Browsing by Author "Nandi, Sulakshana"

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    Addressing the social determinants of health: A case study from the Mitanin (Community Health Worker) programme in India
    (London School of Hygiene and Tropical Medicine, 2014) Nandi, Sulakshana; Schneider, Helen
    The Mitanin Programme, a government community health worker (CHW) programme, was started in Chhattisgarh State of India in 2002. The CHWs (Mitanins) have consistently adopted roles that go beyond health programme- specific interventions to embrace community mobilization and action on local priorities. The aim of this research was to document how and why the Mitanins have been able to act on the social determinants of health, describing the catalysts and processes involved and the enabling programmatic and organiza- tional factors. A qualitative comparative case study of successful action by Mitanin was conducted in two ‘blocks’, purposefully selected as positive exemplars in two districts of Chhattisgarh. One case focused on malnutrition and the other on gender-based violence. Data collection involved 17 in-depth interviews and 10 group interviews with the full range of stakeholders in both blocks, including community members and programme team. Thematic analysis was done using a broad conceptual framework that was further refined. Action on social determinants involved raising awareness on rights, mobilizing women’s collectives, revitalizing local political structures and social action targeting both the community and government service providers. Through these processes, the Mitanins developed identities as agents of change and advocates for the community, both with respect to local cultural and gender norms and in ensuring accountability of service providers. The factors underpinning successful action on social determinants were identified as the significance of the original intent and vision of the programme, and how this was carried through into all aspects of programme design, the role of the Mitanins and their identification with village women, ongoing training and support, and the relative autonomy of the programme. Although the results are not narrowly generalizable and do not necessarily represent the situation of the Mitanin Programme as a whole, the explanatory framework may provide general lessons for programmes in similar contexts.
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    Assessing geographical inequity in availability of hospital services under the state-funded universal health insurance scheme in Chhattisgarh state, India, using a composite vulnerability index
    (Taylor & Francis, 2018) Nandi, Sulakshana; Schneider, Helen; Garg, Samir
    Background: Countries are increasingly adopting health insurance schemes for achieving Universal Health Coverage. India’s state-funded health insurance scheme covers hospital care provided by ‘empanelled’ private and public hospitals. Objective: This paper assesses geographical equity in availability of hospital services under the universal health insurance scheme in Chhattisgarh state. Methods: The study makes use of district data from the insurance scheme and government surveys. Selected socio-economic indicators are combined to form a composite vulnerability index, which is used to rank and group the state’s 27 districts into tertiles, named as highest, middle and lowest vulnerability districts (HVDs, MVDs, LVDs). Indicators of hospital service availability under the scheme – insurance coverage, number of empanelled private/public hospitals, numbers and amounts of claims – are compared across districts and tertiles. Two measures of inequality, difference and ratio, are used to compare availability between tertiles. Results: The study finds that there is a geographical pattern to vulnerability in Chhattisgarh state. Vulnerability increases with distance from the state’s centre towards the periphery. The highest vulnerability districts have the highest insurance coverage, but the lowest availability of empanelled hospitals (3.4 hospitals per 100,000 enrolled in HVDs, vs 8.2/100,000 enrolled in LVDs). While public sector hospitals are distributed equally, the distribution of private hospitals across tertiles is highly unequal, with higher availability in LVDs. The number of claims (per 100,000 enrolled) in the HVDs is 3.5-times less than that in the LVDs. The claim amounts show a similar pattern. Conclusions: Although insurance coverage is higher in the more vulnerable districts, availability of hospital services is inversely proportional to vulnerability and, therefore, the need for these services. Equitable enrolment in health insurance schemes does not automatically translate into equitable access to healthcare, which is also dependent on availability and specific dynamics of service provision under the scheme.
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    Equity, access and utilisation in the state-funded universal insurance scheme (RSBY/MSBY) in Chhattisgarh State, India: What are the implications for Universal Health Coverage?
    (University of the Western Cape, 2019) Nandi, Sulakshana; Schneider, Helen
    Universal Health Coverage (UHC) has provided the impetus for the introduction of publicly-funded health insurance (PFHI) schemes, involving the private sector, especially in low-and middle-income countries with mixed health systems. Although equity is considered as being core to UHC, the implication of UHC interventions for equity in access (availability, affordability and acceptability) beyond financial protection is inadequately researched. India introduced a national PFHI scheme (Rashtriya Swasthya Bima Yojana) in 2007 which has since then been expanded considerably through the Pradhan Mantri Jan Aarogya Yojana (PMJAY) scheme. However, contestation remains as to whether PFHI schemes are the most appropriate interventions for UHC in India. Evidence so far provides cause for concern regarding their impact on financial protection and health equity. With PFHI schemes burgeoning globally, there is an urgent need for a holistic understanding of the pathways of impact of these schemes, including their roles in promoting equity of access and achievement of UHC objectives. The state-funded universal health insurance scheme (RSBY/MSBY) in Chhattisgarh State provided the opportunity to explore these pathways of impact, especially on vulnerable communities, as the State has a universal health insurance scheme. This PhD aims to study equity, access and utilisation in the state-funded universal insurance scheme in Chhattisgarh State of India, in the context of Universal Health Coverage. It is presented as a thesis by publications.
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    Hospital utilization and out of pocket expenditure in public and private sectors under the universal government health insurance scheme in Chhattisgarh State, India: Lessons for universal health coverage
    (Public Library of Science, 2017) Nandi, Sulakshana; Schneider, Helen; Dixit, Priyanka
    Research on impact of publicly financed health insurance has paid relatively little attention to the nature of healthcare provision the schemes engage. India's National Health Insurance Scheme or RSBY was made universal by Chhattisgarh State in 2012. In the State, public and private sectors provide hospital services in a context of extensive gender, social, economic and geographical inequities. This study examined enrolment, utilization (public and private) and out of pocket (OOP) expenditure for the insured and uninsured, in Chhattisgarh. The Chhattisgarh State Central sample (n = 6026 members) of the 2014 National Sample Survey (71st Round) on Health was extracted and analyzed. Variables of enrolment, hospitalization, out of pocket (OOP) expenditure and catastrophic expenditure were descriptively analyzed. Multivariate analyses of factors associated with enrolment, hospitalization (by sector) and OOP expenditure were conducted, taking into account gender, socio-economic status, residence, type of facility and ailment. Insurance coverage was 38.8%. Rates of hospitalization were 33/1000 population among the insured and 29/1000 among the uninsured. Of those insured and hospitalized, 67.2% utilized the public sector. Women, rural residents, Scheduled Tribes and poorer groups were more likely to utilize the public sector for hospitalizations. Although the insured were less likely to incur out of pocket (OOP) expenditure, 95.1% of insured private sector users and 66.0% of insured public sector users, still incurred costs. Median OOP payments in the private sector were eight times those in the public sector. Of households with at least one member hospitalized, 35.5% experienced catastrophic health expenditures (>10% monthly household consumption expenditure). The study finds that despite insurance coverage, the majority still incurred OOP expenditure. The public sector was nevertheless less expensive, and catered to the more vulnerable groups. It suggests the need to further examine the roles of public and private sectors in financial risk protection through government health insurance.
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    Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India
    (Springer Nature, 2020) Nandi, Sulakshana; Schneider, Helen
    Universal health coverage (UHC) has provided the impetus for the introduction of publicly funded health insurance (PFHI) schemes in the mixed health systems of India and many other low- and middle-income countries. There is a need for a holistic understanding of the pathways of impact of PFHI schemes, including their role in promoting equity of access. Methods: This paper applies an equity-oriented evaluation framework to assess the impacts of PFHI schemes in Chhattisgarh State by synthesising literature from various sources and highlighting knowledge gaps. Data were collected from an extensive review of publications on PFHI schemes in Chhattisgarh since 2009, including empirical studies from the first author's PhD and grey literature such as programme evaluation reports, media articles and civil society campaign documents. The framework was constructed using concepts and frameworks from the health policy and systems research literature on UHC, access and health system building blocks, and is underpinned by the values of equity, human rights and the right to health.