Micro-Loans, Insecticide-Treated Bednets, and Malaria: Evidence from a Randomized Controlled Trial in Orissa, India.

We describe findings from the first large-scale cluster randomized controlled trial in a developing country that evaluates the uptake of a health-protecting technology, insecticide-treated bednets (ITNs), through micro-consumer loans, as compared to free distribution and control conditions. Despite a relatively high price, 52 percent of sample households purchased ITNs, highlighting the role of liquidity constraints in explaining earlier low adoption rates. We find mixed evidence of improvements in malaria indices. We interpret the results and their implications within the debate about cost sharing, sustainability and liquidity constraints in public health initiatives in developing countries.

The importance of wage loss in the financial burden of illness: Longitudinal evidence from India.

BACKGROUND: A key aim of Universal Health Coverage (UHC) is to protect individuals and households against the financial risk of illness, and large-scale health insurance expansions are a central focus of the UHC agenda. Importantly, however, health insurance does not protect against a key dimension of financial risk associated with illness: forgone wage income. In this paper, we quantify the economic burden of illness in India attributable - separately - to wage loss and to medical care spending, as well as differences in them across the socio-economic distribution. METHODS: We use data from two longitudinal Indian household surveys: (i) the Village Dynamics in South Asia (VDSA) survey (1300 households surveyed every month for 60 months between 2010 and 2015) and (ii) the Indian Human Development Survey (IHDS) (more than 40,000 households surveyed in 2005 and again in 2011). Our regression models include a series of fixed effects that account for time-invariant household- (or individual-) level and time-varying unobservables common across households. FINDINGS: We find that, in the VDSA sample, wage loss accounts for more than 80% of the total economic burden of illness among the poorest households, but only about 20% of the economic burden of illness among the most affluent. Estimates from the IHDS sample confirm that this socio-economic gradient is present in the Indian population generally. CONCLUSIONS: Wage loss accounts for a substantial share of the total economic burden of illness in India - and disproportionately so among the poorest households. Our findings imply that if UHC is to achieve its objective of protecting households against the financial risk of illness - particularly poor households, the inclusion of wage loss insurance or another illness-related income replacement benefit is needed.

Agreement between dried blood spots and HemoCue in Tamil Nadu, India.

India retains the world's largest burden of anemia despite decades of economic growth and anemia prevention programming. Accurate screening and estimates of anemia prevalence are critical for successful anemia control. Evidence is mixed on the performance of HemoCue, a point-of-care testing device most widely used for large-scale surveys. The use of dried blood spots (DBS) to assess hemoglobin (Hb) concentration is a potential alternative, particularly in field settings. The objective of this study is to assess Hb measurement agreement between capillary HemoCue and DBS among two age groups, children 6-59 months and females age 12-40 years. We analyzed data from the baseline round of a cluster randomized rice fortification intervention in Cuddalore district of Tamil Nadu, India. Capillary blood was collected from a subset of participants for Hb assessment by HemoCue 301 and DBS methods. We calculated Lin's concordance correlation coefficient, and tested bias by conducting paired t-tests of Hb concentration. Independence of the bias and Hb magnitude was examined visually using Bland-Altman plots and statistically tested by Pearson's correlation. We assessed differences in anemia classification using McNemar's test of marginal homogeneity. Concordance between HemoCue and DBS Hb measures was moderate for both children 6-59 months (ρc = 0.67; 95% CI 0.65, 0.71) and females 12-40 years (ρc = 0.67: 95% CI 0.64, 0.69). HemoCue measures were on average 0.06 g/dL higher than DBS for children (95% CI 0.002, 0.12; p = 0.043) and 0.29 g/dL lower than DBS for females (95% CI - 0.34, - 0.23; p < 0.0001). 50% and 56% of children were classified as anemic according to HemoCue and DBS, respectively (p < 0.0001). 55% and 47% of females were classified as anemic according to HemoCue and DBS, respectively (p < 0.0001). There is moderate statistical agreement of Hb concentration between HemoCue and DBS for both age groups. The choice of Hb assessment method has important implications for individual anemia diagnosis and population prevalence estimates. Further research is required to understand factors that influence the accuracy and reliability of DBS as a methodology for Hb assessment.

High prevalence of Wuchereria bancrofti infection as detected by immunochromatographic card testing in five districts of Orissa, India, previously considered to be non-endemic.

India accounts for over one-third of the world's burden of lymphatic filariasis (LF). Although most coastal districts of Orissa state (eastern India) are LF-endemic, the western districts of Orissa are considered non-endemic. During a large-scale insecticide-treated bed net/microfinance trial, we tested one randomly selected adult (age 15-60 years) for LF from a random sample of microfinance-member households in five districts of western Orissa, using immunochromatographic card testing (ICT). Overall, 354 (adjusted prevalence 21%, 95%CI 17-25%) of 1563 persons were ICT positive, with district-wide prevalence rates ranging from 15-32%. This finding was not explained by immigration, as only 3% of subjects had ever lived in previously known LF-endemic districts. These results therefore suggest ongoing autochthonous transmission in districts where LF control programs are not operational. Our results highlight the importance of broad, systematic surveillance for LF in India and call for the implementation of LF control programs in our study districts.