The Best Laid Plans: Access to the Rajiv Aarogyasri community health insurance scheme of Andhra Pradesh

This paper is a qualitative assessment of a public health insurance scheme in the state of Andhra Pradesh, south India, called the Rajiv Aarogyasri Community Health Insurance Scheme (or Aarogyasri), using the case-study method. Focusing on inpatient hospital care and especially on surgical treatments leaves the scheme wanting in meeting the health care needs of and addressing the impoverishing health expenditure incurred by the poor, especially those living in rural areas. Though well-intentioned, people from vulnerable sections of society may find the scheme ultimately unhelpful for their needs. Through an in-depth qualitative approach, the paper highlights not just financial difficulties but also the non-financial barriers to accessing health care, despite the existence of a scheme such as Aarogyasri. Narrative evidence from poor households offers powerful insights into why even the most innovative state health insurance schemes may not achieve their goals and systemic corrections needed to address barriers to health care

Hepatocellular carcinoma with extension to the diaphragm, falciform ligament, rectus abdominis and paraumbilical vein

Hepatocellular carcinoma is the most common primary tumour of the liver. The most common extrahepatic metastatic sites are the lung, lymph nodes, bones and adrenal glands. All forms of HCC demonstrate a tendency for vascular invasion, producing extensive intrahepatic metastases and, occasionally, portal vein or inferior vena cava extension with spread into the right atrium in extreme cases. Tumour spread of abdominal diseases via hepatic ligaments has also been previously reported. We report a rare case of hepatocellular carcinoma with extension into the falciform ligament, overlying rectus sheath and adjacent diaphragm with concomitant infiltration into the recanalised paraumbilical vein

The Best Laid Plans: Access to the Rajiv Aarogyasri community health insurance scheme of Andhra Pradesh

This paper is a qualitative assessment of a public health insurance scheme in the state of Andhra Pradesh, south India, called the Rajiv Aarogyasri Community Health Insurance Scheme (or Aarogyasri), using the case-study method. Focusing on inpatient hospital care and especially on surgical treatments leaves the scheme wanting in meeting the health care needs of and addressing the impoverishing health expenditure incurred by the poor, especially those living in rural areas. Though well-intentioned, people from vulnerable sections of society may find the scheme ultimately unhelpful for their needs. Through an in-depth qualitative approach, the paper highlights not just financial difficulties but also the non-financial barriers to accessing health care, despite the existence of a scheme such as Aarogyasri. Narrative evidence from poor households offers powerful insights into why even the most innovative state health insurance schemes may not achieve their goals and systemic corrections needed to address barriers to health care

Private sector participation in delivering tertiary health care: a dichotomy of access and affordability across two Indian states

Poor quality care in public sector hospitals coupled with the costs of care in the private sector have trapped India's poor in a vicious cycle of poverty, ill health and debt for many decades. To address this, the governments of Andhra Pradesh (AP) and Maharashtra (MH), India, have attempted to improve people’s access to hospital care by partnering with the private sector. A number of government-sponsored schemes with differing specifications have been launched to facilitate this strategy. Aims This article aims to compare changes in access to, and affordability and efficiency of private and public hospital inpatient (IP) treatments between MH and AP from 2004 to 2012 and to assess whether the health financing innovations in one state resulted in larger or smaller benefits compared with the other. Methods We used data from household surveys conducted in 2004 and 2012 in the two states and undertook a difference-in-difference (DID) analysis. The results focus on hospitalization, out-of-pocket expenditure and length of stay. Results The average IP expenditure for private hospital care has increased in both states, but more so in MH. There was also an observable increase in both utilization of and expenditure on nephrology treatment in private hospitals in AP. The duration of stay recorded in days for private hospitals has increased slightly in MH and declined in AP with a significant DID. The utilization of public hospitals has reduced in AP and increased in MH. Conclusion The state of AP appears to have benefited more than MH in terms of improved access to care by involving the private sector. The Aarogyasri scheme is likely to have contributed to these impacts in AP at least in part. Our study needs to be followed up with repeated evaluations to ascertain the long-term impacts of involving the private sector in providing hospital care

Rajiv Aarogyasri Community Health Insurance Scheme evaluation survey

The study was based on a household survey to understand the impact of the Aarogyasri Community Health Insurance Scheme in operation across Andhra Pradesh state, India. It compared access to hospital care with that in the neighbouring state of Maharashtra. This is an impact evaluation study undertaken 5 years after launch of the scheme in 2007. The National Sample Survey Organisation Health Survey* conducted in 2004 provided the baseline data for both states. * See Links section for location of this dataAarogyasri Survey Raw DataField Training Manual APListing Schedule APCode Book APHousehold Survey Tool APCode Book MHField Training Manual MHListing Schedule MHHousehold Survey Tool M

A STUDY ON PATTERN OF ALCOHOL USE USING AUDIT AMONG THE COLLEGE STUDENTS IN A MEDICAL COLLEGE OF NORTH INDIA

ABSTRACT Background: Alcohol and other substance use by medical students poses risks to them and can also have serious consequences on their effectiveness and fitness to practise as tomorrow's doctors. The aim of the study was to find out the prevalence of alcohol use among the undergraduates of Rohilkhand Medical College, Bareilly and the factors affecting its use

Strengthening primary health systems in India

Crippling out of pocket health expenditure and lack of access to health care among the poor are significant challenges to improving health in India. In the highly populated states of Andhra Pradesh (AP) and Madhya Pradesh (MP), which are home to 154 million people, many live in poverty and suffer high rates of disease and mortality. Leading international health expert Professor Mala Rao has been evaluating health financing schemes in both of these states to assess their effectiveness and efficiency on behalf of organisations such as the UK Department for International Development (DFID), and supported by the Wellcome Trust, IDRC and the Rockefeller Foundation. Rao’s review of the Government of Madhya Pradesh’s State Illness Assistance Fund (SIAF) revealed that the scheme was underused and inequitable. It also exposed a poor data management system and highlighted that access to treatment was complex and burdensome. The review supported the development of more efficient financial support for care of the seriously ill and led to significant improvements such as the constitution of a State Steering Group which was tasked with overseeing the restructuring of the scheme. Government orders reflecting Rao’s recommendations have since resulted in a change to the fund management and delivery, re-negotiated costs with healthcare providers, devolved powers to authorize funds at district level, and better verification of SIAF-funded patients. Subsequently, the World Bank has acknowledged ‘substantial progress’ in the management of the scheme, laying the foundations for the eventual development of a single comprehensive health delivery system. For citizens, the number of annual total approvals for treatment has risen more than threefold, and a new feedback system is now being used to support improved monitoring, evaluation and selection of healthcare providers. A separate assessment of the Government of Andhra Pradesh’s (GoAP) Rajiv Aarogyasri Community Health Insurance scheme indicated a need for hospital-based healthcare schemes to be built on a strong platform of primary (family) care. The assessment also informed the development of a similar scheme in Maharashtra, the 'control' state in the research. Findings from both assessments supported the promotion of comprehensive primary care as the most effective means to reduce healthcare costs and improve health literacy, helping people to better understand their health care entitlements and navigate complex care pathways. In recognition of her work, Rao was appointed by the Chair of the Health Workstream of the UK-India CEO Forum as the Public Health academic expert to lead the development of a White Paper exploring the benefits and practicalities of a primary care partnership between India and the UK. The paper reached a very wide global audience of health policy leaders when it was published in the British Medical Journal in May 2012 (doi:10.1136/bmj.e3151). In India, the paper, and its discussion at a UK-India workshop in 2012, influenced the Government of India to encourage states to plan primary care pilots which would inform the development of comprehensive primary care, as a crucial platform for affordable universal health care. In Kerala, Rao has helped to develop proposals for piloting a new model of care across three primary health centres. In May 2013, the Government of India approved funding for the Government of Kerala to implement the proposal, which if successful, will be replicated across the country to reduce out-of-pocket expenses for outpatient care, provide better and more comprehensive and systematic community based care for people with a wide range of medical conditions, and reduce the need for secondary care.Impact case study - UEL website versionImpact case study submitted to REF2014 assessmen

What a difference a state makes: health reform in Andhra Pradesh

In the mid-2000s, India began rolling out large-scale, publicly-financed health insurance schemes mostly targeting the poor. This paper describes and analyzes Andhra Pradesh's Aarogyasri scheme, which covers against the costs of around 900 high-cost procedures delivered in secondary and tertiary hospitals. Using a new household survey, the authors find that 80 percent of families are eligible, equal to about 68 million people, and 85 percent of these families know they are covered; only one-quarter, however, know that the benefit package is limited. The study finds that, contrary to the rules of the program, patients incur quite large out-of-pocket payments during inpatient episodes thought to be covered by Aarogyasri. In the absence of data and program design features that would allow for a rigorous impact evaluation, a comparison is made between Andhra Pradesh and neighboring Maharashtra over an eight-year period spanning the scheme's introduction. During this period, Maharashtra did not introduce any at-scale health initiative that was not also introduced in Andhra Pradesh. Andhra Pradesh other health initiatives were considerably less ambitious and costly than Aarogyasri. The paper finds that Andhra Pradesh recorded faster growth than Maharashtra (even after adjusting for confounders) in inpatient admissions per capita (for all income groups) and in surgery admissions (among the poor only), slower growth in out-of-pocket payments for inpatient care (in total and per admission, but only among the better off), and slower growth in transport and outpatient out-of-pocket costs. The paper argues that these results are consistent with Aarogyasri having the intended effects, but also with minor health initiatives in Andhra Pradesh (especially the ambulance program) playing a rol

Changes in addressing inequalities in access to hospital care in Andhra Pradesh and Maharashtra states of India: a difference-in-differences study using repeated cross-sectional surveys

Objectives: To compare the effects of the Rajiv Aarogyasri Health Insurance Scheme of Andhra Pradesh (AP) with health financing innovations including the Rashtriya Swasthya Bima Yojana (RSBY) in Maharashtra (MH) over time on access to and out-of-pocket expenditure (OOPE) on hospital inpatient care. Study design: A difference-in-differences (DID) study using repeated cross-sectional surveys with parallel control. Setting: National Sample Survey Organisation of India (NSSO) urban and rural ‘first stratum units’, 863 in AP and 1008 in MH. Methods: We used two cross-sectional surveys: as a baseline, the data from the NSSO 2004 survey collected before the Aarogyasri and RSBY schemes were launched; and as postintervention, a survey using the same methodology conducted in 2012. Participants: 8623 households in AP and 10 073 in MH. Main outcome measures: Average OOPE, large OOPE and large borrowing per household per year for inpatient care, hospitalisation rate per 1000 population per year. Results: Average expenditure, large expenditures and large borrowings on inpatient care had increased in MH and AP, but the increase was smaller in AP across these three measures. DIDs for average expenditure and large borrowings were significant and in favour of AP for the rural and the poorest households. Hospitalisation rates also increased in both states but more so in AP, although the DID was not significant and the subgroup analysis presented a mixed picture. Conclusions: Health innovations in AP had a greater beneficial effect on inpatient care-related expenditures than innovations in MH. The Aarogyasri scheme is likely to have contributed to these impacts in AP, at least in part. However, OOPE increased in both states over time. Schemes such as the Aarogyasri and RSBY may result in some positive outcomes, but additional interventions may be required to improve access to care for the most vulnerable sections of the population

Impact of Antiretroviral Therapy on Incidence of Pregnancy among HIV-Infected Women in Sub-Saharan Africa: A Cohort Study

A multicountry cohort study in sub-Saharan Africa by Landon Myer and colleagues reveals higher pregnancy rates in HIV-infected women on antiretroviral therapy (ART)