Indian health system is characterized by a vast public health infrastructure which lies underutilized, and a largely unregulated private market which caters to greater need for curative treatment. High out-of-pocket (OOP) health expenditures poses barrier to access for healthcare. Among those who get hospitalized, nearly 25% are pushed below poverty line by catastrophic impact of OOP healthcare expenditure. Moreover, healthcare costs are spiraling due to epidemiologic, demographic, and social transition. Hence, the need for risk pooling is imperative. The present article applies economic theories to various possibilities for providing risk pooling mechanism with the objective of ensuring equity, efficiency, and quality care. Asymmetry of information leads to failure of actuarially administered private health insurance (PHI). Large proportion of informal sector labor in India's workforce prevents major upscaling of social health insurance (SHI). Community health insurance schemes are difficult to replicate on a large scale. We strongly recommend institutionalization of tax-funded Universal Health Insurance Scheme (UHIS), with complementary role of PHI. The contextual factors for development of UHIS are favorable. SHI schemes should be merged with UHIS. Benefit package of this scheme should include preventive and in-patient curative care to begin with, and gradually include out-patient care. State-specific priorities should be incorporated in benefit package. Application of such an insurance system besides being essential to the goals of an effective health system provides opportunity to regulate private market, negotiate costs, and plan health services efficiently. Purchaser-provider split provides an opportunity to strengthen public sector by allowing providers to compete.

Background: It is over the last decade that research in this field of domestic violence has led to greater recognition of the issue as public health problem. The paper aims to study the prevalence of physical, psychological, and sexual violence and potential risk factors of the women confronting violence within the home in India. Materials and Methods: A multicentric study with analytical cross-sectional design was applied. It covers 18 states in India with 14,507 women respondents. Multistage sampling and probability proportion to size were done. Results: The result shows that overall 39 per cent of women were abused. Women who have a lower household income, illiterate, belonging to lower caste, and have a partner who drinks/bets, etc. found to be important risk factors and place women in India at a greater risk of experiencing domestic violence. Conclusion: As India has already passed a bill against domestic violence, the present results on robustness of the problem will be useful to sensitize the concerned agencies to strictly implement the law. This may lead to more constructive and sustainable response to domestic violence in India for improvement of women health and wellbeing.

Background: Clinico-epidemiological profile of the Human immunodeficiency virus (HIV) epidemic in India is varied and depends on multitude of factors including geographic location. We analyzed the characteristics of HIV-infected patients attending our Immunodeficiency Clinic to determine any changes in their profile over five years. Settings and Design: A retrospective observational study. Materials and Methods: The study sample included all patients with HIV infection from January 1, 2003 to December 31, 2007. Diagnosis of HIV was made according to National AIDS Control Organization guidelines. Results: Of 3 067 HIV-infected patients, 1 887 (61.5%) were male and 1 180 (38.5%) were female patients. Mean age of patients was 35.1 ± 9.0 years. Majority (91.8%) of patients were in the age group of 15 to 49 years. Progressively increasing proportion of female patients was noted from year 2004 onward. Median CD4 count at presentation in year 2003 was 197/μl (Interquartile range [IQR] = 82.5-373) while in year 2007 it was 186.5/μl (IQR = 86.3-336.8). Mean CD4 count of male patients was 203.7 ± 169.4/μl, significantly lower as compared with female patients, which was 284.8 ± 223.3/μl (P value ≤0.05). Every year, substantial proportions of patients presenting to clinic had CD4 count<200/μl indicating advanced disease. Predominant route of transmission was heterosexual in 2 507 (81.7%) patients. Tuberculosis and oropharyngeal candidiasis were the most common opportunistic infections (OIs). Cryptococcal meningitis was the most common central nervous infection. Our patients had comparatively lower median CD4 counts at the time of presentation with various OIs. Conclusions: Patients had advanced stage of HIV infection at the time of presentation throughout five years. Females presented earlier during the course of HIV infection. There is need for early screening and increasing awareness in healthcare providers to make a diagnosis of HIV much sooner.

Context: HIV/AIDS is known to affect an individual not only physically but also mentally, socially, and financially. It is a syndrome that builds a vacuum in a person affecting his/her life as a whole. Aims: The purpose of the present study is to evaluate the quality of life (QOL) of people living with HIV/AIDS (PLHIV) receiving ART and its association with Body mass index (BMI) and CD4 count. Study Design: An observational study was performed on PLHIV receiving ART in Orissa, India. Materials and Methods: Data on sociodemographic profile, BMI, and CD4 were gathered from 153 HIV-positive subjects. QOL was assessed using WHOQOL-HIV BREF scale. Results: The overall QOL score of the subjects was moderate; PLHIV with lower BMI also had poorer QOL (P<0.05). Employment affected only the social health domain of the subjects. Men reported poorer level of independence and physical health while women reported poorer social relationships and environment. All the six domains correlated significantly with the overall QOL indicated by the G-facet. Conclusion: Attention toward improving the nutritional status of PLHIV should be accorded high priority to ensure improvement in the overall QOL of PLHIV.

Background: We conducted a study to assess the impact of small group teaching (SGT) among students by feedback analysis to identify intricacy so that learning can be facilitated. Materials and Methods: This cross-sectional study was undertaken among 182 MBBS students studying at a teaching hospital at Gangtok. Students were provided with a questionnaire following an assignment on a scheduled topic. Students were asked to provide feedback on the modes of teaching-learning practiced in community medicine with the parameters of evaluation including assessment of presentation by faculty member in reference to relevance, sequencing, depth, interaction, etc., to the overall rating of presentations in different teaching-learning methods. Results: The faculty members were on the positive evaluation by the students in the SGT, which was preferred over "lectures" as the teaching-learning methods. Among SGTs "tutorials" were graded better than "practical," "seminar" and "field posting" on the basis of longer duration at a stretch. Among the parameters for evaluation, relevance, depth, and interaction in regard to scheduled topic of presentations, the rating was significantly higher in SGT than different other teaching-learning methods. Largely the students noted that the time devoted and number of hours/sessions allotted for each topic was adequate. Conclusion: All forms of SGT were on the positive appraisal by the students on their learning experience and were considered as a comprehensive tool for in-depth teacher-student interaction.

Background: Integrated management of neonatal and childhood illness (IMNCI) is already operational in many states of India, but there are very few studies in Indian scenario comparing its validity and reliability with the pediatricians' decisions. Objectives: 1) To compare the IMNCI decision with the decision of pediatricians; 2) to assess the significance of multiple presenting symptoms in the IMNCI algorithm. Materials and Methods : The study was conducted among the sick children between 2 months to 5 years presented in pediatric department from January to March 2009. The IMNCI decision was compared with pediatrician's decisions by percent agreement, Kappa and weighted Kappa with the aids of SPSS version 10. Results: The overall diagnostic agreement between IMNCI algorithm and pediatrician's decisions was 36.64%, (Kappa 0.16 and weighted Kappa 0.29) with 51.15% over diagnosis and 12.21% under diagnosis. The importance given by IMNCI algorithm in cases of multiple presenting symptoms was also reflected as it was evident that 37.50% children presented with three symptoms were categorized as red, whereas it was 28.57% and 11.67% for those presented with two and one symptom, respectively, (P < 0.0001). Pediatricians also gave importance for presence of multiple symptoms by considering 50% as admissible in the group presented with three symptoms, 30.16% in the group presented with two symptoms, and 16.67% in the group presented with only one symptom. The association was also statistically significant (P = 0.018). Conclusion: Diagnostic discordance is seen mainly due to over diagnosis of all fever cases as malaria. Importance of presence of comorbidities was also reflected.

Background: Institutional birth and Emergency Obstetric Care (EmOC) are important strategies of the National Rural Health Mission (NRHM). While the Community Health Center (CHC) is expected to serve EmOC needs in NRHM, the CHCs are hamstrung due to chronic shortage of specialist doctors. Alternative strategies are therefore needed for ensuring EmOC. Objectives: This study aims to estimate the EmOC needs in a private rural hospital from case records and find some useful predictors for caesarian section (C-section) and to assess C-section needs in the context of on-call specialist support. Materials and Methods: We analyzed a two-decade series of 2587 obstetric cases in a private rural hospital for normal deliveries and EmOC including C-section. Results: About 80% of the obstetric cases were normal deliveries. Of the remaining 20% cases that required EmOC, nearly one-third required C-section. In the series, two maternal deaths occurred due to hemorrhage. About 13% case records showed past abortion, which adds to EmOC workload. Primipararous mothers with higher age had a greater incidence (23%) of C-section. The C-section rate shows a steady rise from 3% to above 10% in the series. Conclusions : This rural hospital required C-section in 6.4% cases. This C-section workload was managed with the help of on-call specialists. The local hospital team could manage 93.6% of the cases and abortions with only two maternal deaths. This strategy of an on-call specialist team can be an option for CHCs till resident specialists are adequately available.

Background: On August 6, 2010, in the dark of the midnight, there were flash floods due to cloud burst in Leh in Ladakh region of North India. It rained 14 inches in 2 hours, causing loss of human life and destruction. The civil hospital of Leh was badly damaged and rendered dysfunctional. Search and rescue operations were launched by the Indian Army immediately after the disaster. The injured and the dead were shifted to Army Hospital, Leh, and mass casualty management was started by the army doctors while relief work was mounted by the army and civil administration. Objective: The present study was done to document disaster management strategies and approaches and to assesses the impact of flash floods on human lives, health hazards, and future implications of a natural disaster. Materials and Methods: The approach used was both quantitative as well as qualitative. It included data collection from the primary sources of the district collectorate, interviews with the district civil administration, health officials, and army officials who organized rescue operations, restoration of communication and transport, mass casualty management, and informal discussions with local residents. Results: 234 persons died and over 800 were reported missing. Almost half of the people who died were local residents (49.6%) and foreigners (10.2%). Age-wise analysis of the deaths shows that the majority of deaths were reported in the age group of 25-50 years, accounting for 44.4% of deaths, followed by the 11-25-year age group with 22.2% deaths. The gender analysis showed that 61.5% were males and 38.5% were females. A further analysis showed that more females died in the age groups <10 years and ≥50 years. Conclusions: Disaster preparedness is critical, particularly in natural disasters. The Army's immediate search, rescue, and relief operations and mass casualty management effectively and efficiently mitigated the impact of flash floods, and restored normal life.