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

Tenure Security and Urban Social Protection Links: India

Guaranteeing tenure security to the households living in informal settlements (slums) has not seen any progress in urban India. This is because the policymakers have failed to see land tenure status as a continuum from insecure tenure to a legal status. In general, the poor in the cities move from informal to quasi?legal ( de facto ) tenure through various processes, and then to legal tenure ( de jure ) in cases of a public policy intervention that confers property title on them. In the absence of such a policy, the urban poor and low?income migrants can seek to consolidate their urban citizenship through political citizenship in an electoral democracy, through welfare interventions by the state and above all, through their own subversions of urban legalities. This article first illustrates the existence of a continuum of tenure status in informal settlements in Ahmedabad City. It explains the factors that give a slum settlement a particular level of tenure status; and then through quantitative data, links the level of tenure security to social protection outcomes. The article shows that through small public actions, it is possible to improve access of the urban poor to social protection measures and that it is not necessary to leapfrog to extending property rights to the dwellers of these informal settlements. It is essential to realise that if land titles are given in a society where other rights are not present, the poor will not be able to retain them

Protocol for a cluster randomised trial in Madhya Pradesh, India: community health promotion and medical provision and impact on neonates (CHAMPION2); and support to rural India's public education system and impact on numeracy and literacy scores (STRIPES2).

BACKGROUND: Rural areas of India exhibit high neonatal mortality, and low literacy and numeracy. We assess the effect of a complex package of health interventions on neonatal survival and the effect of out-of-school-hours teaching on children's literacy and numeracy in rural Madhya Pradesh. METHODS/DESIGN: This is a cluster-randomised controlled trial with villages (clusters) receiving either a health (CHAMPION2) or education (STRIPES2) intervention. Building on the design of the earlier CHAMPION/STRIPES trial, villages receiving the health intervention are controls for the education intervention and vice versa. The clusters are 196 villages in Satna district, Madhya Pradesh, India: each is at least 5 km from a Community Health Centre, has a population below 2500, and has at least 15 children eligible for the education intervention. The participants in CHAMPION2 are resident married women younger than 50 years of age who had not undergone a family planning operation, provided they are enumerated pre-randomisation or marry a man enumerated pre-randomisation. The participants in STRIPES2 are resident children born 16 June 2010 to 15 June 2013, not in school before the 2018-2019 school year and intending to enrol in first grade in 2018-2019 or 2019-2020. DISCUSSION: In CHAMPION2, the NICE Foundation will deliver a 3.5-year programme comprising Accredited Social Health Activists or village health workers and midwives promoting health knowledge and providing antenatal, postnatal, and neonatal healthcare; community mobilisation; referrals to appropriate government health facilities; and a health education campaign. In STRIPES2, the Pratham Education Foundation will deliver a programme of village-based, before/after school support focusing on literacy and numeracy. As controls, the CHAMPION2 control villages will receive the usual health services (plus the STRIPES2 intervention). STRIPES2 control villages will receive the usual education services (plus the CHAMPION2 intervention). The primary outcome in CHAMPION2 is neonatal mortality. Secondary outcomes include antenatal, delivery, immediate neonatal and postnatal care practices, maternal mortality, stillbirths, early neonatal deaths, perinatal deaths, health knowledge, hospital admissions, maternal blood transfusions, and cost effectiveness. The primary outcome in STRIPES2 is a composite literacy and numeracy test score. Secondary outcomes include separate literacy and numeracy scores, reported school enrolment and attendance, parents' engagement with children's learning, and cost effectiveness. Independent research and implementation teams will conduct the trial. Trial Steering and Data Monitoring Committees, with independent members, will supervise the trial. TRIAL REGISTRATION: Clinical Trial Registry of India: CTRI/2019/05/019296. Registered on 23 May 2019. http://www.ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=31198&EncHid=&modid=&compid=%27,%2731198det%27

Male Use of Female Sex Work in India: A Nationally Representative Behavioural Survey

Heterosexual transmission of HIV in India is driven by the male use of female sex workers (FSW), but few studies have examined the factors associated with using FSW. This nationally representative study examined the prevalence and correlates of FSW use among 31,040 men aged 15–49 years in India in 2006. Nationally, about 4% of men used FSW in the previous year, representing about 8.5 million FSW clients. Unmarried men were far more likely than married men to use FSW overall (PR = 8.0), but less likely than married men to use FSW among those reporting at least one non-regular partner (PR = 0.8). More than half of all FSW clients were married. FSW use was higher among men in the high-HIV states than in the low-HIV states (PR = 2.7), and half of all FSW clients lived in the high-HIV states. The risk of FSW use rose sharply with increasing number of non-regular partners in the past year. Given the large number of men using FSW, interventions for the much smaller number of FSW remains the most efficient strategy for curbing heterosexual HIV transmission in India

Leveraging human capital to reduce maternal mortality in India: enhanced public health system or public-private partnership?

Developing countries are currently struggling to achieve the Millennium Development Goal Five of reducing maternal mortality by three quarters between 1990 and 2015. Many health systems are facing acute shortages of health workers needed to provide improved prenatal care, skilled birth attendance and emergency obstetric services – interventions crucial to reducing maternal death. The World Health Organization estimates a current deficit of almost 2.4 million doctors, nurses and midwives. Complicating matters further, health workforces are typically concentrated in large cities, while maternal mortality is generally higher in rural areas. Additionally, health care systems are faced with shortages of specialists such as anaesthesiologists, surgeons and obstetricians; a maldistribution of health care infrastructure; and imbalances between the public and private health care sectors. Increasingly, policy-makers have been turning to human resource strategies to cope with staff shortages. These include enhancement of existing work roles; substitution of one type of worker for another; delegation of functions up or down the traditional role ladder; innovation in designing new jobs;transfer or relocation of particular roles or services from one health care sector to another. Innovations have been funded through state investment, public-private partnerships and collaborations with nongovernmental organizations and quasi-governmental organizations such as the World Bank. This paper focuses on how two large health systems in India – Gujarat and Tamil Nadu – have successfully applied human resources strategies in uniquely different contexts to the challenges of achieving Millennium Development Goal Five