Contributors RK, SK and PS were involved in the conceptualisation and proof reading of the submission. RK wrote the submission. RK, SK and PS did the literature review for the submission.

Background: Hypertension is the most important risk factor for cardiovascular disease, a major cause of death and disability globally. There is increasing evidence that demonstrates clinically relevant benefits from self-monitoring and self-management of blood pressure. Evidence suggests a reduction of systolic BP by 3.2 mm/hg through self-monitoring. The use of mHealth applications in health care monitoring and self-management can help in the timely delivery of health information. Around 33% of Indians use mHealth applications in their daily life. However, well-designed, user complied mHealth applications are essential to reach the masses and to be effective. A previously conducted study in India demonstrated that applications are not customized according to users' needs and expectations and lacked usability assessment by patients. Therefore, we aimed to develop and test a novel mHealth application on remote monitoring and self-management in hypertension. Methods: The study will be carried out in three phases. The first phase will be an in-depth interview to identify the required parameters to develop a customized mHealth android-based application to monitor hypertension. The second phase is to develop the customized application through the Agile development design using the android studio platform. In the third phase, a community-based cluster randomized trial will be carried out to assess the effectiveness of the mHealth intervention on the remote monitoring and self-management of people with hypertension. A sample of 236 people from 12 villages will be randomized and the mHealth application will be delivered to the intervention group and the standard regimen will be continued in the control group. Results: In the proposed study if the intervention is found to be helpful, then hypertension patients in the community can be encouraged to install the mHealth application. This application, if found effective can improve the health status, knowledge, and self-care approach among hypertensive patients. Registration: CTR India (CTRI/2022/03/041544).

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Reducing catastrophic out-of-pocket expenditure (OOPE) and increasing the rates of institutional deliveries are part of the Sustainable Development Goals (SDGs). India has made significant progress on the maternal and child health front in recent years. India’s National Health Mission (NHM) has been able to increase rates of institutional deliveries. In the present study, we aim to ascertain district-level patterns of percentage of health insurance coverage in the National Family Health Surveys NFHS 4 and NFHS 5. We also aim to ascertain district-level patterns of out-of-pocket expenditure on C-section deliveries in public health facilities in NFHS 4 and NFHS 5. The present study explores district-level data associated with health insurance coverage (%) and out-of-pocket expenditure in a public health facility (in INR) observed across NFHS 4 and NFHS 5. A spatial analysis was carried out using QGIS 3.26 (Mac version) and GeoDA 1.20.0.8. A visual assessment of the maps across NFHS 4 and NFHS 5 shows improvement in insurance coverage at the district level across the two surveys. Despite an increase in insurance coverage, North East India has experienced an increase in OOPE for C-section deliveries. Rajasthan and various parts of South India have experienced a decrease in OOPE for C-section deliveries. Kerala has experienced a rise in insurance coverage and OOPE for C-section deliveries. Univariate LISA cluster and significance maps revealed that Kerala and Tamil Nadu, the eastern coast of India and parts of Mizoram are hot spots, whereas Jammu and Kashmir and parts of Uttar Pradesh and Gujarat are cold spots. Both these findings are significant. Rajasthan emerges as a significant hot spot along with parts of Assam and a few districts on the eastern coast of India in Tamil Nadu and Andhra Pradesh. Jammu and Kashmir, Ladakh, parts of Uttar Pradesh, Maharashtra, and Karnataka have emerged as significant cold spots. The South Indian states of Kerala and Tamil Nadu are no longer hot spots indicating geospatial variations across time. An increase in the number of hot spots across NFHS 4 and NFHS 5 indicates rising out-of-pocket expenditure for C-sections despite growth in health insurance coverage. The present study does not offer any evidence to suggest that health insurance coverage decreases OOPE on C-section deliveries at government facilities. With RSBY having been launched in 2008 and Ayushman Bharat in 2018, high levels of OOPE on C-section deliveries at government facilities raise serious concerns about the efficacy of PFHIs in reducing OOPE. The government would need to plug the well-documented weaknesses of PFHIs, such as fraud, double charging, poor enrolment, and lack of awareness in addition to the unfortunate phenomena of “tips” and “tie ups” mentioned earlier that plague the public healthcare system, if we are to see any reduction in OOPE in the foreseeable future.

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