Size, composition and distribution of human resource for health in India: new estimates using National Sample Survey and Registry data

Objectives We provide new estimates on size, composition and distribution of human resource for health in India and compare with the health workers population ratio as recommended by the WHO. We also estimate size of non-health workers engaged in health sector and the size of technically qualified health professionals who are not a part of the health workforce. Design Nationally representative cross-section household survey and review of published documents by the Central Bureau of Health Intelligence. Setting National Participants Head of household/key informant in a sample of 101 724 households. Interventions Not applicable. Primary and secondary outcome measures The primary outcome was the number and density of health workers,and the secondary outcome was the percentage of health workers who are technically qualified and the percentage of individuals technically qualified and not in workforce. Results The total size of health workforce estimated from the National Sample Survey (NSS) data is 3.8 million as of January 2016, which is about 1.2 million less than the total number of health professionals registered with different councils and associations. The density of doctors and nurses and midwives per 10 000 population is 20.6 according to the NSS and 26.7 based on the registry data. Health workforce density in rural India and states in eastern India is lower than the WHO minimum threshold of 22.8 per 10 000 population. More than 80% of doctors and 70% of nurses and midwives are employed in the private sector. Approximately 25% of the currently working health professionals do not have the required qualifications as laid down by professional councils, while 20% of adequately qualified doctors are not in the current workforce. Conclusions Distribution and qualification of health professionals are serious problems in India when compared with the overall size of the health workers. Policy should focus on enhancing the quality of health workers and mainstreaming professionally qualified persons into the health workforce

The Hypolipidemic Activity of Metal Complexes of Amine Carboxyboranes in Rodents

The metal complexes of amine-carboxyborane including copper, chromium, zinc, calcium amd cobalt were effective hypolipidemic agents lowering both serum cholesterol and triglyceride levels significantly in mice at 8 mg/kg/day, I.P. after 16 days. The agents reduced acetyl CoA synthetase, ATP-dependent citrate lyase, acyl CoA cholesterol acyl transferase, sn-glycerol-3-phosphate acyl transferase activities of rat liver and small intestinal mucosa after 14 days treatment. The neutral cholesterol ester hydrolase activity was elevated by the agents in both tissues. The metal complexes altered lipid levels in the bile of rats after treatment as well as the bile acid composition after 14 days administration, orally. The agents blocked enterohepatic absorption of cholesterol from rat isolated intestinal loops

Impact of India's National Tobacco Control Programme on bidi and cigarette consumption: a difference-in-differences analysis.

BACKGROUND: Despite the importance of decreasing tobacco use to achieve mortality reduction targets of the Sustainable Development Goals in low-income and middle-income countries (LMICs), evaluations of tobacco control programmes in these settings are scarce. We assessed the impacts of India's National Tobacco Control Programme (NTCP), as implemented in 42 districts during 2007-2009, on household-reported consumption of bidis and cigarettes. METHODS: Secondary analysis of cross-sectional data from nationally representative Household Consumer Expenditure Surveys (1999-2000; 2004-2005 and 2011-2012). Outcomes were: any bidi/cigarette consumption in the household and monthly consumption of bidi/cigarette sticks per person. A difference-in-differences two-part model was used to compare changes in bidi/cigarette consumption between NTCP intervention and control districts, adjusting for sociodemographic characteristics and time-based heterogeneity. FINDINGS: There was an overall decline in household-reported bidi and cigarette consumption between 1999-2000 and 2011-2012. However, compared with control districts, NTCP districts had no significantly different reductions in the proportions of households reporting bidi (adjusted OR (AOR): 1.03, 95% CI: 0.84 to 1.28) or cigarette (AOR: 1.01 to 95% CI: 0.82 to 1.26) consumption, or for the monthly per person consumption of bidi (adjusted coefficient: 0.07, 95% CI: -0.13 to 0.28) or cigarette (adjusted coefficient: -0.002, 95% CI: -0.26 to 0.26) sticks among bidi/cigarette consuming households. INTERPRETATION: Our findings indicate that early implementation of the NTCP may not have produced reductions in tobacco use reflecting generally poor performance against the Framework Convention for Tobacco Control objectives in India. This study highlights the importance of strengthening the implementation and enforcement of tobacco control policies in LMICs to achieve national and international child health and premature NCD mortality reduction targets

Multimorbidity, healthcare use and catastrophic health expenditure by households in India: a cross-section analysis of self-reported morbidity from national sample survey data 2017–18

Background: The purpose of this research is to generate new evidence on the economic consequences of multimorbidity on households in terms of out-of-pocket (OOP) expenditures and their implications for catastrophic OOP expenditure. Methods: We analyzed Social Consumption Health data from National Sample Survey Organization (NSSO) 75th round conducted in the year 2017–2018 in India. The sample included 1,13,823 households (64,552 rural and 49,271 urban) through a multistage stratified random sampling process. Prevalence of multimorbidity and related OOP expenditure were estimated. Using Coarsened Exact Matching (CEM) we estimated the mean OOP expenditure for individuals reporting multimorbidity and single morbidity for each episode of outpatient visits and hospital admission. We also estimated implications in terms of catastrophic OOP expenditure for households. Results: Results suggest that outpatient OOP expenditure is invariably lower in the presence of multimorbidity as compared with single conditions of the selected Non-Communicable Diseases(NCDs) (overall, INR 720 [USD 11.3] for multimorbidity vs. INR 880 [USD 14.8] for single). In the case of hospitalization, the OOP expenditures were mostly higher for the same NCD conditions in the presence of multimorbidity as compared with single conditions, except for cancers and cardiovascular diseases. For cancers and cardiovascular, OOP expenditures in the presence of multimorbidity were lower by 39% and 14% respectively). Furthermore, around 46.7% (46.674—46.676) households reported incurring catastrophic spending (10% threshold) because of any NCD in the standalone disease scenario which rose to 63.3% (63.359–63.361) under the multimorbidity scenario. The catastrophic implications of cancer among individual diseases was the highest. Conclusions: Multimorbidity leads to high and catastrophic OOP payments by households and treatment of high expenditure diseases like cancers and cardiovascular are under-financed by households in the presence of competing multimorbidity conditions. Multimorbidity should be considered as an integrated treatment strategy under the existing financial risk protection measures (Ayushman Bharat) to reduce the burden of household OOP expenditure at the country level.Publication Funding was obtained from Research England Policy Impact Fund Grant given by Queen Mary University of London

Changing pattern of household expenditure on health and the role of public health insurance schemes for the poor in India: case of Rashtriya Swasthya Bima Yojana

Background: In order to protect the poor from health shocks, the Government of India launched Rashtriya Swasthya Bima Yojna (RSBY) in 2008. The objectives of this study are: a) to assess the changes in the financial burden of health care on the poor population; b) to estimate the effects of RSBY in reducing the financial burden on the poor; and c) to examine the impact of RSBY on the labour supply of the poor. Methods: The study is based on data from the National Sample Survey Organisation (NSSO). The sample size is between 100-125 thousand households at the all-India level. The study uses pooled cross-section regression analysis to assess the changing pattern of out-of-pocket (OOP) payments on healthcare. The impact of RSBY on financial risk protection and labour force participation rate in India were estimated using the difference-in-differences (DID) method. Findings: My thesis consists of three papers. The findings in the first paper, changing pattern of out-of-pocket payments, reflect that the poorest 20% of households, compared to the richest 20%, realised a slower increase in out-of-pocket as a share of the household’s total expenditure (-0.5%) and catastrophic payments (-2%) during the period of 2000-2012. However, during the same period, Scheduled caste/tribe and Muslim households reported an increased burden of out-of-pocket. The second paper finds reduction in the probability of incurring ‘any inpatient expenditure’ and ‘catastrophic inpatient expenditure’ after RSBY intervention but marginal increase in the ‘per person monthly inpatient expenditure’ and insignificant change in ‘inpatient expenditure as a share of households’ total expenditure’. The effects of the scheme on the total out-of-pocket payment are negligible and non-drug expenditure reflected significant increase. The third paper finds that women’s labour supply increased (3% per annum) but the elderly labour supply declined (1.5%). Further, men switched from self-employment to casual work while women moved to wage-paid regular and casual jobs at the cost of being self-employed. Discussion and conclusion: The poor and other less advantaged population groups realised an increasing OOP burden mainly on account of two factors: i) outpatient care is not covered under RSBY; and ii) the benefit package under the scheme is very modest. Women’s labour supply increased and the elderly labour supply declined in favour of leisure because of possible improvements in health. However, the overall labour supply did not change. The Indian government needs to consider broadening the benefit package and including outpatient coverage under RSBY.</p

Changing Pattern of Household Expenditure on Health and the Role of Public Health Insurance Schemes for the Poor in India: Case of Rashtriya Swasthya Bima Yojana

Background: In order to protect the poor from health shocks, the Government of India launched Rashtriya Swasthya Bima Yojna (RSBY) in 2008. The objectives of this study are: a) to assess the changes in the financial burden of health care on the poor population; b) to estimate the effects of RSBY in reducing the financial burden on the poor; and c) to examine the impact of RSBY on the labour supply of the poor. Methods: The study is based on data from the National Sample Survey Organisation (NSSO). The sample size is between 100-125 thousand households at the all-India level. The study uses pooled cross-section regression analysis to assess the changing pattern of out-of-pocket (OOP) payments on healthcare. The impact of RSBY on financial risk protection and labour force participation rate in India were estimated using the difference-in-differences (DID) method. Findings: My thesis consists of three papers. The findings in the first paper, changing pattern of out-of-pocket payments, reflect that the poorest 20% of households, compared to the richest 20%, realised a slower increase in out-of-pocket as a share of the household’s total expenditure (-0.5%) and catastrophic payments (-2%) during the period of 2000-2012. However, during the same period, Scheduled caste/tribe and Muslim households reported an increased burden of out-of-pocket. The second paper finds reduction in the probability of incurring ‘any inpatient expenditure’ and ‘catastrophic inpatient expenditure’ after RSBY intervention but marginal increase in the ‘per person monthly inpatient expenditure’ and insignificant change in ‘inpatient expenditure as a share of households’ total expenditure’. The effects of the scheme on the total out-of-pocket payment are negligible and non-drug expenditure reflected significant increase. The third paper finds that women’s labour supply increased (3% per annum) but the elderly labour supply declined (1.5%). Further, men switched from self-employment to casual work while women moved to wage-paid regular and casual jobs at the cost of being self-employed. Discussion and conclusion: The poor and other less advantaged population groups realised an increasing OOP burden mainly on account of two factors: i) outpatient care is not covered under RSBY; and ii) the benefit package under the scheme is very modest. Women’s labour supply increased and the elderly labour supply declined in favour of leisure because of possible improvements in health. However, the overall labour supply did not change. The Indian government needs to consider broadening the benefit package and including outpatient coverage under RSBY.This thesis is not currently available on ORA

Adequacy of dietary intakes and poverty in India: Trends in the 1990s

Linear programming methods, indicators of nutritional adequacy from the Indian Council of Medical Research and household expenditure survey data from the National Sample Survey Organization were used to construct poverty lines for India. Poverty ratios were calculated for 1993-1994 and 1999-2000 on the basis of nutritional adequacy poverty lines and compared to official estimates of poverty based on energy requirements. Nutritional adequacy poverty lines are higher than official poverty lines, particularly in rural areas. The application of nutritional adequacy poverty lines points to greater rural-urban poverty differences than in official estimates. Declines in rural poverty during the 1990s were also slower under the nutritional adequacy definition, especially in south India. There is a greater degree of rural-urban and regional bias in nutritional adequacy poverty reduction than suggested by official data. Inter-state variations in changes in nutritional poverty and official poverty in the 1990s are largely explained by differences in assumptions on overall price movements. However, relative price movements in food items also played a role, particularly the slow increase in prices of cereals and edible oils in comparison to the prices of pulses, and in some southern states, compared to milk and vegetable prices as well.

Extending health insurance to the poor in India: An impact evaluation of Rashtriya Swasthya Bima Yojana on out of pocket spending for healthcare

India launched the ‘Rashtriya Swasthya Bima Yojana’ (RSBY) health insurance scheme for the poor in 2008. Utilising 3 waves (1999–2000, 2004–05 and 2011–12) of household level data from nationally representative surveys of the National Sample Survey Organisation (NSSO) (N = 346,615) and district level RSBY administrative data on enrolment, we estimated causal effects of RSBY on out-of-pocket expenditure. Using ‘difference-in-differences’ methods on households in matched districts we find that RSBY did not affect the likelihood of inpatient out-of-pocket spending, the level of inpatient out of pocket spending or catastrophic inpatient spending. We also do not find any statistically significant effect of RSBY on the level of outpatient out-of-pocket expenditure and the probability of incurring outpatient expenditure. In contrast, the likelihood of incurring any out of pocket spending (inpatient and outpatient) rose by 30% due to RSBY and was statistically significant. Although out of pocket spending levels did not change, RSBY raised household non-medical spending by 5%. Overall, the results suggest that RSBY has been ineffective in reducing the burden of out-of-pocket spending on poor households

Health and Millennium Development Goal 1: Reducing Out-of-pocket Expenditures to Reduce Income Poverty - Evidence from India

The first of the eight Millennium Development Goals is to halve extreme poverty and hunger by 2015. In India, thirty two and a half million people fall below the national poverty line by making out-of- pocket payments for health care in a single year. This paper shows how in a country with large out of pocket payments, targeting a few poor states, rural areas and urban poor could drastically bring down the number of people falling below the poverty line and also reduce the poverty deepening effect for those already below the poverty line. High expenditures on drugs are shown to be one of the main reasons for high out of pocket payments. Improved drug availability in public facilities and totally subsidizing the urban poor and rural areas are required for reducing the poverty impact of out of pocket payments. [EQUITAP WP No. 15].out of pocket payments, urban poor, poor state, Poverty, health care payments, Millennium Development Goals, Equity, India, line, country