Cost-effectiveness analysis of parenteral iron therapy compared to oral iron supplements in managing iron deficiency anemia among pregnant women.

OBJECTIVE: This study compared the clinical efficacy and cost-effectiveness of parenteral iron, using intravenous iron sucrose (IVIS) therapy against the standard regimen of oral iron (OI) therapy for managing iron-deficiency anemia (IDA) among pregnant women in a natural primary care setting in Gujarat. DESIGN: A prospective cost-effectiveness study was conducted in natural programme setting wherein 188 pregnant women in their 14 to 18 weeks with moderate and severe anemia women enrolled from two districts of Gujarat, and 142 were followed up until the post-partum phase. The intervention group comprised of 82 participants who were administered IVIS, while the comparison group comprised of 106 participants who were put on OI therapy. Hemoglobin (Hb) levels were measured at periodic intervals, first during enrollment and then during each month of pregnancy period and finally on the 42nd day of the post-natal period. OUTCOME MEASURES: Change in mean Hb level from baseline was the primary outcome, while the incidence of morbidity and mortality was a secondary outcome measure. RESULTS: The intervention group showed a significant incremental mean change in Hb level from 8.2 g/dl to 11.45 g/dl at the fourth follow-up, while the control group's mean Hb level reduced from 9.99 g/dl to 9.55 g/dl. The discounted cost per beneficiary for IVIS was US$ 87, while that for OI was US$ 49. The incremental cost-effectiveness ratio (ICER) was US$ 9.84, which is 0.049% of India's per capita GDP. CONCLUSION: IVIS therapy was more clinically effective and cost-effective than OI therapy among pregnant women for management of moderate and severe anemia.

Capacity Building, Knowledge Enhancement, and Consultative Processes for Development of a Digital Tool (Ni-kshay SETU) to Support the Management of Patients with Tuberculosis: Exploratory Qualitative Study.

BACKGROUND: Achieving the target for eliminating tuberculosis (TB) in India by 2025, 5 years ahead of the global target, critically depends on strengthening the capacity of human resources as one of the key components of the health system. Due to the rapid updates of standards and protocols, the human resources for TB health care suffer from a lack of understanding of recent updates and acquiring necessary knowledge. OBJECTIVE: Despite an increasing focus on the digital revolution in health care, there is no such platform available to deliver the key updates in national TB control programs with easy access. Thus, the aim of this study was to explore the development and evolution of a mobile health tool for capacity building of the Indian health system's workforce to better manage patients with TB. METHODS: This study involved two phases. The first phase was based on a qualitative investigation, including personal interviews to understand the basic requirements of staff working in the management of patients with TB, followed by participatory consultative meetings with stakeholders to validate and develop the content for the mobile health app. Qualitative information was collected from the Purbi Singhbhum and Ranchi districts of Jharkhand and Gandhinagar, and from the Surat districts of Gujarat State. In the second phase, a participatory design process was undertaken as part of the content creation and validation exercises. RESULTS: The first phase collected information from 126 health care staff, with a mean age of 38.4 (SD 8.9) years and average work experience of 8.9 years. The assessment revealed that more than two-thirds of participants needed further training and lacked knowledge of the most current updates to TB program guidelines. The consultative process determined the need for a digital solution in easily accessible formats and ready reckoner content to deliver practical solutions to address operational issues for implementation of the program. Ultimately, the digital platform named Ni-kshay SETU (Support to End Tuberculosis) was developed to support the knowledge enhancement of health care workers. CONCLUSIONS: The development of staff capacity is vital to the success or failure of any program or intervention. Having up-to-date information provides confidence to health care staff when interacting with patients in the community and aids in making quick judgments when handling case scenarios. Ni-kshay SETU represents a novel digital capacity-building platform for enhancing human resource skills in achieving the goal of TB elimination.

Why and where?-Delay in Tuberculosis care cascade: A cross-sectional assessment in two Indian states, Jharkhand, Gujarat.

Tuberculosis (TB) is the second leading cause of death due to infectious diseases globally, and delay in the TB care cascade is reported as one of the major challenges in achieving the goals of the TB control programs. The main aim of this study was to investigate the delay and responsible factors for the delay in the various phases of care cascade among TB patients in two Indian states, Jharkhand and Gujarat. This cross-sectional study was conducted among 990 TB patients from the selected tuberculosis units (TUs) of two states. This study adopted a mixed-method approach for the data collection. The study targeted a diverse profile of TB patients, such as drug-sensitive TB (DSTB), drug resistance TB (DRTB), pediatric TB, and extra-pulmonary TB. It included both public and private sector patients. The study findings suggested that about 41% of pulmonary and 51% of extra-pulmonary patients reported total delay. Delay in initial formal consultation is most common, followed by a delay in diagnosis and treatment initiation in pulmonary patients. While in extra-pulmonary patients, delay in treatment initiation is most common, followed by the diagnosis and first formal consultation. DR-TB patients are more prone to total delay and delay in the treatment initiation among pulmonary patients. Addiction, co-morbidity and awareness regarding monetary benefits available for TB patients contribute significantly to the total delay among pulmonary TB patients. There were system-side factors like inadequacy in active case findings, poor infrastructure, improper adverse drug reaction management and follow-up, resulting in delays in the TB care cascade in different phases. Thus, the multi-disciplinary strategies covering the gambit of both system and demand side attributes are recommended to minimize the delays in the TB care cascade.

Comprehensive league table of cost-utility ratios: A systematic review of cost-effectiveness evidence for health policy decisions in India.

Background and objectives: Although a relatively recent concept for developing countries, the developed world has been using League Tables as a policy guiding tool for a comprehensive assessment of health expenditures; country-specific "League tables" can be a very useful tool for national healthcare planning and budgeting. Presented herewith is a comprehensive league table of cost per Quality Adjusted Life Years (QALY) or Disability Adjusted Life Years (DALY) ratios derived from Health Technology Assessment (HTA) or economic evaluation studies reported from India through a systematic review. Methods: Economic evaluations and HTAs published from January 2003 to October 2019 were searched from various databases. We only included the studies reporting common outcomes (QALY/DALY) and methodology to increase the generalizability of league table findings. To opt for a uniform criterion, a reference case approach developed by Health Technology Assessment in India (HTAIn) was used for the reporting of the incremental cost-effectiveness ratio. However, as, most of the articles expressed the outcome as DALY, both (QALY and DALY) were used as outcome indicators for this review. Results: After the initial screening of 9,823 articles, 79 articles meeting the inclusion criteria were selected for the League table preparation. The spectrum of intervention was dominated by innovations for infectious diseases (33%), closely followed by maternal and child health (29%), and non-communicable diseases (20%). The remaining 18% of the interventions were on other groups of health issues, such as injuries, snake bites, and epilepsy. Most of the interventions (70%) reported DALY as an outcome indicator, and the rest (30%) reported QALY. Outcome and cost were discounted at the rate of 3 by 73% of the studies, at 5 by 4% of the studies, whereas 23% of the studies did not discount it. Budget impact and sensitivity analysis were reported by 18 and 73% of the studies, respectively. Interpretation and conclusions: The present review offers a reasonably coherent league table that reflects ICER values of a range of health conditions in India. It presents an update for decision-makers for making decisions about resource allocation.

Cost-Effectiveness of mHealth Intervention (TeCHO+) for Improving Maternal and Child Health Indicators in Gujarat, India.

Background: Gujarat has implemented an mHealth program, technology for community health operations-plus (TeCHO+) in 2019. TeCHO+ is a mobile and web-based application that essentially enables data entry by the frontline workers providing service at the time and place of service delivery to improve the coverage and data quality. It also facilitates early identification of morbid condition and timely treatment. This study assessed the cost-effectiveness of TeCHO+ program in Gujarat. Materials and Methods: The study compared key program outcome indicators before and after the launch of TeCHO+ program. As the program was launched across the State, eMamta, the previous version of mother and child tracking system was used for comparison. A decision tree was parameterized to estimate change in disability-adjusted life year (DALY) and cost as a result of implementing TeCHO+ from a health system perspective. Results: TeCHO+ incurred a cost of Rs. 2,624 per beneficiary against Rs. 1,075 per beneficiary under the previous eMamta program. TeCHO+ has resulted in significant DALY averted through early identification of high-risk cases both among pregnant women and children. Overall, cost-effectiveness analysis indicated that TeCHO+ incurred an incremental cost of Rs. 1802.84 per DALY averted, which is 1.19% of the GDP per capita of India (year 2020). Conclusion: This study concludes that TeCHO+ is cost-effective for mother and child care and can be considered for replicating.

Cost-Effectiveness of Portable Electrocardiogram for Screening Cardiovascular Diseases at a Primary Health Center in Ahmedabad District, India.

Background: District Health Authority in Ahmedabad, Gujarat has introduced Project Lifeline, 12-lead portable ECG devices across all primary health centers (PHC) in the district to screen cardiac abnormalities among high-risk and symptomatic adults for providing primary management and proper timely referral. The prime purpose of the study was to assess the cost-effectiveness of portable ECG for the screening of cardiovascular diseases (CVD) among high-risk and symptomatic adults at the PHC in Ahmedabad, Gujarat. Methods: Cost-effective analysis was conducted using a societal perspective. An incremental costing approach was adapted, and cost-effectiveness analysis was done using a decision-analytic model. We surveyed 73 patients who screened positive for cardiac abnormality, documented the type of ECG abnormalities, and diagnosed CVD. The program cost was obtained from the implementers. Transition probabilities were derived from primary data supported by expert opinion for the intervention arm, while a systematic search of the literature was undertaken to derive transition probabilities for the control arm. Results: The ECG screening at PHC saves 2.90 life years at an incremental cost of 89.97 USD (6657.47 INR), yielding a cost-effectiveness ratio of 31.07 USD (2,299.06 INR) per life-year saved, which is below the willingness to pay threshold. The budget impact analysis was also performed. Results are sensitive to the relative risk reduction associated with the non-participation and the cost of initial screening. Conclusion: Cost-effectiveness analysis clearly shows that the facility to screen cardiac abnormality at the PHC level is highly recommended for high-risk adults and symptomatic cases.

Protocol for the cost-effectiveness of parenteral iron and oral iron therapy for first-line management of anaemia among pregnant women in a natural programme setting in Gujarat.

INTRODUCTION: Maternal anaemia is a major public health issue in India. The government of India recommends parenteral iron to manage moderate and severe grades of anaemia. In contrast to its clinical efficacy, the cost-effectiveness of intravenous iron sucrose and ferric carboxymaltose is not yet established in Indian context. This article illustrates the protocol of health technology assessment to evaluate the cost-effectiveness of intravenous therapy on the improvement of haemoglobin concentration over oral therapy. METHODS AND ANALYSIS: The study will be carried out in two districts of Gujarat state. The study participants will be selected by a proportionate sampling method from the rural, tribal, desert and coastal region of the districts. Data will be collected over 1 year on key outcome indicators using a mixed-method approach. Key informant interviews will be conducted, and cost data will be gathered to perform cost-effectiveness analysis. ETHICS AND DISSEMINATION: This study is approved by the Technical Appraisal Committee of Health Technology Assessment India, Department of Health Research and Institutional Ethics Committee of the Indian Institute of Public Health, Gandhinagar.

Costing and Cost-Effectiveness of a Mobile Health Intervention (ImTeCHO) in Improving Infant Mortality in Tribal Areas of Gujarat, India: Cluster Randomized Controlled Trial.

BACKGROUND: During 2013, a mobile health (mHealth) program, Innovative Mobile Technology for Community Health Operation (ImTeCHO), was launched in predominantly tribal and rural communities of Gujarat, India. ImTeCHO was developed as a job aid for Accredited Social Health Activists (ASHAs) and staff of primary health centers to increase coverage of maternal, neonatal, and child health care. OBJECTIVE: In this study, we assessed the incremental cost per life-years saved as a result of the ImTeCHO intervention as compared to routine maternal, neonatal, and child health care programs. METHODS: A two-arm, parallel, stratified cluster randomized trial with 11 clusters (primary health centers) randomly allocated to the intervention (280 ASHAs, n=2,34,134) and control (281 ASHAs, n=2,42,809) arms was initiated in 2015 in a predominantly tribal and rural community of Gujarat. A system of surveillance assessed all live births and infant deaths in the intervention and control areas. All costs, including those required during the start-up and implementation phases, were estimated from a program perspective. Incremental cost-effectiveness ratios were estimated by dividing the incremental cost of the intervention with the number of deaths averted to estimate the cost per infant death averted. This was further analyzed to estimate the cost per life-years saved for the purpose of comparability. Sensitivity analysis was undertaken to account for parameter uncertainties. RESULTS: Out of a total of 5754 live births (3014 in the intervention arm, 2740 in the control arm) reported in the study area, per protocol analysis showed that the implementation of ImTeCHO resulted in saving 11 infant deaths per 1000 live births in the study area at an annual incremental cost of US $163,841, which is equivalent to US $54,360 per 1000 live births. Overall, ImTeCHO is a cost-effective intervention from a program perspective at an incremental cost of US $74 per life-years saved or US $5057 per death averted. In a realistic environment with district scale-up, the program is expected to become even more cost-effective. CONCLUSIONS: Overall, the findings of our study strongly suggest that the mHealth intervention as part of the ImTeCHO program is cost-effective and should be considered for replication elsewhere in India. TRIAL REGISTRATION: Clinical Trials Registry of India CTRI/2015/06/005847; http://www.ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=11820&EncHid=&modid=&compid=%27,%2711820det%27.

Expanding health coverage in India: role of microfinance-based self-help groups.

To fulfil its commitment to universal health coverage, it will be necessary for the Indian government to expand access to appropriate and affordable health services. Through the mechanism of microfinance-based self-help groups (SHGs), poor women and their families are provided not only with access to finance to improve their livelihoods but also, in many cases, with a range of basic health services. Governments and non-governmental organisations in India have implemented large-scale programmes for the promotion of SHGs. With 93 million people organised nationally, the SHGs provide an established population base that can potentially be used to extend health coverage. However, the potential for working with SHGs to improve people's access to health services has not been an active part of the national policy discourse.​.

'More health for the money': an analytical framework for access to health care through microfinance and savings groups.

The main contributors to inequities in health relates to widespread poverty. Health cannot be achieved without addressing the social determinants of health, and the answer does not lie in the health sector alone. One of the potential pathways to address vulnerabilities linked to poverty, social exclusion, and empowerment of women is aligning health programmes with empowerment interventions linked to access to capital through microfinance and self-help groups. This paper presents a framework to analyse combined health and financial interventions through microfinance programmes in reducing barriers to access health care. If properly designed and ethically managed such integrated programmes can provide more health for the money spent on health care.

Design and baseline findings of a multi-site non-randomized evaluation of the effect of a health programme on microfinance clients in India.

Microfinance is the provision of financial services for the poor. Health program through microfinance has the potential to address several access barriers to health. We report the design and baseline findings of a multi-site non-randomized evaluation of the effect of a health program on the members of two microfinance organizations from Karnataka and Gujarat states of India. Villages identified for roll-out of health services with microfinance were pair-matched with microfinance only villages. A quantitative survey at inception and twelve months post health intervention compare the primary outcome (incidence of childhood diarrhea), and secondary outcome (place of last delivery, toilet at home, and out-of-pocket expenditure on treatment). At baseline, the intervention and comparison communities were similar except for out-of-pocket expenditure on health. Low reported use of toilet at home indicates the areas are heading towards a sanitation crisis. This should be an area of program priority for the microfinance organizations. While respondents primarily rely on their savings for meeting treatment expenditure, borrowing from friends, relatives, and money-lenders remains other important source of meeting treatment expenditure in the community. Programs need to prioritize steps to ensure awareness about national health insurance schemes, entitlement to increase service utilization, and developing additional health financing safety nets for financing outpatient care, that are responsible for majority of health-debt. Finally we discuss implications of such programs for national policy makers.

The effect of Self-Help Groups on access to maternal health services: evidence from rural India.

INTRODUCTION: The main challenge for achieving universal health coverage in India is ensuring effective coverage of poor and vulnerable communities in the face of high levels of income and gender inequity in access to health care. Drawing on the social capital generated through women's participation in community organizations like SHGs can influence health outcomes. To date, evidence about the impact of SHGs on health outcomes has been derived from pilot-level interventions, some using randomised controlled trials and other rigorous methods. While the evidence from these studies is convincing, our study is the first to analyse the impact of SHGs at national level. METHODS: We analyzed the entire dataset from the third national District Level Household Survey from 601 districts in India to assess the impact of the presence of SHGs on maternal health service uptake. The primary predictor variable was presence of a SHG in the village. The outcome variables were: institutional delivery; feeding newborns colostrum; knowledge about family planning methods; and ever used family planning. We controlled for respondent education, wealth, heard or seen health messages, availability of health facilities and the existence of a village health and sanitation committee. RESULTS: Stepwise logistic regression shows respondents from villages with a SHG were 19 per cent (OR: 1.19, CI: 1.13-1.24) more likely to have delivered in an institution, 8 per cent (OR: 1.08, CI: 1.05-1.14) more likely to have fed newborns colostrum, have knowledge (OR: 1.48, CI 1.39 - 1.57) and utilized (OR: 1.19, CI 1.11 - 1.27) family planning products and services. These results are significant after controlling for individual and village-level heterogeneities and are consistent with existing literature that the social capital generated through women's participation in SHGs influences health outcome. CONCLUSION: The study concludes that the presence of SHGs in a village is associated with higher knowledge of family planning and maternal health service uptake in rural India. To achieve the goal of improving public health nationally, there is a need to understand more fully the benefits of systematic collaboration between the public health community and these grassroots organizations.

Commitment among state health officials & its implications for health sector reform: lessons from Gujarat.

BACKGROUND & OBJECTIVE: Commitment, competencies and skills of people working in the health sector can significantly impact the performance and its reform process. In this study we attempted to analyse the commitment of state health officials and its implications for human resource practices in Gujarat. METHODS: A self-administered questionnaire was used to measure commitment and its relationship with human resource (HR) variables. Employee's organizational commitment (OC) and professional commitment (PC) were measured using OC and PC scale. Fifty five medical officers from Gujarat participated in the study. RESULTS: Professional commitment of doctors (3.21 to 4.01) was found to be higher than their commitment to the organization (3.01 to 3.61). Doctors did not perceive greater fairness in the system on promotion (on the scale of 5, score: 2.55) and were of the view that the system still followed seniority based promotion (score: 3.42). Medical officers were upset about low autonomy in the department with regard to reward and recognition, accounting procedure, prioritization and synchronization of health programme and other administrative activities. INTERPRETATION & CONCLUSION: Our study provided some support for positive effects of progressive HR practices on OC, specifically on affective and normative OC. Following initiatives were identified to foster a development climate among the health officials: providing opportunities for training, professional competency development, developing healthy relationship between superiors and subordinates, providing useful performance feedback, and recognising and rewarding performance. For reform process in the health sector to succeed, there is a need to promote high involvement of medical officers. There is a need to invest in developing leadership quality, supervision skills and developing autonomy in its public health institutions.