Nikkil Sudharsanan

Despite the rollout of public insurance schemes, vulnerable populations in India have low enrollment and use of insurance and continue to experience catastrophic healthcare spending. Our study aims to identify and understand the reasons for under-enrollment and under-use of Tamil Nadu’s Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS) among two key vulnerable populations: tribal populations and those living in urban slums. We constructed a conceptual framework that characterizes insurance enrollment and use as dependent on awareness and understanding, perceived value, hassle costs, and quality of scheme implementation. Based on this framework, we conducted 83 qualitative interviews across three different urban slums and rural tribal sites in Tamil Nadu and used a combination of inductive and deductive coding to identify the main themes and their relationships with each other. We found low awareness and understanding of the scheme. Many respondents never heard of the scheme; surprisingly, this was true even among those who were enrolled and possessed an insurance card.. Among unenrolled individuals, individuals reported being discouraged from enrolling due to the substantial time costs involved, with participants reporting the loss of one or two working days to complete the process, compounded by bureaucratic hurdles and the need for travel. Consistent with our conceptual framework, we found that much of the awareness gaps and high hassle costs could be attributed to the poor implementation of the scheme within the state. Many individuals also reported being charged by empanelled private hospitals for covered health expenditures, which may indicate private hospitals subverting the scheme and extracting additional payments from beneficiaries. Our findings suggest that poor quality implementation of public health insurance in Tamil Nadu drives low awareness and understand among vulnerable populations and creates significant hassle barriers to enrollment and use. Making insurance schemes transparent and easy to use will be critical for ensuring equitable insurance effectiveness and promoting universal health coverage.

Clinicians in low- and middle-income countries (LMICs) often deviate from care guidelines andunder-deliver high-value preventive care. Focusing on hypertension screening, we investigate severalexplanations for under-delivery using a randomized experiment with standardized patients (SPs).Across 600 clinics in two major Indian cities, we found that nearly half of clinicians failed toscreen SPs - even though screening is highly cost-effective and universally recommended by Indianguidelines. We did not find evidence that under-screening was driven by an absence of resourcessuch as equipment and staff or a lack of clinicians’ knowledge on how to screen for hypertension. Our results also suggest that time pressure or clinicians’ personal judgment on which patients shouldbe screened does not drive screening rates. However, we find notable differences in care betweenpublic and private facilities, with private facilities screening significantly more often. Overall, wefind that conventional explanations for under-delivery - such as screening knowledge, resources, ortime pressure - may not be the prime drivers of inadequate preventive care provision in the Indiansetting. Rather, our results suggest that clinician effort in India is highly influenced by providercare environments and incentive structures.

A substantial share of patients at risk of developing cardiovascular disease (CVD) fail to achieve control of CVD risk factors, but clinicians lack a structured approach to identify these patients. We applied machine learning to longitudinal data from two completed randomized controlled trials among 1502 individuals with diabetes in urban India and Pakistan. Using commonly available clinical data, we predict each individual’s risk of failing to achieve CVD risk factor control goals or meaningful improvements in risk factors at one year after baseline. When classifying those in the top quartile of predicted risk scores as at risk of failing to achieve goals or meaningful improvements, the precision for not achieving goals was 73% for HbA1c, 30% for SBP, and 24% for LDL, and for not achieving meaningful improvements 88% for HbA1c, 87% for SBP, and 85% for LDL. Such models could be integrated into routine care and enable efficient and targeted delivery of health resources in resource-constrained settings.

Background: Individuals with high blood pressure in India often miss essential follow-up visits. Missed visits contribute to gaps across the hypertension care continuum and preventable cardiovascular disease. Widespread misconceptions around hypertension care and treatment may contribute to low follow-up attendance rates, but to date, there is limited evidence of the effect of interventions to debunk such misconceptions on health-seeking behavior. We conducted a randomized controlled trial to measure whether combining information debunking commonly-held misconceptions with a standard reminder reduces missed follow-up visits among individuals with high blood pressure and investigated whether any observed effect was moderated through belief change. Methods: We recruited 388 patients with uncontrolled blood pressure from the outpatient wards of two public sub-district hospitals in Punjab, India. Participants randomly assigned to the intervention arm received two WhatsApp messages, sent 3 and 1 days before their physician-requested follow-up visit. The WhatsApp message began with a standard reminder, reminding participants of their upcoming follow-up visit and its purpose. Following the standard reminder, we included brief debunking statements aimed at acknowledging and correcting common misconceptions and misbeliefs about hypertension care seeking and treatment. Participants in the control group received usual care and did not receive any messages. Results: We did not find evidence that the enhanced WhatsApp reminders improved follow-up visit attendance (Main effect: 2.2 percentage points, p-value = 0.603), which remained low across both treatment (21.8%, 95% CI: 15.7%, 27.9%) and control groups (19.6%, 95% CI: 14.2%, 25.0%). Participants had widespread misconceptions about hypertension care but our debunking messages did not successfully correct these beliefs (p-value = 0.187). Conclusions: This study re-affirms the challenge of continuity of care for chronic diseases in India and suggests that simple phone-based health communication methods may not suffice for changing prevalent misconceptions and improving health-seeking behavior. Trial registration: The trial began on July 18th. We registered the trial on July 18th (before recruitment began), including the main outcomes, on the German Clinical Trial Register [Identifier: DRKS00029712] and published a pre-analysis plan in the Open Science Framework [osf.io/67g35].

Global population health during the COVID-19 pandemic is poorly understood because of weak mortality monitoring in low- and middle-income countries. High-quality survey data on 765,180 individuals, representative of one-fourth of India’s population, uncover patterns missed by incomplete vital statistics and disease surveillance. Compared to 2019, life expectancy at birth was 2.6 years lower and mortality was 17% higher in 2020, implying 1.19 million excess deaths in 2020. Life expectancy declines in India were larger and had a younger age profile than in high-income countries. Increases in mortality were greater than expected based on observed seroprevalence and international infection fatality rates, most prominently among the youngest and older age groups. In contrast to global patterns, females in India experienced a life expectancy decline that was 1 year larger than losses for males. Marginalized social groups experienced greater declines than the most privileged social group. These findings uncover large and unequal mortality impacts during the pandemic in the world’s most populous country.

Background In India, several state governments are implementing or considering home-based hypertension screening programs to improve population-wide diagnosis and blood pressure (BP) control rates. However, there is limited evidence on the effectiveness of home-based screening programs in India. Methods Using six waves of population-representative cohort data (N = 15,573), we estimate the causal effect of a home-based hypertension screening intervention on diagnosis, treatment, and BP using a novel application of the Regression Discontinuity Design. Findings We find that screening individuals’ BP in their homes and providing health information and a referral to those with elevated BP did not meaningfully improve hypertension diagnosis (0.1, p-value: 0.82), treatment (−0.2, p-value: 0.49), or BP levels (systolic: −1.8, p-value: 0.03; diastolic: 0.5, p-value: 0.39). This null effect is robust across subpopulations and alternative specifications. Interpretation Our findings suggest that a lack of knowledge of one’s hypertension status might not be the primary reason for low diagnosis and treatment rates in India, where other structural and behavioral barriers may be more relevant. Adapting screening efforts to address these additional barriers will be essential for translating India’s screening efforts into improved population health. Funding This study received no funding. Research in context: Evidence before this study Indian state governments are implementing and scaling-up large home-based screening programs to address the growing burden of cardiometabolic diseases Studies evaluating home-based screening activities in China and Malawi find that they lead to modest improvements in blood pressure levels However, studies from South Africa and Germany find null effects of home-based screening on blood pressure and long-term cardiometabolic outcomes Added value of this study We provide the first evaluation of home-based hypertension screening in India using data representative of adults aged 30 years and older in two of India’s largest cities. In addition to blood pressure level, we investigate the effect of screening on diagnosis and treatment initiation to identify the effects of screening across the continuum of care. We find that home-based hypertension screening did not improve hypertension outcomes suggesting that a lack of knowledge of one’s hypertension status is not the main barrier to health care seeking and achievement of hypertension control. Implications of all the available evidence The mere provision of information on an individual’s hypertension status does not seem to increase hypertension diagnosis and treatment initiation. Other barriers, such as health literacy and inadequate communication strategies, need to be considered when designing home-based hypertension screening programs. Before scaling up existing home-based screening programs, health communication needs to be adapted to local needs and their effectiveness evaluated.

Improving hypertension control in low- and middle-income countries has uncertain implications across socioeconomic groups. In this study, we simulated improvements in the hypertension care cascade and evaluated the distributional benefits across wealth quintiles in 44 low- and middle-income countries using individual-level data from nationally representative, cross-sectional surveys. We raised diagnosis (diagnosis scenario) and treatment (treatment scenario) levels for all wealth quintiles to match the best-performing country quintile and estimated the change in 10-year cardiovascular disease (CVD) risk of individuals initiated on treatment. We observed greater health benefits among bottom wealth quintiles in middle-income countries and in countries with larger baseline disparities in hypertension management. Lower-middle-income countries would see the greatest absolute benefits among the bottom quintiles under the treatment scenario (29.1 CVD cases averted per 1,000 people living with hypertension in the bottom quintile (Q1) versus 17.2 in the top quintile (Q5)), and the proportion of total CVD cases averted would be largest among the lowest quintiles in upper-middle-income countries under both diagnosis (32.0% of averted cases in Q1 versus 11.9% in Q5) and treatment (29.7% of averted cases in Q1 versus 14.0% in Q5) scenarios. Targeted improvements in hypertension diagnosis and treatment could substantially reduce socioeconomic-based inequalities in CVD burden in low- and middle-income countries.

Uncontrolled hypertension is a leading risk factor for mortality globally and affects 26% of adults in India.¹ Underdiagnosis is a primary cause of poor hypertension control as only 37% of Indians with hypertension are diagnosed.¹ To increase diagnosis, Indian guidelines recommend that clinicians opportunistically screen adults for hypertension at all points of care.² This recommendation has substantial policy potential since Indian adults report frequent health care visits. Underdiagnosis despite guideline recommendations and frequent visits suggests that clinicians are not consistently screening for hypertension, leading to missed opportunities for increasing diagnosis.³ While there is evidence of poor guideline adherence in other care domains,^4-6 there is limited research on clinician adherence to hypertension screening guidelines in India.

Background: Uncontrolled hypertension is a leading risk factor for cardiovascular diseases. In Uganda, such diseases account for approximately 10% of all deaths, with 1 in 5 adults having hypertension (>90% of the hypertensive cases are uncontrolled). Although basic health care in the country is available free of cost at government facilities, regularly accessing medication to control hypertension is difficult because supply chain challenges impede availability. Clients therefore frequently suspend treatment or buy medication individually at private facilities or pharmacies (incurring significant costs). In recent years, mobile health (mHealth) interventions have shown increasing potential in addressing health system challenges in sub-Saharan Africa, but the acceptability, feasibility, and uptake conditions of mobile money approaches to chronic disease management remain understudied. Objective: This study aims to design and pilot-test a mobile money–based intervention to increase the availability of antihypertensive medication and lower clients’ out-of-pocket payments. We will build on existing local approaches and assess the acceptability, feasibility, and uptake of the designed intervention. Furthermore, rather than entering the study setting with a ready-made intervention, this research will place emphasis on gathering applied ethnographic insights early, which can then inform the parameters of the intervention prototype and concurrent trial. Methods: We will conduct a mixed methods study following a human-centered design approach. We will begin by conducting extensive qualitative research with a range of stakeholders (clients; health care providers; religious, cultural, and community leaders; academics; and policy makers at district and national levels) on their perceptions of hypertension management, money-saving systems, and mobile money in the context of health care. Our results will inform the design, iterative adaptation, and implementation of an mHealth-facilitated pooled financing intervention prototype. At study conclusion, the finalized prototype will be evaluated quantitatively via a randomized controlled trial. Results: As of August 2023, qualitative data collection, which started in November 2022, is ongoing, with data analysis of the first qualitative interviews underway to inform platform and implementation design. Recruitment for the quantitative part of this study began in August 2023. Conclusions: Our results aim to inform the ongoing discourse on novel and sustainable pathways to facilitate access to medication for the management of hypertension in resource-constrained settings. Trial Registration: German registry of clinical trials DRKS00030922; https://drks.de/search/en/trial/DRKS00030922 International Registered Report Identifier (IRRID): DERR1-10.2196/46614