Kanchan Mukherjee

Developing clinical indicators for the secondary health system in India

QUALITY PROBLEM OR ISSUE One of the prime goals of any health system is to deliver good and competent quality of healthcare. Through World Bank-assisted Maharashtra Health Systems Development Project, Government of Maharashtra in India developed and implemented clinical indicators to improve quality. INITIAL ASSESSMENT During this, clinical areas eligible for monitoring quality of care and roles of health staff working at various levels were identified. CHOICE OF SOLUTION Brainstorming discussion sessions were conducted to refine list of potential clinical indicators and to identify implementation problems. IMPLEMENTATION It was implemented in four stages. (a) Self-explanatory tool of record, standard operating procedures and training manual were prepared during tools preparation stage. (b) Pilot implementation was done to monitor the usefulness of indicators, document the experiences and standardize the system accordingly. (c) The final selection of indicators was done taking into consideration points like data reliability, indicator usefulness etc. For final implementation, 15 indicators for district and 6 indicators for rural hospitals were selected. (d) Transfer of skills was done through training of various hospital functionaries. EVALUATION AND LESSONS LEARNED Selection and prioritization of clinical indicators is the most crucial part. Active participation of local employees is essential for sustainability of the scheme. It is also important to ensure that data recorded/reported is both reliable and valid, to conduct monthly review of the scheme at various levels and to link it with the quality improvement programme.

Usage of Complementary and Alternative Medicine among Severe Hemophilia A Patients in India

Documented evidence of the usage of complementary and alternative medicine among patients with rare disease such as hemophilia is limited. Therefore, we explored the types of complementary and alternative medicines used, the associated sociodemographic and clinical factors, and the cost and reasons for usage among severe hemophilia A patients in India. Our study demonstrates an increased usage of complementary and alternative medicine (42.3%) among hemophiliacs. Significant factors associated with usage of these therapies were economic status, comorbidity status, and education of head of households. Among users of complementary and alternative medicine, cost of these therapies was found to be higher (17.22%) compared with hemostatic drugs (5.63%) from the average cost of treatment (Rs 29 029). The findings of this study warrant multicenter research to explore different dimensions of complementary and alternative medicine and also incorporate it in comprehensive hemophilia care programs to address issues of treatment gap and quality of life of hemophiliacs.

Cost-effectiveness of Childbirth Strategies for Prevention of Mother-to-child Transmission of HIV Among Mothers Receiving Nevirapine in India.

Background: Mother-to-child transmission of HIV is an important mode of spread of HIV in India. With strategies like caesarian section and nevirapine therapy, this spread has been reduced. However, they have costs attached. In this context, this paper attempts to compare the cost-effectiveness of alternative childbirth strategies among HIV-positive mothers receiving nevirapine. Materials and Methods: Using sentinel surveillance data from three districts in Tamil Nadu, a model was created to test the cost-effectiveness of vaginal delivery against elective caesarian section among mothers receiving nevirapine. Sensitivity analysis was applied to evaluate cost per HIV infection prevented. Results: Vaginal delivery is not only cheaper in HIV-infected mothers receiving nevirapine but also cost-effective as compared to elective caesarian section. The incremental cost for preventing an additional HIV infection through caesarian section was Rs. 76,000. Sensitivity analysis reveals that the findings are robust over a range of HIV transmission probabilities, 0.04-0.14 for vaginal delivery and 0.00-0.02 for caesarian section. Conclusions: From a clinical perspective, the findings suggest that pregnant HIV-infected women receiving nevirapine should consider the benefits of a cheaper and safer vaginal delivery. From an economic perspective, the findings support the strategy of vaginal delivery in mothers receiving nevirapine.

Ethical issues in the care of persons living with haemophilia in India.

The recent series of ad interim orders issued by the Bombay High Court under ordinary original civil jurisdiction following public interest litigation (PIL) on the provision of free clotting factor concentrates for persons living with haemophilia, especially those below the poverty line and emergency cases, highlights the need to think about the ethicality of various aspects of access to medicine and the rights of patients suffering from rare diseases from the public health perspective. The PIL (number 82/2012) [Vinay Vijay Nair and Ors vs. Department of Health, State of Maharashtra and Ors), which calls for free treatment for all haemophiliacs who go to the designated hospitals, was followed by the issuance of five ad interim orders (July 19, 2012, October 22, 2012, November 6, 2012, January 24, 2013, and March 19, 2013).

Economic burden of breast cancer to the households in Punjab, India

Introduction: Breast cancer is on rise and cervix cancer is on declining mode according to the cancer registry data in India. The major mode of financing treatment is out-of-pocket (OOP) and this can push 25% of the cancer affected households below the poverty line. Materials and Methods: A cross-sectional descriptive study with a household perspective was done in the state of Punjab. By using probability proportional to the size method and systematic random sampling, the sample was drawn from every district of Punjab. A face-to-face semi-structured interview schedule was administered to 221 patients. Results: The direct cost contributed 79% toward the total cost-of-illness. The cost of drugs (36.23%) followed by cost of hospitalization (27.05%) and productivity loss (13.44%) were the main contributors toward the total cost of illness. The contribution of indirect cost is 21 per cent of the total cost. The cost of treatment depends upon type of facility used (more in private as compared to the public), stage of cancer (stage above first stage cost more than the first stage), and age at the time of diagnosis aged above sixty incurred more expenditure as compared to the aged below sixty. The 84% of the households had experienced the catastrophic health expenditure (CHE) and 51% of the households had faced distress financing (DF). The main financial coping strategies*(*multiple strategies) used were saving (74%), borrowing at low rate of interest (88%), social nets (55%), and selling financial assets (30%).

Cost-Benefit Analysis and Assessment of Quality of Care in patients with Hemophilia undergoing treatment at National Rural Health Mission in Maharashtra, India

BACKGROUND Hemophilia is a genetic disorder with high health care burden. In India, most patients with hemophilia seek care through self-purchasing factor concentrate and incur huge out-of-pocket (OOP) expenditure. In March 2013, the government of India launched a pilot hematology program through the National Rural Health Mission for providing free treatment services to patients with hemophilia in the state of Maharashtra. OBJECTIVES To estimate the benefit-cost ratio of the program from a patient perspective, to estimate reduction in OOP expenditure of the patients and their families, and to assess the quality of care delivered and the barriers to access care among patients with hemophilia. METHODS This cross-sectional study evaluated the intervention of free treatment to patients with hemophilia at four district civil hospitals of Maharashtra. The study sample included 232 people with hemophilia (193 with hemophilia A, 31 with hemophilia B, 6 with von Willebrand disease, and 2 others) under four study arms over a 1-year study period. Cost-benefit analysis was performed for patients undergoing treatment at government hospitals and through nongovernmental organizations. RESULTS The benefit-cost ratio for the government program was 1.89. There was reduction in OOP expenditure by 21% per patient annually for the families. About 98% patients were highly satisfied with the services, whereas a major barrier to access was difficulty in commuting during active bleeding episodes. CONCLUSIONS The government intervention through the National Rural Health Mission was cost-beneficial to the patients with hemophilia. It helped in reducing the OOP expenditure by 21%.

Health technology assessment: A potential roadmap for India

Background: With the signing of the sustainable development goal document, India has embarked on the ambitious task of achieving Universal Health Coverage (UHC) by launching the National Health Assurance Mission (NHAM). However, India has not been able to meet many targets of the previous millennium development goals. Objectives: This article discusses the potential role of health technology assessment (HTA) for achieving UHC in the context of limited public health expenditure in India. Materials and Methods: Secondary literature review was conducted to review the existing HTA structures in different countries. In addition, key informant interviews were held with senior representatives (current and previous) of the National Institute of Healthcare and Clinical Excellence (NICE), Scottish Medicines Consortium (SMC), and evidence review group members from the University of Liverpool. Results: There are many potential applications for HTA in India and other low and middle-income countries. However, there are numerous contextual differences between India and other countries for adopting HTA and it is important to identify these differences and plan accordingly. Conclusions: The challenge for HTA in India is two-fold: data challenge and decision challenge. An incremental data to decision model based on the field practicum model of the Tata Institute of Social Sciences is recommended with the future objective of creating regional HTA hubs in India.

Economic burden of coronary heart disease in North India

Background: The treatment of chronic diseases like coronary heart disease (CHD) is expensive and can consume a significant portion of household′s income, leading to catastrophic effects on families, particularly those of low socioeconomic status. Methodology: This was a cross-sectional study carried out in a private super specialty hospital and a government tertiary care hospital. Nonprobability purposive sampling method was used to collect primary data from a sample of 102 households; having a member suffering from CHD. Economic burden was assessed regarding average out of pocket (OOP) expenditure and prevalence of distress financing (DF) (borrowings or selling of assets) among the households. Results: Average OOP expenditure among those having an episode of hospitalization and those who got treated in outpatient department sessions only was INR 243,606 and INR 48,578, respectively. This expenditure was statistically higher (P < 0.5) for richest than the poorest households. However this expenditure as a proportion of annual household consumption expenditure was highest for the poorer than the richest (P < 0.5). Expenses were reported higher for those who got treatment in private hospital as compared to government hospital by 26%. The prevalence of DF came out to be 38.2% with poorest reporting higher percentage of 67% as compared to 4% in richest households. Conclusion: There is a need to consider the rising OOP expenditure for the treatment of chronic conditions like CHD. There is a need to develop health financing systems that improve the financial risk protection for those requiring treatment.