Patient perception of attributes of primary care: a study of Aam Aadmi Mohalla Clinics in Delhi, India.

BACKGROUND: Aam Aadmi Mohalla Clinics (AAMC) are the community level public primary care facilities recently introduced to strengthen primary care in Delhi, India by bringing affordable healthcare close to home. OBJECTIVES: This study looks at the primary care attributes of AAMC from a patient perspective, to assess their features, strengths and weaknesses. METHODS: Using a primary care survey tool, a cross-sectional survey of 360 users was conducted at 18 facilities across 9 districts of Delhi to gather information on six dimensions of primary care delivery. Thematic analysis of responses to quantitative, multiple-choice and Likert scale questions using percentage of respondents in each category; and a strengths, weaknesses, opportunities and suggestions (SWOS) framework, was used to examine the primary care attributes. RESULTS: AAMCs have done well in improving proximity, availability, physical and financial access to primary care with respondents reporting their residence within 1 kilometre of AAMCs (95%), physician being available (100%), free drugs in stock (99%). Service delivery is however not comprehensive with missing preventive care. Respondents reported missing gatekeeping, weak referral mechanism (6-19%), and low physician's familiarity with their overall health (2%). CONCLUSION: AAMCs have brought affordable healthcare with free medicines and diagnostics to neighbourhood. There is an opportunity for attaining universal healthcare that is responsive to user needs through provision of comprehensive care. Compulsory enrolment of neighbourhood population with an electronic database of patients has an immense potential to improve longitudinality and coordination of care.

Enhanced magnetism and time-stable remanence at the interface of hematite and carbon nanotubes.

The interface of two dissimilar materials is well known for surprises in condensed matter, and provides avenues for rich physics as well as seeds for future technological advancements. We present some exciting magnetization (M) and remanence (µ) results, which conclusively arise at the interface of two highly functional materials, namely the graphitic shells of a carbon nanotube (CNT) and α-Fe2O3, a Dzyaloshinskii-Moriya interaction driven weak ferromagnet (WFM) and piezomagnet (PzM). We show that the encapsulation inside a CNT leads to a significant enhancement in M and correspondingly in µ, a time-stable part of the remanence, exclusive to the WFM phase. Up to 70% of in-field magnetization is retained in the form of µ at room temperature. The lattice parameter of the CNT around the Morin transition of the encapsulate exhibits a clear anomaly, confirming the novel interface effects. Control experiments on bare α-Fe2O3 nanowires bring into the fore that the weak ferromagnets such as α-Fe2O3 are not as weak, as far as their remanence and its stability with time is concerned, and encapsulation inside a CNT leads to a substantial enhancement in these functionalities.

Trovafloxacin attenuates neuroinflammation and improves outcome after traumatic brain injury in mice.

BACKGROUND: Trovafloxacin is a broad-spectrum antibiotic, recently identified as an inhibitor of pannexin-1 (Panx1) channels. Panx1 channels are important conduits for the adenosine triphosphate (ATP) release from live and dying cells that enhances the inflammatory response of immune cells. Elevated extracellular levels ATP released upon injury activate purinergic pathways in inflammatory cells that promote migration, proliferation, phagocytosis, and apoptotic signals. Here, we tested whether trovafloxacin administration attenuates the neuroinflammatory response and improves outcomes after brain trauma. METHODS: The murine controlled cortical impact (CCI) model was used to determine whether in vivo delivery of trovafloxacin has anti-inflammatory and neuroprotective actions after brain trauma. Locomotor deficit was assessed using the rotarod test. Levels of tissue damage markers and inflammation were measured using western blot, qPCR, and immunofluorescence. In vitro assays were used to evaluate whether trovafloxacin blocks ATP release and cell migration in a chemotactic-stimulated microglia cell line. RESULTS: Trovafloxacin treatment of CCI-injured mice significantly reduced tissue damage markers and improved locomotor deficits. In addition, trovafloxacin treatment significantly reduced mRNA levels of several pro-inflammatory cytokines (IL-1ß, IL-6, and TNF-α), which correlates with an overall reduction in the accumulation of inflammatory cell types (neutrophils, microglia/macrophages, and astroglia) at the injury zone. To determine whether trovafloxacin exerted these effects by direct action on immune cells, we evaluated its effect on ATP release and cell migration using a chemotactic-stimulated microglial cell line. We found that trovafloxacin significantly inhibited both ATP release and migration of these cells. CONCLUSION: Our results show that trovafloxacin administration has pronounced anti-inflammatory and neuroprotective effects following brain injury. These findings lay the foundation for future studies to directly test a role for Panx1 channels in pathological inflammation following brain trauma.

A comparison of the cost of outpatient care delivered by Aam Aadmi Mohalla Clinics compared to other public and private facilities in Delhi, India.

Aam Admi Mohalla Clinics (AAMCs) were introduced in Delhi in 2015 as neighbourhood clinics to strengthen the delivery of primary care. To inform the policies on government investments for outpatient care, this study estimated the cost of outpatient care per visit in Delhi for 2019-20 for AAMCs and compared it with urban primary health centres (UPHCs), public hospitals, private clinics and private hospitals. Facility costs for AAMCs and UPHCs were also estimated. Using the data from a national health survey, government annual budgets and reports, a modified top-down methodology was adopted to measure the true cost of public facilities, taking into account both government expenditure and out-of-pocket expenditure (OOPE). Inflation-adjusted OOPE was used to measure the cost of private facilities. The cost per visit at a private clinic at ₹1146 (US$16) was more than 3-times higher than that at a UPHC (₹325/US$5) and 8-times higher than that at AAMCs (₹143/US$2.0). These costs were ₹1099 (US$15) and ₹1818 (US$25) at public and private hospitals respectively. The annual economic cost per facility of a UPHC at ₹ 9 280 000/$130 000 is ∼4-times that at AAMC (₹2 474 000/$35 000). Unit costs are found to be lower at AAMCs. Utilization for outpatient care has shifted in favour of public primary care facilities. Higher investment in public primary care facilities with expanded services for prevention and promotion, upscaled infrastructure and a gate-keeping mechanism can strengthen the delivery of primary care and promote universal health care at a lower cost.

Unit costs for allopathic and AYUSH outpatient care in public facilities in Urban Delhi, India.

Introduction: The National Health Policy, 2017, suggests pluralism in health care with the integrated delivery of AYUSH and allopathic care at public facilities. Information on unit cost of outpatient visits for both types of care at public facilities is useful to guide the policies on health-care delivery. Methods: The costs in 2019-20 were estimated for each type of care at allopathic urban primary health center (UPHC) and AYUSH facilities using top-down methodology and adding out-of-pocket expenditures (OOPE) incurred to reflect true costs. Data from national health survey, annual government budgets, and reports were used. Results: The average cost of an outpatient visit for allopathic care was ₹325 at a UPHC and ₹189 in a homeopathic dispensary and ₹692 in an Ayurvedic dispensary. While OOPE per visit at UPHC was ₹177, no OOPE was incurred at AYUSH facilities. The government expenditure per visit for allopathic care at UPHC at ₹148 was the lowest compared to any type of AYUSH care. The cost per facility for allopathic UPHC was higher than both Ayurvedic and homeopathic dispensaries. Unani dispensaries were least cost-effective, both in terms of cost per visit and cost per facility. Conclusion: Costs per visit at a facility are impacted by footfalls. For Ayurveda, despite lower facility costs as compared to UPHC, per visit costs were higher due to low utilization. Improving evidence-based utilization of AYUSH care is critical for the success of the government policy of mainstreaming AYUSH care at low cost.

Cost of treating sick young infants (0-59 days) with Possible Serious Bacterial Infection in resource-constrained outpatient primary care facilities: An insight from implementation research in two districts of Haryana and Uttar Pradesh (India).

Background: Information on the average and incremental costs of implementing alternative strategies for treating young infants 0-59 days old in primary health facilities with signs of possible serious bacterial infection (PSBI) when a referral is not feasible is limited but valuable for policymakers. Methods: Direct activity costs were calculated for outpatient treatment of PSBI and pneumonia in two districts of India: Palwal, Haryana and Lucknow, Uttar Pradesh. These included costs of staff time and consumables for initial assessment, classification, and referrals; recommended treatment of fast breathing (oral amoxicillin for seven days) and PSBI (injection gentamicin and oral amoxicillin for seven days); and daily assessments. Indirect operational costs included staff training; staff time cost for general management, supervision, and coordination; referral transport; and communication. Results: The average cost per young infant treated for recommended and acceptable treatment for PSBI was 16 US dollars (US$) (95% CI = US$15.4-16.3) in 2018-19 and US$18.5 in 2022 (adjusted for inflation) when all direct and indirect operational costs were considered. The average cost of recommended treatment for pneumonia was US$10.1 (95% CI = US$9.7-10.6) or US$11.7 in 2022, per treated young infant. The incremental cost 2018-2019 for supplies, medicines, and operations (excluding staff time costs) per infant treated for PSBI was US$6.1 and US$4.3 and for pneumonia was US$3.5 and US$2.2 in Palwal and Lucknow, respectively. Operation and administrative costs were 25% in Palwal and 12% in Lucknow of the total PSBI treatment costs. The average cost per live birth for treating PSBI in each population was US$5 in Palwal and US$3 in Lucknow. Higher operation costs for social mobilisation activities in Palwal led to the empowerment of families and timely care-seeking. Conclusions: Costs of treatment of PSBI with the recommended regimen in an outpatient setting, when a referral is not feasible, are under US$20 per treated child and must be budgeted to reduce deaths from neonatal sepsis. The investment must be made in activities that lead to successful identification, prompt care seeking, timely initiation of treatment and follow-up.

Frustration, strain and phase co-existence in the mixed valent hexagonal iridate Ba3NaIr2O9.

Using detailed synchrotron diffraction, magnetization, thermodynamic and transport measurements, we investigate the relationship between the mixed valence of Ir, lattice strain and the resultant structural and magnetic ground states in the geometrically frustrated triple perovskite iridate Ba3NaIr2O9. We observe a complex interplay between lattice strain and structural phase co-existence, which is typically not observed in this family of compounds. The low temperature magnetic ground state is characterized by the absence of long-range magnetic order, and points towards the condensation of a cluster glass state from an extended regime of short range magnetic correlations.

Costs and cost-effectiveness of management of possible serious bacterial infections in young infants in outpatient settings when referral to a hospital was not possible: Results from randomized trials in Africa.

INTRODUCTION: Serious bacterial neonatal infections are a major cause of global neonatal mortality. While hospitalized treatment is recommended, families cannot access inpatient treatment in low resource settings. Two parallel randomized control trials were conducted at five sites in three countries (Democratic Republic of Congo, Kenya, and Nigeria) to compare the effectiveness of treatment with experimental regimens requiring fewer injections with a reference regimen A (injection gentamicin plus injection procaine penicillin both once daily for 7 days) on the outpatient basis provided to young infants (0-59 days) with signs of possible serious bacterial infection (PSBI) when the referral was not feasible. Costs were estimated to quantify the financial implications of scaleup, and cost-effectiveness of these regimens. METHODS: Direct economic costs (including personnel, drugs and consumable costs) were estimated for identification, prenatal and postnatal visits, assessment, classification, treatment and follow-up. Data on time spent by providers on each activity was collected from 83% of providers. Indirect marginal financial costs were estimated for non-consumables/capital, training, transport, communication, administration and supervision by considering only a share of the total research and health system costs considered important for the program. Total economic costs (direct plus indirect) per young infant treated were estimated based on 39% of young infants enrolled in the trial during 2012 and the number of days each treated during one year. The incremental cost-effectiveness ratio was calculated using treatment failure after one week as the outcome indicator. Experimental regimens were compared to the reference regimen and pairwise comparisons were also made. RESULTS: The average costs of treating a young infant with clinical severe infection (a sub-category of PSBI) in 2012 was lowest with regimen D (injection gentamicin once daily for 2 days plus oral amoxicillin twice daily for 7 days) at US$ 20.9 (95% CI US$ 16.4-25.3) or US$ 32.5 (2018 prices). While all experimental regimens B (injection gentamicin once daily plus oral amoxicillin twice daily, both for 7 days), regimen C (once daily of injection gentamicin injection plus injection procaine penicillin for 2 days, thereafter oral amoxicillin twice daily for 5 days) and regimen D were found to be more cost-effective as compared with the reference regimen A; pairwise comparison showed regimen D was more cost-effective than B or C. For fast breathing, the average cost of treatment with regimen E (oral amoxicillin twice daily for 7 days) at US$ 18.3 (95% CI US$ 13.4-23.3) or US$ 29.0 (2018 prices) was more cost-effective than regimen A. Indirect costs were 32% of the total treatment costs. CONCLUSION: Scaling up of outpatient treatment for PSBI when the referral is not feasible with fewer injections and oral antibiotics is cost-effective for young infants and can lead to increased access to treatment resulting in potential reductions in neonatal mortality. CLINICAL TRIAL REGISTRATION: The trial was registered with Australian New Zealand Clinical Trials Registry under ID ACTRN 12610000286044.

In Vitro Assessment of Core-Shell Micellar Nanostructures of Amphiphilic Cationic Polymer-Peptide Conjugates as Efficient Gene and Drug Carriers.

Design and development of biocompatible, biodegradable and stable dual delivery systems for drug and gene is the need of the hour. Here, we have designed a strategy to develop carrier systems consisting of above mentioned properties by (a) incorporating an unnatural amino acid in the peptide backbone, and b) conjugating a low molecular weight cationic polymer (polyethylenimine, PEI) for incorporating cationic charge. Using this strategy, we have synthesized a small series of Boc-FΔF-AH-polyethylenimine conjugates by varying the concentration of Boc-FΔF-aminohexanoic acid, viz., PP-1, PP-2 and PP-3. These conjugates self-assembled in aqueous medium to form micelles in the size range of ~144-205 nm with zeta potential ~ +7.9-14.2 mV bearing core-shell type of conformation. Positive surface of the micelles facilitated the binding of plasmid DNA as well as transportation inside the cells. The hydrophobic core of the nanostructures helped in the encapsulation of the hydrophobic drug molecule, which was then got released in a controlled manner. DNA complexes of the conjugates were not only found non-toxic but also exhibited higher transfection efficacy than the native polymer and Lipofectamine. Altogether, these nanostructures are capable of delivering a drug and a gene simultaneously in vitro and could be used as next-generation delivery agents.

The Composite Planning Technique in Left Sided Breast Cancer Radiotherapy: A Dosimetric Study.

OBJECTIVE: The aim of this retrospective study is to reduce the dose of heart, both lung and opposite breast and left anterior descending artery (LAD) and avoid long term complication and radiation induced secondary malignancies in radiotherapy left breast/chest wall without losing homogeneity and conformity of the Planning Target Volume (PTV), contoured using Radiotherapy Oncology Group (RTOG 1005) guideline. MATERIALS AND METHODS: The treatment plans were generated retrospectively by TFIF, VMAT and Composite techniques for 30 patients. Dose-Volume Histograms (DVHs) were evaluated for PTV and organs at risk (OAR's) and analyzed in two groups BCS and MRM using Wilcoxon signed rank test. RESULTS: The homogeneity index (HI) was improved in Composite technique by 32.72% and 21.81% of VMAT, 50.66% and 49.41% of TFIF in BCS and MRM group respectively. The Conformity Index (CI) for composite plan was statistically same as VMAT and superior by 27.94% and 41.37% of TFIF in BCS and MRM group respectively. The low dose volume V5Gy and V10Gy of the heart were improved in Composite plan by 47.9% and 26.1% of VMAT respectively in BCS group and in MRM group, improved by 21.2% and 45.6% of VMAT. The V5Gy and V10Gy of ipsilateral lung were improved in Composite plan by 16% and 13.7% of VMAT respectively in BCS and 8.4% and 3% of VMAT respectively in MRM group. CONCLUSION: The Composite plan consisting of VMAT and TFIF plan with an optimum selection of fractions can achieve lower low dose exposure to the OAR's without compromising coverage compared to VMAT.

Anisamido-Polyethylenimines as Efficient Nonviral Vectors for the Transport of Plasmid DNA to Sigma Receptor-Bearing Cells In Vitro.

Site-specific delivery of therapeutics promises better outcomes in the treatment of diseases. A small ligand, anisamide, has been shown to specifically bind sigma receptors highly overexpressed on prostate cancer cells, one of the leading cancers causing deaths worldwide. Here, anisamide-tethered polyethylenimine polymers (AP) have been synthesized and evaluated for their capability to transport nucleic acid across the cell membrane. A series of modified polymers (AP-1 to AP-4) was synthesized, physicochemically characterized, and evaluated for their transfection efficiency and cytotoxicity. Postconjugation, there was a marginal decrease in the buffering capacity; however, it did not diminish the ultimate objective of the study rather improved the transfection efficiency and decreased the cytotoxicity making these polymers as efficient and safe vectors for nucleic acid delivery. All the modified polymers displayed enhanced capability to deliver DNA inside the cells. Among the series, the modified polymer, AP-4 (10% attempted substitution), exhibited the highest transfection in HEK293 cells having abundant sigma receptors with minimal cytotoxicity. The projected polymer also showed complete protection of bound DNA against enzymatic degradation. Altogether, the results demonstrated targeting ability of the proposed polymers to deliver nucleic acid to sigma receptor-bearing cells in vitro.

Who pays for health care in Asia?

We estimate the distributional incidence of health care financing in 13 Asian territories that account for 55% of the Asian population. In all territories, higher-income households contribute more to the financing of health care. The better-off contribute more as a proportion of ability to pay in most low- and lower-middle-income territories. Health care financing is slightly regressive in three high-income economies with universal social insurance. Direct taxation is the most progressive source of finance and is most so in poorer economies. In universal systems, social insurance is proportional to regressive. In high-income economies, the out-of-pocket (OOP) payments are proportional or regressive while in low-income economies the better-off spend relatively more OOP. But in most low-/middle-income countries, the better-off not only pay more, they also get more health care.

An in silico comparative dosimetric study of postmastectomy locoregional irradiation using intensity-modulated vs 3-dimensional conventional radiotherapy.

An in silico dosimetric evaluation of intensity-modulated radiation therapy (IMRT) vs 3-dimensional conventional radiation therapy (3D-CRT) treatment plans in postmastectomy radiation therapy (PMRT) to the chest wall and regional lymphatics was conducted. Twenty-five consecutive patients with breast cancer referred for locoregional PMRT, stages T2-4 with N1-3, were planned to receive 50 Gy in 25 fractions with IMRT. Additionally, a 3D-CRT plan was generated using identical contours for the clinical target volumes (CTV), planning target volumes (PTV), and organs at risk (OAR). Treatment plans were assessed using dose-volume histogram (DVH) parameters of D98, D95, D50, D2, and homogeneity index for individual CTVs and PTVs. OARs evaluated were ipsilateral and contralateral lungs, heart, spinal cord, and opposite breast. Most DVH parameters pertaining to CTVs and PTVs significantly favored IMRT. V20 for ipsilateral and contralateral lungs, D33 of heart and maximum dose to spinal cord favored IMRT (all p < 0.001). The mean dose to the opposite breast was significantly lesser with 3D-CRT (5.8 ± 1.8 Gy vs 2.0 ± 1.0 Gy, p < 0.001). Thus, except for the mean dose to the opposite breast, the compliance to DVH constraints applied to PTV and OARs were significantly better with IMRT. At a median follow-up of 76 months (7-91), none had locoregional failure or pulmonary or cardiac morbidity. For PMRT, requiring comprehensive irradiation to both chest wall and regional lymphatics, IMRT offers superior dosimetric advantages over 3D-CRT. This was also corroborated by long-term outcomes in these patients treated with IMRT.

Enzyme sensitive smart inulin-dehydropeptide conjugate self-assembles into nanostructures useful for targeted delivery of ornidazole.

Molecular self-assembly of biodegradable amphiphilic polymers allows rational design of biocompatible nanomaterials for drug delivery. Use of substituted polysaccharides for such applications offers the ease of design and synthesis, and provides higher biofunctionality and biocompatibility to nanomaterials. The present work focuses on the synthesis, characterization and potential biomedical applications of self-assembled polysaccharide-based materials. We demonstrated that the synthesized amphiphilic inulin self-assembled in aqueous medium into nanostructures with average size in the range of 146-486nm and encapsulated hydrophobic therapeutic molecule, ornidazole. Hydrophophic dehydropeptide was conjugated with inulin via a biocompatible ester linkage. Dehydrophenylalanine, an unusual amino acid, was incorporated in the peptide to make it stable at a broader range of pH as well as against proteases. The resulting core-shell type of nanostructures could encapsulate ornidazole in the hydrophobic core and released it in a controlled fashion. By taking the advantage of inulin, which gets degraded in the colon by colonic bacteria, the effect of enzyme, inulinase, present in the microflora of the large intestine, on inulin-peptide degradation followed by drug release has been studied. Altogether, small peptide conjugated to inulin offers novel scaffold for the future design of nanostructures with potential applications in the field of targeted drug delivery.

Fabrication of cationic nanostructures from short self-assembling amphiphilic mixed α/ß-pentapeptide: Potential candidates for drug delivery, gene delivery, and antimicrobial applications.

The present article describes designing and fabrication of nanostructures from a mixed α/ß-pentapeptide, Lys-ßAla-ßAla-Lys-ßAla, which majorly contains non-natural ß-alanine residues in the backbone with two α-lysine residues at 1- and 4-positions. The amphiphilic pentapeptide showed the ability to self-assemble into cationic nanovesicles in an aqueous solution. The average size of peptide nanostructures was found to be ~270 nm with a very high cationic charge of ~+40 mV. TEM micrographs revealed the average size of the same nanostructures ~80 nm bearing vesicular morphology. CD and FTIR spectroscopic studies on self-assembled pentapeptide hinted at random coil conformation which was also correlated with conformational search program using Hyper Chem 8.0. The pentapeptide nanostructures were then tested for encapsulation of hydrophobic model drug moieties, L-Dopa, and curcumin. Transfection efficiency of the generated cationic nanostructures was evaluated on HEK293 cells and compared the results with those obtained in the presence of chloroquine. The cytotoxicity assay performed using MTT depicted ~75-80% cell viability. The obtained nanostructures also gave positive results against both Gram-negative and Gram-positive bacterial strains. Altogether the results advocate the promising potential of the pentapeptide foldamer, H-Lys-ßAla-ßAla-Lys-ßAla-OEt, for drug and gene delivery applications along with the antimicrobial activity.

Costing of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition from a randomised trial in India.

TRIAL DESIGN: Three feeding regimens-centrally produced ready-to-use therapeutic food, locally produced ready-to-use therapeutic food, and augmented, energy-dense, home-prepared food-were provided in a community setting for children with severe acute malnutrition (SAM) in the age group of 6-59 months in an individually randomised multicentre trial that enrolled 906 children. Foods, counselling, feeding support and treatment for mild illnesses were provided until recovery or 16 weeks. METHODS: Costs were estimated for 371 children enrolled in Delhi in a semiurban location after active survey and identification, enrolment, diagnosis and treatment for mild illnesses, and finally treatment with one of the three regimens, both under the research and government setting. Direct costs were estimated for human resources using a price times quantity approach, based on their salaries and average time taken for each activity. The cost per week per child for food, medicines and other consumables was estimated based on the total expenditure over the period and children covered. Indirect costs for programme management including training, transport, non-consumables, infrastructure and equipment were estimated per week per child based on total expenditures for research study and making suitable adjustments for estimations under government setting. RESULTS: No significant difference in costs was found across the three regimens per covered or per treated child. The average cost per treated child in the government setting was estimated at US$56 (<3500 rupees). CONCLUSION: Home-based management of SAM with a locally produced ready-to-use therapeutic food is feasible, acceptable, affordable and very cost-effective in terms of the disability-adjusted life years saved and gross national income per capita of the country. The treatment of SAM at home needs serious attention and integration into the existing health system, along with actions to prevent SAM. TRIAL REGISTRATION NUMBER: NCT01705769; Pre-results.

Effect of payments for health care on poverty estimates in 11 countries in Asia: an analysis of household survey data.

BACKGROUND: Conventional estimates of poverty do not take account of out-of-pocket payments to finance health care. We aimed to reassess measures of poverty in 11 low-to-middle income countries in Asia by calculating total household resources both with and without out-of-pocket payments for health care. METHODS: We obtained data on payments for health care from nationally representative surveys, and subtracted these payments from total household resources. We then calculated the number of individuals with less than the internationally accepted threshold of absolute poverty (US1 dollar per head per day) after making health payments. We also assessed the effect of health-care payments on the poverty gap--the amount by which household resources fell short of the 1 dollar poverty line in these countries. FINDINGS: Our estimate of the overall prevalence of absolute poverty in these countries was 14% higher than conventional estimates that do not take account of out-of-pocket payments for health care. We calculated that an additional 2.7% of the population under study (78 million people) ended up with less than 1 dollar per day after they had paid for health care. In Bangladesh, China, India, Nepal, and Vietnam, where more than 60% of health-care costs are paid out-of-pocket by households, our estimates of poverty were much higher than conventional figures, ranging from an additional 1.2% of the population in Vietnam to 3.8% in Bangladesh. INTERPRETATION: Out-of-pocket health payments exacerbate poverty. Policies to reduce the number of Asians living on less than 1 dollar per day need to include measures to reduce such payments.

Oral tuberculosis following successful treatment of oral malignancy.

Coexistence of tuberculosis and neoplastic lesion in the oral cavity is a rare phenomenon. Till date, only three such cases have been reported in the English literature. A case of oral tuberculosis manifesting 3 months following the successful treatment of cancer of the oral tongue with chemoradiotherapy is presented. The diagnostic dilemma it posed, and its eventual successful control by anti-tubercular treatment, is discussed.

Study raises questions about measurement of 'additionality,'or maintaining domestic health spending amid foreign donations.

Donor nations and philanthropic organizations increasingly require that funds provided for a specific health priority such as HIV should supplement domestic spending on that priority-a concept known as "additionality." We investigated the "additionality" concept using data from Honduras, Rwanda, and Thailand, and we found that the three countries increased funding for HIV in response to increased donor funding. In contrast, the study revealed that donors, faced with increased Global Fund resources for HIV in certain countries, tended to decrease their funding for HIV or shift funds for use in non-HIV health areas. More broadly, we found many problems in the measurement and interpretation of additionality. These findings suggest that it would be preferable for donors and countries to agree on how best to use available domestic and external funds to improve population health, and to develop better means of tracking outcomes, than to try to develop more sophisticated methods to track additionality.