Estimating the Cost of Delivering Tobacco Cessation Intervention Package at Noncommunicable Disease Clinics in Two Districts of North India.

INTRODUCTION: Integrated care is likely to improve outcomes in strained healthcare systems while limiting costs. NCD clinics were introduced under the "National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease, and Stroke" (NPCDCS) in India; however, there is limited literature on the costs of delivering tobacco cessation interventions within NPCDCS. One of the study's objectives was to estimate the cost of delivering a culturally specific patient-centric behavioral intervention package in two district-level NCD clinics in Punjab, India. METHODS: Costing was undertaken using the health systems perspective. A top-down or financial costing approach and a bottom-up or activity-based approach were employed at each step of development and implementation. The opportunity cost was used to include the cost of human resources, infrastructure, and capital resources used. All infrastructure and capital costs were annualized using a 3% annual discount rate. Four additional scenarios were built up concerning three major components to reduce costs further when rolled out on a large scale. RESULTS: The cost of intervention package development, human resource training, and unit cost of implementation were estimated to be INR 6,47,827 (USD 8,874); INR 134,002 (USD 1810); and INR 272 (USD 3.67), respectively. Based on our sensitivity analysis results, the service delivery cost varied from INR 184 (USD 2.48) to INR 326 (USD 4.40) per patient. CONCLUSION: The development costs of the intervention package accounted for the majority proportion of the total cost. Of the total unit cost of implementation, the telephonic follow-up, human resources, and capital resources were the major contributory components. IMPLICATIONS: The current study aims to fill gaps by estimating the unit-level health systems cost of a culturally sensitive, disease-specific, and patient-centric tobacco cessation intervention package delivered at the outpatient settings of NCD clinics at the secondary level hospital, which represents a major link in the health care system of India. Findings from this study could be used to provide supportive evidence to policymakers and program managers for rolling out such interventions in established NCD clinics through the NPCDCS program of the Indian Government.

Factors affecting non-adherence to medical appointments among patients with hypertension at public health facilities in Punjab, India.

Daily adherence to antihypertensive medications is necessary to control hypertension. Under the State hypertension control program, hypertensive patients are enrolled in public health settings, provided with 30-day medication prescriptions, and advised to return to the health facility monthly. However, at least 50-60% of patients do not visit the health facility for their scheduled follow-up appointments. The authors aimed to document the major reasons for missed appointments and to characterize patient and health system barriers. By telephone, the authors interviewed 300 randomly selected patients who missed appointments for more than three consecutive months. Out of the 300, 206 were interviewed using a pre-structured questionnaire to explore patients' experiences along with medical record reviews from the patient database. Not feeling sick or not experiencing any symptoms (24.8%) was the major reason why patients did not return to the clinic, followed by far distance from the facility (22.3%). Among other reasons for missing follow-up appointments, lack of instructions/guidance from the facility (15.3%), acute illness among patients (8.3%), and long waiting time at the facilities (7%) were also documented. Most of these patients (55.4%) continued treatment from other sources, and a majority (54%) preferred private clinics. These results suggest the need for a more patient-centered care model, including education about hypertension as an asymptomatic but life-threatening condition and addressing the barrier of travel distance between a patient's home and the health facility. Further, introducing a reminder system using telephone calls, text messages, or home visits by health workers may increase the follow-up rate among patients.