V R Muraleedharan

The overarching policy question in private expenditure on health that we should all be addressing is, "What must the government do to reduce the debilitating (financial) effects of out-of-pocket healthcare expenditure of people?" A response to a comment (EPW, 21 November 2015) on the authors' earlier piece (EPW, 15 August 2015).

This article investigates India's export performance of spices (whole pepper and capsicum) in the markets of the Organization for Economic Cooperation and Development (OECD) and South and Southeast Asia, which constitute a substantial market for Indian spices. A Constant Market Share model is used to decompose the growth in exports of spices into size of the market effect, market composition effect and competitiveness effect. The analysis is performed for the exports during the nineties, the period India had to resort to increased challenges of food safety. The study confirms that there has not been substantial trade effect for Indian spices due to quality issues, such as sanitary and phytosanitary regulations. This article argues that increase in exports to neighbouring regions is explained more by the increased demand and supply and not by the stringent quality requirements of traditional importing countries. © 2008 Sage Publications.

Planning for urban solid waste management within the framework of sustainable development raises several intra-and inter-generational issues such as public health, livelihood of actors in the informal recycling sector, present and future cost to society, conservation of resources both renewable and nonrenewable, and environmental impacts of waste disposal. It is essential that planners seek to address the above issues 'interactively' by exploring various 'soft' alternatives, instead of 'preactively' extending conventional 'hard' solutions. Such an integrated approach, however, should be developed through consensus among various actors. This paper proposes a Critical Operational Research (COR) framework to facilitate consensus/conflict resolution among actors, and also aid in learning. The nonlinear goal programming model developed within the COR framework provides a platform for discussion among actors involved in urban solid waste management. Its utility as a 'learning' tool is demonstrated by applying it to a typical metropolitan city in India. The exercise highlights the limitations of techno-managerial solutions usually adopted in developing countries, and the scope for the informal sector in urban solid waste management. Copyright © 1996 Elsevier Science Ltd.

Community participation as a strategy for health system strengthening and accountability is an almost ubiquitous policy prescription. In 2005, with the election of a new Government in India, the National Rural Health Mission was launched. This was aimed at ‘architectural correction’ of the health care system, and enshrined ‘communitization’ as one of its pillars. The mission also provided unique policy spaces and opportunity structures that enabled civil society groups to attempt to bring on to the policy agenda as well as implement a more collective action and social justice based approach to community based accountability. Despite receiving a lot of support and funding from the central ministry in the pilot phase, the subsequent roll out of the process, led in the post-pilot phase by the individual state governments, showed very varied outcomes. This paper using both documentary and interview based data is the first study to document the roll out of this ambitious process. Looking critically at what varied and why, the paper attempts to derive lessons for future implementation of such contested concepts.

The disease burden among the elderly population is significantly higher compared to the younger population, according to the data from the 75th round National Sample Survey, 2017-18, which increases their vulnerability during the COVID-19 pandemic. The footprint of elderly population in public facilities for inpatient and outpatient care has increased over the years. Financially, the elderly face far less burden in public facilities than in private facilities.

Objective: We aim to develop a comprehensive checklist for evaluating Health Technology Assessment (HTA) studies commissioned in India. The primary objective of this work is to capture all vital aspects of an HTA study in terms of conduct, reporting and quality. Methodology: The development of a quality appraisal checklist included 3 steps. First, a targeted review of the literature was done to gather information on existing HTA checklists. After reviewing these checklists, an initial draft of the HTA quality appraisal checklist (HTA-QAC) for India was prepared with discussion amongst the authors. Second, the draft checklist was reviewed by the members of the Technical Appraisal Committee (TAC) and their feedback was incorporated. Subsequently, the revised checklist was presented at a virtual meeting of the TAC. Finally, a pilot phase was undertaken to apply HTA-QAC for the approved HTA study reports. Three rounds of virtual discussions were held with the researchers who were involved in the conduct of these HTA studies to resolve any discordance in opinion or develop solutions for the problems in the use of the HTA-QAC followed by a further revision of the checklist. Results: The HTA-QAC is divided into two parts: a self-reporting section to be completed by the author, and the other to be completed by the reviewer. The reviewer checklist has two sections: one to review the report and the other to review the model. The author section is in a self-reporting format, which includes details of basic study information, the rationale for the study, policy relevance, study description, study methods, reporting of model parameters, and results. The reviewer section of the checklist focuses on the quality aspect of the conducted study. The domains included in the report review include details on study methodology, results, discussion, and conclusion. The second part of the reviewer section of HTA-QAC constitutes a review of the model in terms of model assumptions, functionality, model inputs, calculations, uncertainty analysis, model output, and model validation. Conclusion: We recommend a standardised process of quality appraisal to ensure the high quality of HTA evidence for policy use in the Indian context. The proposed HTA-QAC will help authors to ensure standardised reporting, as well as allow reviewers to assess the quality of analysis.

There has been much recent interest in the trade in human organs in India. This paper examines both the extent to which regulatory controls through the Transplantation of Human Organs Act (1994) are effective in curbing commercialization and the nature of the constraints on the effective implementation of this Act. The study, a politico-economic analysis of health sector regulation, is based on a stakeholder analysis drawing on the views of key decision makers, service providers, organ donors and recipients. The findings indicate widespread acknowledgement of an organs trade and highlight four major constraints on the effective implementation of the Act: the commercial interests of middlemen and service providers, the ambiguities and loopholes in the Act; the low monitoring capacity of the regulatory authorities, and the pressures and responsibilities exerted upon the Authorizing Committees. A feature of the Act is that its implementation is subject to a major incentive compatibility constraint - it is seemingly not in the interests of any of the key players, including the regulatory authorities, to restrict the organ trade. To some extent, this institutional problem is created by the specific nature of the regulatory intervention, and, as a consequence, measures involving straightforward redrafting of the regulation might go some way to addressing this incentive problem. Another solution may entail a 'harm-reduction' strategy involving a controlled trade where procurement and organ matching is carried out by a government agency (this would require, however, the prior resolution of the broader ethical question concerning the legitimacy of such trade).

Background & objectives: Public health spending on primary healthcare has increased by four times (in real terms) over the last decade and continues to constitute more than half of the total public health expenditure. The present study estimated the cost of providing healthcare services at sub centre (SC) and primary health centre (PHC) level in four selected States of India. Methods: A total of 51 SCs and 33 PHCs were selected across the four States (Himachal Pradesh, Odisha, Kerala and Tamil Nadu) of India. The economic cost of delivering health services at these facilities was assessed using bottom-up costing methodology during the reference year of 2014-2015. The cost of capital items was annualized and allocation of shared resources was based on appropriate apportioning statistics. Results: The mean annual cost of providing health services at SC and PHC was ₹ 0.69 million (US$ 11,392) and ₹ 5.1 million (US$ 83,837), respectively. Nearly 3/4th and 2/3rd of this cost at the level of SC (74%) and PHC (63%) were spent on salaries. In terms of unit cost, the costs per antenatal care and postnatal care visit were ₹ 221 (173-276) and ₹ 333 (244-461), respectively, at SCs. Similarly, the costs of per patient outpatient consultation and per bed day hospitalization at PHC level were ₹ 121 (91-155) and ₹ 1168 (955-1468), respectively. Interpretation & conclusions: The cost estimates from the present study can be used in economic evaluations, assessing technical efficiency and also for providing valuable information during scale-up of health facilities.

Substantial programmatic efforts have been undertaken to improve the access to maternal care services in the public health system of India, yet the service users are often regarded as passive recipients. Limited research is available on the preferences of service users on what they regard the greatest issues in service delivery. A hospital-based discrete choice experiment (DCE) has been conducted in the public health facilities of Tamil Nadu, a southern state of India. This study uses a sample of 261 women who came for antenatal check-ups across six different public hospitals in Tamil Nadu. The DCE technique, which is rooted in random utility theory (RUT), and conditional logit model have been used to analyze the relative importance of health service attributes. The result showed that regular ward visits by specialist doctors like obstetricians and gynaecologists (O&G) and paediatricians were the most preferred attribute of the maternal care service. Expectant mothers are willing to wait the maximum and are prepared to tolerate health service characteristics in public hospitals, such as poor patient amenities, poor staff attitude and lack of privacy maintained during physical examination, provided specialist doctors are available in the hospitals.

The TN STEMI Program was a multicenter, prospective, observational study conducted in Tamil Nadu, India, that assessed the effects of implementing the STEMI India Model for the management of STEMI. We discuss the economic and societal impact in this article. Given that the intervention resulted in an absolute mortality reduction of 3.4%, we calculated a number needed to treat of 30 patients. At an annualized project cost of INR 15.11 million, this approximately calculates to INR 193,749 (USD 3,311) per life saved. The utility of the TN-STEMI Program can be estimated to be 1,108 life-years. This calculates to approximately INR 13,643 (USD 233) per life-year saved. Our estimates will likely be of particular interest to policy makers in low and middle-income countries, where financial and resource constraints pose a perennial public health challenge.