In a systematic review and meta-analysis, Kazem Rahimi and colleagues examine the burden of heart failure in low- and middle-income countries. Please see later in the article for the Editors' Summary

Every year about 150,000 people develop end stage kidney disease (ESKD) in India, most of whom die without receiving treatment. In 2008, the state of Andhra Pradesh started public funding for hemodialysis (HD). We evaluated the coverage pattern, cost of care and outcomes of patients treated under this scheme. Unique identifiers and billing codes for HD, vascular access and hospitalisation were identified from claims database to construct utilisation, cost and outcome for subjects from 2008 to 2012. Outcomes were classified as death, dialysis discontinuation and kidney transplantation. Costs of HD, vascular access, and hospitalizations were calculated. A total of 13,118 beneficiaries (1.36% of all claimants, mean age 44 years, 73% males) received HD during the study period. The number of people who received HD increased from 29.5 pmp in 2008-09 to 122.2 pmp in 2012-13. Of all patients, 10% died and 37% dropped out in first 6 months. Median time on HD was 170 and 198 days for females and males respectively (p=0.0059). Mortality increased with age and was higher in women and in public hospitals. The average per patient annual expenditure on HD was US$ 4,820. Costs of HD as a proportion of the total healthcare spend increased from 0.78% in 2008-09 to 5.15% in 2011-12. Progressive increase in uptake confirms a high unmet need for renal replacement therapy. High mortality and dropouts suggest the contribution of factors beyond user fees to outcomes. Insurance coverage does not address all inequities in access and the barriers to maintaining long term dialysis care.

BackgroundUniversal healthcare coverage provides healthcare and financial protection to all citizens and might help to facilitate gender equity in care. We assessed the utilisation of hospital care services among women and men in a large underprivileged population with access to free hospital care in India.MethodsThe Rajiv Aarogyasri Community Health Insurance Scheme, a state-sponsored scheme, provided access to free hospital care for poor households across undivided Andhra Pradesh. Claims data for hospitalisations between 2008 and 2012 were analysed to determine the number of individuals, hospitalisations, bed-days and hospital expenditure for sex-specific and sex-neutral conditions, by sex, disease category and age group.ResultsA total of 961 442 individuals (43% women), 1 223 723 hospitalisations (48% women), 7.7 million bed-days (47% women) and hospital expenditure of US$579.3 million (42% women) were recorded. Sex-specific conditions accounted for 27% of hospitalisations, 12% of bed-days and 15% of costs for women, compared with 5%, 4% and 4% in men. Women had a lower share of hospitalisations (42%), bed-days (45%) and costs (39%) for sex-neutral conditions than men. These findings were observed across 14 of 18 disease categories and across all age groups, but especially for older and younger women.InterpretationIn this large underprivileged population in India with access to free hospital care, utilisation of hospital care differed for women and men. For sex-neutral conditions, women accessed a smaller proportion of care than men, suggesting that coverage of hospital care alone is not sufficient to guarantee gender equity in access to healthcare.

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