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Background: Kerala has initiated many Universal Health Coverage (UHC) reforms in the last decade. The Aardram Mission launched in 2017 stands out owing to its scope, objectives, and commitments for strengthening Primary Health Care (PHC) in the State. The current study proposes to explore access and financial protection through the lens of equity in Kerala especially in the context of major UHC reforms carried out during the last decade. This paper will also highlight the key lessons from Kerala's approach towards UHC and health systems strengthening through a political economy approach. Methods: Data from the Kerala state sample of 75th Round (2017-18) National Sample Survey is used for this study. Comparison is also drawn from the 71st Round Sample Survey, 2014, to measure the state's progress in terms of access and financial protection. Logistic regression was used for the calculation. The findings were further explored through a political economy approach. Results: The share of public facilities for outpatient care is 47.5%, which is a significant increase from 34.0% (in 2014) in the state. The share of public sector for out-patient care has increased for the lower socio-economic population in the state. The share of public sector for in-patient care has also increased to 37.3% in 2017-18 from 33.9% in 2014, but not to the extent as the increase shown in outpatient care. The average out-of-pocket-expenditure during hospitalization has increased more in private facilities as compared to public for both outpatient care and hospitalization. Conclusions: Overall increase in the share of public facilities for both outpatient care and hospitalization is indicative of the enhanced trust among the people at large of the public healthcare delivery system in Kerala, post the launch of UHC reforms in the State. The insurance linked UHC reforms would be insufficient for the State to progress further towards UHC. Kerala with a long and successful history in 'public provisioning' should focus more on strengthening PHC through Aardram Mission in its journey towards pursuit of UHC. [ABSTRACT FROM AUTHOR]

Background: Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context. Methods: Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups. Results: Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018. Conclusions: Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results. [ABSTRACT FROM AUTHOR]

Background: Health outcomes in India are characterized by pervasive inequities due to deeply entrenched socio-economic gradients amongst the population. Therefore, it is imperative to investigate these systematic disparities in health, however, evidence of inequities does not commensurate with its policy objectives in India. Thus, our paper aims to examine the magnitude of and trends in horizontal inequities in self-reported morbidity and untreated morbidity in India over the period of 2004 to 2017–18. Methods: The study used cross-sectional data from nationwide healthcare surveys conducted in 2004, 2014 and 2017–18 encompassing sample size of 3,85,055; 3,35,499 and 5,57,887 individuals respectively. Erreygers concentration indices were employed to discern the magnitude and trend in horizontal inequities in self-reported morbidity and untreated morbidity. Need standardized concentration indices were further used to unravel the inter-regional and intra-regional income related inequities in outcomes of interest. Additionally, regression based decomposition approach was applied to ascertain the contributions of both legitimate and illegitimate factors in the measured inequalities. Results: Estimates were indicative of profound inequities in self-reported morbidity as inequity indices were positive and significant for all study years, connoting better-off reporting more morbidity, given their needs. These inequities however, declined marginally from 2004(HI: 0.049, p< 0.01) to 2017–18(HI: 0.045, P< 0.01). Untreated morbidity exhibited pro-poor inequities with negative concentration indices. Albeit, significant reduction in horizontal inequity was found from 2004(HI= − 0.103, p< 0.01) to 2017–18(HI = − 0.048, p< 0.01) in treatment seeking over the years. The largest contribution of inequality for both outcomes stemmed from illegitimate variables in all the study years. Our findings also elucidated inter-state heterogeneities in inequities with high-income states like Andhra Pradesh, Kerala and West Bengal evincing inequities greater than all India estimates and Northeastern states divulged equity in reporting morbidity. Inequities in untreated morbidity converged for most states except in Punjab, Chhattisgarh and Himachal Pradesh where widening of inequities were observed from 2004 to 2017–18. Conclusions: Pro-rich and pro-poor inequities in reported and untreated morbidities respectively persisted from 2004 to 2017–18 despite reforms in Indian healthcare. Magnitude of these inequities declined marginally over the years. Health policy in India should strive for targeted interventions closing inequity gap. [ABSTRACT FROM AUTHOR]

Introduction: Although India has made significant progress in institutional delivery after the implementation of the National Rural Health Mission under which the Janani Suraksha Yojana (JSY) is a sub-programme which played a vital role in the increase of institutional delivery in public facilities. Therefore, this paper aims to provide an understanding of the JSY coverage at the district level in India. Further, it tries to carve out the factors responsible for the regional disparity of JSY coverage at district levels. Methods: The study used the National Family Health Survey data, which is a cross-sectional survey conducted in 2015–16, India. The sample size of this study was 148,145 women aged 15–49 years who gave last birth in the institution during 5 years preceding the survey. Bivariate and multivariate regression analysis was used to fulfill the study objectives. Additionally, Moran's I statistics and bivariate Local Indicator for Spatial Association (LISA) maps were used to understand spatial dependence and clustering of JSY coverage. Ordinary least square, spatial lag and spatial error models were used to examine the correlates of JSY utilization. Results: The value of spatial-autocorrelation for JSY was 0.71 which depicts the high dependence of the JSY coverage over districts of India. The overall coverage of JSY in India is 36.4% and it highly varied across different regions, districts, and even socioeconomic groups. The spatial error model depicts that if in a district the women with no schooling status increase by 10% then the benefits of JSY get increased by 2.3%. Similarly, if in a district the women from poor wealth quintile, it increases by 10% the benefits of JSY also increased by 4.6%. However, the coverage of JSY made greater imperative to understand it due to its clustering among districts of specific states only. Conclusion: It is well reflected in the EAGs states in terms of spatial-inequality in service coverage. There is a need to universalize the JSY programme at a very individual level. And, it is required to revisit the policy strategy and the implementation plans at regional or district levels. [ABSTRACT FROM AUTHOR]

Background: The National Health Mission (NHM), the largest ever publicly funded health programme worldwide, used over half of the national health budget in India and primarily aimed to improve maternal and child health in the country. Though large scale public health investment has improved the health care utilization and health outcomes across states and socio-economic groups in India, little is known on the equity concern of NHM. In this context, this paper examines the utilization pattern and net benefit of public subsidy for institutional delivery by the level of care in India. Methods: Data from the most recent round of the National Family Health Survey (NFHS 4), conducted during 2015–16, was used in the study. A total of 148,645 last birth delivered in a health centre during the 5 years preceding the survey were used for the analyses. Out-of-pocket (OOP) payment on delivery care was taken as the dependent variable and was analysed by primary care and secondary level of care. Benefits Incidence Analysis (BIA), descriptive statistics, concentration index (CI), and concentration curve (CC) were used to do the analysis. Results: Institutional delivery from the public health centres in India is pro-poor and has a strong economic gradient. However, about 28% mothers from richest wealth quintile did not pay for delivery in public health centres compared to 16% among the poorest wealth quintile. Benefit incidence analyses suggests a pro-poor distribution of institutional delivery both at primary and secondary level of care. In 2015–16, at the primary level, about 32.29% of subsidies were used by the poorest, 27.22% by poorer, 20.39% by middle, 13.36% by richer and 6.73% by the richest wealth quintile. The pattern at the secondary level was similar, though the magnitude was lower. The concentration index of institutional delivery in public health centres was − 0.161 [95% CI, − 0.158, − 0.165] compared to 0.296 [95% CI, 0.289, 0.303] from private health centres. Conclusion: Provision and use of public subsidy for institutional delivery in public health centres is pro-poor in India. Improving the quality of service in primary health centres is recommended to increase utilisation and reduce OOP payment for health care in India. [ABSTRACT FROM AUTHOR]

Background: Equity and justice in healthcare payment form an integral part of health policy and planning. In the majority of low and middle-income countries (LMICs), healthcare inequalities are further aggravated by Out of Pocket Expenditure (OOPE). This paper examines the pattern of health equity and regional disparities in healthcare spending among Indian states by applying Andersen's behavioural model of healthcare utilization. Methods: The present study uses data from the 66th quinquennial round of Consumer Expenditure Survey, of the National Sample Survey Organization (NSSO), conducted in 2009-10 by Ministry of Statistics and Programme Implementation (MoSPI), Government of India (GoI). To measure equity and regional disparities in healthcare expenditure, states have been categorized under three heads on the basis of monthly OOPE i.e., Category A (OOPE > =INR 100); Category B (OOPE between INR 50 to 99) and Category C (OOPE < INR 50). Multiple Generalised Linear Regression Model (GLRM) has been employed to explore the effect of various socio-economic covariates on the level of OOPE. Results: The gap in the ratio of average healthcare spending between the poorest and richest households was maximum in Category A states Category B (richest/poorest = 14.60), followed by (richest/poorest 11.70) and Category C (richest/poorest 11.40). Results also indicate geographical concentration of lower level healthcare spending among Indian states (e.g., Odisha, Chhattisgarh and all the north-eastern states). Results from the multivariate analysis suggest that people residing in urban areas, having higher economic status, belonging to non-Muslim communities, non-Scheduled Tribes (STs), and non-poor households spend more on healthcare than their counterparts. Conclusions: In spite of various efforts by the government to reduce the burden of healthcare spending, widespread inequalities in healthcare expenditure are prevalent. Households with high healthcare needs (SCs/STs, and the poor) are in a more disadvantaged position in terms of spending on health care. It has also been observed that spending on healthcare was comparatively lower among backward or isolated states. No doubt, the overall social security measures should be enhanced, but at the same time, looking at the regional differences, more priority should be assigned to the disadvantaged states to reduce the burden of OOPE. It is proposed that there is need to increase government spending, especially for the disadvantaged states and population, to minimise the burden of OOPE. [ABSTRACT FROM AUTHOR]

Background: Empirical evidence shows that the relationship between health-seeking behaviour and diverse gender elements, such as gendered social status, social control, ideology, gender process, marital status and procreative status, changes across settings. Given the high relevance of social settings, this paper intends to explore how gender elements interact with health-seeking practices among men and women residing in an Indian urban slum, in consideration of the unique socio-cultural context that characterises India's slums. Methods: The study was conducted in Sahid Smriti Colony, a peri-urban slum of Kolkata, India. The referral technique was used for selecting participants, as people in the study area were not very comfortable in discussing their health issues and health-seeking behaviours. The final sample included 66 participants, 34 men and 32 women. Data was collected through individual face-to-face in-depth interviews with a semi-structured questionnaire. Results: The data analysis shows six categories of reasons underlying women's preferences for informal healers, which are presented in the form of the following themes: cultural competency of care, easy communication, gender-induced affordability, avoidance of social stigma and labelling, living with the burden of cultural expectations and geographical and cognitive distance of formal health care. In case of men ease of access, quality of treatment and expected outcome of therapies are the three themes that emerged as the reasons behind their preferences for formal care. Conclusion: Our results suggest that both men and women utilise formal and informal care, but with different motives and expectations, leading to contrasting health-seeking outcomes. These gender-induced contrasts relate to a preference for socio-cultural (women) versus technological (men) therapies and long (women) versus fast (men) treatment, and are linked to their different societal and familial roles. The role of women in following and maintaining socio-cultural norms leads them to focus on care that involves long discussions mixed with socio-cultural traits that help avoid economic and social sanctions, while the role of men as bread earners requires them to look for care that ensures a fast and complete recovery so as to avoid financial pressures. [ABSTRACT FROM AUTHOR]

Background: The health of India's children has improved over the past thirty years. Rates of morbidity and anthropometric failure have decreased. What remains unknown, however, is how those patterns have changed when examined by socioeconomic status. We examine changes in 11 indicators of child health by household wealth and maternal education between 1993 and 2021 to fill this critical gap in knowledge. Doing so could lead to policies that better target the most vulnerable children. Methods: We used data from five rounds of India's National Family Health Survey conducted in 1993, 1999, 2006, 2016, and 2021 for this repeated cross-sectional analysis. We studied mother-reported cases of acute respiratory illness and diarrhea, hemoglobin measurements for anemia, and height and weight measurements for anthropometric failure. We examined how the prevalence rates of each outcome changed between 1993 and 2021 by household wealth and maternal education. We repeated this analysis for urban and rural communities. Results: The socioeconomic gradient in 11 indicators of child health flattened between 1993 and 2021. This was in large part due to large reductions in the prevalence among children in the lowest socioeconomic groups. For most outcomes, the largest reductions occurred before 2016. Yet as of 2021, except for mild anemia, outcome prevalence remained the highest among children in the lowest socioeconomic groups. Furthermore, we show that increases in the prevalence of stunting and wasting between 2016 and 2021 are largely driven by increases in the severe forms of these outcomes among children in the highest socioeconomic groups. This finding underscores the importance of examining child health outcomes by severity. Conclusions: Despite substantial reductions in the socioeconomic gradient in 11 indicators of child health between 1993 and 2021, outcome prevalence remained the highest among children in the lowest socioeconomic groups in most cases. Thus, our findings emphasize the need for a continued focus on India's most vulnerable children. [ABSTRACT FROM AUTHOR]

Background: Despite a commendable rise in the number of women seeking delivery care at public health institutions in South India, it is unclear if the benefit accrues to wealthier or poorer socio-economic groups. The study's aim was to investigate at how the public subsidy is distributed among Indian women who give birth in public hospitals in the southern regions. Methods: Data from the Indian Demographic Health Survey's fifth wave (NFHS-5, 2019–21) was used in this study. A total of 22, 403 were institutional deliveries across all the southern states of India were included. Out-of-pocket expenditure (OOPE) on childbirth in health institutions was the outcome variable. We used summary statistics, Benefits Incidence Analysis (BIA), concentration index (CI), and concentration curve (CC) were used. Results: Most women in the lowest, poorest, and medium quintiles of wealth opted to give birth in public facilities. In contrast, about 69% of mothers belonging to highest quintile gave birth in private health institutions. The magnitude of CI and CC of institutional delivery indicates that public sector usage was concentrated among poorer quintiles [CIX: − 0.178; SE: 0.005; p < 0.001] and private sector usage was concentrated among wealthier quintiles [CIX: 0.239; SE: 0.006; p < 0.001]. Benefit incidence analyses suggest that middle quintile of women received the maximum public subsidy in primary health centres (33.23%), followed by richer quintile (25.62%), and poorer wealth quintiles (24.84%). These pattern in the secondary health centres was similar. Conclusion: Poorer groups utilize the public sector for institutional delivery in greater proportions than the private sector. Middle quintiles seem to benefit the most from public subsidy in terms of the median cost of service and non-payment. Greater efforts must be made to understand how and why these groups are being left behind and what policy measures can enhance their inclusion and financial risk protection. [ABSTRACT FROM AUTHOR]

Background: The use of hygienic products, such as sanitary napkins, tampons, and menstrual cups, to absorb menstrual blood is vital for the health and well-being of adolescent girls in India. However, the degree of inequity in the use of such products among this subpopulation remains inadequately explored. To fill this critical knowledge gap, this study aims to investigate the spatiotemporal dynamics of hygienic product use among adolescent girls in India from 2015 to 2020. Methods: In this cross-sectional study, we analyzed data from 117,749 to 114,839 adolescent girls aged 15–19, obtained from two consecutive rounds of the National Family Health Survey (NFHS) conducted in India during 2015-16 and 2019-21. Our approach involved utilizing Erreygers' Concentration Index (ECI) and Concentration Curve to quantitatively assess and visually represent socioeconomic inequality in hygienic product usage. Additionally, we investigated the spatiotemporal variation in this inequality over the study period and decomposed the ECI to identify the key contributing factors. Results: The findings reveal that hygienic product usage among adolescent girls in India has increased by 13 percentage points (PP), from 37% in 2015-16 to 50% in 2019-21. This increase is also visible across all household wealth quintiles. However, the bottom quintiles experienced a greater rise (+ 15 to 16 PP) than the top quintile (+ 8 PP). During the study period, the ECI reduced marginally, from 0.48 in 2015-16 to 0.43 in 2019-21. However, the extent of this reduction varied across different states. The greatest reduction in ECI was recorded in Punjab (-0.23 points), Telangana (-0.16 points), and West Bengal (-0.14 points). In contrast, there were a number of states with high socioeconomic inequality (ECI > 0.30) in 2015-16, where inequality reduction was minimal (< 0.05 points) over the study period. This included more developed states of Kerala, Karnataka, Maharashtra and Gujarat and relatively less developed states of Odisha, Jharkhand, Chhattisgarh, Uttar Pradesh, and Assam. Some states, such as Bihar and Madhya Pradesh, recorded an increase in socioeconomic inequality over the study period, with ECI rising to 0.31 and 0.46 (highest in the country) in 2019-21. The decomposition analysis revealed that the inequality in using hygienic products was primarily explained by place of residence, exposure to mass-media, education, and region of residence. Conclusions: The findings suggest the need for targeted policies to reduce existing socioeconomic inequality in the usage of hygienic products among adolescent girls in India. Specifically, interventions should target regions with low use of hygienic products, economically disadvantaged groups, and poor and vulnerable populations. State-specific policies and programs are also necessary to address the disparities in socioeconomic inequality. Additionally, efforts to reduce inequality should address the underlying factors contributing to inequality. [ABSTRACT FROM AUTHOR]

Background: Reaching hard to reach populations is key to reduce health inequities. Despite targeted interventions, status of crucial public health indicators like neonatal and maternal mortality is still far from optimal. Complex interplay of social determinants can influence both communities and health care workers to effectively access each other. We argue that culturally sensitive and contextually relevant healthcare provision has potential to increase health care utilization by the vulnerable communities living in remote areas. Methods: The study is an exploratory case study using rapid ethnographic techniques to understand the interplay of social determinants in hard to reach areas of Odisha state, India. We used in-depth interviews, focus group discussion, participatory action research and key informant interviews as tools for data collection. The analysis of data has been guided by thematic analysis approach. Results: We found that there are further layers within the designated hard to reach areas and those can be designated as-i) extremely remote ii) remote and iii) reachable areas. Degree of geographic difficulties and cultural dynamics are deciding the 'perceived' isolation and interaction with health care providers in hard to reach areas. This ultimately leads to impacting the utilization of the facilities. At extremely remote areas, felt health needs are mainly fulfilled by traditional healers and ethno-medical practices. In reachable areas, people are more prone to seek care from the public health facilities because of easy accessibility and outreach. Being in middle people in remote areas, diversify health care seeking depending upon social (e.g. patient's gender) economic (e.g. avoid catastrophic expenditure) and health system (timely availability of health human resources, language barriers) factors. Conclusion: Our research highlights the need to value and appreciate different worldviews, beliefs and practices, and their understanding of and engagement with the pluralistic health care system around them. Other than pursuing the 'mainstreaming' of a standardized health system model across hard to reach areas, strategies need to be adaptive as per local factors. To handle that existing policies need revision with a focus on culturally sensitive and contextual care provision. [ABSTRACT FROM AUTHOR]

Background: Non-Communicable Diseases (NCDs) constitute a significant danger to the nation's public health system, both in terms of morbidity and mortality, as well as the financial burden they inflict. Kerala is undergoing an epidemiologic transition, which has significantly impacted the state's morbidity and mortality figures. For decades, the state has been putting in place myriad programs to reduce the burden of NCDs across population groups. Socioeconomic inequalities in NCD testing have been documented in India, although they are understudied in Kerala. The study aimed to estimate and characterize districtwise socioeconomic inequality in Blood Pressure (BP) and Blood Glucose (BG) testing. Methods: A cross-sectional household survey was conducted between July–October 2019 in Kasaragod, Alappuzha, Kollam and Thiruvananthapuram districts of Kerala, India. A total of 6383 participants aged 30 years and above were interviewed using multistage random sampling. Descriptive statistics were derived district-wise. We computed ratios, differences, equiplots, and Erreygers concentration indices for each district to measure socioeconomic inequality in BP and BG testing. Erreygers decomposition techniques were used to estimate the relative contribution of covariates to socioeconomic inequality. Results: There was a significant concentration of BP and BG testing favouring wealthier quintiles in Alappuzha, Kollam, and Thiruvananthapuram districts. The inequality in BP and BG testing was highest in Thiruvananthapuram (0.087 and 0.110), followed by Kollam (0.077 and 0.090), Alappuzha (0.083 and 0.073) and Kasaragod (0.026 and 0.056). Decomposition analysis revealed that wealth quintile and education contributed substantially to socioeconomic inequality in BP and BG testing in all four districts. It was also found that family history of NCDs significantly contributed to observed socioeconomic inequality in BP testing (29, 11, 16, and 27% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram, respectively). Similarly, in BG testing, family history of NCDs substantially contributed to observed socioeconomic inequality, explaining 16–17% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram respectively of the total inequality. Conclusion: While the magnitude of socioeconomic inequality in NCD risk factor testing did not appear to be very high in four Kerala districts, although levels were statistically significant in three of them. Greater exploration is needed on how education and caste contribute to these inequalities and their relationship to NCD risk factors such as family history. From such analyses, we may be able to identify entry points to mitigate inequalities in testing access, as well as burden. [ABSTRACT FROM AUTHOR]

Background: Tribal peoples are among the most marginalised groups worldwide. Evidence on birth outcomes in these groups is scant. We describe inequalities in Stillbirth Rate (SBR), Neonatal Mortality Rate (NMR), and uptake of maternal and newborn health services between tribal and less disadvantaged groups in eastern India, and examine the contribution of poverty and education to these inequalities. Methods: We used data from a demographic surveillance system covering a 1 million population in Jharkhand State (March 2017 – August 2019) to describe SBR, NMR, and service uptake. We used logistic regression analysis combined with Stata's adjrr-command to estimate absolute and relative inequalities by caste/tribe (comparing Particularly Vulnerable Tribal Groups (PVTG) and other Scheduled Tribes (ST) with the less marginalised Other Backward Class (OBC)/none, using the Indian government classification), and by maternal education and household wealth. Results: PVTGs had a higher NMR (59/1000) than OBC/none (31/1000) (rate ratio (RR): 1.92, 95%CI: 1.55–2.38). This was partly explained by wealth and education, but inequalities remained large after adjustment (adjusted RR: 1.59, 95%CI: 1.28–1.98). NMR was also higher among other STs (44/1000), but disparities were smaller (RR: 1.47, 95%CI: 1.23–1.75). There was a systematic gradient in NMR by maternal education and household wealth. SBRs were only higher in poorer groups (RRpoorest vs. least poor:1.56, 95%CI: 1.14–2.13). Uptake of facility-based services was low among PVTGs (e.g. institutional birth: 25% vs. 69% in OBC/none) and among poorer and less educated women. However, 65% of PVTG women with an institutional birth used a maternity vehicle vs. 34% among OBC/none. Visits from frontline workers (Accredited Social Health Activists [ASHAs]) were similar across groups, and ASHA accompaniment of institutional births was similar across caste/tribe groups, and higher among poorer and less educated women. Attendance in participatory women's groups was similar across caste/tribe groups, and somewhat higher among richer and better educated women. Conclusions: PVTGs are highly disadvantaged in terms of birth outcomes. Targeted interventions that reduce geographical barriers to facility-based care and address root causes of high poverty and low education in PVTGs are a priority. For population-level impact, they are to be combined with broader policies to reduce socio-economic mortality inequalities. Community-based interventions reach disadvantaged groups and have potential to reduce the mortality gap. [ABSTRACT FROM AUTHOR]

Background: Though extensive studies have been conducted on assessing the predictors of cognitive functioning among older adults in small community-based samples, very few studies have focused on understanding the impact of socioeconomic status (SES), demographic characteristics and other risk factors such as lifestyle and chronic diseases on the cognitive functioning among adults of all ages in a nationally representative population-based sample across low- and middle-income countries. This study, therefore, seeks to evaluate the impact of SES, demographic characteristics and risk factors on the cognitive functioning of adults across all ages in five selected developing countries. Methods: Data from 12,430 observations obtained from the WHO Study on Global AGEing and Adult Health (SAGE) Wave 1; consisting of 2,486 observations each for China, Ghana, India, the Russian Federation, and South Africa, were used for the study. A meta-regression and a five-step hierarchical linear regression were used to analyze the data, with cognitive functioning as the dependent variable. Independent variables used in this study include SES; assessed by household income and education, demographic characteristics, other risk factors such as lifestyle, self-reported memory difficulty and chronic diseases. Results: This study found that SES and lifestyle significantly predicted cognitive functioning in all the five selected countries as obtained by the pooled results of the meta-regression analysis. The hierarchical linear regression results also revealed that demographic characteristics such as age, type of residency, and self-reported memory difficulty significantly impact cognitive functioning in China, Ghana, Russia, and South Africa. Conclusion: The findings in this study provide new insights for policymakers, caregivers, parents, and individuals, especially those in developing countries, to implement policies and actions targeted at improving SES and eliminating risk factors associated with cognitive decline, as these measures could help improve the cognitive functioning among their populations. [ABSTRACT FROM AUTHOR]

Background: Continuum of Maternal Health Care Services (CMHS) has garnered attention in recent times and reducing socio-economic disparity and geographical variations in its utilisation becomes crucial from an egalitarian perspective. In this study, we estimate inequity in the utilisation of CMHS in India between 2005 and 06 and 2015-16. Methods: We used two rounds of National Family Health Survey (NFHS) - 2005-06 and 2015-16 encompassing a sample size of 34,560 and 178,857 pregnant women respectively. The magnitude of horizontal inequities (HI) in the utilisation of CMHS was captured by adopting the Erreygers Corrected Concentration indices method. Need-based standardisation was conducted to disentangle the variations in the utilisation of CMHS across different wealth quintiles and state groups. Further, a decomposition analysis was undertaken to enumerate the contribution of legitimate and illegitimate factors towards health inequity. Results: The study indicates that the pro-rich inequity in the utilisation of CMHS has increased by around 2 percentage points since the implementation of National Rural Health Mission (NRHM), where illegitimate factors are dominant. Decomposition analysis reveals that the contribution of access related barriers plummeted in the considered period of time. The results also indicate that mother's education and access to media continue to remain major contributors of pro-rich inequity in India. Considering, regional variations, it is found that the percentage of pro-rich inequity in high focus group states increased by around 3% between 2005 and 06 and 2015-16. The performance of southern states of India is commendable. Conclusions: Our study concludes that there exists a pro-rich inequity in the utilisation of CMHS with marked variations across state boundaries. The pro-rich inequity in India has increased between 2005 and 06 and high focus group states suffered predominantly. Decentralisation of healthcare policies and granting greater power to the states might lead to equitable distribution of CMHS. [ABSTRACT FROM AUTHOR]

Background: Kangaroo mother care (KMC) can substantially enhance overall survival of low birthweight babies. In a large randomized controlled trial, we recently showed that supporting mothers to provide community initiated KMC (ciKMC) can reduce mortality among infants up to 180 days of life by 25% (hazard ratio (HR) 0.75). With the current analysis, we aimed to explore if ciKMC promotion leads to increased inequity in survival. Methods: In the trial we randomized 8402 low birthweight babies to a ciKMC (4480 babies) and a control (3922 babies) arm, between 2015 and 2018 in Haryana, India. We estimated the difference in concentration indices, which measure inequality, between babies in the ciKMC and control arms for survival until 180 days of life. Further, we compared the effect of ciKMC promotion across subgroups defined by socioeconomic status, caste, maternal literacy, infant's sex, and religion. Results: Our intervention did not increase survival inequity, as the concentration index in the ciKMC arm of the trial was 0.05 (95% CI -0.07 to 0.17) lower than in the control arm. Survival impact was higher among those belonging to the lower two wealth quintiles, those born to illiterate mothers and those belonging to religions other than Hindu. Conclusions: We found that ciKMC promotion did not increase inequity in survival associated with wealth. The beneficial impact of ciKMC tended to be larger among vulnerable groups. Supporting mothers to provide KMC at home to low birthweight babies will not increase and could indeed reduce inequities in infant survival. Trial registration: ClinicalTrials.gov, NCT02653534. Registered January 12, 2016—Retrospectively registered. [ABSTRACT FROM AUTHOR]

Background: In India the number of registered deaths increased substantially in recent years, improving the potential of the civil registration and vital statistics (CRVS) system to be the primary source of mortality data and providing more families of decedents with the benefits of possessing a death certificate. This study aims to identify whether inequalities in the completeness of death registration between states in India, including by sex, have narrowed during this period of CRVS system strengthening. Methods: Data used in this study are registered deaths by state and year from 2000 to 2018 (and by sex from 2009 to 2018) reported in the Civil Registration Reports published by the Office of Registrar General of India. Completeness of death registration is calculated using the empirical completeness method. Levels and trends inequalities in completeness are measured in each state a socio-economic indicator – the Socio-Demographic Index (SDI). Results: Estimated completeness of death registration in India increased from 58% in 2000 to 81% in 2018. Male completeness rose from 60% in 2009 to 85% in 2018 and was much higher than female completeness, which increased from 54 to 74% in the same period. Completeness remained very low in some states, particularly from the eastern (e.g. Bihar) and north-eastern regions. However, in states from the northern region (e.g. Uttar Pradesh) completeness increased significantly from a low level. There was a narrowing of inequalities in completeness according to the SDI during the period, however large inequalities between states remain. Conclusions: The increase in completeness of death registration in India is a substantial achievement and increases the potential of the death registration system as a routine source of mortality data. Although narrowing of inequalities in completeness demonstrates that the benefits of higher levels of death registration have spread to relatively poorer states of India in recent years, the continued low completeness in some states and for females are concerning. The Indian CRVS system also needs to increase the number of registered deaths with age at death reported to improve their usability for mortality statistics. [ABSTRACT FROM AUTHOR]

Background: Nutritional inequality in India has been estimated typically using stunting, wasting and underweight separately which hide the overall magnitude and severity of undernutrition. We used the Composite Index of Anthropometric Failure (CIAF) that combines all three forms of anthropometric failures to assess the severity of undernutrition and identify the most vulnerable social groups and geographical hotspots. Method: CIAF was constructed using child anthropometric data from the fourth round of the National Family Health Survey (NFHS-4, 2015–16). We considered 24 intersecting sub-groups based on intersections across four main axes of inequality i.e., caste [Scheduled Tribe (ST), Scheduled Caste (SC) and Other], economic position (poor and non-poor), place of residence (rural and urban) and gender (male and female) (eg. ST-Poor-Rural-Female). Cross-tabulation and logistic regression were done to assess the odds of CIAF among intersecting groups and to identify the most vulnerable sub-groups. Concentration curve was plotted to visualise economic position inequality in child undernutrition across caste categories. Choropleth maps were constructed and descriptive analysis of the district-level prevalence of CIAF was performed to identify the geographic clustering of undernutrition. Results: Overall 55.32% of children were undernourished by CIAF and 6.62% of children have simultaneous three anthropometric failure. In sub-group analysis, children from ST and SC caste have a higher risk of undernutrition irrespective of other axis of inequality. Compared with CIAF, economic position inequality was amplified for simultaneous-three-failures among all caste categories. Economic position inequalities within caste are more for other caste and SC categories than with ST. Economic position, caste and gender based inequality in all three failures is more consistent in rural areas than with urban areas. Based on the analysis of the high prevalence in the co-occurrence of two or three failures, 111 districts from 12 of 29 states in India were identified across four geographic clusters. Conclusions: The study shows social and eco-geographical clustering of multi-dimensional anthropometric failures and indicates the need for focused nutritional interventions among SC and ST community in general and ST children from the poor households. Furthermore, governance interventions that target entire regions across districts and states combined with decentralised planning are needed. [ABSTRACT FROM AUTHOR]

Background: Despite substantial reductions in perinatal deaths (stillbirths and early neonatal deaths), India's perinatal mortality rates remain high, both nationally and in individual states. Rates are highest among disadvantaged socio-economic groups. To address this, India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to counsel and support women by visiting them at home before and after childbirth. We conducted a qualitative study to explore the roles of ASHAs' home visits in improving equity in perinatal health between socio-economic position groups in rural Uttar Pradesh (UP), India. Methods: We conducted social mapping in four villages of two districts in UP, followed by three focus group discussions in each village (12 in total) with ASHAs and women who had recently given birth belonging to 'higher' and 'lower' socio-economic position groups (n = 134 participants). We analysed the data in NVivo and Dedoose using a thematic framework approach. Results: Home visits enabled ASHAs to build trusting relationships with women, offer information about health services, schemes and preventive care, and provide practical support for accessing maternity care. This helped many women and families prepare for birth and motivated them to deliver in health facilities. In particular, ASHAs encouraged women who were poorer, less educated or from lower caste groups to give birth in public Community Health Centres (CHCs). However, women who gave birth at CHCs often experienced insufficient emergency obstetric care, mistreatment from staff, indirect costs, lack of medicines, and referrals to higher-level facilities when complications occurred. Referrals often led to delays and higher fees that placed the greatest burden on families who were considered of lower socio-economic position or living in remote areas, and increased their risk of experiencing perinatal loss. Conclusions: The study found that ASHAs built relationships, counselled and supported many pregnant women of lower socio-economic positions. Ongoing inequities in health facility births and perinatal mortality were perpetuated by overlapping contextual issues beyond the ASHAs' purview. Supporting ASHAs' integration with community organisations and health system strategies more broadly is needed to address these issues and optimise pathways between equity in intervention coverage, processes and perinatal health outcomes. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 crisis in India negatively impacted mental health due to both the disease and the harsh lockdown, yet there are almost no qualitative studies describing mental health impacts or the strategies of resilience used, and in particular, no reports from the most vulnerable groups. This study aimed to examine the acute mental health impacts of the COVID-19 crisis as well as coping strategies employed by disadvantaged community members in North India. Methods: We used an intersectional lens for this qualitative study set in rural Tehri Garwhal and urban Dehradun districts of Uttarakhand, India. In-depth interviews were conducted in May 2020 during lockdown, by phone and in person using purposive selection, with people with disabilities, people living in slums with psychosocial disabilities and widows (total n = 24). We used the framework method for analysis following steps of transcription and translation, familiarisation, coding, developing and then applying a framework, charting and then interpreting data. Findings: The participants with compounded disadvantage had almost no access to mobile phones, health messaging or health care and experienced extreme mental distress and despair, alongside hunger and loss of income. Under the realms of intrapersonal, interpersonal and social, six themes related to mental distress emerged: feeling overwhelmed and bewildered, feeling distressed and despairing, feeling socially isolated, increased events of othering and discrimination, and experiencing intersectional disadvantage. The six themes summarising coping strategies in the COVID-19 crisis were: finding sense and meaning, connecting with others, looking for positive ways forward, innovating with new practices, supporting others individually and collectively, and engaging with the natural world. Conclusions: People intersectionally disadvantaged by their social identity experienced high levels of mental distress during the COVID-19 crisis, yet did not collapse, and instead described diverse and innovative strategies which enabled them to cope through the COVID-19 lockdown. This study illustrates that research using an intersectional lens is valuable to design equitable policy such as the need for access to digital resources, and that disaggregated data is needed to address social inequities at the intersection of poverty, disability, caste, religious discrimination and gender inherent in the COVID-19 pandemic in India. [ABSTRACT FROM AUTHOR]

The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity in primary care is a challenge not only for developing countries but also for low and medium income countries (LMIC). Health services in LMIC countries are being provided by both public and private health care providers. However, a critical knowledge gap exists on understanding the true extent of multimorbidity in both types of primary care settings. Methods: We undertook a study to identify multimorbidity prevalence and healthcare utilization among both public and private primary care attendees in Odisha state of India. A total of 1649 patients attending 40 primary care facilities were interviewed using a structured multimorbidity assessment questionnaire collecting information on 22 chronic diseases, medication use, number of hospitalization and number of outpatient visits. Result: The overall prevalence of multimorbidity was 28.3% and nearly one third of patients of public facilities and one fourth from private facilities had multimorbidity. Leading diseases among patients visiting public facilities included acid peptic diseases, arthritis and chronic back pain. No significant difference in reporting of hypertension and diabetes across the facilities was seen. Besides age, predictors of multimorbidity among patients attending public facilities were, females [AOR: 1.6; 95% CI 1.1–1.3] and non-aboriginal groups [AOR: 1.6; 95%CI 1.1–2.3] whereas, in private females [AOR: 1.6; 95%CI 1.1–2.4], better socioeconomic conditions [AOR 1.4; 95% CI 1.0–2.1] and higher educational status [primary school completed [AOR 2.6; 95%CI 1.6–4.2] and secondary schooling and above [AOR 2.0; 95%CI 1.1–3.6] with reference to no education were seen to be the determinants of multimorbidity. Increased number of hospital visits to public facilities were higher among lower educational status patients [IRR: 1.57; 95% CI 1.13–2.18] whereas, among private patients, the mean number of hospital visits was 1.70 times more in higher educational status [IRR: 1.70; 95%CI 1.01–3.69]. The mean number of medicines taken per day was higher among patients attending private hospitals. Conclusion: Our findings suggest that, multimorbidity is being more reported in public primary care facilities. The pattern and health care utilization in both types of settings are different. A comprehensive care approach must be designed for private care providers. [ABSTRACT FROM AUTHOR]

Background: In 2005, the Indian Government introduced the Janani Suraksha Yojana (JSY) scheme - a conditional cash transfer program that incentivizes women to deliver in a health facility -- in order to reduce maternal and neonatal mortality. Our study aimed to measure and explain socioeconomic inequality in the receipt of JSY benefits. Methods: We used prospectively collected data on 3,682 births (in 2009-2010) from a demographic surveillance system in five districts in Jharkhand and Odisha state, India. Linear probability models were used to identify the determinants of receipt of JSY benefits. Poor-rich inequality in the receipt of JSY benefits was measured by a corrected concentration index (CI), and the most important drivers of this inequality were identified using decomposition techniques. Results: While the majority of women had heard of the scheme (94% in Odisha, 85% in Jharkhand), receipt of JSY benefits was comparatively low (62% in Odisha, 20% in Jharkhand). Receipt of the benefits was highly variable by district, especially in Jharkhand, where 5% of women in Godda district received the benefits, compared with 40% of women in Ranchi district. There were substantial pro-rich inequalities in JSY receipt (CI 0.10, standard deviation (SD) 0.03 in Odisha; CI 0.18, SD 0.02 in Jharkhand) and in the institutional delivery rate (CI 0.16, SD 0.03 in Odisha; CI 0.30, SD 0.02 in Jharkhand). Delivery in a public facility was an important determinant of receipt of JSY benefits and explained a substantial part of the observed poor-rich inequalities in receipt of the benefits. Yet, even among public facility births in Jharkhand, pro-rich inequality in JSY receipt was substantial (CI 0.14, SD 0.05). This was largely explained by district-level differences in wealth and JSY receipt. Conversely, in Odisha, poorer women delivering in a government institution were at least as likely to receive JSY benefits as richer women (CI -0.05, SD 0.03). Conclusion: JSY benefits were not equally distributed, favouring wealthier groups. These inequalities in turn reflected pro-rich inequalities in the institutional delivery. The JSY scheme is currently not sufficient to close the poor-rich gap in institutional delivery rate. Important barriers to institutional delivery remain to be addressed and more support is needed for low performing districts and states. [ABSTRACT FROM AUTHOR]

Background: Millions of poor households in India undertake short duration rural to urban migration along with their children to find work in the informal economy in the city. While literature has documented the precarity of such temporary jobs, typically characterized by low wages, insecure jobs, harsh recruitment regimes and economic vulnerability, little is known about its implications for children who migrate with their parents to the city. In this study, we draw attention to children of migrant construction workers and focus on their overall nutritional well-being, which remains under-studied. Our objectives were to categorize the current nutritional status of children under the age of five and determine the underlying causes of poor nutritional outcomes. Methods: The field work for this study was undertaken between May 2017 and January 2018 at five construction sites in the city of Ahmedabad. We undertook anthropometric measurements of children under the age of five [N = 131; (male: 46%, female 53%); (mean age: 31.7 months)] and categorized their nutritional status. Using the UNICEF framework on undernutrition, we examined the underlying causes of poor nutritional outcomes among this group of children with the help of qualitative methods such as interviews, focused group discussions and participant observation at the field sites. Results: Undernutrition was highly prevalent among the children (N = 131): stunted (40.5%); wasted (22.1%); and underweight (50.4%). We found common factors across parents interviewed such as similar misperceptions of malnutrition, long hours of work and lack of childcare provision at the worksite which resulted in disrupted quality of care. While socio-cultural beliefs and lack of information influenced breastfeeding, other factors such as inability to take breaks or lack of space further impaired infant feeding practices more broadly. Lack of dietary diversity at home, poor hygiene and sanitation, and economic inability to seek healthcare further affected child nutritional status. Conclusions: Our study addresses a critical gap in migration literature in India by building a comprehensive narrative of migrant children's experiences at construction sites. We find that parents' informal work setting exposes children to a nutritionally challenging environment. Policies and programs seeking to address undernutrition, a critical challenge in India, must pay attention to the specific needs of migrant children. [ABSTRACT FROM AUTHOR]

Background: Despite large investment in central and state sponsored schemes for maternal care, out-of-pocket expenditure (OOPE) and catastrophic health spending (CHS) on institutional delivery remain high over time, across states and across socio-economic groups. Though many studies have examined the OOPE and CHS, few studies have examined the nature and extent of distress financing on institutional delivery in India. Data: Data from the fourth round of National Family Health Survey (NFHS 4), 2015–16 was used for the analysis. Distress financing was defined as borrowing money or selling assets to meet the OOPE on delivery care. Composite variables, descriptive analyses, concentration index (CI), concentration curve (CC) and predicted probability were used to estimate the extent of distress financing for institutional delivery in India. Results: The OOPE on institutional delivery has strong economic and educational gradient. One in four mothers resorted to borrowing or selling to meet the OOPE on institutional delivery. The extent of distress financing on institutional delivery was high in poorer state of Bihar and Odisha and in the state of Telangana that had highest prevalence of caesarean delivery. Savings was more prevalent among mothers compared to those who met the OOPE by borrowing/selling of assets. Finding are robust across the states of India. The predicted probability of incurring distress financing was 0.31 among mothers belonging to the poorest wealth quintile compared to 0.09 in the richest quintile, and 0.40 for those who incurred OOPE of more than INR 20,000. The probability of incurring distress financing was higher for mothers who had caesarean birth, delivered in private health centers and incurred high OOPE on institutional delivery. Conclusion: Distress financing on institutional delivery was higher among the less educated, poor and in private health centers. Increasing use of public health centers, reducing caesarean births, improving the availability of medicine and diagnostic services can reduce the extent of distress financing in India. [ABSTRACT FROM AUTHOR]

Background: A consensus is developing on interventions to improve newborn survival, but little is known about how to reduce socioeconomic inequalities in newborn mortality in low- and middle-income countries. Participatory learning and action (PLA) through women's groups can improve newborn survival and home care practices equitably across socioeconomic strata, as shown in cluster randomised controlled trials. We conducted a qualitative study to understand the mechanisms that led to the equitable impact of the PLA approach across socioeconomic strata in four trial sites in India, Nepal, Bangladesh, and Malawi. Methods: We conducted 42 focus group discussions (FGDs) with women who had attended groups and women who had not attended, in poor and better-off communities. We also interviewed six better-off women and nine poor women who had delivered babies during the trials and had demonstrated recommended behaviours. We conducted 12 key informant interviews and five FGDs with women's group facilitators and fieldworkers. Results: Women's groups addressed a knowledge deficit in poor and better-off women. Women were engaged through visual learning and participatory tools, and learned from the facilitator and each other. Facilitators enabled inclusion of all socioeconomic strata, ensuring that strategies were low-cost and that discussions and advice were relevant. Groups provided a social support network that addressed some financial barriers to care and gave women the confidence to promote behaviour change. Information was disseminated through home visits and other strategies. The social process of learning and action, which led to increased knowledge, confidence to act, and acceptability of recommended practices, was key to ensuring behaviour change across social strata. These equitable effects were enabled by the accessibility, relevance, and engaging format of the intervention. Conclusions: Participatory learning and action led to increased knowledge, confidence to act, and acceptability of recommended practices. The equitable behavioural effects were facilitated by the accessibility, relevance, and engaging format of the intervention across socioeconomic groups, and by reaching-out to parts of the population usually not accessed. A PLA approach improved health behaviours across socioeconomic strata in rural communities, around issues for which there was a knowledge deficit and where simple changes could be made at home. [ABSTRACT FROM AUTHOR]

Background: In Bangladesh, India and Nepal, neonatal outcomes of poor infants are considerably worse than those of better-off infants. Understanding how these inequalities vary by country and place of delivery (home or facility) will allow targeting of interventions to those who need them most. We describe socio-economic inequalities in newborn care in rural areas of Bangladesh, Nepal and India for all deliveries and by place of delivery. Methods: We used data from surveillance sites in Bangladesh, India and from Makwanpur and Dhanusha districts in Nepal, covering periods from 2001 to 2011. We used literacy (ability to read a short text) as indicator of socioeconomic status. We developed a composite score of nine newborn care practices (score range 0–9 indicating infants received no newborn care to all nine newborn care practices). We modeled the effect of literacy and place of delivery on the newborn care score and on individual practices. Results: In all study sites (60,078 deliveries in total), use of facility delivery was higher among literate mothers. In all sites, inequalities in newborn care were observed: the difference in new born care between literate and illiterate ranged 0.35–0.80. The effect of literacy on the newborn care score reduced after adjusting for place of delivery (range score difference literate-illiterate: 0.21–0.43). Conclusion: Socioeconomic inequalities in facility care greatly contribute to inequalities in newborn care. Improving newborn care during home deliveries and improving access to facility care are a priority for addressing inequalities in newborn care and newborn mortality. [ABSTRACT FROM AUTHOR]