Does Public Spending Reflect the Need for Health: A Cross-sectional Analysis at District Level in India.

BACKGROUND: There is mixed evidence on the extent of association between the allocation of public revenue for healthcare and its indicators of need. OBJECTIVE: In this study, we examined the relationship between allocations through state health financing (SHF) and the Central Government with infant mortality. MATERIALS AND METHODS: District-wise infant mortality rate (IMR) was computed using National Family Health Survey-4 data. State-wise data for health budgets through SHF and National Health Mission (NHM, a Centrally Sponsored Scheme), were obtained for the year 2015-16. We used a multivariable analysis through generalized linear model method using identity-link function. RESULTS: We found per capita SHF (₹3169) to be more than 12 times that of public health spending per capita through NHM (₹261). IMR was lower in districts with higher SHF allocation, although statistically insignificant. The allocation through NHM was higher in districts with higher IMR, which is statistically significant. Every unit percentage increase in per capita net state domestic product and female literacy led to 0.31% and 0.54% decline, while a 1% increase in under-five diarrhoea prevalence led to 0.17% increase in IMR. CONCLUSION: The NHM has contributed to enhancing vertical equity in health-care financing. The States' need to be more responsive to the differences in districts while allocating health-care resources. There needs to be a focus on spending on social determinants, which should be the cornerstone for any universal health coverage strategy.

Wealth and education-related inequalities in the utilisation of reproductive, maternal, newborn, and child health interventions within scheduled tribes in India: an analysis of Odisha and Jharkhand.

BACKGROUND: The utilisation of Reproductive, Maternal, Newborn and Child Health (RMNCH) services remains lower among the Scheduled Tribes (ST) in India than among the rest of the country's population. The tribal population's poorest and least-educated households are further denied access to RMNCH care due to the intersection of their social status, wealth, and education levels. The study analyses the wealth- and education-related inequalities in the utilisation of RMNCH services within the ST population in Odisha and Jharkhand. METHODOLOGY: We have constructed two summary measures, namely, the Co-coverage indicator and a modified Composite Coverage Index (CC), to determine wealth- and education-related inequalities in the utilisation of RMNCH indicators within the ST population in Odisha and Jharkhand. The absolute and relative inequalities with respect to wealth and education within the ST population are estimated by employing the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII). RESULTS: The results of the study highlight that access to RMNCH services is easier for women who are better educated and belong to wealthier households. The SII and RII values in the co-coverage indicator and modified CCI exhibit an increase in wealth-related inequalities in Odisha between NFHS-4 (2015-16) and NFHS-5 (2019-21) whereas in Jharkhand, the wealth- and education-related absolute and relative inequalities present a reduction between 2016 and 2021. Among the indicators, utilisation of vaccination was high, while the uptake of Antenatal Care Centre Visits and Vitamin A supplementation should be improved. INTERPRETATION: The study results underscore the urgent need of targeted policies and interventions to address the inequalities in accessing RMNCH services among ST communities. A multi-dimensional approach that considers the socioeconomic, cultural and geographical factors affecting healthcare should be adopted while formulating health policies to reduce inequalities in access to healthcare.

Variations in the prevalence of caesarean section deliveries in India between 2016 and 2021 - an analysis of Tamil Nadu and Chhattisgarh.

BACKGROUND: The prevalence of C-sections in India increased from 17.2% to 2006 to 21.5% in 2021. This study examines the variations in C-section prevalence and the factors correlating to these variations in Tamil Nadu (TN) and Chhattisgarh (CG). METHODS: Delivery by C-section as the outcome variable and several demographic, socio-economic, and clinical variables were considered as explanatory variables to draw inferences from unit-level data from the National Family Health Survey (NFHS-4; 2015-16 and NFHS-5; 2019-21). Descriptive statistics, bivariate percentage distribution, Pearson's Chi-square test, and multivariate binary logistic regression models were employed. The Slope Index of Inequality (SII) and the Concentration Index (CIX) were used to analyse absolute and relative inequality in C-section rates across wealth quintiles in public- and private-sector institutions. RESULTS: The prevalence of C-sections increased across India, TN and CG despite a decrease in pregnancy complications among the study participants. The odds of caesarean deliveries among overweight women were twice (OR = 2.11; 95% CI 1.95-2.29; NFHS-5) those for underweight women. Women aged 35-49 were also twice (OR = 2.10; 95% CI 1.92-2.29; NFHS-5) as likely as those aged 15-24 to have C-sections. In India, women delivering in private health facilities had nearly four times higher odds (OR = 3.90; 95% CI 3.74-4.06; NFHS-5) of having a C-section; in CG, the odds were nearly ten-fold (OR = 9.57; 95% CI:7.51,12.20; NFHS-5); and in TN, nearly three-fold (OR = 2.65; 95% CI-2.27-3.10; NFHS-5) compared to those delivering in public facilities. In public facilities, absolute inequality by wealth quintile in C-section prevalence across India and in CG increased in the five years until 2021, indicating that the rich increasingly delivered via C-sections. In private facilities, the gap in C-section prevalence between the poor (the bottom two quintiles) and the non-poor narrowed across India. In TN, the pattern was inverted in 2021, with an alarming 73% of the poor delivering via C-sections compared to 64% of those classified as non-poor. CONCLUSION: The type of health facility (public or private) had the most impact on whether delivery was by C-section. In India and CG, the rich are more likely to have C-sections, both in the private and in the public sector. In TN, a state with good health indicators overall, the poor are surprisingly more likely to have C-sections in the private sector. While the reasons for this inversion are not immediately evident, the implications are worrisome and pose public health policy challenges.

Patterns in the prevalence and wealth-based inequality of cervical cancer screening in India.

BACKGROUND: Cervical cancer is the second leading cause of deaths due to cancer among women in India. This study assesses the prevalence of cervical cancer screening among women in the 30 to 49 years age-group and its relation to demographic, social and economic factors. The equity in the prevalence of screening is studied with respect to the women's household wealth. METHODS: Data from the fifth National Family Health Survey are analyzed. The adjusted odds ratio is used to assess the prevalence of screening. The Concentration Index (CIX) and the Slope Index of Inequality (SII) are analyzed to assess the inequality. RESULTS: The average national prevalence of cervical cancer screening is found to be 1.97% (95% C.I, 1.8-2.1), ranging from 0.2% in West Bengal and Assam to 10.1% in Tamil Nadu. Screening is significantly more prevalent among the following demographics: educated, higher age group, Christian, scheduled caste, Government health insurance coverage, and high household wealth. Significantly lower prevalence is found among Muslim women, women from scheduled tribes, general category castes, non-Government health insurance coverage, high parity, and those who use oral contraceptive pills and tobacco. Marital status, place of residence, age at first sexual activity, and IUD usage are not significant influencers. At the national level, CIX (0.22 (95% C.I, 0.20-0.24)) and SII (0.018 (95% C.I, 0.015-0.020)) indicate significantly higher prevalence of screening among women from the wealthier quintiles. Significantly higher screening prevalence among wealthier quintiles in the North-East (0.1), West (0.21) and Southern (0.05) regions and among the poor quintiles in the Central (-0.05) region. Equiplot analysis shows a "top inequality pattern" in the North, North-East and Eastern regions, with overall low performance where the rich alone manage to avail screening. The Southern region exhibits an overall progress in screening prevalence with the exception of the poorest quintile, which is left behind. Pro-poor inequality exists in the Central region, with significantly higher prevalence of screening among poor. CONCLUSION: The prevalence of cervical cancer screening is very low (2%) in India. Cervical cancer screening is substantially higher among women with education and Government Health insurance coverage. Wealth-based inequality exists in the prevalence of cervical cancer screening and the prevalence is concentrated among the women from wealthier quintiles.

Development of a Health Technology Assessment Quality Appraisal Checklist (HTA-QAC) for India.

OBJECTIVE: We aim to develop a comprehensive checklist for evaluating Health Technology Assessment (HTA) studies commissioned in India. The primary objective of this work is to capture all vital aspects of an HTA study in terms of conduct, reporting and quality. METHODOLOGY: The development of a quality appraisal checklist included 3 steps. First, a targeted review of the literature was done to gather information on existing HTA checklists. After reviewing these checklists, an initial draft of the HTA quality appraisal checklist (HTA-QAC) for India was prepared with discussion amongst the authors. Second, the draft checklist was reviewed by the members of the Technical Appraisal Committee (TAC) and their feedback was incorporated. Subsequently, the revised checklist was presented at a virtual meeting of the TAC. Finally, a pilot phase was undertaken to apply HTA-QAC for the approved HTA study reports. Three rounds of virtual discussions were held with the researchers who were involved in the conduct of these HTA studies to resolve any discordance in opinion or develop solutions for the problems in the use of the HTA-QAC followed by a further revision of the checklist. RESULTS: The HTA-QAC is divided into two parts: a self-reporting section to be completed by the author, and the other to be completed by the reviewer. The reviewer checklist has two sections: one to review the report and the other to review the model. The author section is in a self-reporting format, which includes details of basic study information, the rationale for the study, policy relevance, study description, study methods, reporting of model parameters, and results. The reviewer section of the checklist focuses on the quality aspect of the conducted study. The domains included in the report review include details on study methodology, results, discussion, and conclusion. The second part of the reviewer section of HTA-QAC constitutes a review of the model in terms of model assumptions, functionality, model inputs, calculations, uncertainty analysis, model output, and model validation. CONCLUSION: We recommend a standardised process of quality appraisal to ensure the high quality of HTA evidence for policy use in the Indian context. The proposed HTA-QAC will help authors to ensure standardised reporting, as well as allow reviewers to assess the quality of analysis.

Stakeholders' Perspective on Working Towards a Healthy Ageing Society: Evidence from a Rapidly Ageing Context.

The combined demographic and epidemiologic transition may significantly challenge the ageing population, especially with a weak health and non-health supporting system. The study aims to elicit the supply side stakeholders' view on healthy ageing and the readiness for a healthy ageing society in the Kerala context, which is one of India's most advanced states in terms of demographic and epidemiologic transition. Data from various stakeholders in the field of Gerontology was collected using semi-structured in-depth interviews. A four-step content analysis and themes identification procedure were followed for the data analysis. The study results reiterated the World Health Organisation's (WHO) conceptualisation of healthy ageing, indicating that the intrinsic and extrinsic factors independently or their interacted effect played a potential role in determining healthy ageing. However, the results also revealed that healthy ageing represents only a partial achievement of successful ageing or ageing well. Quality of life (productive/active ageing) and well-being (happiness and freedom) dimensions are inevitable for successful aging. The four overarching themes emerged for preparing a healthy ageing society include (i) planning and resources, (ii) leadership, governance and implementation, (iii) ageing in place, and (iv) opportunities and challenges. The stakeholders perceived that to work towards a healthy ageing society, there is a crucial role for government and non-government partners at various levels.

Wealth inequalities in nutritional status among the tribal under-5 children in India: A temporal trend analysis using NFHS data of Jharkhand and Odisha states - 2006-21.

Background: Undernutrition remains a major public health concern in India, especially among children belonging to the Scheduled Tribes (ST). In this study, we analyse wealth inequalities in nutritional outcomes within ST communities in two tribal-dominated states of India, namely, Odisha and Jharkhand. The study also compares the trends in nutrition outcomes between ST and Non-ST children in these states. Methods: We have conducted a trend analysis of the prevalence and inequalities in the nutritional indicators among ST children under age five using unit-level data of the National Family Health Survey (NFHS) [NFHS-3(2005-06),4 (2015-16) and 5(2019-2021)]. Wealth-related inequalities were analysed using the Slope Index of Inequality (SII), which measures absolute inequality, and the relative Concentration Index (CIX), which measures relative inequality. We have also analysed the correlation between Antenatal Care (ANC) visits and nutritional indicators using the Pearson Correlation test. Results: The trend analysis shows that the prevalence of undernutrition remains higher among ST children in India as compared to Non-ST children between NFHS-3 (2005-06) and NFHS-5 (2019-2020) in Jharkhand and Odisha. The SII and CIX values show that statistically significant inequalities in stunting and underweight exist among children belonging to various wealth quintiles within the ST category in both states. Wasting is found to be significantly prevalent across all wealth quintiles. Also, we found a negative association between ANC visits and all three nutritional indicators. Interpretation: Our study highlights the importance of monitoring both the absolute and relative wealth inequalities in nutritional outcomes. This is due to the fact that while inequalities across groups may reduce, the prevalence of poor nutritional outcomes may increase among certain groups. Such observations, therefore, will enable policymakers to focus further on those groups and devise appropriate interventions.

Wealth related inequality in women and children malnutrition in the state of Chhattisgarh and Tamil Nadu.

BACKGROUND: Child and maternal malnutrition are the most serious health risks in India, accounting for 15% of the country's total disease burden. Malnutrition in children can manifest as 'stunting' (low height in relation to age) or 'wasting' (low weight in relation to height) or both and underweight or obesity among women. Other nutritional indicators show that India lags behind, with high levels of anaemia in women of reproductive age. The study aims to analyse the wealth related inequalities in the nutrition status among women and children of different wealth quintiles in a high focus state (Chhattisgarh; CG) and a non-high focus state (Tamil Nadu; TN) in India. METHODS: We used National Family Health Survey-3rd (2005-06) & 4th (2015-16) to study the trends and differentials of inequalities in the nutrition status. We have used two summary indices. - absolute inequalities using the slope index of inequality (SII), and relative inequalities using the concentration index (CIX). RESULTS: There is reduction in wealth related inequality in nutrition status of women and children from all wealth quintiles between 2005-06 and 2015-16. However the reduction in inequality in some cases such as that of severe stunting among children was accompanied by increase among children from better off households The values of SII and CIX imply that malnutrition except obesity is still concentrated among the poor. The prevalence of anaemia (mild, moderate and severe) has reduced among women and children in the past decade. The converging pattern observed with respect to prevalence of mild and moderate anaemia is not only due to reduction in prevalence of anaemia among women from poor households but an increase in prevalence in rich households. CONCLUSION: Malnutrition remains a major challenge in India, despite encouraging progress in maternal and nutrition outcomes over the last decade. Our study findings indicate the importance of looking at the change in inequalities of nutrition status of women and children of different wealth quintiles sub nationally. Given the country's rapidly changing malnutrition profile, with progress across several indicators of under nutrition but rapidly rising rates of overweight/obesity, particularly among adults, appropriate strategies needs to be devised to tackle the double burden of malnutrition.

Cost of delivering primary healthcare services through public sector in India.

Background & objectives: Public health spending on primary healthcare has increased by four times (in real terms) over the last decade and continues to constitute more than half of the total public health expenditure. The present study estimated the cost of providing healthcare services at sub centre (SC) and primary health centre (PHC) level in four selected States of India. Methods: A total of 51 SCs and 33 PHCs were selected across the four States (Himachal Pradesh, Odisha, Kerala and Tamil Nadu) of India. The economic cost of delivering health services at these facilities was assessed using bottom-up costing methodology during the reference year of 2014-2015. The cost of capital items was annualized and allocation of shared resources was based on appropriate apportioning statistics. Results: The mean annual cost of providing health services at SC and PHC was ₹ 0.69 million (US$ 11,392) and ₹ 5.1 million (US$ 83,837), respectively. Nearly 3/4th and 2/3rd of this cost at the level of SC (74%) and PHC (63%) were spent on salaries. In terms of unit cost, the costs per antenatal care and postnatal care visit were ₹ 221 (173-276) and ₹ 333 (244-461), respectively, at SCs. Similarly, the costs of per patient outpatient consultation and per bed day hospitalization at PHC level were ₹ 121 (91-155) and ₹ 1168 (955-1468), respectively. Interpretation & conclusions: The cost estimates from the present study can be used in economic evaluations, assessing technical efficiency and also for providing valuable information during scale-up of health facilities.

Pandemic resilience and health systems preparedness: lessons from COVID-19 for the twenty-first century.

The pandemic of COVID-19 disease has acted like a stress test on every aspect of life, but particularly exposed weaknesses of health systems design and capacity. There have been similar pandemics in the past, and the threat of more frequent future pandemics in the twenty-first century is real. It is therefore important to learn the right lessons with regard to health systems preparedness and resilience. The five design features that this paper discusses are related to the organization of primary care services, planned surge capacity in secondary and tertiary care, a robust disease surveillance system that is integrated with the health management information system, adequate domestic capacity in being able to innovate and scale up production and logistics of much needed medical products and a governance approach that recognizes the importance of the health systems being able to continuously learn and adapt to meet changing needs. In addition to this, the organizational capacity of the system to deliver required services would need more investment in financial resources, and a suitable health human resource policy.

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.

National Methodological Guidelines to Conduct Budget Impact Analysis for Health Technology Assessment in India.

OBJECTIVE: Our paper aims to present Budget Impact Analysis (BIA) guidelines for health technology assessment (HTA) in India. METHODOLOGY: A Systematic Literature Review (SLR) was conducted to retrieve information on existing BIA guidelines internationally. The initial set of principles for India were put together based on an interactive process between authors, taking into consideration the existing evidence on BIA and features of Indian healthcare system. These were reviewed by Technical Appraisal Committee (TAC) of Health Technology Assessment in India (HTAIn) for their inputs. Three rounds of consultations were held before finalising the guidelines. Finally, user feedback on the draft guidelines was obtained from the policy makers and programme managers involved in the budgeting decisions. RESULTS: We recommend a payer's perspective, which will include both a multi-payer (depicting the current situation in India) and a single-payer scenario (which reflects a futuristic universal health care situation). A time horizon of 1-4 years is recommended. For estimation of eligible population, a top-down approach is considered appropriate. The future and current mix of interventions should be analysed for different utilisation and coverage patterns. We do not recommend discounting; however, inflation adjustments should be performed. The presentation of results should include total and disaggregated results, segregated year-wise throughout the chosen time horizon, as well as segregated by the type of resources. Deterministic sensitivity analysis and scenario analysis are recommended to address uncertainty. CONCLUSION: Our recommendations, which are tailored for the Indian healthcare and financing context, aim to promote consistency and transparency in the conduct as well as reporting of the BIA. BIA should be used along with evidence from economic evaluation for decision making, and not as a substitute to evidence on value for money.

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.

Equity and elderly health in India: reflections from 75th round National Sample Survey, 2017-18, amidst the COVID-19 pandemic.

BACKGROUND: Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) outbreak, called coronavirus disease - 2019 (COVID-19), has affected more than 200 countries across the globe with a higher fatality rate among the elderly population. Aim of the study is to highlight the vulnerability of the aged amidst the current COVID-19 pandemic, and in the light of the recent international evidence, suggests what government could do to mitigate their vulnerability. METHODS: Data from the recently released (November 2019) 75th Round National Sample Survey (NSS), which was conducted from July 2017 to June 2018, across 8077 rural villages and 6181 urban wards was used for this study. Data collected from 555,115 individuals (rural: 325,232; urban: 229,232) included 42,762 elderly individuals (60 years or above). Bivariate and multivariate analyses were used for the calculation. RESULTS: Of the total sample of elderly individuals, 27.7% reported suffering from an ailment in the last 15 days, whereas 8.5% had been hospitalized during the last 365 days. Among the elderly, hospitalization rate was higher in the urban areas (OR: 1.23), general social category (OR: 1.18), richest economic quintile (OR: 1.69), and among those living alone (OR: 2.40). Also, among the elderly, 64% of those in the scheduled tribe (social group) and 51% in the poorest economic quintile utilized public facilities for hospitalization. Cardiovascular ailments were the major cause for hospitalization (18.1%) and outpatient visit (32%) among the elderly. Ailments related to diabetes and hypertension constituted 55% of outpatient visit for the elderly. Only 18.9% of the elderly had health insurance though chances of facing catastrophic health expenditures were high among the elderly. 6.6% of elderly female and 1.6% male live alone, and 27.5% of age 80 years and above are immobile. 50% of male and 90% of female are financially dependent on others and more so in poorer economic quintiles. CONCLUSIONS: The vulnerability of India's elderly increases across economic levels, and other dimensions such as the place of residence, gender, social group (caste), marital status, living arrangements, surviving children, and economic dependence. The current COVID-19 pandemic poses a greater risk of social isolation among the elderly, which may cause detrimental health impact. TRIAL REGISTRATION: Not applicable since the study is based on secondary data.

Cost of Delivering Secondary Healthcare Through the Public Sector in India.

BACKGROUND: Government spending on provision of secondary healthcare has increased four-fold (in real terms) over the last decade in India. The evidence on the cost of secondary care to the health system is limited. The present study estimates the total and unit cost of services at community health centres (CHCs) and district hospitals (DHs) across India. METHODS: The present study was undertaken in 19 CHCs and ten DHs across the four Indian states of Himachal Pradesh, Tamil Nadu, Kerala and Odisha to assess the economic cost of health services using a bottom-up methodology. Data on annual consumption of both capital and recurrent resources, spent in the provision of health services during the financial year of 2014-2015, were collected. Capital expenditure was annualised and shared resources were allocated to each of the shared activities using appropriate statistics. RESULTS: The mean annual costs of providing services at the CHC and DH level were 17 million Indian rupees (₹) ($US0.27 million) and ₹147 million ($US2.3 million), respectively. More than half of this annual cost was attributed to salaries (57% and 62% for CHC and DH level, respectively) and curative care (60% and 65%, respectively). At CHCs, the unit cost ranged from ₹134 (95% confidence interval [CI] 104-160) for an outpatient consultation to ₹3833 (95% CI 2668-5839) for institutional delivery. Similarly, at DH level, the unit cost varied from ₹183 (95% CI 124-248) for an outpatient consultation in an orthopaedics department to ₹4764 (95% CI 3268-6960) for an operation. CONCLUSION: The estimates from the present study may help generate benchmarks to aid in setting up provider payment rates and be used in future economic evaluations.

Economic and Societal Impact of a Systems-of-Care Approach for STEMI Management in Low and Middle-Income Countries: Insights from the TN STEMI Program.

The TN STEMI Program was a multicenter, prospective, observational study conducted in Tamil Nadu, India, that assessed the effects of implementing the STEMI India Model for the management of STEMI. We discuss the economic and societal impact in this article. Given that the intervention resulted in an absolute mortality reduction of 3.4%, we calculated a number needed to treat of 30 patients. At an annualized project cost of INR 15.11 million, this approximately calculates to INR 193,749 (USD 3,311) per life saved. The utility of the TN-STEMI Program can be estimated to be 1,108 life-years. This calculates to approximately INR 13,643 (USD 233) per life-year saved. Our estimates will likely be of particular interest to policy makers in low and middle-income countries, where financial and resource constraints pose a perennial public health challenge.

Accountability in the health system of Tamil Nadu, India: exploring its multiple meanings.

BACKGROUND: Accountability is increasingly being demanded of public services and is a core aspect of most recent frameworks of health system strengthening. Community-based accountability is an increasingly used strategy, and was a core aspect of India's flagship National Rural Health Mission (NRHM; 2005-2014). Research on policy implementation has called for policy analysts to go beyond the superficial articulation of a particular policy intervention to study the underlying meaning this has for policy-makers and other actors of the implementation process and to the way in which problems sought to be addressed by the policy have been identified and 'problematised'. METHODS: This research, focused on state level officials and health NGO leaders, explores the meanings attached to the concept of accountability among a number of key actors during the implementation of the NRHM in the south Indian state of Tamil Nadu. The overall research was guided by an interpretive approach to policy analysis and the problematisation lens. Through in-depth interviews we draw on the interviewees' perspectives on accountability. RESULTS: The research identifies three distinct perspectives on accountability among the key actors involved in the implementation of the NRHM. One perspective views accountability as the achievement of pre-set targets, the other as efficiency in achieving these targets, and the final one as a transformative process that equalises power differentials between communities and the public health system. We also present the ways in which these differences in perspectives are associated with different programme designs. CONCLUSIONS: This research underlines the importance of going beyond the statements of policy to exploring the underlying beliefs and perspectives in order to more comprehensively understand the dynamics of policy implementation; it further points to the impacts of these perspectives on the design of initiatives in response to the policy.

Community Action for Health in India's National Rural Health Mission: One policy, many paths.

Community participation as a strategy for health system strengthening and accountability is an almost ubiquitous policy prescription. In 2005, with the election of a new Government in India, the National Rural Health Mission was launched. This was aimed at 'architectural correction' of the health care system, and enshrined 'communitization' as one of its pillars. The mission also provided unique policy spaces and opportunity structures that enabled civil society groups to attempt to bring on to the policy agenda as well as implement a more collective action and social justice based approach to community based accountability. Despite receiving a lot of support and funding from the central ministry in the pilot phase, the subsequent roll out of the process, led in the post-pilot phase by the individual state governments, showed very varied outcomes. This paper using both documentary and interview based data is the first study to document the roll out of this ambitious process. Looking critically at what varied and why, the paper attempts to derive lessons for future implementation of such contested concepts.

Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening.

In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.