Early-Neonatal, Late-Neonatal, Postneonatal, and Child Mortality Rates Across India, 1993-2021.

Importance: The global success of the child survival agenda depends on how rapidly mortality at early ages after birth declines in India, and changes need to be monitored to evaluate the status. Objective: To understand the disaggregated patterns of decrease in early-life mortality across states and union territories (UTs) of India. Design, Setting, and Participants: Repeated cross-sectional data from the 5 rounds of the National Family Health Survey conducted in 1992-1993, 1998-1999, 2005-2006, 2015-2016, and 2019-2021 were used in a representative population-based study. The study was based on data of children born in the past 5 years with complete information on date of birth and age at death. The analysis was conducted in February 2024. Exposure: Time and geographic units. Main Outcomes and Measures: Mortality rates were computed for 4 early-life periods: early-neonatal (first 7 days), late-neonatal (8-28 days), postneonatal (29 days to 11 months), and child (12-59 months). For early and late neonatal periods, the rates are expressed as deaths per 1000 live births, for postneonatal, as deaths per 1000 children aged at least 29 days and for child, deaths per 1000 children aged at least 1 year. These are collectively mentioned as deaths per 1000 for all mortalities. The relative burden of each of the age-specific mortalities to total mortality in children younger than 5 years was also computed. Results: The final analytical sample included 33 667 (1993), 29 549 (1999), 23 020 (2006), 82 294 (2016), and 64 242 (2021) children who died before their fifth birthday in the past 5 years of each survey. Mortality rates were lowest for the late-neonatal and child periods; early-neonatal was the highest in 2021. Child mortality experienced the most substantial decrease between 1993 and 2021, from 33.5 to 6.9 deaths per 1000, accompanied by a substantial reduction in interstate inequalities. While early-neonatal (from 33.5 to 20.3 deaths per 1000), late-neonatal (from 14.1 to 4.1 deaths per 1000), and postneonatal (from 31.0 to 10.8 deaths per 1000) mortality also decreased, interstate inequalities remained notable. The mortality burden shifted over time and is now concentrated during the early-neonatal (48.3% of total deaths in children younger than 5 years) and postneonatal (25.6%) periods. A stagnation or worsening for certain states and UTs was observed from 2016 to 2021 for early-neonatal, late-neonatal, and postneonatal mortality. If this pattern continues, these states and UTs will not meet the United Nations Sustainable Development Goal targets related to child survival. Conclusions and Relevance: In this repeated cross-sectional study of 5 time periods, the decrease in mortality during early-neonatal and postneonatal phases of mortality was relatively slower, with notable variations across states and UTs. The findings suggest that policies pertaining to early-neonatal and postneonatal mortalities need to be prioritized and targeting of policies and interventions needs to be context-specific.

Age- and Gender-Specific Prevalence of Intellectually Disabled Population in India.

Intellectual disability in India is substantially under-reported, especially amongst females. This study quantifies the prevalence and gender bias in household reporting of intellectual disability by estimating the age-and-gender specific prevalence of the intellectually disabled by education, Socio-Demographic Index (SDI) score, place of residence, (rural/urban) and income of household head. We estimated prevalence (per 100,000) at 179 (95% CI: 173 to 185) for males and 120 (95% CI: 115 to 125) for females. Gender differences declined sharply with increased education, was higher for lower ages and low income and varied little by state development. Under-identification and under-reporting due to stigma are two plausible reasons for the gender differences in prevalence that increase with age.

Socio-economic distribution of modifiable risk factors for cardiovascular diseases: An analysis of the national longitudinal ageing study in India.

The association of socioeconomic status (SES) with modifiable risk factors for cardiovascular diseases (CVDs) is unclear in developing nations. We studied SES variations in major risk factors and their percentage distribution for adults aged 45 years or above in India. Using individual records of 59,672 individuals aged 45 years or above from the Longitudinal Ageing Study in India Wave 1 (cross-sectional study design), 2017-18, we chart age-and-sex-adjusted prevalence of clinical risk factors such as measured high blood pressure, hypertension, overweight, obesity, central adiposity and self-reported high blood glucose; and lifestyle risk factors such as excessive use of alcohol, current use of smoking and smokeless tobacco and physical inactivity across SES variables of education, quintiles of mean per capita expenditure and social caste. Multivariable analysis was used to explore the SES gradient of risk factors. The sample used in the study is predominantly rural (69.9%), illiterate (50.7%), has more females (54.2%), and belongs to other backward classes (45.6%). Prevalence of high blood pressure, overweight, obesity, central adiposity, high blood glucose, and physical inactivity increased; and excessive alcohol consumption and current use of smoking/smokeless tobacco decreased with income, education, and social caste. However, no significant income gradient was noted for lifestyle risk factors except the use of smokeless tobacco. The income gradient was largest for central adiposity (waist-circumference) with a difference of 23.4 percentage points as it increased from 38.7% among the poorest to 62.1% among the richest. The major burden of CVDs risk factors among older adults aged 45+ years falls among high SES.

Corrigendum to- "Prevalence of Zero-Food among infants and young children in India: patterns of change across the States and Union Territories of India, 1993-2021".

[This corrects the article DOI: 10.1016/j.eclinm.2023.101890.].

Socioeconomic and geographic variation in coverage of health insurance across India.

Introduction: In India, regular monitoring of health insurance at district levels (the most essential administrative unit) is important for its effective uptake to contain the high out of pocket health expenditures. Given that the last individual data on health insurance coverage at district levels in India was in 2016, we update the evidence using the latest round of the National Family Health Survey conducted in 2019-2021. Methods: We use the unit records of households from the latest round (2021) of the nationally representative National Family Health Survey to calculate the weighted percentage (and 95% CI) of households with at least one member covered by any form of health insurance and its types across socio-economic characteristics and geographies of India. Further, we used a random intercept logistic regression to measure the variation in coverage across communities, district and state. Such household level study of coverage is helpful as it represents awareness and outreach for at least one member, which can percolate easily to the entire household with further interventions. Results: We found that only 2/5th of households in India had insurance coverage for at least one of its members, with vast geographic variation emphasizing need for aggressive expansion. About 15.5% were covered by national schemes, 47.1% by state health scheme, 13.2% by employer provided health insurance, 3.3% had purchased health insurance privately and 25.6% were covered by other health insurance schemes (not covered above). About 30.5% of the total variation in coverage was attributable to state, 2.7% to districts and 9.5% to clusters. Household size, gender, marital status and education of household head show weak gradient for coverage under "any" insurance. Discussion: Despite substantial increase in population eligible for state sponsored health insurance and rise in private health insurance companies, nearly 60% of families do not have a single person covered under any health insurance scheme. Further, the existing coverage is fragmented, with significant rural/urban and geographic variation within districts. It is essential to consider these disparities and adopt rigorous place-based interventions for improving health insurance coverage.

Progress on Sustainable Development Goal indicators in 707 districts of India: a quantitative mid-line assessment using the National Family Health Surveys, 2016 and 2021.

Background: India has committed itself to accomplishing the Sustainable Development Goals (SDGs) by 2030. Meeting these goals would require prioritizing and targeting specific areas within India. We provide a mid-line assessment of the progress across 707 districts of India for 33 SDG indicators related to health and social determinants of health. Methods: We used data collected on children and adults from two rounds of the National Family Health Survey (NFHS) conducted in 2016 and 2021. We identified 33 indicators that cover 9 of the 17 official SDGs. We used the goals and targets outlined by the Global Indicator Framework, Government of India and World Health Organization (WHO) to determine SDG targets to be met by 2030. Using precision-weighted multilevel models, we estimated district mean for 2016 and 2021, and using these values, computed the Annual Absolute Change (AAC) for each indicator. Using the AAC and targets, we classified India and each district as: Achieved-I, Achieved-II, On-Target and Off-Target. Further, when a district was Off-Target on a given indicator, we further identified the calendar year in which the target will be met post-2030. Findings: India is not On-Target for 19 of the 33 SDGs indicators. The critical Off-Target indicators include Access to Basic Services, Wasting and Overweight Children, Anaemia, Child Marriage, Partner Violence, Tobacco Use, and Modern Contraceptive Use. For these indicators, more than 75% of the districts were Off-Target. Because of a worsening trend observed between 2016 and 2021, and assuming no course correction occurs, many districts will never meet the targets on the SDGs even well after 2030. These Off-Target districts are concentrated in the states of Madhya Pradesh, Chhattisgarh, Jharkhand, Bihar, and Odisha. Finally, it does not appear that Aspirational Districts, on average, are performing better in meeting the SDG targets than other districts on majority of the indicators. Interpretation: A mid-line assessment of districts' progress on SDGs suggests an urgent need to increase the pace and momentum on four SDG goals: No Poverty (SDG 1), Zero Hunger (SDG 2), Good Health and Well-Being (SDG 3) and Gender Equality (SDG 5). Developing a strategic roadmap at this time will help India ensure success with regards to meeting the SDGs. India's emergence and sustenance as a leading economic power depends on meeting some of the more basic health and social determinants of health-related SDGs in an immediate and equitable manner. Funding: This work was funded by the Bill and Melinda Gates Foundation, INV-002992.

Prevalence of Zero-Food among infants and young children in India: patterns of change across the States and Union Territories of India, 1993-2021.

Background: The extent of food deprivation and insecurity among infants and young children-a critical phase for children's current and future health and well-being-in India is unknown. We estimate the prevalence of food deprivation among infants and young children in India and describe its evolution over time at sub-national levels. Methods: Data from five National Family Health Surveys (NFHS) conducted in 1993, 1999, 2006, 2016 and 2021 for the 36 states/Union Territories (UTs) of India were used. The study population consisted of the most recent children (6-23 months) born to mothers (aged 15-49 years), who were alive and living with the mother at the time of survey (n = 175,614 after excluding observations that had no responses to the food question). Food deprivation was defined based on the mother's reporting of the child having not eaten any food of substantial calorific content (i.e., any solid/semi-solid/soft/mushy food types, infant formula and powdered/tinned/fresh milk) in the past 24 hours (h), which we labelled as "Zero-Food". In this study, we analyzed Zero-Food in terms of percent prevalence as well as population headcount burden. We calculated the Absolute Change (AC) to quantify the change in the percentage points of Zero-Food across time periods for all-India and by states/UTs. Findings: The prevalence of Zero-Food in India marginally declined from 20.0% (95% CI: 19.3%-20.7%) in 1993 to 17.8% (95% CI: 17.5%-18.1%) in 2021. There were considerable differences in the trajectories of change in the prevalence of Zero-Food across states. Chhattisgarh, Mizoram, and Jammu and Kashmir experienced high increase in the prevalence of Zero-Food over this time period, while Nagaland, Odisha, Rajasthan and Madhya Pradesh witnessed a significant decline. In 2021, Uttar Pradesh (27.4%), Chhattisgarh (24.6%), Jharkhand (21%), Rajasthan (19.8%) and Assam (19.4%) were states with the highest prevalence of Zero-Food. As of 2021, the estimated number of Zero-Food children in India was 5,998,138, with the states of Uttar Pradesh (28.4%), Bihar (14.2%), Maharashtra (7.1%), Rajasthan (6.5%), and Madhya Pradesh (6%) accounting for nearly two-thirds of the total Zero-Food children in India. Zero-Food in 2021 was concerningly high among children aged 6-11 months (30.6%) and substantial even among children aged 18-23 months (8.5%). Overall, socioeconomically advantaged groups had lower prevalence of Zero-Food than disadvantaged groups. Interpretation: Concerted efforts at the national and state levels are required to further strengthen existing policies, and design and develop new ones to provide affordable food to children in a timely and equitable manner to ensure food security among infants and young children. Funding: This study was supported by a grant from the Bill & Melinda Gates Foundation INV-002992.

Prevalence of pain and its treatment among older adults in India: a nationally representative population-based study.

ABSTRACT: There were no estimates of the prevalence of pain and its treatment in the older population of India obtained from face-to-face interviews with a nationally representative sample. We addressed this evidence gap by using data on 63,931 individuals aged 45 years and older from the 2017/2018 Longitudinal Ageing Study in India. We identified pain from an affirmative response to the question: Are you often troubled by pain? We also identified those who reported pain that limited usual activities and who received treatment for pain. We estimated age- and sex-adjusted prevalence of pain, pain limiting usual activity and treatment, and compared these estimates across states and sociodemographic groups. We used a multivariable probit model to estimate full adjusted differences in the probability of each outcome across states and sociodemographic groups. We estimated that 36.6% (95% confidence interval [CI]: 35.3-37.8) of older adults in India were often troubled by pain and 25.2% (95% CI: 24.2-26.1) experienced pain limiting usual activity. We estimated that 73.3% (95% CI: 71.9-74.6) of those often troubled by pain and 76.4% (95% CI: 74.9-78.0) of those with pain that limited usual activity received treatment. There was large variation in each outcome across states. Fully adjusted prevalence of pain and pain limiting usual activity were higher among individuals who were female, older, less educated, rural residents, and poorer. Prevalence of treatment among those troubled by pain was lower among socially disadvantaged groups.

Components of Out-of-Pocket Expenditure and Their Relative Contribution to Economic Burden of Diseases in India.

Importance: High out-of-pocket expenditure (OOPE) on health in India may limit achieving universal health coverage. A clear insight on the components of health expenditure may be necessary to make allocative decisions to reduce OOPE, and such details by sociodemographic group and state have not been studied in India. Objective: To analyze the relative contribution of drugs, diagnostic tests, doctor and surgeon fees, and expenditure on other medical services and nonmedical health-related services, such as transport, lodging, and food, by sociodemographic characteristics of patients, geography, and type of illness. Design, Setting, and Participants: A population-based cross-sectional health consumption survey conducted by the National Sample Survey Organisation in 2018 was analyzed in this cross-sectional study. Respondents who provided complete information on costs of medicine, doctors, diagnostics tests, other medical costs, and nonmedical costs were selected. Data were analyzed from August through September 2021. Main Outcomes and Measures: Mean and median share of components (ie, medicine, diagnostic tests, doctor fees, other medical costs, and nonmedical costs) in total health care expenditure and income were calculated. Bivariate survey-weighted mean (with 95% CI) and median (IQR) expenditures were calculated for each component across sociodemographic characteristics. The proportion of total expenditure and income contributed by each cost was calculated for each individual. Mean and median were then used to summarize such proportions at the population level. The association between state net domestic product per capita and component share of each health care service was graphically explored. Results: Health expenditure details were analyzed for 43 781 individuals for inpatient costs (27 272 [64.3%] women; 26 830 individuals aged 25-64 years [59.9%]) and 8914 individuals for outpatient costs (4176 [48.2%] women; 4901 individuals aged 25-64 years [54.2%]); most individuals were rural residents (24 106 inpatients [67.0]; 4591 outpatients [63.9%]). Medicines accounted for a mean of 29.1% (95% CI, 28.9%-29.2%) of OOPE among inpatients and 60.3% (95% CI, 59.7%-60.9%) of OOPE among outpatients. Doctor consultation charges were a mean of 15.3% (95% CI, 15.1%-15.4%) of OOPE among inpatients and 12.4% (95% CI, 12.1%-12.6%) of OOPE among outpatients. Diagnostic tests accounted for a mean of 12.3% (95% CI, 12.2%-12.4%) of OOPE for inpatient and 9.2% (95% CI, 8.9%-9.5%) of OOPE for outpatient services. Nonmedical costs accounted for a mean of 23.6% (95% CI, 23.3%-23.8%) of OOPE among inpatients and 14.6% (95% CI, 14.1%-15.1%) of OOPE among outpatients. Mean share of OOPE from doctor consultations and diagnostic test charges increased with socioeconomic status. For example, for the lowest vs highest monthly per capita income quintile among inpatients, doctor consultations accounted for 11.5% (95% CI, 11.1%-11.8%) vs 21.2% (95% CI, 20.8%-21.6%), and diagnostic test charges accounted for 10.9% (95% CI, 10.6%-11.1%) vs 14.3% (95% CI, 14.0%-14.5%). The proportion of mean annual health expenditure from mean annual income was $299 of $1918 (15.6%) for inpatient and $391 of $1788 (21.9%) for outpatient services. Conclusions and Relevance: This study found that nonmedical costs were significant, share of total health care OOPE from doctor consultation and diagnostic test charges increased with socioeconomic status, and annual cost as a proportion of annual income was lower for inpatient than outpatient services.

Distress financing in coping with out-of-pocket expenditure for maternity care in India.

BACKGROUND: The cost of maternity care is seen as the barrier in utilizing maternity care, resulting in high maternal deaths. This study focuses on the distress financing and its coping mechanisms associated with maternity care expenditure in India so that corrective measures can be taken to reduce the burden of maternity care. METHODS: This study used the National Sample Survey (NSS) data conducted in 20,014-15 (71st round of NSS) and 2017-18(75th round of NSS). We define distress financing as use of formal borrowing, borrowing from friends or family or sale of asser to finance maternity care. Percentage of pregnant/delivered females using distress financing were calculated.. The present study also used multinomial logistic regression with 95% to understand the impact of socio-economic variables on distress financing and concentration index to measure the inequality in maternity care expenditure. RESULTS: This study found that the maternity care expenditure has decreased from the INR. 9379 in 2014-15 to INR. 7835 in 2017-18. The percentage of households using distress financing is higher among the poorest (13.2%). Almost 14% of the SC households experience distress financing. Among EAG + A states, particularly in Madhya Pradesh and Uttarakhand, the percentage of households are which experience a high level of distress financing increased from 8.9 to 18.3 and 0.7 to 8.1 from 2014-15 to 2017-18 respectively. The study finds that more urban households (37%) utilized insurance than rural households (26%). Among EAG + A states, 67.9 percent of households were dependent upon household savings, and it was 63.6 percent in the non-EAG states. The households with a high burden of maternity care expenditure were at higher risk of borrowing money to finance the cost of maternity as compared to use of savings/income for the same (relative risk (RR) (R: 2.59; P < 0.01; 95% CI: 2.15-3.13). Mothers belonging to the SC caste were at significantly higher risk (RR: 1.43; P < 0.1; 95% CI: 1.07-1.91). of using borrowings as compared to the use of income/savings. Mothers with college education were 50% more likely to use health insurance as compared to those with primary education. CONCLUSIONS: The study found that even though many programs for maternity care services are there, the maternity care expenditure, particularly the delivery care expenses, is very high in many states. The study recommends that India should increase subsidized maternity care facilities to decrease catastrophic maternity expenditure among households.

Children's education and level of health care utilization among parents: a pooled cross-sectional study from national population-based survey in India.

The study of upward spill over on parents of their offspring's education is vital for understanding the family dynamics and role of adult children in the decisions of parents. Such association has widespread implication and application on ageing policies. We use pooled data from population-based cross-sectional health consumption surveys conducted by the National Sample Survey Organization in 2014 and 2018 (rounds 71 and 75, respectively) in this study. The analysis is restricted to individuals aged 60 and above, who are head of the household or their spouse and have children aged 25 years or above. The analysis is carried out for inpatient and outpatient cases separately. For inpatient analysis, the dependent variable is designed as a rank variable representing an increasing level of health care utilization. For the same partial proportional odds are calculated. For outpatient cases, the dependent variable is binary that takes the value 0 if the parents use public facilities and 1 if private facilities are used. Here, binary logistic regression is used for analysis. The odds of parents using a higher level of inpatient as well as outpatient health care are higher for those with better-educated children (inpatient: OR are 2.6 (p < 0.001, CI: 2.0-3.5); outpatient: OR are 1.5 (p < 0.001, CI: 1.1-2.2)). Education of children does influence the level of health care utilization among parents. Therefore, policy interventions can target offspring of working age group, who can assimilate information better and transfer it to their parents.