Improving access to medicines for non-communicable diseases in rural India: a mixed methods study protocol using quasi-experimental design.

BACKGROUND: India has the distinction of financing its healthcare mainly through out-of-pocket expenses by individual families contributing to catastrophic health expenditure and impoverishment. Nearly 70 % of the expenditure is on medicines purchased at private pharmacies. Patients with chronic ailments are especially affected, as they often need lifelong medicines. Over the past years in India, there have been several efforts to improve drug availability at government primary health centres. In this study, we aim to understand health system factors that affect utilisation and access to generic medicines for people with non-communicable diseases. METHODS: This study aims to understand if (and how) a package of interventions targeting primary health centres and community participation platforms affect utilisation and access to generic medicines for people with non-communicable diseases in the current district context in India. This study will employ a quasi-experimental design and a qualitative theory-driven approach. PHCs will be randomly assigned to one of three arms of the intervention. In one arm, PHCs will receive inputs to optimise service delivery for non-communicable diseases, while the second arm will receive an additional package of interventions to strengthen community participation platforms for improving non-communicable disease care. The third arm will be the control. We will conduct household and facility surveys, before and after the intervention and will estimate the effect of the intervention by difference-in-difference analysis. Sample size for measuring effects was calculated based on obtaining at least 30 households for each primary health centre spread across three distance-based clusters. Primary outcomes include availability and utilisation of medicines at primary health centres and out-of-pocket expenditure for medicines by non-communicable disease households. Focus group discussions with patients and in-depth interviews with health workers will also be conducted. Qualitative and process documentation data will be used to explain how the intervention could have worked. DISCUSSION: By taking into consideration several health system building blocks and trying to understand how they interact, our study aims to generate evidence for health planners on how to optimise health services to improve access to medicines. TRIAL REGISTRATION: Protocol registered on Clinical Trials Registry of India with registration identifier number CTRI/2015/03/005640 on 17(th) March 2015.

No longer diseases of the wealthy: prevalence and health-seeking for self-reported chronic conditions among urban poor in Southern India.

BACKGROUND: The burden of chronic conditions is high in low- and middle-income countries and poses a significant challenge to already weak healthcare delivery systems in these countries. Studies investigating chronic conditions among the urban poor remain few and focused on specific chronic conditions rather than providing overall profile of chronic conditions in a given community, which is critical for planning and managing services within local health systems. We aimed to assess the prevalence and health- seeking behaviour for self-reported chronic conditions in a poor neighbourhood of a metropolitan city in India. METHODS: We conducted a house-to-house survey covering 9299 households (44514 individuals) using a structured questionnaire. We relied on self-report by respondents to assess presence of any chronic conditions, including diabetes and hypertension. Multivariable logistic regression was used to analyse the prevalence and health-seeking behaviour for self-reported chronic conditions in general as well as for diabetes and hypertension in particular. The predictor variables included age, sex, income, religion, household poverty status, presence of comorbid chronic conditions, and tiers in the local health care system. RESULTS: Overall, the prevalence of self-reported chronic conditions was 13.8% (95% CI = 13.4, 14.2) among adults, with hypertension (10%) and diabetes (6.4%) being the most commonly reported conditions. Older people and women were more likely to report chronic conditions. We found reversal of socioeconomic gradient with people living below the poverty line at significantly greater odds of reporting chronic conditions than people living above the poverty line (OR = 3, 95% CI = 1.5, 5.8). Private healthcare providers managed over 80% of patients. A majority of patients were managed at the clinic/health centre level (42.9%), followed by the referral hospital (38.9%) and the super-specialty hospital (18.2%) level. An increase in income was positively associated with the use of private facilities. However, elderly people, people below the poverty line, and those seeking care from hospitals were more likely to use government services. CONCLUSIONS: Our findings provide further evidence of the urgent need to improve care for chronic conditions for urban poor, with a preferential focus on improving service delivery in government health facilities.