Vikram Pathania

Private practitioners and public health: weak links in tuberculosis control

Evidence suggests that all sections of the population in poor countries seek care from private practitioners. The private medical sector varies considerably between and within countries in size, composition, level of organisation, types of services delivered, and socioeconomic groups served. There are few statistics for the amount of health care delivered by the private sector in poor countries. 1 However, information on health expenditure suggests that most poor countries have a large and growing private medical sector. Surveys indicate that the private sector is an important source of care, even for poor people and even where public services are widely available. 2 Private practitioners are widely used to treat people with diseases such as tuberculosis, malaria, sexually transmitted infections, diarrhoeal disease, and acute respiratory infections. 3 For example, in India 80% of households prefer to use the private sector for treatment of minor illnesses and 75% of households prefer to use the private sector for treatment of major illnesses. 4 In nine of the world’s poorest countries, 47% of visits to private-health providers were by the poorest 20% of people compared with 59% of visits among the richest 20% . Communicable diseases dominate the disease burden in poor countries. Tuberculosis is a leading cause of death of young people and adults. This disease causes about 8 million new cases and 2 million deaths every year. Despite much worldwide attention and implementation of the WHO recommended DOTS strategy by 119 countries, only 40% of estimated tuberculosis cases are notified worldwide. Experts believe that private practitioners manage a large proportion of the unreported majority of tuberculosis cases. The focus of international efforts is on the improvement of tuberculosis control in the 22 countries with the highest burden. Panel 1 shows that in nearly all these countries private expenditure on health accounts for a high proportion of total health expenditure. Furthermore, most of this private expenditure is out-of-pocket expense, which suggests considerable use of private practitioners and private pharmacies on a fee-for-service basis (panel 1).

The Effect of Fast Food Restaurants on Obesity and Weight Gain

We investigate how changes in the supply of fast food restaurants affect weight outcomes of 3 million children and 3 million pregnant women. Among ninth graders, a fast food restaurant within 0.1 miles of a school results in a 5.2 percent increase in obesity rates. Among pregnant women, a fast-food restaurant within 0.5 miles of residence results in a 1.6 percent increase in the probability of gaining over 20 kilos. The implied effects on caloric intake are one order of magnitude larger for children than for mothers, consistent with smaller travel cost for adults. Non-fast food restaurants and future fast-food restaurants are uncorrelated with weight outcomes. (JEL I12, J13, J16, L83)

Public-private mix for DOTS implementation: what makes it work?

OBJECTIVE To compare processes and outcomes of four public-private mix (PPM) projects on DOTS implementation for tuberculosis (TB) control in New Delhi, India; Ho Chi Minh City, Viet Nam; Nairobi, Kenya; and Pune, India. METHODS Cross-project analysis of secondary data from separate project evaluations was used. Differences among PPM project sites in impact on TB control (change in case detection, treatment outcomes and equity in access) were correlated with differences in chosen intervention strategies and structural conditions. FINDINGS The analysis suggests that an effective intervention package should include the following provider-side components: (1) orienting private providers (PPs) and the staff of the national TB programme (NTP); (2) improving the referral and information system through simple practical tools; (3) the NTP adequately supervising and monitoring PPs; and (4) the NTP providing free anti-TB drugs to patients treated in the private sector. CONCLUSION Getting such an intervention package to work requires that the NTP be strongly committed to supporting, supervising and evaluating PPM projects. Further, using a local nongovernmental organization or a medical association as an intermediary may facilitate collaboration. Investing time and effort to ensure that sufficient dialogue takes place among all stakeholders is important to help build trust and achieve a high level of agreement.

A cost-benefit analysis of BCG revaccination in the Czech Republic.

We assessed the direct and indirect economic costs and benefits of the current policy of revaccinating tuberculin-negative schoolchildren in the Czech Republic. The analysis is conducted from the perspective of the payer for health care. In considering whether revaccination should be discontinued, we consistently made assumptions which tend to favor revaccination. The direct costs of revaccination are estimated at Czech Koruna (KCR) 15.0 million (US

Can increased primary care access reduce demand for emergency care? Evidence from England's 7-day GP opening

0.46 million) annually. The direct benefits are the treatment costs saved for future cases averted by revaccination. These range from KCR 0.5 million (US

Medicines and vaccines for the world's poorest: Is there any prospect for public-private cooperation?

0.015 million, ambulatory care, excluding transmission benefits) to KCR 13.7 million (US

The impact of malaria control on infant mortality in Kenya

0.4 million, hospitalization, including transmission benefits). Costs exceed benefits even if children are revaccinated without prior tuberculin testing. The major indirect cost is the loss of work output attributable to tuberculosis morbidity. Counting the averted loss in output as a benefit does not change the results qualitatively, although there is a 50% chance that the benefits will be greater than costs if treatment continues to be hospital-based. Thus, the costs of revaccination in the Czech Republic are found to exceed benefits over most, plausible variations in parameter values. The cost-benefit ratio is especially large if patients are given ambulatory treatment, as recommended by the World Health Organization.

Public Distribution System Reforms and Consumption in Chhattisgarh: A Comparative Empirical Analysis

Restricted access to primary care can lead to avoidable, excessive use of expensive emergency care. Since 2013, partly to alleviate overcrowding at the Accident & Emergency (A&E) units of hospitals, the UK has been piloting 7-day opening of General Practitioner (GP) practices to improve primary care access for patients. We evaluate the impact of these pilots on patient attendances at A&E. We estimate that 7-day GP opening has reduced A&E attendances by patients of pilot practices by 9.9% with most of the impact on weekends which see A&E attendances fall by 17.9%. The effect is non-monotonic in case severity with most of the fall occurring in cases of moderate severity. An additional finding is that there is also a 9.9% fall in weekend hospital admissions (from A&E) which is entirely driven by a fall in admissions of elderly patients. The impact on A&E attendances appears to be bigger among wealthier patients. We present evidence in support of a causal interpretation of our results and discuss policy implications.

Food Price Subsidies and Nutrition: Evidence from State Reforms to India's Public Distribution System

This paper reviews the current status of the global pharmaceutical industry and its research and development focus in the context of the health care needs of the developing world. It will consider the attempts to improve access to critical drugs and vaccines, and increase the research effort directed at key public health priorities in the developing world. In particular, it will consider prospects for public-private collaboration. The challenges and opportunities in such public-private partnerships will be discussed briefly along with a look at factors that may be key to success. Much of the focus is on HIV/AIDS where the debate on the optimal balance between intellectual property rights (IPR) and human rights to life and health has been very public and emotive.

Driving Under the (Cellular) Influence: The Link between Cell Phone Use and Vehicle Crashes

Since the early 2000s there has been a rapid intensification of malaria control efforts across Africa. I exploit baseline differences in the regional incidence of malaria coupled with the sharp timing of the intensified campaign to investigate the impact on infant mortality in Kenya. Postintervention, I find a significant reduction in postneonatal mortality in the malarious regions relative to the nonmalarious regions. In contrast, I find no evidence of an impact on neonatal mortality, which is consistent with epidemiological literature that finds neonates enjoy significant protection from malaria. I rule out alternative explanations such as differential preexisting trends, changes in maternal and infant care, or the contemporaneous expansion of HIV/AIDS prevention and treatment. I find that the malaria campaign reduced postneonatal mortality by 33% in the malarious regions during 2004–8.