Declining free healthcare and rising treatment costs in India: an analysis of national sample surveys 1986-2004

The article focuses on trends in health-seeking behaviour of people and choosing between government and private sources, reasons for not accessing health care and the cost of treatment by examining three rounds of NSS data on health care use and morbidity pattern during 1986–87, 1995–96 and 2004. With variation across states, treatment-seeking from public providers has declined and preference for private providers has increased over the period. Although overall health-seeking behaviour has improved for both males and females, a significant percentage of people, more in rural than urban areas, do not seek treatment due to lack of accessibility and consider that the illness is not serious enough to require treatment. The financial reason for not seeking treatment was also an important issue in rural areas. There has also been change in the cost of health care over time. While the health care cost has increased, the gap between the public and the private has reduced, owing to perhaps increased cost of treatment in public health facilities following the levying of user-fees and curtailing distribution of free medicine. Practically all states reported decline in availability of free both out-patient and in-patient care. The article concludes with supporting the adaptation of innovative public-private partnership in health sector for various services realizing the limitations of the state provision of health, particularly in rural and remote areas, and the growing preference of consumers for private health providers. As effectiveness of public spending also depends on the choice of health interventions, target population and technical efficiency partnering with private health providers could work towards reducing the health inequalities in the country

Bans of WHO Class I Pesticides in Bangladesh –Suicide Prevention without Hampering Agricultural Output

Pesticide self-poisoning is a major problem in Bangladesh. Over the past 20-years, the Bangladesh government has introduced pesticide legislation and banned highly hazardous pesticides (HHPs) from agricultural use. We aimed to assess the impacts of pesticide bans on suicide and on agricultural production.We obtained data on unnatural deaths from the Statistics Division of Bangladesh Police, and used negative binomial regression to quantify changes in pesticide suicides and unnatural deaths following removal of WHO Class I toxicity HHPs from agriculture in 2000. We assessed contemporaneous trends in other risk factors, pesticide usage and agricultural production in Bangladesh from 1996 to 2014.Mortality in hospital from pesticide poisoning fell after the 2000 ban: 15.1% vs 9.5%, relative reduction 37.1% [95% confidence interval (CI) 35.4 to 38.8%]. The pesticide poisoning suicide rate fell from 6.3/100 000 in 1996 to 2.2/100 000 in 2014, a 65.1% (52.0 to 76.7%) decline. There was a modest simultaneous increase in hanging suicides [20.0% (8.4 to 36.9%) increase] but the overall incidence of unnatural deaths fell from 14.0/100 000 to 10.5/100 000 [25.0% (18.1 to 33.0%) decline]. There were 35 071 (95% CI 25 959 to 45 666) fewer pesticide suicides in 2001 to 2014 compared with the number predicted based on trends between 1996 to 2000. This reduction in rate of pesticide suicides occurred despite increased pesticide use and no change in admissions for pesticide poisoning, with no apparent influence on agricultural output.Strengthening pesticide regulation and banning WHO Class I toxicity HHPs in Bangladesh were associated with major reductions in deaths and hospital mortality, without any apparent effect on agricultural output. Our data indicate that removing HHPs from agriculture can rapidly reduce suicides without imposing substantial agricultural costs

Impact of a hospital improvement initiative in Bangladesh on patient experiences and satisfaction with services: two cross-sectional studies

<p>Abstract</p> <p>Background</p> <p>The Bangladesh government implemented a pilot Hospital Improvement Initiative (HII) in five hospitals in Sylhet division between 1998 and 2003. This included management and behaviour change training for staff, waste disposal and procurement, and referral arrangements. Two linked cross-sectional surveys in 2000 and 2003 assessed the impact of the HII, assessing both patients' experience and satisfaction and public views and use of the hospitals.</p> <p>Methods</p> <p>In each survey we asked 300 consecutive outpatients and a stratified random sample of 300 inpatients in the five hospitals about waiting and consultation time, use of an agent for admission, and satisfaction with privacy, cleanliness, and staff behaviour. The field teams observed cleanliness and privacy arrangements, and visited a sample of households in communities near the hospitals to ask about their opinions and use of the hospital services. Analysis examined changes over time in patients' experience and views. Multivariate analysis took account of other variables potentially associated with the outcomes. Survey managers discussed the survey findings with gender stratified focus groups in each sample community.</p> <p>Results</p> <p>Compared with 2000, an outpatient in three of the hospitals in 2003 was more likely to be seen within 10 minutes and for at least five minutes by the doctor, but outpatients were less likely to report receiving all the prescribed medicines from the hospital. In 2003, inpatients were more likely to have secured admission without using an agent. Although patients’ satisfaction with several aspects of care improved, most changes were not statistically significant. Households in 2003 were significantly more likely to rate the hospitals as good than in 2000. Use of the hospitals did not change, except that more households used the medical college hospital for inpatient care in 2003. Focus groups confirmed criticisms of services and suggested improvements.</p> <p>Conclusion</p> <p>Improvements in some aspects of patients' experience may have been due to the programme, but the decreased availability of medicines in government facilities across the country over the period also occurred in these hospitals. Monitoring patients’ experience and satisfaction as well as public views and use of hospital services is feasible and useful for assessing service interventions.</p