Zachary Wagner

Government health insurance for people below poverty line in India: quasi-experimental evaluation of insurance and health outcomes

Objectives To evaluate the effects of a government insurance program covering tertiary care for people below the poverty line in Karnataka, India, on out-of-pocket expenditures, hospital use, and mortality. Design Geographic regression discontinuity study. Setting 572 villages in Karnataka, India. Participants 31 476 households (22 796 below poverty line and 8680 above poverty line) in 300 villages where the scheme was implemented and 28 633 households (21 767 below poverty line and 6866 above poverty line) in 272 neighboring matched villages ineligible for the scheme. Intervention A government insurance program (Vajpayee Arogyashree scheme) that provided free tertiary care to households below the poverty line in about half of villages in Karnataka from February 2010 to August 2012. Main outcome measure Out-of-pocket expenditures, hospital use, and mortality. Results Among households below the poverty line, the mortality rate from conditions potentially responsive to services covered by the scheme (mostly cardiac conditions and cancer) was 0.32% in households eligible for the scheme compared with 0.90% among ineligible households just south of the eligibility border (difference of 0.58 percentage points, 95% confidence interval 0.40 to 0.75; P<0.001). We found no difference in mortality rates for households above the poverty line (households above the poverty line were not eligible for the scheme), with a mortality rate from conditions covered by the scheme of 0.56% in eligible villages compared with 0.55% in ineligible villages (difference of 0.01 percentage points, −0.03 to 0.03; P=0.95). Eligible households had significantly reduced out-of-pocket health expenditures for admissions to hospitals with tertiary care facilities likely to be covered by the scheme (64% reduction, 35% to 97%; P<0.001). There was no significant increase in use of covered services, although the point estimate of a 44.2% increase approached significance (−5.1% to 90.5%; P=0.059). Both reductions in out-of-pocket expenditures and potential increases in use might have contributed to the observed reductions in mortality. Conclusions Insuring poor households for efficacious but costly and underused health services significantly improves population health in India.

Private Sector Provision of Oral Rehydration Therapy for Child Diarrhea in Sub-Saharan Africa

Although diarrheal mortality is cheaply preventable with oral rehydration therapy (ORT), over 700,000 children die of diarrhea annually and many health providers fail to treat diarrheal cases with ORT. Provision of ORT may differ between for-profit and public providers. This study used Demographic and Health Survey data from 19,059 children across 29 countries in sub-Saharan Africa from 2003 to 2011 to measure differences in child diarrhea treatment between private for-profit and public health providers. Differences in treatment provision were estimated using probit regression models controlling for key confounders. For-profit providers were 15% points less likely to provide ORT (95% confidence interval [CI] 13-17) than public providers and 12% points more likely to provide other treatments (95% CI 10-15). These disparities in ORT provision were more pronounced for poorer children in rural areas. As private healthcare in sub-Saharan Africa continues to expand, interventions to increase private sector provision of ORT should be explored.

The Impact of Repeat HIV Testing on Risky Sexual Behavior: Evidence from a Randomized Controlled Trial in Malawi

A significant proportion of HIV-positive adults in sub-Saharan Africa are in serodiscordant relationships. Identification of such serodiscordant couples through couple HIV testing and counseling (HTC) is thought to promote safe sexual behavior and reduce the probability of within couple seroconversion. However, it is possible HTC benefits are not sustained over time and therefore repeated HTC may be more effective at preventing seroconversion than one time HTC. We tested this theory in Zomba, Malawi by randomly assigning 170 serodiscordant couples to receive repeated HTC and 167 serodiscordant couples to receive one time HTC upon study enrollment (control group). We used linear probability models and probit model with couple fixed effects to assess the impact of the intervention on risky sexual behavior. At one-year follow-up, we found that couples that received repeated HTC reported significantly more condom use. However, we found no difference in rate of seroconversion between groups, nor did we find differences in subjective expectations about seroconversion or false beliefs about HIV, two expected pathways of behavior change. We conclude that repeated HTC may promote safe sexual behavior, but this result should be interpreted with caution, as it is inconsistent with the result from biological and subjective outcomes.

Impact of health insurance for tertiary care on postoperative outcomes and seeking care for symptoms: quasi-experimental evidence from Karnataka, India

Objectives To evaluate the effects of a government insurance programme covering tertiary care for the poor in Karnataka, India—Vajpayee Arogyashree Scheme (VAS)—on treatment seeking and postoperative outcomes. Design Geographic regression discontinuity. Setting 572 villages in Karnataka, India. Participants 3478 households in 300 villages where VAS was implemented and 3486 households in 272 neighbouring matched villages ineligible for VAS. Intervention A government insurance programme that provided free tertiary care to households below the poverty line in half of villages in Karnataka from February 2010 to August 2012. Main outcome measure Seeking treatment for symptoms, posthospitalisation well-being, occurrence of infections during hospitalisation and need for rehospitalisation. Results The prevalence of symptoms was nearly identical for households in VAS-eligible villages compared with households in VAS-ineligible villages. However, households eligible for VAS were 4.96 percentage points (95% CI 1 to 8.9; p=0.014) more likely to seek treatment for their symptoms. The increase in treatment seeking was more pronounced for symptoms of cardiac conditions, the condition most frequently covered by VAS. Respondents from VAS-eligible villages reported greater improvements in well-being after a hospitalisation in all categories assessed and they were statistically significant in 3 of the 6 categories (walking ability, pain and anxiety). Respondents eligible for VAS were 9.4 percentage points less likely to report any infection after their hospitalisation (95% CI −20.2 to 1.4; p=0.087) and 16.5 percentage points less likely to have to be rehospitalised after the initial hospitalisation (95% CI −28.7 to −4.3; p<0.01). Conclusions Insurance for tertiary care increased treatment seeking among eligible households. Moreover, insured patients experienced better posthospitalisation outcomes, suggesting better quality of care received. These results suggest that there are several pathways through which tertiary care insurance could improve health, aside from increasing utilisation of the services that the programme directly subsidises.

Barriers to use of oral rehydration salts for child diarrhea in the private sector: evidence from India

Diarrhea is the second leading cause of child mortality in India. Most deaths are cheaply preventable with the use of oral rehydration salts (ORS), yet many health providers still fail to provide ORS to children seeking diarrheal care. In this study, we use survey data to assess whether children visiting private providers for diarrheal care were less likely to use ORS than those visiting public providers. Results suggest that children who visited private providers were 9.5 percentage points less likely to have used ORS than those who visited public providers (95% CI 5-14). We complimented these results with in-depth interviews of 21 public and 17 private doctors in Gujarat, India, assessing potential drivers of public-private disparities in ORS use. Interview results suggested that lack of direct medication dispensing in the private sector might be a key barrier to ORS use in the private sector.

Comparative performance of public and private sector delivery of BCG vaccination: Evidence from Sub-Saharan Africa

BACKGROUND The private sector is an important source of health care in the developing world. However, there is limited evidence on how private providers compare to public providers, particularly for preventive services such as immunizations. We used data from Sub-Saharan Africa (SSA) to assess public-private differences in Bacillus Calmette-Guérin (BCG) vaccine delivery. METHODS AND FINDINGS We used demographic and health surveys from 102,629 children aged 0-59 months from 29 countries across SSA to measure differences in BCG status for children born at private versus public health facilities (BCG is recommended at birth). We used a probit model to estimate public-private differences in BCG delivery, while controlling for key confounders. Next, we estimated how differences in BCG status evolved over time for children born at private versus public facilities. Finally, we estimated heterogeneity in public-private differences based on wealth and rural-urban residency. We found that children born at a private facility were 7.1 percentage points less likely to receive BCG vaccine in the same month as birth than children born at a public facility (95% CI 6.3-8.0; p<0.001). Most of this difference was driven by for-profit private providers (as opposed to NGOs) where the BCG provision rate was 10.0 percentage points less than public providers (95% CI 9.0-11.2; p<0.001) compared to only 2.4 percentage points for NGOs (95% CI 1.0-3. 8; p<0.01). Moreover, children born at private for-profit facilities remained less likely to be vaccinated up to 59 months after birth. Finally, public-private differences were more pronounced for poorer children and children in rural areas. CONCLUSIONS The for-profit private sector performed substantially worse than the public sector in providing BCG vaccine to newborns, resulting in a longer duration of vulnerability to tuberculosis. This disparity was greater for poorer children and children in rural areas.

Social health insurance for the poor: lessons from a health insurance programme in Karnataka, India

Life-saving technology used to treat catastrophic illnesses such as heart disease and cancer is often out of reach for the poor. As life expectancy increases in poor countries and the burden from chronic illnesses continues to rise, so will the unmet need for expensive tertiary care. Understanding how best to increase access to and reduce the financial burden of expensive tertiary care is a crucial task for the global health community in the coming decades. In 2010, Karnataka, a state in India, rolled out the Vajpayee Arogyashree scheme (VAS), a social health insurance scheme focused on increasing access to tertiary care for households below the poverty line. VAS was rolled out in a way that allowed for robust evaluation of its causal effects and several studies have examined various impacts of the scheme on poor households. In this analysis article, we summarise the key findings and assess how these findings can be used to inform other social health insurance schemes. First, the evidence suggests that VAS led to a substantial reduction in mortality driven by increased tertiary care utilisation as well as use of better quality facilities and earlier diagnosis. Second, VAS significantly reduced the financial burden of receiving tertiary care. Third, these benefits of social health insurance were achieved at a reasonable cost to society and taxpayers. Several unique features of VAS led to its success at improving health and financial well-being including effective outreach via health camps, targeting expensive conditions with high disease burden, easy enrolment process, cashless treatment, bundled payment for hospital services, participation of both public and private hospitals and prior authorisation to improve appropriateness of care.

Reply to Gonzalez-Serna et al

We thank Gonzalez-Serna and his colleagues for initiating a discussion on our paper that models the impact of the test-and-treat policy on the human immunodeficiency virus (HIV) epidemic in Los Angeles County. Gonzalez-Serna et al contest the relevance of our findings that test-and-treat could potentially increase multidrug resistance (MDR) in Los Angeles by 89% [1]. Using observational data from British Columbia, Canada, they show that MDR and total drug resistance prevalence in British Columbia decreased over a period during which antiretroviral treatment (ART) prevalence increased by 60%. There are several reasons why this finding might not be particularly relevant for evaluating the impact of test-and-treat in Los Angeles or other regions of the world. First, British Columbia is a distinct setting with vastly different demographics and healthcare characteristics than Los Angeles. There is evidence that MDR prevalence in Canada is generally much lower than in the United States [2]. As with any mathematical model, our results are a product of the assumptions we make about parameter values and initial conditions, which are setting-specific. Because MDR prevalence in Los Angeles is higher at baseline than in British Columbia, the force of infection of transmitted resistance is higher, causing faster growth. Model results may be different with dynamics based on British Columbia characteristics. Second, these findings from British Columbia are inconsistent with findings in other parts of the world [3–6]. A recent World Health Organization report highlights the growth of drug-resistant HIV in low- and middle-income countries over the past decade, and shows a positive association between ART coverage and prevalence of transmitted drug-resistant HIV [7]. Third, a recent Canadian surveillance report shows that the results Gonzales-Serna et al report from British Columbia might not even generalize to other provinces in Canada. This report surveys 6 Canadian provinces and shows that prevalence of resistance increased by approximately 70% from 1999 to 2008 and there was no reduction in MDR [8]. Furthermore, a considerable proportion of transmitted drug resistance in both the United States and Canada remains undetected [9]. Fourth, early-stage HIV (ESH) treatment—a hallmark of test-and-treat—stayed relatively stable in British Columbia from 1995 to 2008 [10]. It is likely that ESH will coincide with lower levels of adherence, a strong predictor of increases in acquired drug resistance. Gonzalez-Serna et al also note a decrease in clinical significance of MDR, as dozens of different drug classes are now available. They suggest that pandrug resistance is the appropriate resistance measure instead of triple-therapy resistance, which we use. Even if this were true, MDR will likely raise HIV treatment costs for cash-strapped patients or healthcare systems. In addition, with expansion of early treatment, MDR detection might be more difficult as patients are asymptomatic and might not be monitored closely. Without close monitoring of resistance, patients could unknowingly develop MDR and thus delay initiation of second-line treatment. Therefore, the clinical significance of MDR may be greater with a larger ESH treatment prevalence. We agree with Gonzalez-Serna et al (and state in the main text) that test-and-treat is likely to bring epidemiologic benefits even with MDR growth, and we do not recommend abandoning this policy. However, Gonzalez-Serna et al downplay potential implications of MDR growth. We believe a prudent approach would be to evaluate the cost-effectiveness of test-and-treat compared to other policies, and if adoption of test-and-treat is warranted, it should be accompanied by initiatives to control and closely monitor MDR such as expanded MDR surveillance and interventions to improve adherence.