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

Stressful life-events exposure is associated with 17-year mortality, but it is health-related events that prove predictive

Objectives Despite the widely-held view that psychological stress is a major cause of poor health, few studies have examined the relationship between stressful life-events exposure and death. The present analyses examined the association between overall life-events stress load, health-related and health-unrelated stress, and subsequent all-cause mortality.\ud \ud Design This study employed a prospective longitudinal design incorporating time-varying covariates.\ud \ud Methods Participants were 968 Scottish men and women who were 56 years old. Stressful life-events experience for the preceding 2 years was assessed at baseline, 8–9 years and 12–13 years later. Mortality was tracked for the subsequent 17 years during which time 266 participants had died. Cox's regression models with time-varying covariates were applied. We adjusted for sex, occupational status, smoking, BMI, and systolic blood pressure.\ud \ud Results Overall life-events numbers and their impact scores at the time of exposure and the time of assessment were associated with 17-year mortality. Health-related event numbers and impact scores were strongly predictive of mortality. This was not the case for health-unrelated events.\ud \ud Conclusions The frequency of life-events and the stress load they imposed were associated with all-cause mortality. However, it was the experience and impact of health-related, not health-unrelated, events that proved predictive. This reinforces the need to disaggregate these two classes of exposures in studies of stress and health outcomes.\u

Fertility, social class, gender, and the professional model: statistical explanation and historical significance

In 2012 Barnes and Guinnane published a revised statistical analysis of the critical evaluation of the official 1911 social class model of fertility decline that was presented in chapter 6 of Szreter’s Fertility Class and Gender in Britain, 1860-1940 (FCG). They argue that the official model of five ranked social classes is, after all, a satisfactory statistical summary of the fertility variance found among the married couples of England and Wales at the famous 1911 fertility census and so they conclude that, pace Szreter, the official model provides a satisfactory account of the nation’s fertility decline as one of social class differentials. It is acknowledged here that B&G have deployed superior statistical techniques. But it is pointed-out that FCG identified far more fundamental problems with the design of the 1911 official model. It was a social evolutionary model privileging male professional occupations, not a modelling of recognised social class theory at the time or since. In FCG it was therefore termed ‘the professional model’. The central historiographical claim of Fertility, Class and Gender is re-affirmed: that in order to study fruitfully and to further elucidate the complex historical relationship between social class and the fertility decline among married couples in England and Wales, an alternative approach to that of the professional model of fertility variation is needed, one which explicitly integrates gender relations with social class.This is the accepted manuscript. It's currently embargoed until 19/03/2017. The final version is available from Wiley at http://onlinelibrary.wiley.com/doi/10.1111/ehr.12102/abstrac

Self-reported health and cardiovascular reactions to psychological stress in a large community sample: Cross-sectional and prospective associations

Exaggerated cardiovascular reactions to acute psychological stress have been implicated in a number of adverse health outcomes. This study examined, in a large community sample, the cross-sectional and prospective associations between reactivity and self-reported health. Blood pressure and heart rate were measured at rest and in response to an arithmetic stress task. Self-reported health was assessed concurrently and five years later. In cross-sectional analyses, those with excellent/good self-reported health exhibited larger cardiovascular reactions than those with fair/poor subjective health. In prospective analyses, participants who had larger cardiovascular reactions to stress were more likely to report excellent/good health five years later, taking into account their reported health status at the earlier assessment. The findings suggest that greater cardiovascular reactivity may not always be associated with negative health outcomes

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

On the measurement of inequalities in health

This paper offers a critical appraisal of the various methods employed to date to measure inequalities in health. It suggests that only two of these—the slope index of inequality and the concentration index—are likely to present an accurate picture of socioeconomic inequalities in health. The paper also presents several empirical examples to illustrate of the dangers of using other measures such as the range, the Lorenz curve and the index of dissimilarity

Life events and hemodynamic stress reactivity in the middle-aged and elderly

Recent versions of the reactivity hypothesis, which consider it to be the product of stress exposure and exaggerated haemodynamic reactions to stress that confers cardiovascular disease risk, assume that reactivity is independent of the experience of stressful life events. This assumption was tested in two substantial cohorts, one middle-aged and one elderly. Participants had to indicate from a list of major stressful life events up to six they had experienced in the previous two years. They were also asked to rate how disruptive and stressful they were, at the time of occurrence and now. Blood pressure and pulse rate were measured at rest and in response to acute mental stress. Those who rated the events as highly disruptive at the time of exposure and currently exhibited blunted systolic blood pressure reactions to acute stress. The present results suggest that acute stress reactivity may not be independent of stressful life events experience

The STRIPES Trial - Support to Rural India's Public Education System

Background Performance of primary school students in India lags far below government expectations, and major disparity exists between rural and urban areas. The Naandi Foundation has designed and implemented a programme using community members to deliver after-school academic support for children in over 1,100 schools in five Indian states. Assessments to date suggest that it might have a substantial effect. This trial aims to evaluate the impact of this programme in villages of rural Andhra Pradesh and will compare test scores for children in three arms: a control and two intervention arms. In both intervention arms additional after-school instruction and learning materials will be offered to all eligible children and in one arm girls will also receive an additional 'kit' with a uniform and clothes. Methods/Design The trial is a cluster-randomised controlled trial conducted in conjunction with the CHAMPION trial. In the CHAMPION trial 464 villages were randomised so that half receive health interventions aiming to reduce neonatal mortality. STRIPES will be introduced in those CHAMPION villages which have a public primary school attended by at least 15 students at the time of a baseline test in 2008. 214 villages of the 464 were found to fulfil above criteria, 107 belonging to the control and 107 to the intervention arm of the CHAMPION trial. These latter 107 villages will serve as control villages in the STRIPES trial. A further randomisation will be carried out within the 107 STRIPES intervention villages allocating half to receive an additional kit for girls on the top of the instruction and learning materials. The primary outcome of the trial is a composite maths and language test score. Discussion The study is designed to measure (i) whether the educational intervention affects the exam score of children compared to the control arm, (ii) if the exam scores of girls who receive the additional kit are different from those of girls living in the other STRIPES intervention arm. One of the goals of the STRIPES trial is to provide benefit to the controls of the CHAMPION trial. We will also conduct a cost-benefit analysis in which we calculate the programme cost for 0.1 standard deviation improvement for both intervention arms