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Item A comprehensive examination of the economic impact of out-of-pocket health expenditures in India(Health Policy Plan., 2023) Mehak Nanda; Rajesh SharmaMore than 50% of health expenditure is financed through out-of-pocket payments in India, imposing a colossal financial burden on households. Amidst the rising incidence of non-communicable diseases, injuries, and an unfinished agenda of infectious diseases, this study examines comprehensively the economic impact of out-of-pocket health expenditure (OOPE) across 17 disease categories in India. Data from the latest round of the National Sample Survey (2017-18), titled 'Household Social Consumption: Health', were employed. Outcomes, namely, catastrophic health expenditure (CHE), poverty headcount ratio, distressed financing, foregone care, and loss of household earnings, were estimated. Results showed that 49% of households that sought hospitalization and/or outpatient care experienced CHE and 15% of households fell below the poverty line due to OOPE. Notably, outpatient care was more burdensome (CHE: 47.8% and impoverishment: 15.0%) than hospitalization (CHE: 43.1% and impoverishment: 10.7%). Nearly 16% of households used distressed sources to finance hospitalization-related OOPE. Cancer, genitourinary disorders, psychiatric and neurological disorders, obstetric conditions, and injuries imposed a substantial economic burden on households. OOPE and associated financial burden were higher among households where members sought care in private healthcare facilities compared with those treated in public facilities across most disease categories. The high burden of OOPE necessitates the need to increase health insurance uptake and consider outpatient services under the purview of health insurance. Concerted efforts to strengthen the public health sector, improved regulation of private healthcare providers, and prioritizing health promotion and disease prevention strategies are crucial to augment financial risk protection.Item A critique of the policy discourse on primary health care under the Aardram mission of Kerala(Health Policy Plan., 2023) Sreenidhi Sreekumar; T. K. Sundari RavindranIn 2017, the State of Kerala in India, launched the 'Aardram' mission for health. One of the aims of the mission was to enhance the primary health care (PHC) provisioning in the state through the family health centre (FHC) initiative. This was envisaged through a comprehensive PHC approach that prioritized preventive, promotive, curative, rehabilitative and palliative services, and social determinants of health. Given this backdrop, the study aimed to examine the renewed policy commitment towards comprehensive PHC and the extent to which it remains true to the globally accepted ideals of PHC.This was undertaken using a critical discourse analysis (CDA) of the policy discourse on PHC. This included examining the policy documents related to FHC and Aardram as well as the narratives of policy-level actors on PHC and innovations for them. Through CDA we examined the discursive representation of PHC and innovations for improving it at the level of local governments in the state. Though the mission envisaged a shift from the influence of market-driven ideas of health, analysis of the current policy discourse on PHC suggested otherwise. The discourse continues to carry a curative care bias within its ideas of PHC. The disproportionate emphasis on strategies for early detection, treatment and infrastructural improvements meant limited space for preventive, protective and promotive dimensions, thus digressing from the gatekeeping role of PHC. The reduced emphasis on preventive and promotive dimensions and depoliticization of social determinants of health within the PHC discourse indicates that, in the long run, the mission puts at risk its stated goals of social justice and health equity envisioned in the FHC initiative.Item A comparison of the cost of outpatient care delivered by Aam Aadmi Mohalla Clinics compared to other public and private facilities in Delhi, India(Health Policy Plan., 2023) Charu C. Garg; Roopali GoyankaAam Admi Mohalla Clinics (AAMCs) were introduced in Delhi in 2015 as neighbourhood clinics to strengthen the delivery of primary care. To inform the policies on government investments for outpatient care, this study estimated the cost of outpatient care per visit in Delhi for 2019-20 for AAMCs and compared it with urban primary health centres (UPHCs), public hospitals, private clinics and private hospitals. Facility costs for AAMCs and UPHCs were also estimated. Using the data from a national health survey, government annual budgets and reports, a modified top-down methodology was adopted to measure the true cost of public facilities, taking into account both government expenditure and out-of-pocket expenditure (OOPE). Inflation-adjusted OOPE was used to measure the cost of private facilities. The cost per visit at a private clinic at (sic)1146 (US$16) was more than 3-times higher than that at a UPHC ((sic)325/US$5) and 8-times higher than that at AAMCs ((sic)143/US$2.0). These costs were (sic)1099 (US$15) and (sic)1818 (US$25) at public and private hospitals respectively. The annual economic cost per facility of a UPHC at (sic) 9 280 000/$130 000 is similar to 4-times that at AAMC ((sic)2 474 000/$35 000). Unit costs are found to be lower at AAMCs. Utilization for outpatient care has shifted in favour of public primary care facilities. Higher investment in public primary care facilities with expanded services for prevention and promotion, upscaled infrastructure and a gate-keeping mechanism can strengthen the delivery of primary care and promote universal health care at a lower cost.Item An ex-ante economic evaluation of the Maternal and Child Health Voucher Scheme as a decision-making tool in Myanmar(Health Policy Plan., 2016) Pritaporn Kingkaew; Pitsaphun Werayingyong; San San Aye; Nilar Tin; Alaka Singh; Phone Myint; Yot TeerawattananonReducing child and maternal mortality in order to meet the health-related Millennium Development Goals (MDGs) 4 and 5 remains a major challenge in Myanmar. Inadequate care during pregnancy and labour plays an important role in the maternal mortality rate in Myanmar. A Maternal and Child Health (MCH) Voucher Scheme comprising a subsidization for pregnant women to receive four antenatal care (ANC), delivery and postnatal care (PNC) free-of-charge was planned to help women overcome financial barriers in addition to raising awareness of ANC and delivery with skilled birth attendants (SBA), which can reduce the rate of maternal and neonatal death. This study is part of an ex-ante evaluation of a feasibility study of the MCH Voucher Scheme. A cost-utility analysis was conducted using a decision tree model to assess the cost per disability-adjusted life years (DALYs) averted from the MCH Voucher Scheme compared with the current situation. Most input parameters were obtained from Myanmar context. From the base-case analysis, where the financial burden on households was fully subsidized, the MCH Voucher Scheme increased utilization for ANC from 73% up to 93% and for delivery from SBAs from 51% up to and 71%, respectively; hence, it is considered to be very cost-effective with an incremental cost-effectiveness ratio of 381 027 kyats per DALY averted (2010, price year). From the probabilistic sensitivity analysis, the MCH Voucher Scheme had a 52% chance of being a cost-effective option at 1 GDP per capita threshold compared to the current situation. Given that the Voucher Scheme is currently being implemented in one township in Myanmar as a result of this study, ongoing evaluation of the effectiveness and cost-effectiveness of this scheme is warranted.Item Addressing the social determinants of health: a case study from the Mitanin (community health worker) programme in India(Health Policy Plan., 2014) Sulakshana Nandi; Helen SchneiderThe Mitanin Programme, a government community health worker (CHW) programme, was started in Chhattisgarh State of India in 2002. The CHWs (Mitanins) have consistently adopted roles that go beyond health programme-specific interventions to embrace community mobilization and action on local priorities. The aim of this research was to document how and why the Mitanins have been able to act on the social determinants of health, describing the catalysts and processes involved and the enabling programmatic and organizational factors. A qualitative comparative case study of successful action by Mitanin was conducted in two 'blocks', purposefully selected as positive exemplars in two districts of Chhattisgarh. One case focused on malnutrition and the other on gender-based violence. Data collection involved 17 in-depth interviews and 10 group interviews with the full range of stakeholders in both blocks, including community members and programme team. Thematic analysis was done using a broad conceptual framework that was further refined. Action on social determinants involved raising awareness on rights, mobilizing women's collectives, revitalizing local political structures and social action targeting both the community and government service providers. Through these processes, the Mitanins developed identities as agents of change and advocates for the community, both with respect to local cultural and gender norms and in ensuring accountability of service providers. The factors underpinning successful action on social determinants were identified as the significance of the original intent and vision of the programme, and how this was carried through into all aspects of programme design, the role of the Mitanins and their identification with village women, ongoing training and support, and the relative autonomy of the programme. Although the results are not narrowly generalizable and do not necessarily represent the situation of the Mitanin Programme as a whole, the explanatory framework may provide general lessons for programmes in similar contexts.Item A composite indicator to measure universal health care coverage in India: way forward for post-2015 health system performance monitoring framework(Health Policy Plan., 2017) Shankar Prinja; Rakesh Gupta; Pankaj Bahuguna; Atul Sharma; Arun Kumar Aggarwal; Amit Phogat; Rajesh KumarBackground There is limited work done on developing methods for measurement of universal health coverage. We undertook a study to develop a methodology and demonstrate the practical application of empirically measuring the extent of universal health coverage at district level. Additionally, we also develop a composite indicator to measure UHC. Methods A cross-sectional survey was undertaken among 51 656 households across 21 districts of Haryana state in India. Using the WHO framework for UHC, we identified indicators of service coverage, financial risk protection, equity and quality based on the Government of India and the Haryana Government's proposed UHC benefit package. Geometric mean approach was used to compute a composite UHC index (CUHCI). Various statistical approaches to aggregate input indicators with or without weighting, along with various incremental combinations of input indicators were tested in a comprehensive sensitivity analysis. Findings The population coverage for preventive and curative services is presented. Adjusting for inequality, the coverage for all the indicators were less than the unadjusted coverage by 0.1-6.7% in absolute term and 0.1-27% in relative term. There was low unmet need for curative care. However, about 11% outpatient consultations were from unqualified providers. About 30% households incurred catastrophic health expenditures, which rose to 38% among the poorest 20% population. Summary index (CUHCI) for UHC varied from 12% in Mewat district to 71% in Kurukshetra district. The inequality unadjusted coverage for UHC correlates highly with adjusted coverage. Conclusion Our paper is an attempt to develop a methodology to measure UHC. However, careful inclusion of others indicators of service coverage is recommended for a comprehensive measurement which captures the spirit of universality. Further, more work needs to be done to incorporate quality in the measurement framework.Item Abortion quality of care from the client perspective: a qualitative study in India and Kenya(Health Policy Plan., 2021) Sarah E. Baum; Rebecca Wilkins; Muthoni Wachira; Deepesh Gupta; Shamala Dupte; Peter Ngugi; Shelly MakleffQuality healthcare is a key part of people's right to health and dignity, yet access to high-quality care can be limited by legal, social and economic contexts. There is limited consensus on what domains constitute quality in abortion care and the opinions of people seeking abortion have little representation in current abortion quality measures. In this qualitative study, we conducted 45 interviews with abortion clients in Mumbai, India, and in Eldoret and Thika, Kenya, to assess experiences with abortion care, definitions of quality and priorities for high-quality abortion care. Among the many aspects of care that mattered to clients, the client-provider relationships emerged as essential. Clients prioritized being treated with kindness, respect and dignity; receiving information and counselling that was personalized to their individual situation and reassurance and support from their provider throughout the entire abortion process, including follow-up after the abortion. Many clients also noted the importance of skilled providers and appropriate care. There were similarities across the two country contexts, yet there were some differences in how clients defined high-quality care; therefore, specific political and cultural influences must be considered when implementing measurement and improving person-centred quality of care. These domains, particularly interpersonal interactions, should be prioritized in India and Kenya when health systems, facilities and providers design person-centred measures for quality in abortion care.