Socio-Economic Status Differences in Changing Affordability of Tobacco Products from 2011-2012 to 2018-2019 in India.

INTRODUCTION: We studied the change in affordability of tobacco products, an important determinant of tobacco use, across the different socio-economic status (SES) in India. AIMS AND METHODS: We calculated affordability in the form of relative income price (RIP-cost of tobacco products relative to income) for the years 2011-2012 and 2018-2019 using three different denominators, that is per capita gross domestic product (GDP) and net state domestic product at national and state levels, respectively; monthly per capita consumer expenditure (MPCE); and individual wages. We investigated RIP for cigarettes, bidis, and smokeless tobacco (SLT) across different SES groups (caste groups, type of employment, and education). RESULTS: RIP increased marginally for cigarettes, bidis and remained almost constant for SLT across casual workers. However, when RIP was adjusted with SES variables, there was no significant change (p > .05) in the affordability of products for casual workers in the year 2018-2019 as compared to 2011-2012. For regular workers, cigarettes and bidis became marginally less affordable (ß < 1), whereas affordability remained constant for SLT. All products became more affordable for backward caste groups within regular workers. When RIP was calculated using MPCE all tobacco products became less affordable in the year 2018-2019. However, after adjusting for SES variables SLT reported no change in affordability. There was a marginal increase in affordability for all products when RIP was calculated with GDP. CONCLUSIONS: Although implementation of GST has increased the price of tobacco products, it is still not sufficient to reduce the affordability of tobacco products, particularly SLT and especially for the lower SES group. IMPLICATIONS: Tobacco use and economic disadvantage conditions of the population are intricately linked. Affordability of tobacco products is influenced by socio-economic indicators like age, sex, income, education, etc. The literature measuring the affordability of tobacco products across different SES groups is scant in India. Additionally, existing literature measures affordability of tobacco products based on per capita GDP as a proxy for income. This is the first study in Indian context to report the change in affordability of tobacco products across different SES groups after adjusting for SES indicators, using individual-level income data. We have calculated the change in affordability of tobacco products between the year 2011-2012 and 2018-2019 using GDP, household income, and individual wages as a proxy for income.

Multimorbidity, healthcare use and catastrophic health expenditure by households in India: a cross-section analysis of self-reported morbidity from national sample survey data 2017-18.

BACKGROUND: The purpose of this research is to generate new evidence on the economic consequences of multimorbidity on households in terms of out-of-pocket (OOP) expenditures and their implications for catastrophic OOP expenditure. METHODS: We analyzed Social Consumption Health data from National Sample Survey Organization (NSSO) 75th round conducted in the year 2017-2018 in India. The sample included 1,13,823 households (64,552 rural and 49,271 urban) through a multistage stratified random sampling process. Prevalence of multimorbidity and related OOP expenditure were estimated. Using Coarsened Exact Matching (CEM) we estimated the mean OOP expenditure for individuals reporting multimorbidity and single morbidity for each episode of outpatient visits and hospital admission. We also estimated implications in terms of catastrophic OOP expenditure for households. RESULTS: Results suggest that outpatient OOP expenditure is invariably lower in the presence of multimorbidity as compared with single conditions of the selected Non-Communicable Diseases(NCDs) (overall, INR 720 [USD 11.3] for multimorbidity vs. INR 880 [USD 14.8] for single). In the case of hospitalization, the OOP expenditures were mostly higher for the same NCD conditions in the presence of multimorbidity as compared with single conditions, except for cancers and cardiovascular diseases. For cancers and cardiovascular, OOP expenditures in the presence of multimorbidity were lower by 39% and 14% respectively). Furthermore, around 46.7% (46.674-46.676) households reported incurring catastrophic spending (10% threshold) because of any NCD in the standalone disease scenario which rose to 63.3% (63.359-63.361) under the multimorbidity scenario. The catastrophic implications of cancer among individual diseases was the highest. CONCLUSIONS: Multimorbidity leads to high and catastrophic OOP payments by households and treatment of high expenditure diseases like cancers and cardiovascular are under-financed by households in the presence of competing multimorbidity conditions. Multimorbidity should be considered as an integrated treatment strategy under the existing financial risk protection measures (Ayushman Bharat) to reduce the burden of household OOP expenditure at the country level.

Incremental Benefits of Multiple Tobacco Control Interventions: A Factorial Randomized Control Trial.

Tobacco control requires a comprehensive approach. The present study aims to examine the incremental effectiveness of health systems intervention when combined with other interventions in enhancing knowledge and practices of physicians in tobacco cessation. METHODS: A randomized control trial was conducted among 437 physicians in 12 districts of two states of India in 2011-13. The interventions consisted of Health Systems (H), Community (C) and Youth intervention (Y). Administrative Blocks /Mandals were randomly assigned to one of the three interventions (HC /HCY/HY) and control units. The health system intervention consisted of training physicians and developing a system of patient support and supervision for tobacco cessation. The primary outcome was change in knowledge and practices of physicians in tobacco cessation. Logistic regression model was applied to assess the impact of single and combination of interventions. RESULTS: An increase in knowledge was observed on effects of tobacco on adverse birth outcomes, advice on NRT and, information provided on chronic disease management among physicians in HC, HY and HCY intervention units compared to control units from pre-intervention to post-intervention. Statistically significant change was observed in knowledge of physicians on effects of tobacco on adverse birth outcomes in HC (OR- 4.75, p-0.02) and HCY (OR- 5.08, p-0.04) intervention units. CONCLUSIONS: HCY intervention was most effective in enhancing knowledge and practices of physicians in tobacco cessation. Our study suggests that individual tobacco control interventions when combined together has an incremental effect and increases the likelihood of provision of tobacco cessation services in primary care. 
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Impact of India's National Tobacco Control Programme on bidi and cigarette consumption: a difference-in-differences analysis.

BACKGROUND: Despite the importance of decreasing tobacco use to achieve mortality reduction targets of the Sustainable Development Goals in low-income and middle-income countries (LMICs), evaluations of tobacco control programmes in these settings are scarce. We assessed the impacts of India's National Tobacco Control Programme (NTCP), as implemented in 42 districts during 2007-2009, on household-reported consumption of bidis and cigarettes. METHODS: Secondary analysis of cross-sectional data from nationally representative Household Consumer Expenditure Surveys (1999-2000; 2004-2005 and 2011-2012). Outcomes were: any bidi/cigarette consumption in the household and monthly consumption of bidi/cigarette sticks per person. A difference-in-differences two-part model was used to compare changes in bidi/cigarette consumption between NTCP intervention and control districts, adjusting for sociodemographic characteristics and time-based heterogeneity. FINDINGS: There was an overall decline in household-reported bidi and cigarette consumption between 1999-2000 and 2011-2012. However, compared with control districts, NTCP districts had no significantly different reductions in the proportions of households reporting bidi (adjusted OR (AOR): 1.03, 95% CI: 0.84 to 1.28) or cigarette (AOR: 1.01 to 95% CI: 0.82 to 1.26) consumption, or for the monthly per person consumption of bidi (adjusted coefficient: 0.07, 95% CI: -0.13 to 0.28) or cigarette (adjusted coefficient: -0.002, 95% CI: -0.26 to 0.26) sticks among bidi/cigarette consuming households. INTERPRETATION: Our findings indicate that early implementation of the NTCP may not have produced reductions in tobacco use reflecting generally poor performance against the Framework Convention for Tobacco Control objectives in India. This study highlights the importance of strengthening the implementation and enforcement of tobacco control policies in LMICs to achieve national and international child health and premature NCD mortality reduction targets.

Quantifying the financial burden of households' out-of-pocket payments on medicines in India: a repeated cross-sectional analysis of National Sample Survey data, 1994-2014.

OBJECTIVE: The objective of this research is to generate new evidence on financial implications of medicines out-of-pocket (OOP) payments for households. Another objective is to investigate which disease conditions contributed to a significant proportion of households' financial burden. SETTING: All Indian states including union territories, 1993-2014. DESIGN: Repeated cross-sectional household surveys. DATA: Secondary data of nationwide Consumer Expenditure Surveys for the years 1993-1994, 2004-2005 and 2011-2012 and one wave of Social Consumption: Health for the year 2014 from National Sample Survey Organisation. OUTCOME MEASURES: OOP expenditure on healthcare in general and medicines in specific. RESULTS: Total OOP payments and medicines OOP payments were estimated to be 6.77% (95% CI 6.70% to 6.84%) and 4.49% (95% CI 4.45% to 4.54%) of total consumption expenditure, respectively, in the year 2011-2012 which marked significant increase since 1993-1994. These proportions were 11.46% (95% CI 11.36% to 11.56%) and 7.60% (95% CI 7.54% to 7.67%) of non-food expenditure, respectively, in the same year. Total OOP payments and medicines OOP payments were catastrophic for 17.9% (95% CI 17.7% to 18.2%) and 11.2% (95% CI 11.0% to 11.4%) households, respectively, in 2011-2012 at the 10% of total consumption expenditure threshold, implying 29 million households incurred catastrophic OOP payments in the year 2011-2012. Further, medicines OOP payments pushed 3.09% (95% CI 2.99% to 3.20%), implying 38 million persons into poverty in the year 2011-2012. Among the leading cause of diseases that caused significant OOP payments are cancers, injuries, cardiovascular diseases, genitourinary conditions and mental disorders. CONCLUSIONS: Purchase of medicines constitutes the single largest component of the total OOP payments by households. Hence, strengthening government intervention in providing medicines free in public healthcare facilities has the potential to considerably reduce medicine-related spending and total OOP payments of households and reduction in OOP-induced poverty.

What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries.

Private health care in low-income and middle-income countries is very extensive and very heterogeneous, ranging from itinerant medicine sellers, through millions of independent practitioners-both unlicensed and licensed-to corporate hospital chains and large private insurers. Policies for universal health coverage (UHC) must address this complex private sector. However, no agreed measures exist to assess the scale and scope of the private health sector in these countries, and policy makers tasked with managing and regulating mixed health systems struggle to identify the key features of their private sectors. In this report, we propose a set of metrics, drawn from existing data that can form a starting point for policy makers to identify the structure and dynamics of private provision in their particular mixed health systems; that is, to identify the consequences of specific structures, the drivers of change, and levers available to improve efficiency and outcomes. The central message is that private sectors cannot be understood except within their context of mixed health systems since private and public sectors interact. We develop an illustrative and partial country typology, using the metrics and other country information, to illustrate how the scale and operation of the public sector can shape the private sector's structure and behaviour, and vice versa.

Have Socioeconomic Inequalities in Tobacco Use in India Increased Over Time? Trends From the National Sample Surveys (2000-2012).

INTRODUCTION: India has experienced marked sociocultural change, economic growth and industry promotion of tobacco products over the past decade. Little is known about the influence of these factors on socioeconomic patterning of tobacco use. This study examines trends in tobacco use by socioeconomic status (SES) in India between 2000 and 2012. METHODS: We analyzed data in 2014 from nationally-representative repeated cross-sectional National Sample Surveys (NSS) in India for 1999-2000, 2004-2005 and 2011-2012 (n = 346 612 households). Prevalence and volume trends in cigarette, "bidi" and smokeless tobacco use were examined by household expenditure, educational attainment and caste/tribe status using Two-part model. RESULTS: Prevalence of any tobacco use remained consistent in the poorest households (61.5% to 62.7%) and declined among the richest (43.8% to 36.8%) between 2000-2012. Bidi use declined across all groups (poorest: 26.3% to 16.8%, richest: 19.8% to 10.7%) while cigarette use increased (poorest: 1.2% to 1.3%, richest: 6.5% to 7.0%). Relative to educated and general caste households, between 2000 and 2012 cigarette use in illiterate households increased by 38% and among Scheduled Tribe households increased by 32%. Smokeless tobacco use increased for all households (poorest: 26.2% to 33.9%, richest: 11.4% to 13.5%, Scheduled Tribe: 31.1% to 34.8%, general caste: 13.6% to 18.5%), with greater increases among richer, more educated and general caste households. CONCLUSION: Marked SES patterning of tobacco use has persisted in India. Improving enforcement of tobacco control policies and monitoring comprehensive smoke-free legislations are needed to address this growing burden. IMPLICATIONS: We found "resilient" tobacco patterns in the last decade despite prevention interventions. SES continues to be inversely associated with tobacco products, with the exception of cigarettes. The declines in bidi use may be getting replaced by increase in cigarette use trends, especially among lower SES groups. The use of smokeless tobacco products has increased across all SES groups and the volume of smokeless tobacco use is not been declining despite a number of policies on tobacco use. This may be attributed to inadequate attention to chewed forms of tobacco in current policies, particularly to implementing pictoral warnings and regulating surrogate advertising. Evaluating the implementation of anti-tobacco policies and ensuring equity dimensions in interventions is urgently needed to address tobacco use inequalities.

Price elasticity of tobacco products among economic classes in India, 2011-2012.

OBJECTIVES: The objectives of this study are to: (1) examine the pattern of price elasticity of three major tobacco products (bidi, cigarette and leaf tobacco) by economic groups of population based on household monthly per capita consumption expenditure in India and (2) assess the effect of tax increases on tobacco consumption and revenue across expenditure groups. SETTING: Data from the 2011-2012 nationally representative Consumer Expenditure Survey from 101,662 Indian households were used. PARTICIPANTS: Households which consumed any tobacco or alcohol product were retained in final models. PRIMARY OUTCOME MEASURES: The study draws theoretical frameworks from a model using the augmented utility function of consumer behaviour, with a two-stage two-equation system of unit values and budget shares. Primary outcome measures were price elasticity of demand for different tobacco products for three hierarchical economic groups of population and change in tax revenue due to changes in tax structure. We finally estimated price elasticity of demand for bidi, cigarette and leaf tobacco and effects of changes in their tax rates on demand for these tobacco products and tax revenue. RESULTS: Own price elasticities for bidi were highest in the poorest group (-0.4328) and lowest in the richest group (-0.0815). Cigarette own price elasticities were -0.832 in the poorest group and -0.2645 in the richest group. Leaf tobacco elasticities were highest in the poorest (-0.557) and middle (-0.4537) groups. CONCLUSIONS: Poorer group elasticities were the highest, indicating that poorer consumers are more price responsive. Elasticity estimates show positive distributional effects of uniform bidi and cigarette taxation on the poorest consumers, as their consumption is affected the most due to increases in taxation. Leaf tobacco also displayed moderate elasticities in poor and middle tertiles, suggesting that tax increases may result in a trade-off between consumption decline and revenue generation. A broad spectrum rise in tax rates across all products is critical for tobacco control.

Evidence for cost-effectiveness of lifestyle primary preventions for cardiovascular disease in the Asia-Pacific Region: a systematic review.

BACKGROUND: Countries of the Asia Pacific region account for a major share of the global burden of disease due to cardiovascular disease (CVD) and this burden is rising over time. Modifiable behavioural risk factors for CVD are considered a key target for reduction in incidence but their effectiveness and cost-effectiveness tend to depend on country context. However, no systematic assessment of cost-effectiveness of interventions addressing behavioural risk factors in the region exists. METHODS: A systematic review of the published literature on cost-effectiveness of interventions targeting modifiable behavioural risk factors for CVD was undertaken. Inclusion criteria were (a) countries in Asia and the Pacific, (b) studies that had conducted economic evaluations of interventions (c) published papers in major economic and public health databases and (d) a comprehensive list of search words to identify appropriate articles. All authors independently examined the final list of articles relating to methodology and findings. RESULTS: Under our inclusion criteria a total of 28 studies, with baseline years ranging from 1990 to 2012, were included in the review, 19 conducted in high-income countries of the region. Reviewed studies assessed cost-effectiveness of interventions for tobacco control, alcohol reduction, salt intake control, physical activity and dietary interventions. The majority of cost-effectiveness analyses were simulation analyses mostly relying on developed country data, and only 6 studies used effectiveness data from RCTs in the region. Other than for Australia, no direct conclusions could be drawn about cost-effectiveness of interventions targeting behavioural risk factors due to the small number of studies, interventions that varied widely in design, and varied methods for measurement of costs associated with interventions. CONCLUSIONS: Good quality cost-effectiveness information on interventions targeting behavioural interventions for the Asia-Pacific region remains a major gap in the literature.

The economic burden of cancers on Indian households.

We assessed the burden of cancer on households' out-of-pocket health spending, non-medical consumption, workforce participation, and debt and asset sales using data from a nationally representative health and morbidity survey in India for 2004 of nearly 74 thousand households. Propensity scores were used to match households containing a member diagnosed with cancer (i.e. cancer-affected households) to households with similar socioeconomic and demographic characteristics (controls). Our estimates are based on data from 1,645 households chosen through matching. Cancer-affected households experienced higher levels of outpatient visits and hospital admissions and increased out-of-pocket health expenditures per member, relative to controls. Cancer-affected households spent between Indian Rupees (INR) 66 and INR 85 more per member on healthcare over a 15-day reference period, than controls and additional expenditures (per member) incurred on inpatient care by cancer-affected households annually is equivalent to 36% to 44% of annual household expenditures of matched controls. Members without cancer in cancer-affected households used less health-care and spent less on healthcare. Overall, adult workforce participation rates were lower by between 2.4 and 3.2 percentage points compared to controls; whereas workforce participation rates among adult members without cancer were higher than in control households. Cancer-affected households also had significantly higher rates of borrowing and asset sales for financing outpatient care that were 3.3% to 4.0% higher compared to control households; and even higher for inpatient care.

The Economic impact of Non-communicable Diseases on households in India.

BACKGROUND: In India, Non Communicable Diseases (NCDs) and injuries account for an estimated 62% of the total age-standardized burden of forgone Disability Adjusted Life Years (DALYs). Public and private financing of clinical services to reduce the NCD burden is a major challenge. METHODS: We used National Sample Survey Organization (NSSO) survey data from 1995-96 and 2004 covering nearly 200 thousand households to assess healthcare utilization patterns and out of pocket health spending by disease category. For this purpose, self-reported diseases and conditions were categorized into NCDs and non-NCDs. Survey data were used to assess how households financed their overall health expenditures and related this pattern to specific health conditions. We measured catastrophic spending on NCD-related hospitalization, defined as occurring when health expenditures exceeded 40% of a household's ability to pay, that is, household consumption spending less combined survival consumption expenditure; and impoverishment when per capita expenditure within the household decreased to below the poverty line once health spending was netted out. RESULTS: The share of NCDs in out of pocket health expenses incurred by households increased over time, from 31.6 percent in 1995-96 to 47.3 percent in 2004. In both years, own savings and income were the most important source of financing for many health conditions, typically between 40-60 percent of all spending, whereas 30-35 percent was from borrowing. The odds of catastrophic hospitalization expenditures for cancer was nearly 170% greater and for CVD and injuries 22 percent greater than the odds due to communicable diseases. Impoverishment patterns were similar. CONCLUSIONS: Out of pocket expenses for treating NCDs rose sharply over the period from 1995-96 to 2004. When NCDs are present, the financial risks to which Indians households are exposed are significant.