Cost of implementing the QualityRights programme in public hospitals in Gujarat providing mental healthcare.

Background & objectives: Investment in mental health is quite meagre worldwide, including in India. The costs of new interventions must be clarified to ensure the appropriate utilization of available resources. The government of Gujarat implemented QualityRights intervention at six public mental health hospitals. This study was aimed to project the costs of scaling up of the Gujarat QualityRights intervention to understand the additional resources needed for a broader implementation. Methods: Economic costs of the QualityRights intervention were calculated using an ingredients-based approach from the health systems' perspective. Major activities within the QualityRights intervention included assessment visits, meetings, training of trainers, provision of peer support and onsite training. Results: Total costs of implementing the QualityRights intervention varied from Indian Rupees (₹) 0.59 million to ₹ 2.59 million [1United States Dollars (US $) = ₹ 74.132] across six intervention sites at 2020 prices with 69-79 per cent of the cost being time cost. Scaling up the intervention to the entire State of Gujarat would require about two per cent increase in financial investment, or about 7.5 per cent increase in total cost including time costs over and above the costs of usual care for people with mental health conditions in public health facilities across the State. Interpretation & conclusions: The findings of this study suggest that human resources were the major cost contributor of the programme. Given the shortage of trained human resources in the mental health sector, appropriate planning during the scale-up phase of the QualityRights intervention is required to ensure all staff members receive the required training, and the treatment is not compromised during this training phase. As only about two per cent increase in financial cost can improve the quality of mental healthcare significantly, the State government can plan for its scale-up across the State.

Impact of COVID-19 restrictive measures on income and health service utilization of tuberculosis patients in India.

BACKGROUND: The nationwide lockdown (March 25 to June 8, 2020) to curb the spread of coronavirus infection had significant health and economic impacts on the Indian economy. There is limited empirical evidence on how COVID-19 restrictive measures may impact the economic welfare of specific groups of patients, e.g., tuberculosis patients. We provide the first such evidence for India. METHODS: A total of 291 tuberculosis patients from the general population and from a high-risk group, patients from tea garden areas, were interviewed at different time points to understand household income loss during the complete lockdown, three and eight months after the complete lockdown was lifted. Income loss was estimated by comparing net monthly household income during and after lockdown with prelockdown income. Tuberculosis service utilization patterns before and during the lockdown period also were examined. Household income loss, travel and other expenses related to tuberculosis drug pickup were presented in 2020 US dollars (1 US$ = INR 74.132). RESULTS: 26% of households with tuberculosis patients in tea garden areas and 51% of households in the general population had zero monthly income during the complete lockdown months (April-May 2020). Overall income loss slowly recovered during July-August compared to April-May 2020. Approximately 7% of patients in the general population and 4% in tea garden areas discontinued their tuberculosis medicines because of the complete lockdown. CONCLUSION: Discontinuation of medicine will have an additional burden on the tuberculosis elimination program in terms of additional cases, including multidrug resistant tuberculosis cases. Income loss for households and poor restoration of income after the lockdown will likely have an impact on the nutrition of tuberculosis patients and families. Tuberculosis patients working in the informal sector were the worst affected group during the nationwide lockdown. This emphasizes that a policy priority must continue to protect those working in informal sectors from the economic consequences of such restrictive measures, including paid sick leave, additional food support, and direct benefit transfers. Alongside ensuring widespread access to COVID-19 vaccines, these policy actions remain pivotal in ensuring the well-being of those who are unfortunate enough to be living with tuberculosis.

Cost Per DALY Averted in a Surgical Unit of a Private Hospital in India.

BACKGROUNDS: Cost-effectiveness analysis plays an important role to guide resource allocation decisions, however, information on cost per disability-adjusted life year (DALY) averted by health facilities is not available in many developing economies, including India. We estimated cost per DALY averted for 2611 patients admitted for surgical interventions in a 106-bed private for-profit hospital in northern India. METHODS: Costs were calculated using standard costing methods for the financial year 2012-2013, and effectiveness was measured in DALYs averted using risk of death/disability, effectiveness of treatment and disability weights from 2010 global burden of disease study. RESULTS: During the study period, total operating cost of the hospital for treating surgical patients was USD 1,554,406 and the hospital averted 9401 DALYs resulting in a cost per DALY averted of USD 165. CONCLUSIONS: Even though this study was based on one hospital in India, however, the hospital is a private hospital which is expected to have less surgical case load compared to government health facilities, cost per DALY averted for the surgical interventions is much lower than the cost-effectiveness threshold for India (USD 1508 in 2012). This study therefore provides evidence to re-think the common notion that surgical care is expensive and therefore of lower value than other health interventions.

Current costs & projected financial needs of India's Universal Immunization Programme.

BACKGROUND & OBJECTIVES: India's Universal Immunization Programme (UIP) is one of the largest programmes in the world in terms of quantities of vaccines administered, number of beneficiaries, number of immunization sessions, and geographical extent and diversity of areas covered. Strategic planning for the Programme requires credible information on the cost of achieving the objectives and the financial resources needed at national, State, and district levels. We present here expenditures on immunization services in India in 2012 (baseline) and projected costs for five years (2013-2017). METHODS: Data were collected from the Immunization Division of the Ministry of Health and Family Welfare, Government of India, and immunization partners, such as the World Health Organization and UNICEF. The cost components were immunization personnel, vaccines and injection supplies, transportation, trainings, social mobilization, advocacy and communication activities, disease surveillance, Programme management, maintenance of cold chain and other equipment, and capital costs. RESULTS: Total baseline expenditure was ₹ 3,446 crore [1 crore = 10 million] (US$718 million), including shared personnel costs. In 2012, the government paid for 90 per cent of the Programme. Total resource requirements for 2013-2017 are ₹ 34,336 crore (US$ 5, 282 million). Allocations for vaccines increase from ₹ 511 crore in 2013 to ₹ 3,587 crore in 2017 as new vaccines are assumed to be introduced in the Programme. INTERPRETATION & CONCLUSIONS: The projections show that the government immunization budget will be double in 2017 as compared to 2013. It will increase from ₹ 4,570 crore in 2013 to ₹ 9,451 crore in 2017.

Out of pocket expenditure to deliver at public health facilities in India: a cross sectional analysis.

BACKGROUND: To expand access to safe deliveries, some developing countries have initiated demand-side financing schemes promoting institutional delivery. In the context of conditional cash incentive scheme and free maternity care in public health facilities in India, studies have highlighted high out of pocket expenditure (OOPE) of Indian families for delivery and maternity care. In this context the study assesses the components of OOPE that women incurred while accessing maternity care in public health facilities in Uttar Pradesh, India. It also assesses the determinants of OOPE and the level of maternal satisfaction while accessing care from these facilities. METHOD: It is a cross-sectional analysis of 558 recently delivered women who have delivered at four public health facilities in Uttar Pradesh, India. All OOPE related information was collected through interviews using structured pre-tested questionnaires. Frequencies, Mann-Whitney test and categorical regression were used for data reduction. RESULTS: The analysis showed that the median OOPE was INR 700 (US$ 11.48) which varied between INR 680 (US$ 11.15) for normal delivery and INR 970 (US$ 15.9) for complicated cases. Tips for getting services (consisting of gifts and tips for services) with a median value of INR 320 (US$ 5.25) contributed to the major share in OOPE. Women from households with income more than INR 4000 (US$ 65.57) per month, general castes, primi-gravida, complicated delivery and those not accompanied by community health workers incurred higher OOPE. The significant predictors for high OOPE were caste (General Vs. OBC, SC/ST), type of delivery (Complicated Vs. Normal), and presence of ASHA (No Vs. Yes). OOPE while accessing care for delivery was one among the least satisfactory items and 76 % women expressed their dissatisfaction. CONCLUSION: Even though services at the public health facilities in India are supposed to be provided free of cost, it is actually not free, and the women in this study paid almost half of their mandated cash incentives to obtain delivery care.

Estimating the effectiveness of a hospital's interventions in India: impact of the choice of disability weights.

OBJECTIVE: To calculate the effect of using two different sets of disability weights for estimates of disability-adjusted life-years (DALYs) averted by interventions delivered in one hospital in India. METHODS: DALYs averted by surgical and non-surgical interventions were estimated for 3445 patients who were admitted to a 106-bed private hospital in a semi-urban area of northern India in 2012-2013. Disability weights were taken from global burden of disease (GBD) studies. We used the GBD 1990 disability weights and then repeated all of our calculations using the corresponding GBD 2010 weights. DALYs averted were estimated for surgical and non-surgical interventions using disability weight, risk of death and/or disability, and effectiveness of treatment. FINDINGS: The disability weights assigned in the GBD 1990 study to the sequelae of conditions such as cataract, cancer and injuries were substantially different to those assigned in the GBD 2010 study. These differences in weights led to large differences in estimates of DALYs averted. For all surgical interventions delivered to this patient cohort, 11 517 DALYs were averted if we used the GDB 1990 weights and 9401 DALYs were averted if we used the GDB 2010 disability weights. For non-surgical interventions 5168 DALYs were averted using the GDB 1990 disability weights and 5537 DALYS were averted using the GDB 2010 disability weights. CONCLUSION: Estimates of the effectiveness of hospital interventions depend upon the disability weighting used. Researchers and resource allocators need to be very cautious when comparing results from studies that have used different sets of disability weights.

Estimation of potential social support requirement for tuberculosis patients in India.

Providing social support to tuberculosis (TB) patients is a recommended strategy as households having TB patients find themselves in a spiral of poverty because of high cost, huge income loss and several other economic consequences associated with TB treatment. However, there are few examples of social support globally. The Indian government introduced "Nikshay Poshan Yojana" scheme in 2018 to provide nutritional support for all registered TB patients. Financial incentive of Indian Rupee (INR) 500 (US$6) per month was proposed to be transferred directly to the registered beneficiaries' validated bank accounts. We examined the reach, timing, amount of benefit receipt, and the extent to which the benefit alleviated catastrophic costs (used as a proxy to measure the impact on permanent economic welfare as catastrophic cost is the level of cost that is likely to result in a permanent negative economic impact on households) by interviewing 1482 adult drug-susceptible TB patients from 16 districts of four states during 2019 to 2023, using the methods recommended by the World Health Organisation for estimating household costs of TB nationally. We also estimated the potential amount of social support required to achieve a zero catastrophic cost target. At the end of treatment, 31%-54% study participants received the benefit. 34%-60% of TB patients experienced catastrophic costs using different estimation methods and the benefit helped 2% study participants to remain below the catastrophic cost threshold. A uniform benefit amount of INR 10000 (US$127) for 6 months of treatment could reduce the incidence of catastrophic costs by 43%. To improve economic welfare of TB patients, levels of benefit need to be substantially increased which will have considerable budgetary impact on the TB programme. Hence, a targeted rather than universal approach may be considered. To maximise impact, at least half of the revised amount should be given immediately after treatment registration.

Catastrophic costs for tuberculosis patients in India: Impact of methodological choices.

As financial risk protection is one of the goals towards universal health coverage, detailed information on costs, catastrophic costs and other economic consequences related to any disease are required for designing social protection measures. End Tuberculosis (TB) Strategy set a milestone of achieving zero catastrophic cost by 2020. However, a recent literature review noted that 7%-32% TB affected households in India faced catastrophic cost. Studies included in the review were small scale cross-sectional. We followed a cohort of 1482 notified drug-susceptible TB patients from four states in India: Assam, Maharashtra, Tamil Nadu, and West Bengal to provide a comprehensive picture of economic burden associated with TB treatment. Treatment cost was calculated using World Health Organization guidelines on TB patient cost survey and both human capital and output approaches of indirect cost (time, productivity, and income loss related to an episode) calculation were used to provide the range of households currently facing catastrophic cost. Depending on choice of indirect cost calculation method, 30%-61% study participants faced catastrophic cost. For over half of them, costs became catastrophic even before starting TB treatment as there was average 7-9 weeks delay from symptom onset to treatment initiation which was double the generally accepted delay of 4 weeks. During that period, they made average 8-11 visits to different providers and spent money on consultations, drugs, tests, and travel. Following the largest cohort of drug-susceptible TB patients till date, the study concluded that a significant proportion of study participants faced catastrophic cost and the proportion was much higher when income loss was considered as indirect cost calculation method. Therefore, ensuring uninterrupted livelihood during TB treatment is an absolute necessity. Another reason of high cost was the delay in diagnosis and costs incurred during pre-diagnosis period. This delay and consequently, economic burden, can be reduced by both supply side (intense private sector engagement, rapid diagnosis) and demand side (community engagement) initiatives. Reimbursement of expenses incurred before treatment initiation could be used as short-term measure for mitigating financial hardship.

Economic burden of suicides and suicide attempts in low- and middle-income countries: a systematic review of costing studies.

INTRODUCTION: Suicide is a major public health concern in low- and middle-income countries (LMICs) due to its substantial psychological, social, and economic impact. There is little synthesized evidence to estimate the economic burden of suicide and suicide attempts in such economies. The present systematic literature review aims to examine existing evidence on the cost of illness (COI) in the case of suicides and suicide attempts and assess their quality. METHODS: A systematic review was carried out using electronic databases, such as Medline, EMBASE, EconLit, PsycINFO, and CINAHL using keywords like 'suicide and suicide attempts,' 'cost of illness,' and economic burden." The quality assessment of studies was conducted along with the per-person cost estimation to understand the variation of methods followed across the studies. RESULT: 14 studies qualified for final data extraction and synthesis out of 4,164 studies. The studies showed heterogeneity across objectives, settings, and methods, with cost estimates reflecting a wide range of costings per person in suicide and suicide attempts. CONCLUSION: It is challenging to determine and compare the economic estimates of suicide. Intensive research is warranted with standardized cost assessment techniques and wider perspectives to understand the true economic burden of suicide. REGISTRATION: PROSPERO Registration No- CRD42022294080.

Health impact and cost-effectiveness of expanding routine immunization coverage in India through Intensified Mission Indradhanush.

Many children do not receive a full schedule of childhood vaccines, yet there is limited evidence on the cost-effectiveness of strategies for improving vaccination coverage. Evidence is even scarcer on the cost-effectiveness of strategies for reaching 'zero-dose children', who have not received any routine vaccines. We evaluated the cost-effectiveness of periodic intensification of routine immunization (PIRI), a widely applied strategy for increasing vaccination coverage. We focused on Intensified Mission Indradhanush (IMI), a large-scale PIRI intervention implemented in India in 2017-2018. In 40 sampled districts, we measured the incremental economic cost of IMI using primary data, and used controlled interrupted time-series regression to estimate the incremental vaccination doses delivered. We estimated deaths and disability-adjusted life years (DALYs) averted using the Lives Saved Tool and reported cost-effectiveness from immunization programme and societal perspectives. We found that, in sampled districts, IMI had an estimated incremental cost of 2021US$13.7 (95% uncertainty interval: 10.6 to 17.4) million from an immunization programme perspective and increased vaccine delivery by an estimated 2.2 (-0.5 to 4.8) million doses over a 12-month period, averting an estimated 1413 (-350 to 3129) deaths. The incremental cost from a programme perspective was $6.21 per dose ($2.80 to dominated), $82.99 per zero-dose child reached ($39.85 to dominated), $327.63 ($147.65 to dominated) per DALY averted, $360.72 ($162.56 to dominated) per life-year saved and $9701.35 ($4372.01 to dominated) per under-5 death averted. At a cost-effectiveness threshold of 1× per-capita GDP per DALY averted, IMI was estimated to be cost-effective with 90% probability. This evidence suggests IMI was both impactful and cost-effective for improving vaccination coverage, though there is a high degree of uncertainty in the results. As vaccination programmes expand coverage, unit costs may increase due to the higher costs of reaching currently unvaccinated children.

Mental Health Care Support in Rural India: A Cluster Randomized Clinical Trial.

Importance: More than 150 million people in India need mental health care but few have access to affordable care, especially in rural areas. Objective: To determine whether a multifaceted intervention involving a digital health care model along with a community-based antistigma campaign leads to reduced depression risk and lower mental health-related stigma among adults residing in rural India. Design, Setting, and Participants: This parallel, cluster randomized, usual care-controlled trial was conducted from September 2020 to December 2021 with blinded follow-up assessments at 3, 6, and 12 months at 44 rural primary health centers across 3 districts in Haryana and Andhra Pradesh states in India. Adults aged 18 years and older at high risk of depression or self-harm defined by either a Patient Health Questionnaire-9 item (PHQ-9) score of 10 or greater, a Generalized Anxiety Disorder-7 item (GAD-7) score of 10 or greater, or a score of 2 or greater on the self-harm/suicide risk question on the PHQ-9. A second cohort of adults not at high risk were selected randomly from the remaining screened population. Data were cleaned and analyzed from April 2022 to February 2023. Interventions: The 12-month intervention included a community-based antistigma campaign involving all participants and a digital mental health intervention involving only participants at high risk. Primary health care workers were trained to identify and manage participants at high risk using the Mental Health Gap Action Programme guidelines from the World Health Organization. Main Outcomes and Measures: The 2 coprimary outcomes assessed at 12 months were mean PHQ-9 scores in the high-risk cohort and mean behavior scores in the combined high-risk and non-high-risk cohorts using the Mental Health Knowledge, Attitude, and Behavior scale. Results: Altogether, 9928 participants were recruited (3365 at high risk and 6563 not at high risk; 5638 [57%] female and 4290 [43%] male; mean [SD] age, 43 [16] years) with 9057 (91.2%) followed up at 12 months. Mean PHQ-9 scores at 12 months for the high-risk cohort were lower in the intervention vs control groups (2.77 vs 4.48; mean difference, -1.71; 95% CI, -2.53 to -0.89; P < .001). The remission rate in the high-risk cohort (PHQ-9 and GAD-7 scores <5 and no risk of self-harm) was higher in the intervention vs control group (74.7% vs 50.6%; odds ratio [OR], 2.88; 95% CI, 1.53 to 5.42; P = .001). Across both cohorts, there was no difference in 12-month behavior scores in the intervention vs control group (17.39 vs 17.74; mean difference, -0.35; 95% CI, -1.11 to 0.41; P = .36). Conclusions and Relevance: A multifaceted intervention was effective in reducing depression risk but did not improve intended help-seeking behaviors for mental illness. Trial Registration: Clinical Trial Registry India: CTRI/2018/08/015355.

The α5 neuronal nicotinic acetylcholine receptor subunit plays an important role in the sedative effects of ethanol but does not modulate consumption in mice.

BACKGROUND: Alcohol use disorders (AUDs) are a major public health problem, and the few treatment options available to those seeking treatment offer only modest success rates. There remains a need to identify novel targets for the treatment of AUDs. The neuronal nicotinic acetylcholine receptors (nAChRs) represent a potential therapeutic target in the brain, as recent human genetic studies have implicated gene variants in the α5 nAChR subunit as high risk factors for developing alcohol dependence. METHODS: Here, we evaluate the role of the α5* nAChR for ethanol (EtOH)-mediated behaviors using male α5+/+ and α5-/- transgenic mice. We characterized the effect of hypnotic doses of EtOH and investigated drinking behavior using an adapted drinking-in-the-dark (DID) paradigm that has been shown to induce high EtOH consumption in mice. RESULTS: We found the α5 subunit to be important in mediating the sedative effects of EtOH. The α5-/- mice showed slower recovery from EtOH-induced sleep, as measured by loss of righting reflex. Additionally, the α5-/- mice showed enhanced impairment to EtOH-induced ataxia. We found the initial sensitivity to EtOH and EtOH metabolism to be similar in both α5+/+ and α5-/- mice. Hence, the enhanced sedation is likely due to a difference in the acute tolerance of EtOH in α5-/- mice. However, the α5 subunit did not play a role in EtOH consumption for EtOH concentrations ranging from 5 to 30% using the DID paradigm. Additionally, varenicline was effective in reducing EtOH intake in α5-/- mice. CONCLUSIONS: Together, our data suggest that the α5 nAChR subunit is important for the sedative effects of EtOH but does not play a role in EtOH consumption in male mice. Varenicline can be a treatment option even when there is loss of function of the α5 nAChR subunit.

Journey of the tuberculosis patients in India from onset of symptom till one-year post-treatment.

Historically, economic studies on tuberculosis estimated out-of-pocket expenses related to tuberculosis treatment and catastrophic cost, however, no study has yet been conducted to understand the post-treatment economic conditions of the tuberculosis patients in India. In this paper, we add to this body of knowledge by examining the experiences of the tuberculosis patients from the onset of symptoms till one-year post-treatment. 829 adult drug-susceptible tuberculosis patients from general population and from two high risk groups: urban slum dwellers and tea garden families were interviewed during February 2019 to February 2021 at their intensive and continuation phases of treatment and about one-year post-treatment using adapted World Health Organization tuberculosis patient cost survey instrument. Interviews covered socio-economic conditions, employment status, income, out-of-pocket expenses and time spent for outpatient visits, hospitalization, drug-pick up, medical follow-ups, additional food, coping strategies, treatment outcome, identification of post-treatment symptoms and treatment for post-treatment sequalae/recurrent cases. All costs were calculated in 2020 Indian rupee (INR) and converted into US dollar (US$) (1 US$ = INR 74.132). Total cost of tuberculosis treatment since the onset of symptom till one-year post-treatment ranged from US$359 (Standard Deviation (SD) 744) to US$413 (SD 500) of which 32%-44% of costs incurred in pre-treatment phase and 7% in post-treatment phase. 29%-43% study participants reported having outstanding loan with average amount ranged from US $103 to US$261 during the post-treatment period. 20%-28% participants borrowed during post-treatment period and 7%-16% sold/mortgaged personal belongings. Therefore, economic impact of tuberculosis persists way beyond treatment completion. Major reasons of continued hardship were costs associated with initial tuberculosis treatment, unemployment, and reduced income. Therefore, policy priorities to reduce treatment cost and to protect patients from the economic consequences of the disease by ensuring job security, additional food support, better management of direct benefit transfer and improving coverage through medical insurances need consideration.

Examining decentralization and managerial decision making for child immunization program performance in India.

Despite widespread adoption of decentralization reforms, the impact of decentralization on health system attributes, such as access to health services, responsiveness to population health needs, and effectiveness in affecting health outcomes, remains unclear. This study examines how decision space, institutional capacities, and accountability mechanisms of the Intensified Mission Indradhanush (IMI) in India relate to measurable performance of the immunization program. Data on decision space and its related dimensions of institutional capacity and accountability were collected by conducting structured interviews with managers based in 24 districts, 61 blocks, and 279 subcenters. Two measures by which to assess performance were selected: (1) proportion reduction in the DTP3 coverage gap (i.e., effectiveness), and (2) total IMI doses delivered per incremental USD spent on program implementation (i.e., efficiency). Descriptive statistics on decision space, institutional capacity, and accountability for IMI managers were generated. Structural equation models (SEM) were specified to detect any potential associations between decision space dimensions and performance measures. The majority of districts and blocks indicated low levels of decision space. Institutional capacity and accountability were similar across areas. Increases in decision space were associated with less progress towards closing the immunization coverage gap in the IMI context. Initiatives to support health workers and managers based on their specific contextual challenges could further improve outcomes of the program. Similar to previous studies, results revealed strong associations between each of the three decentralization dimensions. Health systems should consider the impact that management structures have on the efficiency and effectiveness of health services delivery. Future research could provide greater evidence for directionality of direct and indirect effects, interaction effects, and/or mediators of relationships.

Protocol for the implementation and evaluation of a community-based behavior change intervention to reduce dietary salt intake in India.

Excess dietary salt intake is well established as a leading cause of high blood pressure and associated cardiovascular disease, yet current salt intake in India is nearly 11 g per day, more than twice World Health Organization maximum recommended intake of 5 g per day. Although dietary survey data from India indicate that the main sources of dietary salt are salt added during cooking at home, and few salt reduction efforts have focused on interventions at the household level. As a result, there is little evidence of the effectiveness of behavior change programs to reduce salt intake at the household level. The study aims to develop and implement a community based behavioral change intervention to reduce salt intake delivered by front line community-based health volunteers; and evaluate the preliminary effectiveness, acceptability, and feasibility of delivering a salt reduction behavior change program and potential to support future scale-up. The study is a pre-post intervention design, and outcomes will be evaluated from a random sample of 1500 participants from 28 villages in two primary health centers in Siddipet, Telangana. Primary outcome is change in salt-related KAB (knowledge, attitude, and behavior) score, and secondary outcomes will be changes in salt intake measured by 24 h urinary sodium excretion and change in scores using the subscales of the COM-B ("capability", "opportunity", "motivation" and "behavior") tool. Findings will be used to inform future public health policies to support implementation of scalable community-based interventions to reduce salt intake and control hypertension, the leading-cause of death in India.

Cost of conducting Measles-Rubella vaccination campaign in India.

A Measles-Rubella (MR) vaccination campaign was launched in India in a phased manner in February 2017 to cover children aged 9 months to 15 years. As evidence on campaign vaccine delivery costs is limited, the delivery cost for MR campaign from a government provider perspective was estimated in four Indian states, namely, Assam, Gujarat, Himachal Pradesh, and Uttar Pradesh. Costs were calculated in top-down and bottom-up approaches using data collected from 84 sites at different administrative levels and immunization partners in the study states from August 2019 to March 2020. All costs were presented in 2019 US$ and Indian Rupee (INR). The financial cost per dose of the MR campaign including all partner support ranged from US$0.16 (INR 10.95) in Uttar Pradesh to US$0.34 (INR 24.13) in Gujarat. In Uttar Pradesh, the full economic cost per dose was US$0.87 (INR 61.39). The key financial cost drivers were incentives related to service delivery and supervision, the printing of reporting formats for record-keeping, social mobilization, and advocacy. The financial delivery cost per dose estimated was higher than the government pre-fixed budget per child for the MR campaign, probably indicating an insufficient budget. However, the study found underutilization of MR budget in two states and use of other sources of funding for the campaign indicating the need for proper utilization of the campaign budgets by the states. Unit cost information generated from this study will be useful for planning, cost projections, and economic analysis of future vaccination campaigns in India.

Public finance of universal routine childhood immunization in India: district-level cost estimates.

India's Universal Immunization Programme (UIP) is among the largest routine childhood vaccination programmes in the world. However, only an estimated 65% of Indian children under the age 2 years were fully vaccinated in 2019. We estimated the cost of raising childhood vaccination coverage to a minimum of 90% in each district in India. We obtained vaccine price data from India's comprehensive multi-year strategic plan for immunization. Cost of vaccine delivery by district was derived from a 2018 field study in 24 districts. We used propensity score matching methods to match the remaining Indian districts with these 24, based on indicators from the National Family Health Survey (2015-16). We assumed the same unit cost of vaccine delivery in matched pair districts and estimated the total and incremental cost of providing routine vaccines to 90% of the current cohort of children in each district. The estimated national cost of providing basic vaccinations-one dose each of Bacillus Calmette-Guerin (BCG) and measles vaccines, and three doses each of oral polio (OPV) and diphtheria, pertussis and tetanus vaccines-was $784.91 million (2020 US$). Considering all childhood vaccines included in UIP during 2018-22 (one dose each of BCG, hepatitis B and measles-rubella; four doses of OPV; two doses of inactivated polio; and three doses each of rotavirus, pneumococcal and pentavalent vaccines), the estimated national cost of vaccines and delivery to 90% of target children in each district was $1.73 billion. The 2018 UIP budget for vaccinating children, pregnant women and adults was $1.17 billion (2020 US$). In comparison, $1.73 billion would be needed to vaccinate 90% of children in all Indian districts with the recommended schedule of routine childhood vaccines. Additional costs for infrastructural investments and communication activities, not incorporated in this study, may also be necessary.

Return on investment of the electronic vaccine intelligence network in India.

The electronic vaccine intelligence network (eVIN) was introduced by India's Ministry of Health and Family Welfare in 12 states and was implemented by the United Nations Development Programme through the Gavi health system strengthening support during 2014-17 to replace the traditional paper-based cold-chain management system with an electronic vaccine logistics management system. An economic assessment was conducted as part of the overall assessment of eVIN. The objective of the economic assessment was to conduct a return on investment analysis of eVIN implementation. Return on investment was defined as the ratio of total benefits (savings) from eVIN to total investment in eVIN. All costs were calculated in 2020 prices and reported in Indian rupees (1 US dollar = INR 74.132). A one-rupee investment in eVIN led to a return of INR 0.52 for traditional vaccines. The highest cost savings from eVIN was from better vaccine stock management. When same percentage of savings from the new vaccines were incorporated into the analysis, one-rupee investment in eVIN led to a return of INR 1.41. In the future, when only recurrent costs will exist, the return from eVIN will be even higher: a one-rupee investment in eVIN will yield a return of INR 2.93. The assessment of eVIN showed promising results in streamlining the vaccine flow network and ensuring equity in vaccine stock management along with good return on investment; hence, there was a rapid expansion of eVIN in all 731 districts across 36 states and union territories in the country.

An intervention to reduce stigma and improve management of depression, risk of suicide/self-harm and other significant emotional or medically unexplained complaints among adolescents living in urban slums: protocol for the ARTEMIS project.

BACKGROUND: There are around 250 million adolescents in India. Adolescents are vulnerable to common mental disorders with depression and self-harm accounting for a major share of the burden of death and disability in this age group. Around 20% of children and adolescents are diagnosed with/ or live with a disabling mental illness. A national survey has found that suicide is the third leading cause of death among adolescents in India. The authors hypothesise that an intervention involving an anti-stigma campaign co-created by adolescents themselves, and a mobile technology-based electronic decision support system will help reduce stigma, depression, and suicide risk and improve mental health for high-risk adolescents living in urban slums in India. METHODS: The intervention will be implemented as a cluster randomised control trial in 30 slum clusters in each of the cities of Vijayawada and New Delhi in India. Adolescents aged 10 to 19 years will be screened for depression and suicide ideation using the Patient Health Questionnaire (PHQ-9). Two evaluation cohorts will be derived-a high-risk cohort with an elevated PHQ-9 score ≥ 10 and/or a positive response (score ≥ 2) to the suicide risk question on the PHQ-9, and a non-high-risk cohort comprising an equal number of adolescents not at elevated risk based on these scores. DISCUSSION: The key elements that ARTEMIS will focus on are increasing awareness among adolescents and the slum community on these mental health conditions as well as strengthening the skills of existing primary healthcare workers and promoting task sharing. The findings from this study will provide evidence to governments about strategies with potential for addressing the gaps in providing care for adolescents living in urban slums and experiencing depression, other significant emotional or medically unexplained complaints or increased suicide risk/self-harm and should have relevance not only for India but also for other low- and middle-income countries. TRIAL STATUS: Protocol version - V7, 20 Dec 2021 Recruitment start date: tentatively after 15th July 2022 Recruitment end date: tentatively 14th July 2023 (1 year after the trial start date) TRIAL REGISTRATION: The trial has been registered in the Clinical Trial Registry India, which is included in the WHO list of Registries ( https://www.who.int/clinical-trials-registry-platform/network/primary-registries ) Reference No. CTRI/2022/02/040307 . Registered on 18 February 2022. The tentative start date of participant recruitment for the trial will begin after 15th July 2022.

Cost effectiveness of targeted HIV prevention interventions for female sex workers in India.

OBJECTIVE: To ascertain the cost effectiveness of targeted interventions for female sex workers (FSW) under the National AIDS Control Programme in India. METHODS: A compartmental mathematical Markov state model was used over a 20-year time horizon (1995-2015) to estimate the cost effectiveness of FSW targeted interventions, with a health system perspective. The incremental costs and effects of FSW targeted interventions were compared against a baseline scenario of mass media for the general population alone. The incremental cost-effectiveness ratio was computed at a 3% discount rate using HIV infections averted and disability-adjusted life-years (DALY) as benefit measures. It was assumed that the transmission of the HIV virus moves from a high-risk group (FSW) to the client population and finally to the general population (partners of clients). RESULT: Targeted interventions for FSW result in a reduction of 47% (1.6 million) prevalent and 36% (2.7 million) cumulative HIV cases, respectively, in 2015. Adult HIV prevalence in India, with and without (mass media only) FSW interventions, would be 0.25% and 0.48% in 2015. Indian government and development partners spend an average US $104 (INR4680) per HIV infection averted and US $10.7 (INR483) per DALY averted. Discounting at 3%, FSW targeted interventions cost US $105.5 (INR4748) and US $10.9 (INR490) per HIV case and DALY averted, respectively. CONCLUSION: At the current gross domestic product in India, targeted intervention is a cost-effective strategy for HIV prevention in India.