Comparing socio-economic inequalities in self-reported and undiagnosed hypertension among adults 45 years and over in India: what explains these inequalities?

BACKGROUND: Hypertension (HTN) is a leading cause of mortality and morbidity in developing countries. For India, the hidden burden of undiagnosed hypertension is a major concern. This study aims to assess and explain socio-economic inequalities among self-reported and undiagnosed hypertensives in India. METHODS: The study utilized data from the Longitudinal Aging Study in India (LASI), a nationally-representative survey of more than 72,000 older adults. The study used funnel plots, multivariable logistic regression, concentration indices, and decomposition analysis to explain the socio-economic gap in the prevalence of self-reported and undiagnosed hypertension between the richest and the poorest groups. RESULTS: The prevalence of self-reported and undiagnosed hypertension was 27.4 and 17.8% respectively. Monthly per capita consumption expenditure (MPCE) quintile was positively associated with self-reported hypertension but negatively associated with undiagnosed hypertension. The concentration index for self-reported hypertension was 0.133 (p < 0.001), whereas it was - 0.047 (p < 0.001) for undiagnosed hypertension. Over 50% of the inequalities in self-reported hypertension were explained by the differences in the distribution of the characteristics whereas inequalities remained unexplained for undiagnosed hypertension. Obesity and diabetes were key contributors to pro-rich inequality. CONCLUSIONS: Results imply that self-reported measures underestimate the true prevalence of hypertension and disproportionately affect the poorer MPCE groups. The prevalence of self-reported HTN was higher in the richest group, whereas socio-economic inequality in undiagnosed hypertension was significantly concentrated in the poorest group. As majority of the inequalities remain unexplained in case of undiagnosed hypertension, broader health systems issues including barriers to access to health care may be contributing to inequalities.

Assessment of Variation in Cesarean Delivery Rates Between Public and Private Health Facilities in India From 2005 to 2016.

Importance: The rates of cesarean deliveries have more than doubled in India, from 8% of deliveries in 2005 to 17% of deliveries in 2016. The World Health Organization recommends that cesarean deliveries should not exceed 10% to 15% of all deliveries in any country. An understanding of the association of private and public facilities with the increase in cesarean delivery rates in India is needed. Objective: To assess the association of public vs private sector health care facilities with cesarean delivery rates in India and to estimate the potential cost savings if private sector facilities followed World Health Organization recommendation for cesarean deliveries. Design, Setting, and Participants: This cross-sectional study used institutional delivery data from the representative National Family Health Survey (NFHS) in India, including data from the NFHS-1 (1992-1993), the NFHS-3 (2005-2006), and the NFHS-4 (2015-2016). The NFHS-3 and NFHS-4 provided data on 22 647 deliveries and 195 366 deliveries, respectively. The NHFS-4 was the first survey to provide data on out-of-pocket expenditures for delivery by facility type, allowing for a comparison of cesarean deliveries and costs between public and private facilities. The primary sample comprised all pregnant women who delivered infants in public and private institutional facilities in India and who were included the NFHS-3 and the NFHS-4; data on pregnant women who were included in the NFHS-1 were used for comparison. The study's findings were analyzed through geographic mapping, data tabulation, funnel plots, multivariate logistic regression analyses, and potential cost-savings scenario analyses. Data were analyzed from June to December 2019. Main Outcomes and Measures: The main outcome was the rate of cesarean deliveries by facility type (public vs private) and by participant socioeconomic, demographic, and health characteristics. Secondary outcomes were the potential number of avoidable cesarean deliveries and the potential cost savings if private sector facilities followed the World Health Organization recommendations for cesarean deliveries. Results: In the NFHS-3, 22 610 total births occurred at institutional facilities. Of those, 2178 births (15.2%) were cesarean deliveries in public facilities, and 3200 births (27.9%) were cesarean deliveries in private facilities. Of 195 366 total institutional births in the NFHS-4, 15 165 births (11.9%) were cesarean deliveries in public facilities, and 20 506 births (40.9%) were cesarean deliveries in private facilities. The cesarean delivery rate in public health facilities increased from 7.2% in the NFHS-1 to 11.9% in the NFHS-4, whereas in private health facilities, the rate increased from 12.3% to 40.9% during the same period. A substantial increase was found in cesarean delivery rates between the NFHS-3 (2005-2006) and the NFHS-4 (2015-2016), with 22 states exceeding the World Health Organization's upper threshold of 15% in the NFHS-4. The odds ratio for cesarean deliveries in private facilities compared with public facilities increased from 1.62 (95% CI, 1.49-1.76) in the NFHS-3 to 4.17 (95% CI, 4.04-4.30) in the NFHS-4. The number of avoidable cesarean deliveries would have been 1.83 million, with a potential cost savings of $320.60 million, if private sector facilities in India had followed the 15% threshold for cesarean delivery rates recommended by the World Health Organization. Conclusions and Relevance: In this study, private sector health facilities were associated with a substantial increase in cesarean deliveries in India. Further research is needed to assess the factors underlying the increase in cesarean deliveries in private sector facilities.

Primary health care, now and forever? A case study of a paradigm change.

The year 2008 marked the 30th anniversary of the Alma Ata Declaration that made Primary Health Care (PHC) the global health policy of member states of the World Health Organization (WHO). Why has PHC remained relevant? In part, this is because of growing evidence that health is a result of social, political, and economic environments, not merely of control of diseases and infirmities through interventions based on biomedical science. Using the conceptual framework developed by Thomas Kuhn, this article traces the emergence of PHC as a new paradigm based on social determinants to address poor health among populations (not individuals), especially those that are low-income. It traces the history of PHC over the last 30 years, focusing on policy developments within WHO. It selects three issues: definitions of PHC; financing and delivery of health services, including lay people's involvement in health care, as examples of the new paradigm; and opposition by those whose concept of health is based on the control of disease and infirmities paradigm. The article concludes by asking whether PHC will continue to be relevant and whether the question mark in the title of this article will be removed in the future.

A renewed focus on primary health care: revitalize or reframe?

The year 2008 celebrated 30 years of Primary Health Care (PHC) policy emerging from the Alma Ata Declaration with publication of two key reports, the World Health Report 2008 and the Report of the Commission on the Social Determinants of Health. Both reports reaffirmed the relevance of PHC in terms of its vision and values in today's world. However, important challenges in terms of defining PHC, equity and empowerment need to be addressed.This article takes the form of a commentary reviewing developments in the last 30 years and discusses the future of this policy. Three challenges are put forward for discussion (i) the challenge of moving away from a narrow technical bio-medical paradigm of health to a broader social determinants approach and the need to differentiate primary care from primary health care; (ii) The challenge of tackling the equity implications of the market oriented reforms and ensuring that the role of the State in the provision of welfare services is not further weakened; and (iii) the challenge of finding ways to develop local community commitments especially in terms of empowerment.These challenges need to be addressed if PHC is to remain relevant in today's context. The paper concludes that it is not sufficient to revitalize PHC of the Alma Ata Declaration but it must be reframed in light of the above discussion.

Public views of health system issues in four Asian countries.

To elicit the public's views on health system issues, we conducted an opinion poll survey in Bangladesh, Mongolia, Nepal, and Sri Lanka. We focused on health inequalities. The results show high levels of dissatisfaction with government health services in all four of the countries. Access to government health services was an important concern. A sizable number of respondents reported that their governments did not consider their views at all in shaping health care services. The policy implications of the study findings are discussed.

Cost-effectiveness of malaria control interventions when malaria mortality is low: insecticide-treated nets versus in-house residual spraying in India.

Malaria is one of the leading causes of morbidity and mortality in the developing world and a major public health problem in India. Disillusioned by in-house residual spraying (IRS), and increasingly aware that insecticide-treated nets (ITNs) have proved to be effective in reducing malaria mortality and morbidity in various epidemiological settings, policy-makers in India are keen to identify which is the more cost-effective malaria control intervention. A community randomised controlled trial was set up in Surat to compare the effectiveness and efficiency of IRS and ITNs. Both control strategies were shown to be effective in preventing malaria over the base-case scenario of early diagnosis and prompt treatment. The mean costs per case averted for ITNs was statistically significantly lower (Rs. 1848, 1567-2209; US$ 52) than IRS (Rs. 3121, 2386-4177, US$ 87). The incremental cost-effectiveness ratio for ITNs over IRS was Rs. 799 (US$ 22). The conclusions were robust to changes in assumptions. This study expands the scope of recent comparative economic evaluations of ITNs and IRS, since it was carried out in a low mortality malaria endemic area.