Policy intervention for access to medicine: Does it work similarly for poor and non-poor?

Many federal states in India have recently taken steps to improve distribution and affordability of medicines across public hospitals for reducing high out-of-pocket (OOP) expenditure. West Bengal has introduced a Public-Private Partnership (PPP) scheme, Fair Price Medicine Shops (FPMS) within government hospitals in 2012, which offers high discounts on maximum retail price of the drugs. This model introduces the state as a facilitator, rather than provider or financer, of health care. This paper attempts to measure its impact on OOP expenditure (OOPE) of patients using propensity-score-matching technique on the data collected from primary survey among patients. The study finds that although for non-poor patients, the average OOPE has reduced significantly, the impact has been counter-productive for the poor patients, hinting that PPP intervention seems to work only for relatively better-off people, as the best alternative for the poorest remains to be free provision of drugs from the government. The difference in outcome lay in the fact that the nature of control groups differed between poor and non-poor patients. Those poor patients who did not visit FPMS received most of the medicines free (hence OOPE nearly zero), while for the non-poor patients not visiting FPMS bought the drugs from outside retail shops.

Health financing strategies to reduce out-of-pocket burden in India: a comparative study of three states.

BACKGROUND: To achieve the Sustainable Development Goals, Indian States have implemented different strategies to arrest high out-of-pocket expenditure (OOPE) and to increase equity into healthcare system. Tamil Nadu (TN) and Rajasthan have implemented free medicine scheme in all public hospitals and West Bengal (WB) has devised Fair Price Medicine Shop (FPMS) scheme, a public-private-partnership model in the state. In this background, the objectives of the paper are to - 1. Study the utilization pattern of public in-patient care facilities for the states, 2. Examine the effectiveness of the strategies adopted by the states to arrest high OOPE and 3. Analyze the extent of equity in public in-patient care services in the states. METHODS: National Sample Survey (71st and 60th round) data, Detailed Demand for Grants of the state governments and the National Rural/Urban Health Mission data have been used for the study. Exploratory data analysis and benefit incidence analysis have been applied to estimate the utilization, OOPE and extend of equity in the states. RESULTS: The results show that overall utilization of public facilities in TN and Rajasthan has increased substantially; whereas, utilization of public facility has decreased in WB even among the poorest. In addition, OOPE for both medical and medicine is the highest in WB among three states for public sector hospitalizations. Surprisingly, OOPE on medicine is the highest for the poorest class of WB. Analysis showed that the mismatch between actual need and FPMS drug-list has led to high OOPE in the state. Overall, benefit incidence of public subsidy is the highest among the poorest class in all the states. However, geographical sector-wise inequity in public subsidy distribution persists in the states. Analysis of cost of inpatient care shows that TN provides the maximum subsidy for hospitalization and WB provides the minimum. An inverse relationship between utilization of inpatient care and public subsidy has been observed from the analysis. CONCLUSION: In conclusion we could say that TN & Rajasthan have successfully implemented their health financing strategies to reduce the health expenditure burden. However, policy-level changes are required to improve the situation in WB.

Impact of integrated child development scheme on child malnutrition in West Bengal, India.

With child malnutrition detected as a persistent problem in most of the developing countries, public policy has been directed towards offering community-based supplementary feeding provision and nutritional information to caregivers. India, being no exception, has initiated these programs as early as 1970s under integrated child development scheme. Using propensity score matching technique on primary data of 390 households in two districts of West Bengal, an Eastern state in India, the study finds that impact of being included in the program and receiving supplementary feeding is insignificant on child stunting measures, though the program can break the intractable barriers of child stunting only when the child successfully receives not only just the supplementary feeding but also his caregiver collects crucial information on nutritional awareness and growth trajectory of the child. Availability of regular eggs in the feeding diet too can reduce protein-related undernutrition. Focusing on just feeding means low depth of other services offered under integrated child development scheme, including pre-school education, nutritional awareness, and hygiene behavior; thus repealing a part of the apparent food-secure population who puts far more importance on the latter services.

Access and barriers to immunization in West Bengal, India: quality matters.

While many studies attempted to evaluate performance of immunization programmes in developing countries by full coverage, there is a growing awareness about the limitations of such evaluation, irrespective of the overall quality of performance. Availability of human resources, equipment, supporting drugs, and training of personnel are considered to be crucial indicators of the quality of immunization programme. Also, maintenance of time schedule has been considered crucial in the context of the quality of immunization. In addition to overall coverage of vaccination, the coverage of immunization given at right time (month-specific) is to be considered with utmost importance. In this paper, District Level Household and Facility Survey-3 (DLHS-3) 2007-2008 data have been used in exploring the quality of immunization in terms of month-specific vaccine coverage and barriers to access in West Bengal, India. In West Bengal, the month-specific coverage stands badly below 20% but the simple non-month-specific coverage is as high as 75%. Among the demand-side factors, birthplace of the child and religion of the household heads came out as significant predictors while, from the supply-side, availability of male health workers and equipment at the subcentres, were the important determinants for month-specific vaccine coverage. Hence, there should be a vigorous attempt to make more focused planning, keeping in mind the nature of the barriers, for improvement of the month-specific coverage in West Bengal.

Purification and characterization of fructan and fructansucrase from Lactobacillus fermentum AKJ15 isolated from Kodo ko jaanr, a fermented beverage from north-eastern Himalayas.

Fructansucrase and fructan produced from Lactobacillus fermentum AKJ15 were isolated from seeds of Kodo ko jaanr, a fermented mild-alcoholic beverage prepared in North East India. The strain was identified by 16S rRNA gene sequence analysis and biochemical characterization. The strain displayed maximum fructansucrase activity of 4.3 U/ml (1.02 U/mg) at 28°C at 180 rpm. The enzyme purified by polyethylene glycol-400 gave specific activity of 5 U/mg and showed 90 kDa band on non-denaturing Sodium Dodecyl Sulphate-Poly Acrylamide Gel Electrophoresis (SDS-PAGE). The purified enzyme confirmed the presence of fructan by periodic acid Schiff's staining which showed magenta colour bands with both sucrose and raffinose. The strain produced 10.2 mg/ml fructan in broth under optimized culture conditions. The purified fructansucrase displayed V(max) of 5.42 U/mg and K(m) of 16.65 mM. The enzyme showed maximum activity at 30°C and at pH 5. The structure of fructan was analysed by (1)H and (13)C NMR spectra confirming ß-(2-1) and ß-(2-6) linkages.

Inequity in hospitalization care: a study on utilization of healthcare services in West Bengal, India.

BACKGROUND: Out of eight commonly agreed Millennium Development Goals (MDG), six are related to the attainment of Universal Health Coverage (UHC) throughout the globe. This universalization of health status suggests policies to narrow the gap in access and benefit sharing between different socially and economically underprivileged classes with that of the better placed ones and a consequent expansion of subsidized healthcare appears to be a common feature for most of the developing nations. The National Health Policy in India (2002) suggests expansion of market-based care for the affording class and subsidized care for the deserving class of the society. So, the benefit distribution of this limited public support in health sector is important to examine to study the welfare consequences of the policy. This paper examines the nature of utilization to inpatient care by different socio-economic groups across regions and gender in West Bengal (WB), India. The benefit incidence of public subsidies across these socio-economic groups has also been verified for different types of services like medicines, diagnostics and professional care etc. METHODS: National Sample Survey Organization (NSSO) has collected information on all hospitalized cases (60(th) round, 2004) with a recall period of 365 days from the sampled households through stratified random sampling technique. The data has been used to assess utilization of healthcare services during hospitalization and the distribution of public subsidies among the patients of different socio-economic background; a Benefit Incidence Analysis (BIA) has also been carried out. RESULTS: Analysis shows that though the rate of utilization of public hospitals is quite high, other complementary services like medicine, doctor and diagnostic tests are mostly purchased from private market. This leads to high Out-of-Pocket (OOP) expenditure. Moreover, BIA reveals that the public subsidies are mostly enjoyed by the relatively better placed patients, both socially and economically. The worse situation is observed for gender related inequality in access and benefit from public subsidies in the state. CONCLUSION: Focused policies are required to ensure proper distribution of public subsidies to arrest high OOP expenditure. Drastic change in policy targeting is needed to secure equity without compromising efficiency.