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Background There are many indicators and methods in use for measuring access to healthcare, much of which relate to physical access or utilization of services. This study measures unmet healthcare needs in a district with relatively good physical access and insurance coverage and discusses the relevance of our findings for the design and monitoring of progress towards achieving universal health coverage (UHC). Methods A multi-stage sampling survey identified and interviewed a sample of 3153 individuals from 598 households drawn from 13 villages and seven urban wards. In-depth qualitative interviews of five purposively chosen individuals from each village and urban ward, was also undertaken. The study examined access in terms of perceived healthcare needs and unperceived or latent healthcare needs and the proportion of such needs that utilized effective health care and the proportion that did not. Estimation of unperceived healthcare needs was limited to five tracer conditions- hypertension, diabetes, depression, rheumatic conditions and dependence in activities of daily living in the elderly. Bivariate, multivariate (logistic regression), and thematic analyses were used for this study. Results Out of the total population, 10.47% reported perceived healthcare needs for acute ailments in the last 15 days, and 10.62% of the population self-reported suffering from chronic conditions. 12.75% of those with acute ailment and 18.40% of those with chronic ailment received no treatment, while 27.83% and 9.07% respectively took care from informal care provider. Unperceived healthcare needs were high in all five-tracer conditions studied. Incomplete treatment was another form of unmet need. Inappropriate care conceals unmet healthcare needs. Unperceived healthcare needs were significantly higher for poor and marginalized population subgroup, whereas perceived healthcare needs were higher among upper socioeconomic and less marginalized population. Conclusion The measurement of unmet healthcare needs should include both perceived and latent needs, as well as incomplete care and care from informal providers. Further, inappropriate care conceals a lot of unmet healthcare needs, and its measurement is not easy. In a context of information asymmetry and prevailing health markets, the measurement of unmet healthcare needs in all its complexity, becomes essential for measuring progress towards UHC. Trial registration: Not Applicable

Introduction: Out of Pocket Expenditure (OOPE) contributes to impoverishment and Catastrophic Health Expenditure (CHE) and restricts equitable access to healthcare in many Low and Medium Income Countries (LMICs), including India. Indian government has implemented different strategies to expand access and to reduce OOPE in public and private hospitals in its mixed healthcare system. The study aims to assess the long-term pattern of utilization, OOPE and CHE in public and private hospitals and to draw policy lessons for Universal Health Coverage in India. Methods: Indian government conducts periodic household surveys called National Sample Survey (NSS). Unit data from the last four rounds of NSS (1996 to 2017) on healthcare utilization were analysed. Multivariate analysis was used to find out determinants of utilization, choice of provider, OOPE and CHE. Propensity Score Matching was applied to find effect of specific variables on OOPE and CHE. Results: The share of public-sector in hospital-utilisation fell from 1996 to 2004 but grew consistently after 2004, reaching 51% of utilization in 2017. Socio-economically vulnerable sections were more likely to utilize public-sector. Mean OOPE per hospitalization in public-sector registered a decline from 2004 to 2017, while it increased substantially in private-sector. OOPE in private sector was around six times greater than public sector in 2017 and incidence of CHE was nine times. Utilising private-sector was an important determinant of incurring CHE. Coverage under publicly funded insurance was ineffective in reducing OOPE or CHE. Discussion: Public sector provided effective protection to the poor from financial risk. While, the structural-adjustment policies of 1990s had resulted in reduction in public-sector utilisation, the supply-side strengthening of public sector after 2005 was more effective in improving access and financial-protection. For achieving UHC, Indian health-system needs increased public funding for strengthening public-sector, especially to provide services for NCDs and injuries. Persistently high OOPE in private-sector raises doubts whether public-funding or contracting can align provider incentives with goals of UHC. The debate on public-private provider mix and financing policies continues to hold relevance for health-systems performance across LMICs.

Background Community Case Management of Malaria (CCMM) has been implemented through community health workers (CHWs) in many countries. Existing studies have shown that CHWs can be viable means of implementing CCMM. However, not many studies have examined the coverage under large-scale CCMM programmes. India is a big contributor to global malaria burden. Chhattisgarh is a leading state in India in terms of malaria incidence and mortality. CCMM was implemented on a large scale through the ‘mitanin’ CHWs in rural Chhattisgarh from 2015. Under CCMM, 37,696 CHWs in 84 high-burden administrative blocks of the state were trained and equipped with rapid diagnostic tests (RDT), artemisinin-based combination therapy (ACT) and chloroquine. Methods This descriptive quantitative study assesses coverage of CCMM in detection and treatment of Malaria over three rounds of household surveys—2015, 2016 and 2018. Household-interviews covered more than 15,000 individuals in each round, using multi-stage random sampling across the 84 blocks. The main objectives were to find out the coverage in identification and treatment of malaria and the share of CHWs in them. A 15-days recall was used to find out cases of fever and healthcare sought by them. Results In 2018, 62% of febrile cases in rural population contacted CHWs. RDT, ACT and chloroquine were available with 96%, 80% and 95% of CHWs, respectively. From 2015 to 2018, the share of CHWs in testing of febrile cases increased from 34 to 70%, while it increased from 28 to 69% in treatment of malaria cases. CHWs performed better than other providers in treatment-completion and administered medication under direct observation to 72% of cases they treated. Conclusion This study adds to one of the most crucial but relatively less reported area of CCMM programmes, i.e. the extent of coverage of the total febrile population by CHWs, which subsequently determines the actual coverage of case-management in malaria. Mitanin-CHWs achieved high coverage and treatment-completion rates that were rarely reported in context of large-scale CCMM elsewhere. Close to community, well-trained CHWs with sufficient supplies of rapid tests and anti-malarial drugs can play a key role in achieving the desired coverage in malaria-management.