National sample surveys show poor households face catastrophic expenditure for oral healthcare services in India.

INTRODUCTION: Globally people pay out-of-pocket (OOP) to access Oral healthcare services. In India, there is limited evidence on estimates of OOP expenditure. We undertook an analysis of national sample survey data on household health care expenditure to understand the expenditure pattern for Oral healthcare services and the catastrophic burden. METHOD: The expenditure reported for Oral healthcare services from two surveys: 71st round and 75th round, published by National Sample Survey Office (NSSO) was extracted. Based on monthly household consumption expenditure three economic groups were made: poor, middle- and rich-income groups. The OOP expenditure pattern while accessing day-care services and hospitalization and in public and private sector and the catastrophic expenditure were analysed. RESULTS: A total of 204 and 155 households from two national surveys reported to have accessed day-care Oral services respectively. The median OOP expenditure in public sector remained same at US $ 4 in both surveys. Over 35% of 78 households in 71st round and 42% of 167 in 75th round used public sector hospitalization services. The median expenditure of hospitalization doubled from US$ 58 (IQR 21-263) in 71st round to US $ 125 (IQR 45-363) in 75th round. Households from poor income groups spent seven times more for Oral healthcare services during the recent survey and faced catastrophic expenditure. CONCLUSION: The OOP expenditure for Oral healthcare has significant catastrophic household expenditure among the poor. There is a need to increase investment in public sector and insurance to protect poor against hospitalization expenditure in private sector.

Insights from national survey on household expenditure for primary healthcare services availed through informal healthcare providers.

INTRODUCTION: Ensuring accessible and affordable primary healthcare services of optimal quality is a core component of universal health coverage (UHC). Though a substantial percentage of population avail healthcare services from informal healthcare providers (IHPs) in rural India, the information regarding the extent of out-of-pocket (OOP) expenditure during such encounters is limited. METHOD: The study analyzed publicly available data of 75th National Sample Survey (NSS) to understand the household expenditure pattern on availing service from IHPs. OOP expenditure for services availed from IHPs were extracted from main data sets and analyzed for both out-patient care and hospitalization. The OOP was summarized across the five wealth quintiles based on monthly per capita expenditure (MPCE) and disease groupings derived from the ailments recorded during the survey. RESULTS: In total, 721 households accessed IHPs as part of out-patient consultation for infectious disease (67%). Households from rural areas (78%), households belonging to backward groups (75%), households from the poorest quintile and women (52%) access the services of IHPs. The median OOP for all services was INR 240 (IQR 120-600) and more than 90% of total OOP is accounted for medical expenditure. CONCLUSION: The programs need to define healthcare packages to engage IHPs to increase the reach and reduce OOP expenditure on households.

Rising Catastrophic Expenditure on Households Due to Tuberculosis: Is India Moving Away From the END-TB Goal?

Introduction: One of the targets of the END-TB strategy is to ensure zero catastrophic expenditure on households due to TB. The information about household catastrophic expenditure is limited in India and, therefore difficult to monitor. The objective is to estimate household and catastrophic expenditure for Tuberculosis using national sample survey data. Methods: For arriving at out-of-pocket expenditure due to tuberculosis and its impact on households the study analyzed four rounds of National Sample Survey data (52nd round-1995-1996, 60th round-2004-2005, 71st round-2014-15, and 75th round 2017-2018). The household interview survey data had a recall period of 365 days for inpatient/ hospitalization and 15 days for out-patient care expenditure. Expenditure amounting to >20% of annual household consumption expenditure was termed as catastrophic. Results: A 5-fold increase in median outpatient care cost in 75th round is observed compared to previous rounds and increase has been maximum while accessing public sector. The overall expense ratio of public v/s private is 1:3, 1:4, 1:5, and 1:5, respectively across four rounds for hospitalization. The prevalence of catastrophic expenditure due to hospitalization increased from 16.5% (52nd round) to 43% (71st round), followed by a decline to 18% in the recent 75th round. Conclusion: Despite free diagnostic and treatment services offered under the national program, households are exposed to catastrophic financial expenditure due to tuberculosis. We strongly advocate for risk protection mechanisms such as cash transfer or health insurance schemes targeting the patients of tuberculosis, especially among the poor.

Impact of Advocacy, Communication, Social Mobilization and Active Case Finding on TB Notification in Jharkhand, India.

Community-level benefits of screening for active tuberculosis (TB) disease remain uncertain. Project Axshya (meaning free of TB) conducted advocacy, communication, social mobilization, and active case finding among vulnerable/marginalized populations of India. Among 15 districts of Jharkhand state, the project was initiated in 36 subdistrict level administrative units - tuberculosis units (TUs) in a staggered manner between April 2013 and September 2014, and continued till the end of 2015. Seven TUs did not implement the project. We assessed the relative change in the quarterly TB case finding indicators (n = 4) after inclusion of a TU within the project. By fitting four multilevel models (mixed-effects maximum likelihood regression using random intercept), we adjusted for secular (over previous five quarters) and seasonal trends, baseline differences within Axshya and non-Axshya TUs, and population size and clustering within districts and within TUs. After inclusion of a TU within the project, we found a significant increase [95% confidence interval (CI)] in TU-level presumptive TB sputum examination rate, new sputum-positive TB Case Notification Rate (CNR), sputum-positive TB CNR, and all forms TB CNR by 12 (5.5, 18.5), 1.1 (0.5, 1.7), 1.3 (0.6, 2.0), and 1.2 (0.1, 2.2) per 100,000 population per quarter, respectively. Overall, the project resulted in an increase (95% CI) in sputum examination and detection of new sputum-positive TB, sputum-positive TB and all forms of TB patients by 22,410 (10,203, 34,077), 2066 (923, 3210), 2380 (1162, 3616), and 2122 (203, 4059), respectively. This provides evidence for implementing project Axshya over and above the existing passive case finding.

Active case finding among marginalised and vulnerable populations reduces catastrophic costs due to tuberculosis diagnosis.

BACKGROUND: There is limited evidence on whether active case finding (ACF) among marginalised and vulnerable populations mitigates the financial burden during tuberculosis (TB) diagnosis. OBJECTIVES: To determine the effect of ACF among marginalised and vulnerable populations on prevalence and inequity of catastrophic costs due to TB diagnosis among TB-affected households when compared with passive case finding (PCF). METHODS: In 18 randomly sampled ACF districts in India, during March 2016 to February 2017, we enrolled all new sputum-smear-positive TB patients detected through ACF and an equal number of randomly selected patients detected through PCF. Direct (medical and non-medical) and indirect costs due to TB diagnosis were collected through patient interviews at their residence. We defined costs due to TB diagnosis as 'catastrophic' if the total costs (direct and indirect) due to TB diagnosis exceeded 20% of annual pre-TB household income. We used concentration curves and indices to assess the extent of inequity. RESULTS: When compared with patients detected through PCF (n = 231), ACF patients (n = 234) incurred lower median total costs (US$ 4.6 and 20.4, p < 0.001). The prevalence of catastrophic costs in ACF and PCF was 10.3 and 11.5% respectively. Adjusted analysis showed that patients detected through ACF had a 32% lower prevalence of catastrophic costs relative to PCF [adjusted prevalence ratio (95% CI): 0.68 (0.69, 0.97)]. The concentration indices (95% CI) for total costs in both ACF [-0.15 (-0.32, 0.11)] and PCF [-0.06 (-0.20, 0.08)] were not significantly different from the line of equality and each other. The concentration indices (95% CI) for catastrophic costs in both ACF [-0.60 (-0.81, -0.39)] and PCF [-0.58 (-0.78, -0.38)] were not significantly different from each other: however, both the curves had a significant distribution among the poorest quintiles. CONCLUSION: ACF among marginalised and vulnerable populations reduced total costs and prevalence of catastrophic costs due to TB diagnosis, but could not address inequity.

Status of Tuberculosis services in Indian Prisons.

INTRODUCTION: Prisons are known to be a high risk environment for tuberculosis (TB) due to overcrowding, low levels of nutrition, poor infection control and lack of accessible healthcare services. India has nearly 1400 prisons housing 0.37 million inmates. However, information on, availability of diagnostic and treatment services for TB in the prison settings is limited. This study examined the availability of TB services in prisons of India. Simultaneously, prison inmates were screened for tuberculosis. METHOD: The study was conducted in 157 prisons across 300 districts between July-December 2013. Information on services available and practices followed for screening, diagnosis and treatment of TB was collected. Additionally, the inmates and prison staff were sensitised on TB using interpersonal communication materials. The inmates were screened for cough ≥2 weeks as a symptom of TB. Those identified as presumptive TB patients (PTBP) were linked with free diagnostic and treatment services. RESULTS: Diagnostic and treatment services for TB were available in 18% and 54% of the prisons respectively. Only half of the prisons screened inmates for TB on entry, while nearly 60% practised periodic screening of inmates. District level prisons (OR, 6.0; 95% CI, 1.6-22.1), prisons with more than 500 inmates (OR, 52; 95% CI, 1.4-19.2), and prisons practising periodic screening of inmates (OR, 2.7; 95% CI, 1.0-7.2) were more likely to diagnose TB cases. 19% of the inmates screened had symptoms of TB (cough ≥2 weeks) and 8% of the PTBP were diagnosed with TB on smear microscopy. CONCLUSION: The TB screening, diagnostic and treatment services are sub-optimal in prisons in India and need to be strengthened urgently.

Serial survey shows community intervention may contribute to increase in knowledge of Tuberculosis in 30 districts of India.

BACKGROUND: Correct knowledge about Tuberculosis (TB) is essential for appropriate healthcare seeking behaviour and to accessing diagnosis and treatment services timely. There are several factors influencing knowledge about TB. The present study was conducted to assess the change in community knowledge of Tuberculosis (TB) and its association with respondent's socio-demographic characteristics in two serial knowledge-attitude-practice surveys. METHODS: Community level interventions including community meetings with youth groups, village health committees and self-help groups and through mass media activities were undertaken to create awareness and knowledge about TB and service availability. Increase in knowledge on TB and its association with respondent's socio-demographic characteristics was assessed by two serial KAP surveys in 2010-2011 (baseline) and 2012-2013 (midline) in 30 districts of India. Correct knowledge of TB was assessed by using lead questions and scores were assigned. The composite score was dichotomized into two groups (score 0-6, poor TB knowledge and score 7-13, good TB knowledge). RESULTS: In baseline and midline survey, 4562 and 4808 individuals were interviewed. The correct knowledge about TB; cough ≥2 weeks, transmission through air, 6-8 months treatment duration, and free treatment increased by 7 % (p-value <0.05), 11 % (p-value <0.05), 2 % (p-value <0.05), and 8 % (p-value <0.05) in midline compared to baseline, respectively. The knowledge on sputum smear test for diagnosis of TB was 66 % in both surveys while knowledge on availability of free treatment and that TB is curable disease decreased by 5 % and 2 % in midline (p-0.001), compared to baseline, respectively. The mean score for correct knowledge about TB increased from 60 % in baseline to 71 % in midline which is a 11 % increase (p-value <0.001). The misconception regarding on transmission of TB by- sharing of food and clothes and handshake persisted in midline. Respondents residing in northern (OR, 2.2, 95 % CI, 1.7-2.6) and western districts (OR, 3.4, 95 % CI, 2.7-4.1) of India and age groups- 25-34 years (OR, 1.3; 95 % CI, 1.1-1.6) and 45-44 years (OR, 1.4; 95 % CI, 1.1-1.7)- were independently associated with good TB knowledge. CONCLUSIONS: The knowledge about TB has increased over a period of 2 years and this may be attributable to the community intervention in 30 districts of India. The study offers valuable lesson for designing TB related awareness programmes in India and in other high burden countries.

Using dental care resources optimally: quality-efficiency trade-offs in a competitive private market.

PURPOSE: Modern lifestyle changes led to increased dental care needs in India. Consequently, there has been a sharp rise in dentist numbers. Karnataka state alone produces 2,500 dentists annually, who are engaged in the non-government sector owing to inadequate public sector opportunities. This article aims to assess Karnataka private dental clinic quality and efficiency. DESIGN/METHODOLOGY/APPROACH: Dentists were interviewed using a close-ended, structured interview schedule and their clinics were assessed using a checklist adopted from guidelines for providing machinery and equipment under the National Oral Health Care Programme (NOHCP). Dental "hotel" and clinical quality were scored based on this checklist. FINDINGS: Clinical quality was "excellent" in 12 per cent of clinics and poor in 49 per cent. Clinics with better infrastructure charged higher price (p < 0.05). Multi-chair clinics charging fixed rates were high (81 per cent). According to 59.5 per cent of dentists, competition did not improve quality while 27 per cent felt that competition increased price, not quality. About 30.9 per cent of the poor quality clinics, 41 per cent average quality clinics and 26 per cent good quality clinics were technically efficient. PRACTICAL IMPLICATIONS: The multi chair clinics offered better quality at higher prices and single chair clinics provided poorer quality at lower prices. In other words, they had a sub-optimal price-quality mix. Therefore, there is a need to regulate price and quality in all clinics to arrive at an optimal price-quality mix so that clients are not overburdened financially even while receiving good quality dental care. ORIGINALITY/VALUE: The article advocates that resources are used optimally as a way to achieve value for money and to achieve break-even points thereby providing quality care in a competitive market. Factors that influence dental practitioner behaviour are evaluated.