Upendra Bhojani

Out-of-pocket healthcare payments on chronic conditions impoverish urban poor in Bangalore, India

BackgroundThe burden of chronic conditions is on the rise in India, necessitating long-term support from healthcare services. Healthcare, in India, is primarily financed through out-of-pocket payments by households. Considering scarce evidence available from India, our study investigates whether and how out-of-pocket payments for outpatient care affect individuals with chronic conditions.MethodsA large census covering 9299 households was conducted in Bangalore, India. Of these, 3202 households that reported presence of chronic condition were further analysed. Data was collected using a structured household-level questionnaire. Out-of-pocket payments, catastrophic healthcare expenditure, and the resultant impoverishment were measured using a standard technique.ResultsThe response rate for the census was 98.5%. Overall, 69.6% (95%CI=68.0-71.2) of households made out-of-pocket payments for outpatient care spending a median of 3.2% (95%CI=3.0-3.4) of their total income. Overall, 16% (95%CI=14.8-17.3) of households suffered financial catastrophe by spending more than 10% of household income on outpatient care. Occurrence and intensity of financial catastrophe were inequitably high among poor. Low household income, use of referral hospitals as place for consultation, and small household size were associated with a greater likelihood of incurring financial catastrophe.The out-of-pocket spending on chronic conditions doubled the number of people living below the poverty line in one month, with further deepening of their poverty. In order to cope, households borrowed money (4.2% instances), and sold or mortgaged their assets (0.4% instances).ConclusionsThis study provides evidence from India that the out-of-pocket payment for chronic conditions, even for outpatient care, pushes people into poverty. Our findings suggest that improving availability of affordable medications and diagnostics for chronic conditions, as well as strengthening the gate keeping function of the primary care services are important measures to enhance financial protection for urban poor. Our findings call for inclusion of outpatient care for chronic conditions in existing government-initiated health insurance schemes.

No longer diseases of the wealthy: prevalence and health-seeking for self-reported chronic conditions among urban poor in Southern India

BackgroundThe burden of chronic conditions is high in low- and middle-income countries and poses a significant challenge to already weak healthcare delivery systems in these countries. Studies investigating chronic conditions among the urban poor remain few and focused on specific chronic conditions rather than providing overall profile of chronic conditions in a given community, which is critical for planning and managing services within local health systems. We aimed to assess the prevalence and health- seeking behaviour for self-reported chronic conditions in a poor neighbourhood of a metropolitan city in India.MethodsWe conducted a house-to-house survey covering 9299 households (44514 individuals) using a structured questionnaire. We relied on self-report by respondents to assess presence of any chronic conditions, including diabetes and hypertension. Multivariable logistic regression was used to analyse the prevalence and health-seeking behaviour for self-reported chronic conditions in general as well as for diabetes and hypertension in particular. The predictor variables included age, sex, income, religion, household poverty status, presence of comorbid chronic conditions, and tiers in the local health care system.ResultsOverall, the prevalence of self-reported chronic conditions was 13.8% (95% CI = 13.4, 14.2) among adults, with hypertension (10%) and diabetes (6.4%) being the most commonly reported conditions. Older people and women were more likely to report chronic conditions. We found reversal of socioeconomic gradient with people living below the poverty line at significantly greater odds of reporting chronic conditions than people living above the poverty line (OR = 3, 95% CI = 1.5, 5.8). Private healthcare providers managed over 80% of patients. A majority of patients were managed at the clinic/health centre level (42.9%), followed by the referral hospital (38.9%) and the super-specialty hospital (18.2%) level. An increase in income was positively associated with the use of private facilities. However, elderly people, people below the poverty line, and those seeking care from hospitals were more likely to use government services.ConclusionsOur findings provide further evidence of the urgent need to improve care for chronic conditions for urban poor, with a preferential focus on improving service delivery in government health facilities.

Constraints faced by urban poor in managing diabetes care: patients’ perspectives from South India

Background Four out of five adults with diabetes live in low- and middle-income countries (LMIC). India has the second highest number of diabetes patients in the world. Despite a huge burden, diabetes care remains suboptimal. While patients (and families) play an important role in managing chronic conditions, there is a dearth of studies in LMIC and virtually none in India capturing perspectives and experiences of patients in regard to diabetes care. Objective The objective of this study was to better understand constraints faced by patients from urban slums in managing care for type 2 diabetes in India. Design We conducted in-depth interviews, using a phenomenological approach, with 16 type 2- diabetes patients from a poor urban neighbourhood in South India. These patients were selected with the help of four community health workers (CHWs) and were interviewed by two trained researchers exploring patients’ experiences of living with and seeking care for diabetes. The sampling followed the principle of saturation. Data were initially coded using the NVivo software. Emerging themes were periodically discussed among the researchers and were refined over time through an iterative process using a mind-mapping tool. Results Despite an abundance of healthcare facilities in the vicinity, diabetes patients faced several constraints in accessing healthcare such as financial hardship, negative attitudes and inadequate communication by healthcare providers and a fragmented healthcare service system offering inadequate care. Strongly defined gender-based family roles disadvantaged women by restricting their mobility and autonomy to access healthcare. The prevailing nuclear family structure and inter-generational conflicts limited support and care for elderly adults. Conclusions There is a need to strengthen primary care services with a special focus on improving the availability and integration of health services for diabetes at the community level, enhancing patient centredness and continuity in delivery of care. Our findings also point to the need to provide social services in conjunction with health services aiming at improving status of women and elderly in families and society.

Health system challenges in organizing quality diabetes care for urban poor in South India.

Background Weak health systems in low- and middle-income countries are recognized as the major constraint in responding to the rising burden of chronic conditions. Despite recognition by global actors for the need for research on health systems, little attention has been given to the role played by local health systems. We aim to analyze a mixed local health system to identify the main challenges in delivering quality care for diabetes mellitus type 2. Methods We used the health system dynamics framework to analyze a health system in KG Halli, a poor urban neighborhood in South India. We conducted semi-structured interviews with healthcare providers located in and around the neighborhood who provide care to diabetes patients: three specialist and 13 non-specialist doctors, two pharmacists, and one laboratory technician. Observations at the health facilities were recorded in a field diary. Data were analyzed through thematic analysis. Result There is a lack of functional referral systems and a considerable overlap in provision of outpatient care for diabetes across the different levels of healthcare services in KG Halli. Inadequate use of patients’ medical records and lack of standard treatment protocols affect clinical decision-making. The poor regulation of the private sector, poor systemic coordination across healthcare providers and healthcare delivery platforms, widespread practice of bribery and absence of formal grievance redress platforms affect effective leadership and governance. There appears to be a trust deficit among patients and healthcare providers. The private sector, with a majority of healthcare providers lacking adequate training, operates to maximize profit, and healthcare for the poor is at best seen as charity. Conclusions Systemic impediments in local health systems hinder the delivery of quality diabetes care to the urban poor. There is an urgent need to address these weaknesses in order to improve care for diabetes and other chronic conditions.

Intervening in the local health system to improve diabetes care: lessons from a health service experiment in a poor urban neighborhood in India.

Background Many efficacious health service interventions to improve diabetes care are known. However, there is little evidence on whether such interventions are effective while delivered in real-world resource-constrained settings. Objective To evaluate an intervention aimed at improving diabetes care using the RE-AIM (reach, efficacy/effectiveness, adoption, implementation, and maintenance) framework. Design A quasi-experimental study was conducted in a poor urban neighborhood in South India. Four health facilities delivered the intervention (n=163 diabetes patients) and the four matched facilities served as control (n=154). The intervention included provision of culturally appropriate education to diabetes patients, use of generic medications, and standard treatment guidelines for diabetes management. Patients were surveyed before and after the 6-month intervention period. We did field observations and interviews with the doctors at the intervention facilities. Quantitative data were used to assess the reach of the intervention and its effectiveness on patients’ knowledge, practice, healthcare expenditure, and glycemic control through a difference-in-differences analysis. Qualitative data were analyzed thematically to understand adoption, implementation, and maintenance of the intervention. Results Reach: Of those who visited intervention facilities, 52.3% were exposed to the education component and only 7.2% were prescribed generic medications. The doctors rarely used the standard treatment guidelines for diabetes management. Effectiveness: The intervention did not have a statistically and clinically significant impact on the knowledge, healthcare expenditure, or glycemic control of the patients, with marginal reduction in their practice score. Adoption: All the facilities adopted the education component, while all but one facility adopted the prescription of generic medications. Implementation: There was poor implementation of the intervention, particularly with regard to the use of generic medications and the standard treatment guidelines. Doctors’ concerns about the efficacy, quality, availability, and acceptability by patients of generic medications explained limited prescriptions of generic medications. The patients’ perception that ailments should be treated through medications limited the use of non-medical management by the doctors in early stages of diabetes. The other reason for the limited use of the standard treatment guidelines was that these doctors mainly provided follow-up care to patients who were previously put on a given treatment plan by specialists. Maintenance: The intervention facilities continued using posters and television monitors for health education after the intervention period. The use of generic medications and standard treatment guidelines for diabetes management remained very limited. Conclusions Implementing efficacious health service intervention in a real-world resource-constrained setting is challenging and may not prove effective in improving patient outcomes. Interventions need to consider patients’ and healthcare providers’ experiences and perceptions and how macro-level policies translate into practice within local health systems.

Health system challenges in delivering maternal health care: evidence from a poor urban neighbourhood in South India

Methods The paper draws on fieldwork conducted in KG Halli, a poor urban slum neighbourhood in Bangalore. The fieldwork is part of a larger urban health action research project (UHARP), carried out in this area since 2009. The project aims at enhancing quality of health care of residents in this area. This paper is based on data collected over a period of two years (2009-2011) through (1) household census (n = 9,299, response rate = 98.5%) using a questionnaire on socio-demographic characteristics, illness profile, health seeking behaviour, and healthcare expenditure; (2) interviews with healthcare providers (n = 16), and (3) observational field notes on issues related to maternal health including mapping of health facilities in the area. Data were analysed from the lens of a health system analysis framework developed by Van Olmen and colleagues [1] to identify larger systemic challenges in delivery of service. Results The mapping exercise shows that there are two government facilities and two private clinics providing antenatal care (ANC) and two private hospitals providing ANC and institutional delivery services for a population of over 44,500 in KG Halli. There is poor operational and administrative integration between different levels of care and facilities. A pregnant lady usually gets antenatal check-up at first-level care and delivers at maternity home (secondary level) or in a hospital at tertiary level. Referral to secondary or tertiary facilities is often based on informal understanding of rules among providers regarding registered ANC versus non-registered referred cases; the former determines the legitimacy for treatment in the secondary centre; secondary/tertiary government facilities that cater to most of the institutional deliveries are situated at a distance of around 6 km to 15 km from the area. Despite the distance and‘patient-unfriendly’ attitude of the health staff, women deliver in government centres (56% of total institutional deliveries). This is due to both perceived high cost of care in private sector and apprehension that cost and number of caesarean sections performed is high in private sector. Our survey results show that 60% of all caesarean sections were conducted in private hospital, whereas 40% in government hospitals during the study period. Women reported that the cost of a caesarean section in a private facility is five times more than in the government facility. We also found that oversight mechanisms to ensure quality of care in both government and private facilities are poorly implemented as KG Halli lies on the border of two administrative subdivisions and struggles to find a space between the ‘rural’

Health systems research and the Gadchiroli debate: a plea for universal and equitable ethics.

We were pleased to read, in the January-March 2010 issue of this journal, Abhay bang’s response to criticism of the Gadchiroli trial on ethical grounds (1). While it is not within the ambit of this article to comment on the Gadchiroli trial principal investigator’s clarifications, we would like to extend the debate on standards of care that he discusses to standards of ethics, with particular reference to health systems research.

EPHP 2016: Bringing evidence into public health policy: enhancing equity and engendering intersectoral action for health

Since 2010, the national conferences on bringing Evidence into Public Health Policy (EPHP) serve as a unique platform to promote exchanges among researchers, practitioners and policymakers for better population health in India. With the central objective of contributing to informed policy and action, each EPHP focuses on concepts and initiatives of significant importance for health in India where informed policymaking can make a difference. The first EPHP in 2010 focused on ‘Five years of National Rural Health Mission’.1 The National Rural Health Mission—now National Health Mission taking into its ambit the National Urban Health Mission—was and remains a significant structural reform in the Indian health landscape. Paving the road for improved healthcare delivery, the mission connected the health system again with the community by introducing Accredited Social Health Activists, community monitoring …

EPHP 2016, BANGALORE, 8–9 JULY 2016, THIRD NATIONAL CONFERENCE ON BRINGING EVIDENCE INTO PUBLIC HEALTH POLICY EQUITABLE INDIA: ALL FOR HEALTH AND WELLBEING

![Graphic][1] Acknowledgements All EPHP 2016 abstracts were independently peer-reviewed by two experts. We thank the following experts, in alphabetical order: Asha Kilaru, Ashish Kumar Upadhyay, Amitabha Sarkar, Bart Criel, Bontha Babu, … [1]: /embed/inline-graphic-1.gif

Challenges in organizing quality diabetes care for the urban poor: a local health system perspective

India is urbanizing at a rapid pace. Moreover, a quarter of the urban population lives in slum areas [1]. Unfavorable social determinants in health and huge inequities in access to healthcare within urban India leave the urban poor with dismal health indicators [2]. The burden from chronic diseases is also on rise in India, disproportionately so for urban population, and is now the leading cause of deaths [3,4]. India is leading the diabetes epidemic in the world [5]. In urban south India, diabetes prevalence is on a rapid rise (from 5% in 1984 to 13.9% in 2000) [6]. There has been a growing concern among public health researchers/programmers regarding the neglect of urban poor in governments’ health policies/programs [7,8]. The government health services remain primarily oriented towards management of acute episodes [9]. In this study, we analyze a local health system in Bangalore’s KG Halli neighborhood, identify the main challenges in organizing the quality diabetes care, and discuss the way forward. KG Halli has a population of over 44,500 with one notified slum area. The median per-capita income is INR 2200/month.