associates. By cadre, there were 3.3 qualified allopathic doctors and 3.1 nurses and midwives per 10 000 population; this is around one quarter of the World Health Organization benchmark of 22.8 doctors, nurses and midwives per 10 000 population. Out of all qualified workers, 77.4% were located in urban areas, even though the urban population is only 31% of the total population of the country. This urban-rural difference was higher for allopathic doctors (density 11.4 times higher in urban areas) compared to nurses and midwives (5.5 times higher in urban areas). CONCLUSION The study highlights several areas of concern: overall low numbers of qualified health workers; a large presence of unqualified health workers, particularly in rural areas; and large urban-rural differences in the distribution of qualified health workers.
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Affiliation(s)
- Krishna D Rao
- Department of International Health, Johns Hopkins University, Baltimore, MD, United States of America
| | - Renu Shahrawat
- National Institute of Health and Family Welfare, New Delhi, India
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Lee TJ, Saran I, Rao KD. Ageing in
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ndia: Financial hardship from health expenditures. Int J Health Plann Manage 2017; 33:414-425. [DOI: 10.1002/hpm.2478] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/01/2017] [Indexed: 11/10/2022] Open
Affiliation(s)
- Ting‐Hsuan J. Lee
- Department of International HealthThe Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Indrani Saran
- Duke Global Health InstituteDuke University Durham North Carolina USA
| | - Krishna D. Rao
- Department of International HealthThe Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
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Shrestha S, Chatterjee S, Rao KD, Dowdy DW. Potential impact of spatially targeted adult tuberculosis vaccine in Gujarat, India. J R Soc Interface 2016; 13:rsif.2015.1016. [PMID: 27009179 DOI: 10.1098/rsif.2015.1016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 02/29/2016] [Indexed: 11/12/2022] Open
Abstract
Some of the most promising vaccines in the pipeline for tuberculosis (TB) target adolescents and adults. Unlike for childhood vaccines, high-coverage population-wide vaccination is significantly more challenging for adult vaccines. Here, we aimed to estimate the impact of vaccine delivery strategies that were targeted to high-incidence geographical 'hotspots' compared with randomly allocated vaccination. We developed a spatially explicit mathematical model of TB transmission that distinguished these hotspots from the general population. We evaluated the impact of targeted and untargeted vaccine delivery strategies in India--a country that bears more than 25% of global TB burden, and may be a potential early adopter of the vaccine. We collected TB notification data and conducted a demonstration study in the state of Gujarat to validate our estimates of heterogeneity in TB incidence. We then projected the impact of randomly vaccinating 8% of adults in a single mass campaign to a spatially targeted vaccination preferentially delivered to 80% of adults in the hotspots, with both strategies augmented by continuous adolescent vaccination. In consultation with vaccine developers, we considered a vaccine efficacy of 60%, and evaluated the population-level impact after 10 years of vaccination. Spatial heterogeneity in TB notification (per 100,000/year) was modest in Gujarat: 190 in the hotspots versus 125 in the remaining population. At this level of heterogeneity, the spatially targeted vaccination was projected to reduce TB incidence by 28% after 10 years, compared with a 24% reduction projected to achieve via untargeted vaccination--a 1.17-fold augmentation in the impact of vaccination by spatially targeting. The degree of the augmentation was robust to reasonable variation in natural history assumptions, but depended strongly on the extent of spatial heterogeneity and mixing between the hotspot and general population. Identifying high-incidence hotspots and quantifying spatial mixing patterns are critical to accurate estimation of the value of targeted intervention strategies.
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Affiliation(s)
- Sourya Shrestha
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD 21205, USA
| | | | - Krishna D Rao
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD 21205, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD 21205, USA
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Chatterjee S, Sarkar A, Rao KD. Using Misoprostol for Primary versus Secondary Prevention of Postpartum Haemorrhage - Do Costs Matter? PLoS One 2016; 11:e0164718. [PMID: 27755601 PMCID: PMC5068696 DOI: 10.1371/journal.pone.0164718] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 09/29/2016] [Indexed: 11/29/2022] Open
Abstract
Background Postpartum heammorrhage (PPH), defined as blood loss greater than or equal to 500 ml within 24 hours after birth, is the leading cause of maternal deaths globally and in India. Misoprostol is an important option for PPH management in setting where oxytocin (the gold standard for PPH prevention and treatment) in not available or not feasible to use. For the substantial number of deliveries which take place at home or at lower level heatlh facilities in India, misoprostol pills can be adminstered to prevent PPH. The standard approach using misoprostol is to administer it prophylactically as primary prevention (600 mcg). An alternative strategy could be to administer misoprostol only to those who are at high risk of having PPH i.e. as secondary prevention. Methods This study reports on the relative cost per person of a strategy involving primary versus secondary prevention of PPH using misoprostol. It is based on a randomized cluster trial that was conducted in Bijapur district in Karnataka, India between December 2011 and March 2014 among pregnant women to compare two community-level strategies for the prevention of PPH: primary and secondary. The analysis was conducted from the government perspective using an ingredient approach. Results The cluster trial showed that there were no significant differences in clinical outcomes between the two study arms. However, the results of the cost analysis show that there is a difference of INR 6 (US$ 0.1) per birth for implementing the strategies primary versus secondary prevention. In India where 14.9 million births take place at sub-centres and at home, this additional cost of INR 6 per birth translates to an additional cost of INR 94 (US$ 1.6) million to the government to implement the primary prevention compared to the secondary prevention strategy. Conclusion As clinical outcomes did not differ significantly between the two arms in the trial, taking into account the difference in costs and potential issues with sustainability, secondary prevention might be a more strategic option.
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Affiliation(s)
| | | | - Krishna D. Rao
- Johns Hopkins University, Baltimore, United States of America
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Rao KD, Ramani S, Hazarika I, George S. When do vertical programmes strengthen health systems? A comparative assessment of disease-specific interventions in India. Health Policy Plan 2016; 29:495-505. [PMID: 23749734 DOI: 10.1093/heapol/czt035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Disease-specific programmes have had a long history in India and their presence has increased over time. This study has two objectives: first, it reports on the interaction between local health systems and key disease-specific programmes in India—National AIDS Control Program (NACP) (HIV/AIDS), Revised National Tuberculosis Control Program (RNTCP) (TB) and National Vector Borne Disease Control Program (NVBDCP) (Malaria), and second, it examines which factors create an enabling environment for disease-specific programmes to strengthen health systems. METHODS A total of 103 in-depth interviews were conducted in six states in 2009 and 2010. Key informants included managers of disease control programmes and health systems, central and state health ministry and staff from peripheral health facilities. Analytical themes were derived from the World Health Organization (WHO) building block and the Systems Rapid Assessment framework. FINDINGS Disease-specific programmes contribute to strengthening some components of the health system by sharing human and material resources, increasing demand for health services by improving public perceptions of service quality, encouraging civil society involvement in service delivery and sharing diseasespecific information with local health system managers. These synergies were observed more frequently in the RNTCP and NVBDCP compared with the NACP. CONCLUSIONS Disease-specific programmes in India are widely regarded as having made a substantial contribution in disease control. They can have both positive and negative effects on health systems. Certain conditions are necessary for them to have a positive influence on health systems—the programme needs to have an explicit policy to strengthen local health systems, and should also be embedded within the health system administration.
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Rao KD, Nagulapalli S, Arora R, Madhavi M, Andersson E, Ingabire MG. An Implementation Research Approach to Evaluating Health Insurance Programs: Insights from India. Int J Health Policy Manag 2016; 5:295-9. [PMID: 27239878 DOI: 10.15171/ijhpm.2016.32] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 03/09/2016] [Indexed: 11/09/2022] Open
Abstract
One of the distinguishing features of implementation research is the importance given to involve implementers in all aspects of research, and as users of research. We report on a recent implementation research effort in India, in which researchers worked together with program implementers from one of the longest serving government funded insurance schemes in India, the Rajiv Aarogyasri Scheme (RAS) in the state of undivided Andhra Pradesh, that covers around 70 million people. This paper aims to both inform on the process of the collaborative research, as well as, how the nature of questions that emerged out of the collaborative exercise differed in scope from those typically asked of insurance program evaluations. Starting in 2012, and over the course of a year, staff from the Aarogyasri Health Care Trust (AHCT), and researchers held a series of meetings to identify research questions that could serve as a guide for an evaluation of the RAS. The research questions were derived from the application of a Logical Framework Approach ("log frame") to the RAS. The types of questions that emerged from this collaborative effort were compared with those seen in the published literature on evaluations of insurance programs in low- and middle-income countries (LMICs). In the published literature, 60% of the questions pertained to output/outcome of the program and the remaining 40%, relate to processes and inputs. In contrast, questions generated from the RAS participatory research process between implementers and researchers had a remarkably different distribution - 81% of questions looked at program input/processes, and 19% on outputs and outcomes. An implementation research approach can lead to a substantively different emphasis of research questions. While there are several challenges in collaborative research between implementers and researchers, an implementation research approach can lead to incorporating tacit knowledge of program implementers into the research process, research questions that are more relevant to the research needs of policy-makers, and greater knowledge translation of the research findings.
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Affiliation(s)
- Krishna D Rao
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Elin Andersson
- The Graduate Institute of International and Development Studies, Geneva, Switzerland
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Rao KD, Peters DH. Urban health in India: many challenges, few solutions. The Lancet Global Health 2015; 3:e729-30. [DOI: 10.1016/s2214-109x(15)00210-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 09/15/2015] [Accepted: 09/18/2015] [Indexed: 11/24/2022]
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Norheim OF, Baltussen R, Johri M, Chisholm D, Nord E, Brock D, Carlsson P, Cookson R, Daniels N, Danis M, Fleurbaey M, Johansson KA, Kapiriri L, Littlejohns P, Mbeeli T, Rao KD, Edejer TTT, Wikler D. Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis. Cost Eff Resour Alloc 2014; 12:18. [PMID: 25246855 PMCID: PMC4171087 DOI: 10.1186/1478-7547-12-18] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 07/18/2014] [Indexed: 11/10/2022] Open
Abstract
This Guidance for Priority Setting in Health Care (GPS-Health), initiated by the World Health Organization, offers a comprehensive map of equity criteria that are relevant to health care priority setting and should be considered in addition to cost-effectiveness analysis. The guidance, in the form of a checklist, is especially targeted at decision makers who set priorities at national and sub-national levels, and those who interpret findings from cost-effectiveness analysis. It is also targeted at researchers conducting cost-effectiveness analysis to improve reporting of their results in the light of these other criteria. THE GUIDANCE WAS DEVELOP THROUGH A SERIES OF EXPERT CONSULTATION MEETINGS AND INVOLVED THREE STEPS: i) methods and normative concepts were identified through a systematic review; ii) the review findings were critically assessed in the expert consultation meetings which resulted in a draft checklist of normative criteria; iii) the checklist was validated though an extensive hearing process with input from a range of relevant stakeholders. The GPS-Health incorporates criteria related to the disease an intervention targets (severity of disease, capacity to benefit, and past health loss); characteristics of social groups an intervention targets (socioeconomic status, area of living, gender; race, ethnicity, religion and sexual orientation); and non-health consequences of an intervention (financial protection, economic productivity, and care for others).
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Affiliation(s)
- Ole F Norheim
- Department of Global Public Health and Primary Care, University of Bergen, PB 7800, 5020 Bergen, Norway
| | - Rob Baltussen
- Nijmegen International Centre for Health Systems Research and Education (NICHE), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Mira Johri
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Québec, Canada
| | - Dan Chisholm
- Department of Health Systems Financing, World Health Organization, Geneva, Switzerland
| | - Erik Nord
- Norwegian Institute of Public Health, Oslo, Norway
| | - DanW Brock
- Harvard Medical School, Harvard University, Cambridge, USA
| | - Per Carlsson
- National Centre for Priority Setting in Health Care, Linköping University, Linköping, Sweden
| | | | - Norman Daniels
- Harvard School of Public Health, Harvard University, Cambridge, USA
| | - Marion Danis
- Section on Ethics and Health Policy, NIH Clinical Centre, Bethesda, USA
| | - Marc Fleurbaey
- Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, USA
| | - Kjell A Johansson
- Department of Global Public Health and Primary Care, University of Bergen, PB 7800, 5020 Bergen, Norway
| | - Lydia Kapiriri
- Department of Health, Aging, and Society, McMaster University, Hamilton, Canada
| | - Peter Littlejohns
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, King’s College London, Previous affiliation the National Institute for Health and Care Excellence (NICE), London, England, UK
| | - Thomas Mbeeli
- Ministry of Health and Social Services, Windhoek, Namibia
| | | | - Tessa Tan-Torres Edejer
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Québec, Canada
| | - Dan Wikler
- Harvard School of Public Health, Harvard University, Cambridge, USA
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Abstract
BACKGROUND Research on health systems is an important contributor to improving health system performance. Importantly, research on program and policy implementation can also create a culture of public accountability. In the last decade, significant health system reforms have been implemented in India. These include strengthening the public sector health system through the National Rural Health Mission (NRHM), and expansion of government-sponsored insurance schemes for the poor. This paper provides a situation analysis of health systems research during the reform period. METHODS We reviewed 9,477 publications between 2005 and 2013 in two online databases, PubMed and IndMED. Articles were classified according to the WHO classification of health systems building blocks. RESULTS Our findings indicate the number of publications on health systems progressively increased every year from 92 in 2006 to 314 in 2012. The majority of papers were on service delivery (40%), with fewer on information (16%), medical technology and vaccines (15%), human resources (11%), governance (5%), and financing (8%). Around 70% of articles were lead by an author based in India, the majority by authors located in only four states. Several states, particularly in eastern and northeastern India, did not have a single paper published by a lead author located in a local institution. Moreover, many of these states were not the subject of a single published paper. Further, a few select institutions produced the bulk of research. Of the foreign author lead papers, 77% came from five countries (USA, UK, Canada, Australia, and Switzerland). CONCLUSIONS The growth of published research during the reform period in India is a positive development. However, bulk of this research is produced in a few states and by a few select institutions Further strengthening health systems research requires attention to neglected health systems domains like human resources, financing, and governance. Importantly, research capacity needs to be strengthened in states and institutions that have a scarcity of researchers, as well as states that have been the focus of little research. While more funding for health systems research is required, this funding needs to be targeted at deficient health systems domains, geographical areas, and institutions.
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Affiliation(s)
- Krishna D Rao
- Health Systems Program, Department of International Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, Maryland 21205, USA
- Public Health Foundation of India, ISID Campus, Vasant Kunj Institutional Area, Vasant Kunj, New Delhi 110070, India
| | - Radhika Arora
- Public Health Foundation of India, ISID Campus, Vasant Kunj Institutional Area, Vasant Kunj, New Delhi 110070, India
| | - Abdul Ghaffar
- Alliance for Health Policy and Systems Research, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
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Rao KD, Petrosyan V, Araujo EC, McIntyre D. Progress towards universal health coverage in BRICS: translating economic growth into better health. Bull World Health Organ 2014; 92:429-35. [PMID: 24940017 PMCID: PMC4047799 DOI: 10.2471/blt.13.127951] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 03/10/2014] [Accepted: 03/10/2014] [Indexed: 11/27/2022] Open
Abstract
Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--represent some of the world's fastest growing large economies and nearly 40% of the world's population. Over the last two decades, BRICS have undertaken health-system reforms to make progress towards universal health coverage. This paper discusses three key aspects of these reforms: the role of government in financing health; the underlying motivation behind the reforms; and the value of the lessons learnt for non-BRICS countries. Although national governments have played a prominent role in the reforms, private financing constitutes a major share of health spending in BRICS. There is a reliance on direct expenditures in China and India and a substantial presence of private insurance in Brazil and South Africa. The Brazilian health reforms resulted from a political movement that made health a constitutional right, whereas those in China, India, the Russian Federation and South Africa were an attempt to improve the performance of the public system and reduce inequities in access. The move towards universal health coverage has been slow. In China and India, the reforms have not adequately addressed the issue of out-of-pocket payments. Negotiations between national and subnational entities have often been challenging but Brazil has been able to achieve good coordination between federal and state entities via a constitutional delineation of responsibility. In the Russian Federation, poor coordination has led to the fragmented pooling and inefficient use of resources. In mixed health systems it is essential to harness both public and private sector resources.
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Affiliation(s)
- Krishna D Rao
- Public Health Foundation of India, ISID Campus, Vasant Kunj Institutional Area, New Delhi 110070, India
| | - Varduhi Petrosyan
- American University of Armenia, School of Public Health, Yerevan, Armenia
| | - Edson Correia Araujo
- Health, Nutrition and Population, The World Bank, Washington, United States of America
| | - Diane McIntyre
- Health Economics Unit, University of Cape Town, Cape Town, South Africa
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Affiliation(s)
- Krishna D Rao
- Public Health Foundation of India, ISID Campus, Vasant Kunj Institutional Area, New Delhi 110070, India.
| | - T Sundararaman
- National Health Systems Resource Center, Ministry of Health and Family Welfare, Government of India, India
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Rao KD, Ryan M, Shroff Z, Vujicic M, Ramani S, Berman P. Rural clinician scarcity and job preferences of doctors and nurses in India: a discrete choice experiment. PLoS One 2013; 8:e82984. [PMID: 24376621 PMCID: PMC3869745 DOI: 10.1371/journal.pone.0082984] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 10/29/2013] [Indexed: 11/18/2022] Open
Abstract
The scarcity of rural doctors has undermined the ability of health systems in low and middle-income countries like India to provide quality services to rural populations. This study examines job preferences of doctors and nurses to inform what works in terms of rural recruitment strategies. Job acceptance of different strategies was compared to identify policy options for increasing the availability of clinical providers in rural areas. In 2010 a Discrete Choice Experiment was conducted in India. The study sample included final year medical and nursing students, and in-service doctors and nurses serving at Primary Health Centers. Eight job attributes were identified and a D-efficient fractional factorial design was used to construct pairs of job choices. Respondent acceptance of job choices was analyzed using multi-level logistic regression. Location mattered; jobs in areas offering urban amenities had a high likelihood of being accepted. Higher salary had small effect on doctor, but large effect on nurse, acceptance of rural jobs. At five times current salary levels, 13% (31%) of medical students (doctors) were willing to accept rural jobs. At half this level, 61% (52%) of nursing students (nurses) accepted a rural job. The strategy of reserving seats for specialist training in exchange for rural service had a large effect on job acceptance among doctors, nurses and nursing students. For doctors and nurses, properly staffed and equipped health facilities, and housing had small effects on job acceptance. Rural upbringing was not associated with rural job acceptance. Incentivizing doctors for rural service is expensive. A broader strategy of substantial salary increases with improved living, working environment, and education incentives is necessary. For both doctors and nurses, the usual strategies of moderate salary increases, good facility infrastructure, and housing will not be effective. Non-physician clinicians like nurse-practitioners offer an affordable alternative for delivering rural health care.
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Affiliation(s)
- Krishna D. Rao
- Public Health Foundation of India, New Delhi, India
- * E-mail:
| | - Mandy Ryan
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland
| | - Zubin Shroff
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Marko Vujicic
- American Dental Association, Chicago, Illinois, United States of America
| | - Sudha Ramani
- Indian Institute of Public Health (Hyderabad), Hyderabad, India
| | - Peter Berman
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
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Ramani S, Rao KD, Ryan M, Vujicic M, Berman P. For more than love or money: attitudes of student and in-service health workers towards rural service in India. Hum Resour Health 2013; 11:58. [PMID: 24261330 PMCID: PMC4222605 DOI: 10.1186/1478-4491-11-58] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 11/06/2013] [Indexed: 05/04/2023]
Abstract
BACKGROUND While international literature on rural retention is expanding, there is a lack of research on relevant strategies from pluralistic healthcare environments such as India, where alternate medicine is an integral component of primary care. In such contexts, there is a constant tug of war in national policy on "Which health worker is needed in rural areas?" and "Who can, realistically, be got there?" In this article, we try to inform this debate by juxtaposing perspectives of three cadres involved in primary care in India-allopathic, ayurvedic and nursing-on rural service. We also identify key incentives for improved rural retention of these cadres. METHODS We present qualitative evidence from two states, Uttarakhand and Andhra Pradesh. Eighty-eight in-depth interviews with students and in-service personnel were conducted between January and July 2010. Generic thematic analysis techniques were employed, and the data were organized in a framework that clustered factors linked to rural service as organizational (salary, infrastructure, career) and contextual (housing, children's development, safety). RESULTS Similar to other studies, we found that both pecuniary and non-pecuniary factors (salary, working conditions, children's education, living conditions and safety) affect career preferences of health workers. For the allopathic cadre, rural primary care jobs commanded little respect; respondents from this cadre aimed to specialize and preferred private sector jobs. Offering preferential admission to specialist courses in exchange for a rural stint appears to be a powerful incentive for this cadre. In contrast, respondents from the Ayurvedic and nursing cadres favored public sector jobs even if this meant rural postings. For these two cadres, better salary, working and rural living conditions can increase recruitment. CONCLUSIONS Rural retention strategies in India have predominantly concentrated on the allopathic cadre. Our study suggests incentivizing rural service for the nursing and Ayurvedic cadres is less challenging in comparison to the allopathic cadre. Hence, there is merit in strengthening rural incentive strategies for these two cadres also. In our study, we have developed a detailed framework of rural retention factors and used this for delineating India-specific recommendations. This framework can be adapted to other similar contexts to facilitate international cross-cadre comparisons.
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Affiliation(s)
- Sudha Ramani
- Indian Institute of Public Health, Hyderabad, Plot # 1, A N V Arcade, Amar Co-operative Society, Kavuri Hills, Madhapur, Hyderabad 500 081, India
| | - Krishna D Rao
- Public Health Foundation of IndiaISID Campus, 4 Institutional Area, Vasant Kunj, New Delhi 110070, India
| | - Mandy Ryan
- Health Economics Research Unit, Division of Applied Health Sciences, College of Life Sciences and Medicine, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, Scotland
| | - Marko Vujicic
- Human Development Network, The World Bank, 1818 H Street, NW, Washington DC 20433, USA
| | - Peter Berman
- Department of Global Health and Population, Harvard University, 665 Huntington Avenue, Building I, 11th Floor, Boston, Massachusetts 02115, USA
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Rao KD, Stierman E, Bhatnagar A, Gupta G, Gaffar A. As good as physicians: patient perceptions of physicians and non-physician clinicians in rural primary health centers in India. Glob Health Sci Pract 2013; 1:397-406. [PMID: 25276553 PMCID: PMC4168595 DOI: 10.9745/ghsp-d-13-00085] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 08/14/2013] [Indexed: 11/06/2022]
Abstract
Non-physician clinicians (NPCs), including both specially trained medical assistants and physicians trained in India systems of medicine, perform similarly to physicians in terms of patient satisfaction, trust, and perceived quality, thus supporting the use and scale up of NPCs in primary care. Background: Attracting physicians to rural areas has been a long-standing challenge in India. Government efforts to address the shortage of rural physicians include posting non-physician clinicians (NPCs) at primary health centers (PHCs) in select areas. Performance assessments of NPCs have typically focused on the technical quality of their care with little attention to the perspectives of patients. This study investigates patient views of physicians (Medical Officers) and NPCs in terms of patient satisfaction, perceived quality, and provider trust. NPCs include: Indian system of medicine physicians (AYUSH Medical Officers) and clinicians with 3 years of training, such as Rural Medical Assistants (RMAs). At PHCs without clinicians, paramedics provide clinical care, although they are not trained for this. Methods: PHCs in the state of Chhattisgarh were stratified by provider type: Medical Officer, AYUSH Medical Officer, RMA, or paramedic. PHCs were randomly sampled in each group. A total of 1,082 exiting patients were sampled from138 PHCs. Factor analysis was used to identify perceived quality domains. Multiple regression analysis was used to test for group differences. Results: Patients of Medical Officers and NPCs reported similar levels of satisfaction, trust, and perceived quality, with scores of 84% for Medical Officers, 80% for AYUSH Medical Officers, and 85% for RMAs. While there were no significant differences in these outcomes between these groups, scores for paramedical staff were significantly lower, at 73%. Conclusions: Physicians and NPCs performed similarly in terms of patient satisfaction, trust, and perceived quality. From a patient's perspective, this supports the use and scale up of NPCs in primary care settings in India. Leaving clinician posts vacant undermines public trust and quality perceptions of government health services.
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Affiliation(s)
- Krishna D Rao
- Public Health Foundation of India , New Delhi , India ; Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
| | | | - Aarushi Bhatnagar
- Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
| | - Garima Gupta
- National Health Resource Center, Ministry of Health and Family Welfare, Government of India , New Delhi , India
| | - Abdul Gaffar
- Alliance for Health Policy and Systems Research, World Health Organization , Geneva , Switzerland
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Steinhardt LC, Rao KD, Hansen PM, Alam S, Peters DH. The effects of user fees on quality and utilization of primary health-care services in Afghanistan: a quasi-experimental health financing pilot study in a post-conflict setting. Int J Health Plann Manage 2013; 28:e280-97. [DOI: 10.1002/hpm.2178] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 09/24/2012] [Accepted: 02/11/2013] [Indexed: 11/09/2022] Open
Affiliation(s)
- Laura C. Steinhardt
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland USA
| | | | | | | | - David H. Peters
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland USA
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Koon AD, Rao KD, Tran NT, Ghaffar A. Embedding health policy and systems research into decision-making processes in low- and middle-income countries. Health Res Policy Syst 2013; 11:30. [PMID: 23924162 PMCID: PMC3750690 DOI: 10.1186/1478-4505-11-30] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 07/30/2013] [Indexed: 11/21/2022] Open
Abstract
Attention is increasingly directed to bridging the gap between the production of knowledge and its use for health decision-making in low- and middle-income countries (LMICs). An important and underdeveloped area of health policy and systems research (HPSR) is the organization of this process. Drawing from an interdisciplinary conception of embeddedness, a literature review was conducted to identify examples of embedded HPSR used to inform decision-making in LMICs. The results of the literature review were organized according to the World Health Organization’s Building Blocks Framework. Next, a conceptual model was created to illustrate the arrangement of organizations that produce embedded HPSR and the characteristics that facilitate its uptake into the arena of decision-making. We found that multiple forces converge to create context-specific pathways through which evidence enters into decision-making. Depending on the decision under consideration, the literature indicates that decision-makers may call upon an intricate combination of actors for sourcing HPSR. While proximity to decision-making does have advantages, it is not the position of the organization within the network, but rather the qualities the organization possesses, that enable it to be embedded. Our findings suggest that four qualities influence embeddedness: reputation, capacity, quality of connections to decision-makers, and quantity of connections to decision-makers and others. In addition to this, the policy environment (e.g. the presence of legislation governing the use of HPSR, presence of strong civil society, etc.) strongly influences uptake. Through this conceptual model, we can understand which conditions are likely to enhance uptake of HPSR in LMIC health systems. This raises several important considerations for decision-makers and researchers about the arrangement and interaction of evidence-generating organizations in health systems.
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Affiliation(s)
- Adam D Koon
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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Clark AD, Griffiths UK, Abbas SS, Rao KD, Privor-Dumm L, Hajjeh R, Johnson H, Sanderson C, Santosham M. Impact and cost-effectiveness of Haemophilus influenzae type b conjugate vaccination in India. J Pediatr 2013; 163:S60-72. [PMID: 23773596 PMCID: PMC5748935 DOI: 10.1016/j.jpeds.2013.03.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To estimate the potential health impact and cost-effectiveness of nationwide Haemophilus influenzae type b (Hib) vaccination in India. STUDY DESIGN A decision support model was used, bringing together estimates of demography, epidemiology, Hib vaccine effectiveness, Hib vaccine costs, and health care costs. Scenarios favorable and unfavorable to the vaccine were evaluated. State-level analyses indicate where the vaccine might have the greatest impact and value. RESULTS Between 2012 and 2031, Hib conjugate vaccination is estimated to prevent over 200 000 child deaths (∼1% of deaths in children <5 years of age) in India at an incremental cost of US$127 million per year. From a government perspective, state-level cost-effectiveness ranged from US$192 to US$1033 per discounted disability adjusted life years averted. With the inclusion of household health care costs, cost-effectiveness ranged from US$155-US$939 per discounted disability adjusted life year averted. These values are below the World Health Organization thresholds for cost effectiveness of public health interventions. CONCLUSIONS Hib conjugate vaccination is a cost-effective intervention in all States of India. This conclusion does not alter with plausible changes in key parameters. Although investment in Hib conjugate vaccination would significantly increase the cost of the Universal Immunization Program, about 15% of the incremental cost would be offset by health care cost savings. Efforts should be made to expedite the nationwide introduction of Hib conjugate vaccination in India.
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Affiliation(s)
- Andrew D. Clark
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ulla K. Griffiths
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Rana Hajjeh
- Division of Bacterial Diseases, National Center of Immunization and Respiratory Diseases, Centers for Disease Control, Atlanta, GA
| | - Hope Johnson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Colin Sanderson
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Shroff ZC, Murthy S, Rao KD. Attracting doctors to rural areas: a case study of the post-graduate seat reservation scheme in andhra pradesh. Indian J Community Med 2013; 38:27-32. [PMID: 23559700 PMCID: PMC3612293 DOI: 10.4103/0970-0218.106624] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 06/17/2012] [Indexed: 11/05/2022] Open
Abstract
Background: Attracting doctors to rural posts is an ongoing challenge for health departments across different states in India. One strategy adopted by several states to make rural service attractive for medical graduates is to reserve post-graduate (PG) seats in medical colleges for doctors serving in the public sector. Objective: This study examines the PG reservation scheme in Andhra Pradesh to understand its role in improving rural recruitment of doctors and specialists, the challenges faced by the scheme and how it can be strengthened. Materials and Methods: Qualitative case study methodology was adopted in which a variety of stakeholders such as government officials, health systems managers and serving Medical Officers were interviewed. This was supplemented with quantitative data on the scheme obtained from the Health, Medical and Family Welfare Department in Andhra Pradesh. Results: The PG reservation scheme appears to have been one of the factors responsible in attracting doctors to the public sector and to rural posts, with a reduction in vacancies at both the Primary Health Centre and Community Health Centre levels. Expectedly, in-service candidates have a better chance of getting a PG seat than general candidates. However, problems such as the mismatch of the demand and supply of certain types of specialist doctors, poor academic performance of in-service candidates as well as quality of services and enforcement of the post-PG bond need to be resolved. Conclusion: The PG reservation scheme is a powerful incentive to attract doctors to rural areas. However, better monitoring of service quality, strategically aligning PG training through the scheme with the demand for specialists as well as stricter enforcement of the financial bond are required to improve the scheme's effectiveness.
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Rao KD, Sundararaman T, Bhatnagar A, Gupta G, Kokho P, Jain K. Which doctor for primary health care? Quality of care and non-physician clinicians in India. Soc Sci Med 2013; 84:30-4. [PMID: 23517701 DOI: 10.1016/j.socscimed.2013.02.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 01/21/2013] [Accepted: 02/07/2013] [Indexed: 10/27/2022]
Abstract
The scarcity of rural physicians in India has resulted in non-physician clinicians (NPC) serving at primary health centers (PHC). This study examines the clinical competence of NPCs and physicians serving at PHCs to treat a range of medical conditions. The study is set in Chhattisgarh state, where physicians (medical officers) and NPCs: Rural Medical Assistants (RMA), and Indian system of medicine physicians (AYUSH Medical Officers) serve at PHCs. Where no clinician is available, Paramedics (pharmacists and nurses) usually provide care. In 2009, PHCs in Chhattisgarh were stratified by type of clinical care provider present. From each stratum a representative sample of PHCs was randomly selected. Clinical vignettes were used to measure provider competency in managing diarrhea, pneumonia, malaria, TB, preeclampsia and diabetes. Prescriptions were analyzed. Overall, the quality of medical care was low. Medical Officers and RMAs had similar average competence scores. AYUSH Medical Officers and Paramedicals had significantly lower average scores compared to Medical Officers. Paramedicals had the lowest competence scores. While 61% of Medical Officer and RMA prescriptions were appropriate for treating the health condition, only 51% of the AYUSH Medical Officer and 33% of the prescriptions met this standard. RMAs are as competent as physicians in primary care settings. This supports the use of RMA-type clinicians for primary care in areas where posting Medical Officers is difficult. AYUSH Medical Officers are less competent and need further clinical training. Overall, the quality of medical care at PHCs needs improvement.
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Affiliation(s)
- Krishna D Rao
- Public Health Foundation of India, ISID Campus, India.
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Rao KD, Bhatnagar A, Berman P. So many, yet few: Human resources for health in India. Hum Resour Health 2012; 10:19. [PMID: 22888906 PMCID: PMC3541981 DOI: 10.1186/1478-4491-10-19] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 06/18/2012] [Indexed: 05/21/2023]
Abstract
BACKGROUND In many developing countries, such as India, information on human resources in the health sector is incomplete and unreliable. This prevents effective workforce planning and management. This paper aims to address this deficit by producing a more complete picture of India's health workforce. METHODS Both the Census of India and nationally representative household surveys collect data on self-reported occupations. A representative sample drawn from the 2001 census was used to estimate key workforce indicators. Nationally representative household survey data and official estimates were used to compare and supplement census results. RESULTS India faces a substantial overall deficit of health workers; the density of doctors, nurses and midwifes is a quarter of the 2.3/1000 population World Health Organization benchmark. Importantly, a substantial portion of the doctors (37%), particularly in rural areas (63%) appears to be unqualified. The workforce is composed of at least as many doctors as nurses making for an inefficient skill-mix. Women comprise only one-third of the workforce. Most workers are located in urban areas and in the private sector. States with poorer health and service use outcomes have a lower health worker density. CONCLUSIONS Among the important human resources challenges that India faces is increasing the presence of qualified health workers in underserved areas and a more efficient skill mix. An important first step is to ensure the availability of reliable and comprehensive workforce information through live workforce registers.
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Affiliation(s)
| | | | - Peter Berman
- Harvard School of Public Health, Boston, MA, USA
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Huffman MD, Rao KD, Pichon-Riviere A, Zhao D, Harikrishnan S, Ramaiya K, Ajay VS, Goenka S, Calcagno JI, Caporale JE, Niu S, Li Y, Liu J, Thankappan KR, Daivadanam M, van Esch J, Murphy A, Moran AE, Gaziano TA, Suhrcke M, Reddy KS, Leeder S, Prabhakaran D. A cross-sectional study of the microeconomic impact of cardiovascular disease hospitalization in four low- and middle-income countries. PLoS One 2011; 6:e20821. [PMID: 21695127 PMCID: PMC3114849 DOI: 10.1371/journal.pone.0020821] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 05/13/2011] [Indexed: 11/22/2022] Open
Abstract
Objective To estimate individual and household economic impact of cardiovascular disease (CVD) in selected low- and middle-income countries (LMIC). Background Empirical evidence on the microeconomic consequences of CVD in LMIC is scarce. Methods and Findings We surveyed 1,657 recently hospitalized CVD patients (66% male; mean age 55.8 years) from Argentina, China, India, and Tanzania to evaluate the microeconomic and functional/productivity impact of CVD hospitalization. Respondents were stratified into three income groups. Median out-of-pocket expenditures for CVD treatment over 15 month follow-up ranged from 354 international dollars (2007 INT$, Tanzania, low-income) to INT$2,917 (India, high-income). Catastrophic health spending (CHS) was present in >50% of respondents in China, India, and Tanzania. Distress financing (DF) and lost income were more common in low-income respondents. After adjustment, lack of health insurance was associated with CHS in Argentina (OR 4.73 [2.56, 8.76], India (OR 3.93 [2.23, 6.90], and Tanzania (OR 3.68 [1.86, 7.26] with a marginal association in China (OR 2.05 [0.82, 5.11]). These economic effects were accompanied by substantial decreases in individual functional health and productivity. Conclusions Individuals in selected LMIC bear significant financial burdens following CVD hospitalization, yet with substantial variation across and within countries. Lack of insurance may drive much of the financial stress of CVD in LMIC patients and their families.
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Affiliation(s)
- Mark D. Huffman
- Departments of Preventive Medicine and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- Centre for Chronic Disease Control, New Delhi, India
| | | | - Andres Pichon-Riviere
- Institute for Clinical Effectiveness Research and Health Policy, Buenos Aires, Argentina
- Initiative for Cardiovascular Health Research in Developing Countries, New Delhi, India
| | - Dong Zhao
- Initiative for Cardiovascular Health Research in Developing Countries, New Delhi, India
- Department of Epidemiology, Capital Medical University affiliated Beijing Anzhen Hospital and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - S. Harikrishnan
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Kaushik Ramaiya
- Department of Internal Medicine, Shree Hindu Mandal Hospital, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - V. S. Ajay
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, New Delhi, India
- Initiative for Cardiovascular Health Research in Developing Countries, New Delhi, India
| | - Shifalika Goenka
- Public Health Foundation of India, New Delhi, India
- Initiative for Cardiovascular Health Research in Developing Countries, New Delhi, India
| | - Juan I. Calcagno
- Institute for Clinical Effectiveness Research and Health Policy, Buenos Aires, Argentina
| | - Joaquín E. Caporale
- Institute for Clinical Effectiveness Research and Health Policy, Buenos Aires, Argentina
| | - Shaoli Niu
- Cadre Ward, Navy General Hospital, Beijing, China
| | - Yan Li
- Department of Epidemiology, Capital Medical University affiliated Beijing Anzhen Hospital and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Jing Liu
- Department of Epidemiology, Capital Medical University affiliated Beijing Anzhen Hospital and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - K. R. Thankappan
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Meena Daivadanam
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Jan van Esch
- Department of Internal Medicine, Shree Hindu Mandal Hospital, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Adrianna Murphy
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Andrew E. Moran
- Division of General Medicine, Columbia University Medical Center, New York, New York, United States of America
| | - Thomas A. Gaziano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Marc Suhrcke
- School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, United Kingdom
| | - K. Srinath Reddy
- Public Health Foundation of India, New Delhi, India
- Initiative for Cardiovascular Health Research in Developing Countries, New Delhi, India
| | - Stephen Leeder
- Initiative for Cardiovascular Health Research in Developing Countries, New Delhi, India
- Menzies Centre for Health Policy, University of Sydney, Sydney, Australia
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, New Delhi, India
- Initiative for Cardiovascular Health Research in Developing Countries, New Delhi, India
- * E-mail:
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48
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Abstract
Protecting households from high out-of-pocket (OOP) payments for health care is an important health system goal. High OOP payments can push households into poverty and make them vulnerable to catastrophic health expenditures. This study, based in India, aims to: (a) estimate OOP payments for health and related impoverishment across economic groups; (b) decompose OOP payments and relate the contribution of their components to impoverishment; and (c) examine how well recently introduced national insurance schemes meant for the poor are able to provide financial protection. The analysis of nationally representative data from India shows that 3.5% of the population fall below the poverty line and 5% households suffer catastrophic health expenditures. The poverty deepening impact of OOP payments was at a maximum in people below the poverty line in comparison with those above (Rs. 10.45 vs. Rs. 1.50, respectively). Medicines constitute the main share (72%) of total OOP payments. This share reaches 82% for outpatient care, compared with 42% for inpatient care. Removing OOP payments for inpatient care leads to a negligible fall in the poverty headcount ratio and poverty gap. However, if OOP payments for either medicines or outpatient care are removed then only 0.5% people fall into poverty due to spending on health. These findings suggest that insurance schemes which cover only hospital expenses, like those being rolled out nationally in India, will fail to adequately protect the poor against impoverishment due to spending on health. Further, issues related to identifying the poor and their targeting also constrain the scheme's impact. A broader coverage of benefits, to include medicines and outpatient care for the poor and near poor (i.e. those just above the poverty line), is necessary to achieve significant protection from impoverishment.
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Affiliation(s)
- Renu Shahrawat
- National Institute of Health and Family Welfare, New Delhi, India
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49
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Abstract
India has a severe shortage of human resources for health. It has a shortage of qualified health workers and the workforce is concentrated in urban areas. Bringing qualified health workers to rural, remote, and underserved areas is very challenging. Many Indians, especially those living in rural areas, receive care from unqualified providers. The migration of qualified allopathic doctors and nurses is substantial and further strains the system. Nurses do not have much authority or say within the health system, and the resources to train them are still inadequate. Little attention is paid during medical education to the medical and public health needs of the population, and the rapid privatisation of medical and nursing education has implications for its quality and governance. Such issues are a result of underinvestment in and poor governance of the health sector--two issues that the government urgently needs to address. A comprehensive national policy for human resources is needed to achieve universal health care in India. The public sector will need to redesign appropriate packages of monetary and non-monetary incentives to encourage qualified health workers to work in rural and remote areas. Such a policy might also encourage task-shifting and mainstreaming doctors and practitioners who practice traditional Indian medicine (ayurveda, yoga and naturopathy, unani, and siddha) and homoeopathy to work in these areas while adopting other innovative ways of augmenting human resources for health. At the same time, additional investments will be needed to improve the relevance, quantity, and quality of nursing, medical, and public health education in the country.
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Affiliation(s)
- Mohan Rao
- Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
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50
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Affiliation(s)
- Vikram Patel
- London School of Hygiene and Tropical Medicine, London, UK.
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