Publicly funded health insurance schemes and demand for health services: evidence from an Indian state using a matching estimator approach.

Using Demographic and Health Survey data (2015-16) from the state of Andhra Pradesh, we estimate the differential probability of hysterectomy (removal of uterus) for women (aged 15-49 years) covered under publicly funded health insurance (PFHI) schemes relative to those not covered. To reduce the extent of selection bias into treatment assignment (PFHI coverage) we use matching methods, propensity score matching, and coarsened exact matching, achieving a comparable treatment and control group. We find that PFHI coverage increases the probability of undergoing a hysterectomy by 7-11 percentage points in our study sample. Sub-sample analysis indicates that the observed increase is significant for women with lower education levels and higher order parity. Additionally, we perform a test of no-hidden bias by estimating the treatment effect on placebo outcomes (doctor's visit, health check-up). The robustness of the results is established using different matching specifications and sensitivity analysis. The study results are indicative of increased demand for surgical intervention associated with PFHI coverage in our study sample, suggesting a need for critical evaluation of the PFHI scheme design and delivery in the context of increasing reliance on PFHI schemes for delivering specialised care to poor people, neglect of preventive and primary care, and the prevailing fiscal constraints in the healthcare sector.

Rising premature menopause and variations by education level in India.

The proportion of women experiencing premature menopause is on the rise in India, particularly in the age groups of 30-39 years. Consequently, there is a need to understand the factors influencing the prevalence of premature menopausal status among women. Our study uses the data from 180,743 women gathered during the latest Indian version of the Demography Health Survey (National Family Health Survey-5). Our results suggest that close to 5% of women in rural areas and 3% of women in urban areas experience premature menopause, and this figure varies across Indian States. The regression results show that surgical menopause, lower levels of education, poorer wealth index, rural residence, female sterilization, and insurance coverage are key drivers of premature menopause. One of the striking factors is that the prevalence of premature menopause among those with the lowest levels of education (6.85%) is around seven times higher than those with the highest level of education (0.94%). We conducted a decomposition analysis to delve into the factors contributing to this inequality. The results show that undergoing a hysterectomy (surgical menopause) account for 73% of the gap in premature menopausal rates between women with the lowest and highest levels of education. This indicates that women with poor education are more likely to undergo hysterectomy at a younger age. This finding warrants further exploration as we would expect that women from lower socio-economic background would have limited access to surgical care, however, our results suggest otherwise. This perhaps indicates a lack of awareness, lack of alternative treatment options, and over-reliance on surgical care while neglecting conservative management. Our results have implications for addressing the diverse needs of the increasing number of women in their post-menopause phase and for focusing on conservative treatment options for these women.

Empowered but abused? A moderated mediation analysis to explore the relationship between wife's relative resources, relational empowerment and physical abuse.

There is a growing body of literature focusing on the direct relationship between women's relative resources (WRR) and intimate partner violence (IPV). However, the underlying mechanism remains largely unexplored. Grounded in the popular sociological theories, Relative Resource Theory (RRT) and Gendered Resource Theory (GRT), this study addresses the research gap by proposing a moderated-mediation model to i) understand the process through which WRR influences the relational empowerment and violence victimization, and, ii) explain the role of husband's patriarchal attitude in the proposed linkages. We posit that the relationship between WRR and IPV is mediated by relational empowerment, and husband's patriarchal attitude moderates the relationship between relational empowerment and physical abuse. The proposed model is tested in the Indian context using secondary data collected from 47,514 married couples. As our variables of interest were latent constructs, we first used factor analysis in AMOS v.22. Then, using the Structural Equation Modelling (SEM) technique, the proposed model is tested in SPSS v.22 using the bootstrap Confidence Interval (C.I.) method. In our study sample, about 28% of ever-married women reported experiencing spousal violence in the last 12 months. The study finds that WRR is a significant predictor of relational empowerment (ß = 0.21, p < 0.01), and relational empowerment is negatively associated (ß = -0.06; p < 0.01) with violence victimization, thus supporting mediating role of relational empowerment in WRR-Abuse linkage. The interaction of the husband's patriarchal attitude with relational empowerment significantly predicts violence victimization. Our study results indicate the critical role of socio-cultural norms, rooted in patriarchy, in understanding IPV. The study findings suggest that the potential of women empowerment initiatives against IPV is conditional on men's progressive attitude. The study findings call for acknowledging the complexity of the interaction between patriarchal attitude and IPV on the one hand, and women's position in society, in any attempt at empowerment.

Challenges in delivering primary care via telemedicine during COVID-19 pandemic in India: A review synthesis using systems approach.

Background: Countries, including India, were quick to adopt telemedicine for delivering primary care in response to the widespread disruptions due to the coronavirus disease 2019 (COVID-19) pandemic. This expeditious adoption was critical and the challenges faced during this exigency could guide the design and delivery of future telemedicine applications toward strengthening primary healthcare services. Methods: To identify the challenges in delivering primary care via telemedicine technology in the Indian context, a scoping review was conducted. Drawing from the systems approach in healthcare delivery, the review findings are summarized at four levels, patient, provider, healthcare organizations, and policy. Results: The initial search yielded 247 articles and 13 met our inclusion criteria. This review highlighted that telemedicine facilitated the continuity of care during COVID-19 but not without challenges. Low levels of education and computer literacy along with the language barriers posed the predominant challenges at the patient level. Providers had concerns related to digital literacy, clinical process flows, legal liabilities, and unethical behavior of the patients. The policy-level challenges include data privacy and security, reimbursement models, unethical behavior by the patient, or provider, and regulating prescriptions of psychotropic drugs. A lack of an integrated telehealthcare model covering diagnostics, prescriptions, and medication supply mirrored the existing fragmentation of care delivery. Conclusion: Telemedicine has the potential to improve primary healthcare delivery even beyond COVID-19. Currently, telemedicine applications in India are only facilitating a remote consultation wherein an integrated person-centered care is lacking. There is a need to acknowledge and factor in the inter-connectedness of health system elements for ensuring an effective and efficient healthcare delivery via telemedicine.