Search

Background and objective: On the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences. Methods: We used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca–Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas. Results: Significant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural–urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services. Conclusions: While the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage. [ABSTRACT FROM AUTHOR]

Background: China has made intensive efforts to eliminate extreme poverty by 2020. This paper aims to evaluate the changes in health service needs, utilization, and medical expenses for poor people during the poverty alleviation period. Methods: The study used data from national health services surveys in 2013 and 2018. The poor people were identified and certified by the local government. Health service needs, utilization, medical expenses, and reimbursement rates were analyzed and compared between 2013 and 2018, between the poor and the non-poor groups. Results: People living in poverty were usually elderly, illiterate, and unemployed. The poor people had a significantly higher two-week morbidity rate and a higher prevalence of chorionic non-communicable diseases than the non-poor group. For both the poor and non-poor, health service needs increased between 2013 and 2018. Accordingly, the poor people had more use of outpatient and inpatient services. The annual inpatient admission rates were 20.8% and 13.1% for the poor and non-poor, respectively, in 2018. The average medical expenses per inpatient admission were much lower for the poor than for the non-poor. Out-of-pocket (OOP) payment share decreased from 41.9% to 2013 to 31.9% in 2018 for the poor, while for the non-poor, the OOP rate was much higher (45.4%) and had no significant changes between the two surveys. The reduction in the OOP share occurred mostly in rural areas. Conclusions: Poverty alleviation in China may have positive effect in improving poor people's access to health services, and reducing their financial burden due to illness and health service utilization. [ABSTRACT FROM AUTHOR]

Background: The accessibility and fairness of the floating population's access to basic public health services have an important impact on improving the health level of the whole population. Existing studies have shown that medical insurance and social integration have an impact on basic public health services, but there are few studies on the specific influence path between the three. Therefore, the research purpose of this paper is to explore the effects of medical insurance for urban and rural residents and basic medical insurance for urban employees on the utilization of basic public health services, and to analyze the mediating effect of social integration. Methods: The data in this paper are derived from the 2017 China Mobile Population Dynamic Monitoring Survey data, which collects information on 31 provinces (regions, cities) and Xinjiang Production and Construction Corps mobile population 169,989 people, all of whom come from China's relatively concentrated mobile population inflow areas (NHC FPSCo. 2021. Floating Population Service Center of NHC). After deleting part of the missing data and replacing the mean value, 154,586 people were finally included in the analysis. The proportion is 90.9%. Based on the data of China's floating population dynamic survey in 2017,we used Logistic regression method to analyze the effects of basic medical insurance for urban and rural residents, basic medical insurance for urban employees and social integration on the utilization of basic public health services. Then we used the Bootstrap method of structural equation model to analyze the mediating effect of social integration. Results: Medical insurance for urban and rural residents (β = 0.236;95%CI:1.195 ~ 1.342) has positive impact on health education, it (β = 0,190;95%CI:1.150 ~ 1.272) also has positive impact on the establishment of residents' health records. Social integration (including political participation (β = 0.312;95%CI:1.324 ~ 1.410),activity participation (β = 0.724;95%CI:2.009 ~ 2.119), identity (β = 0.421; 95%CI:1.387 ~ 1.675))has positive impact on health education, it ((β = 0.312;95%CI:1.324 ~ 1.410), (β = 0.404;95%CI:1.463 ~ 1.534), (β = 0.282;95%CI:1.191 ~ 1.477)) also has positive impact on the establishment of residents' health records. In addition, BMIUE (β = 0.169;95%CI:1.150 ~ 1.219) has an impact on the establishment of residents' health records. The direct effect of medical insurance on the utilization of public health services was 0.092 (95%CI: 0.093 ~ 0.103), social integration was a partial mediator, the mediating effect was 0.127 (95%CI: 0.108 ~ 0.127), and the mediating effect size was 57.73%. Conclusions: Medical insurance can directly promote the floating population to use basic public health services, and can indirectly promote the improvement of public health service utilization level through social integration. [ABSTRACT FROM AUTHOR]

As part of its commitment to advance health equity, the World Health Organization (WHO) has a developed area of work to promote and strengthen health inequality monitoring. This includes an emphasis on the collection, analysis and use of disaggregated health data, which are central to evidence-informed decision making. The aim of this paper is to review WHO's work on health inequality monitoring, namely the 2022–27 Inequality monitoring and analysis strategy and corresponding activities, resources and tools. The strategy has three goals pertaining to: strengthening capacity for health inequality monitoring; generating and disseminating the latest evidence on health inequality and supporting data disaggregation; and developing and refining health inequality monitoring methods, resources and best practices. In alignment with these goals, WHO has published reference materials focused on conceptual approaches to health inequality monitoring, which are applied in the global State of Inequality report series. The Health Inequality Monitoring eLearning channel on OpenWHO and capacity building workshops and webinars facilitate the uptake and application of inequality monitoring practices across diverse settings and stakeholders. A key tool available to support the analysis and reporting aspects of health inequality monitoring is the Health Equity Assessment Toolkit (HEAT) application, which allows users to explore data interactively. The Health Inequality Data Repository, a collection of the largest publicly available database of disaggregated data from around the globe, further enables inequality monitoring and analyses. This collection of resources is an important contribution to promote health inequality monitoring across diverse settings. The uptake of evidence from health inequality monitoring remains crucial to the advancement of equity as part of global health and development initiatives. [ABSTRACT FROM AUTHOR]

Background: Language has been well documented to be a key determinant of accessing healthcare. Most of the literature about language barrier in accessing healthcare is in the context of miscommunication. However, it is critical to consider the historical and political contexts and power dynamics underlying actions. The literature in this matter is short. In this paper we aimed to find out how first-language affects access to healthcare for people who do not speak the official language, with a particular focus on language oppression. Methods: We conducted this qualitative study based on patient-reported experiences of the Kurds in Turkey, which is a century-long oppressed population. We conducted 12 in-depth interviews (all ethnically Kurdish, non-Turkish speaking) in Şırnak, Turkey, in 2018–2019 using maximum variation strategy. We used Levesque's 'Patient-Centred Access to Healthcare' framework which addresses individual and structural dimensions to access. Results: We found that Kurds who do not speak the official language face multiple first-language related barriers in accessing healthcare. Poor access to health information, poor patient-provider relationship, delay in seeking health care, dependence on others in accessing healthcare, low adherence to treatments, dissatisfaction with services, and inability to follow health rights were main issues. As an unusual outcome, we discovered that the barrier processes in accessing healthcare are particularly complicated in the context of oppression and its internalization. Internalized oppression, as we found in our study, impairs access to healthcare with creating a sense of reluctance to seek healthcare, and impairs their individual and collective agency to struggle for change. Conclusions: A human-rights-based top-down policy shift, and a bottom-up community empowerment approach is needed. At the system level, official recognition of oppressed populations, acknowledgement of the determinants of their health; and incorporating their language in official capacities (particularly education and healthcare) is crucial. Interventions should include raising awareness among relevant professions and stakeholders that internalized oppression is an issue in accessing healthcare to be considered. Given that internalized oppression can be in other forms than language or ethnicity, future research aimed at examining other aspects of access to healthcare should pay a special attention to internalized oppression. [ABSTRACT FROM AUTHOR]

Background: The use of evidence-based (EB) and evidence-informed (EI) criteria in determining the effectiveness of health interventions has been widely adopted by national and international agencies in their attempt to address health gaps, particularly around Ending the HIV Epidemic (EHE) initiatives. Utilization of these rigorous standards has proven critical in making progress towards achieving EHE goals, yet many communities remain unreached and underserved despite widespread adoption of EB/EI standards in public health research and practice. Although a crucial tool for innovative healthcare delivery, emphasis on the use of EB/EI parameters has created bias within the cycle of knowledge creation that favors well-resourced institutions given their capacity to meet the rigorous evaluation standards required of EB/EI science. This bias can systematically exclude institutions more aligned with community needs, such as community-based organizations and other grass-roots initiatives, which may have long-standing interventions that more effectively engage marginalized groups but do not have the capacity to meet EB/EI standards. Main body: This paper will explore the manifestation of systematic bias and research inequity in the process of identifying and assessing EB/EI HIV care interventions through the lens of a Health Resources and Services Administration funded initiative, coined the Center for Innovation and Engagement, which supports people living with HIV in the United States. An overview of the initiative is provided along with examples of how promising interventions with positive outcomes for members of marginalized communities are excluded in place of interventions that meet traditional standards of scientific rigor but are not novel or particularly innovative. Themes around academic imperialism and power hierarchies will be considered along with key barriers, lessons learned, and recommendations for promoting more equitable EB/EI research practice. Conclusions: It is crucial for entities supporting public health interventions to prioritize equity and inclusion in all stages of funding, design, and implementation. This is particularly true for conditions, such as HIV, that disproportionally impact the most marginalized. This will require approaching EB/EI research with a critical lens towards power and a willingness to dismantle historical dynamics that perpetuate inequities as a way of encouraging truly innovative solutions to support those who need it most. [ABSTRACT FROM AUTHOR]

Background: The security of medical insurance fund is very important to health equity. In China, the expenditure of medical insurance fund has increased sharply year after year, and the balance of local medical insurance fund is difficult to sustain. To realize the equitable distribution of the medical insurance burden, the central government has to continuously increase transfer payments, which causes regional unfairness in the distribution of central financial resources. This paper explores the influence of central transfer payments on the balance of medical insurance fund, influential mechanisms, and the strategic behavior of local governments. Methods: First, we constructed a dynamic game model between central government and local governments and analyzed the mechanism of central transfer payments affecting the balance of local medical insurance fund. Then, based on the provincial panel data of 28 provincial administrative regions in China from 2004 to 2014, an empirical test was made. The spatial regression model was constructed, and the transfer payments obtained by neighboring provinces in the previous year were taken as instrumental variables. Results: Central transfer payments led to strategic behaviors by local governments that resulted in increased local health insurance fund expenditures and lower balance rates. Moreover, the central transfer payments demonstrated "path dependence". Central transfer payments had a significant negative influence on the local NCMS fund balance rate. The local government subsidy and per capita GDP had a significant positive impact on the local NCMS fund balance rate. The obtained transfer payments of local governments had a significant space correlation. This study based on NCMS data remains valid. Conclusions: Central transfer payments induced the strategic behavior of local governments, which neglected to supervise the expenditure of medical insurance fund, reducing the efficiency of medical insurance fund management and use. The financial resources of medical insurance fund are unevenly distributed among provinces. Measures such as strengthening the supervision ability and initiatives of local governments, refining the central transfer payment mechanism, promoting the economic growth of western regions, and increasing rates for individual contributions appropriately can ensure that the medical insurance fund are used well and distributed equitably. [ABSTRACT FROM AUTHOR]

Background: Emergency department crowding is an obstacle in the process of obtaining emergency care services, which will lead to the increase of time cost. Most studies focused on the direct access to emergency medical resources, and few studies took the crowding of hospital emergency department as an evaluation index to reflect the convenience of obtaining emergency medical resources. It is a significance for the identification of areas with insufficient access to emergency service resources with this method. Methods: This paper utilizes the improved potential model and the inverted Two-Step Floating Catchment Area method, combined with network map API service data to evaluate response time, delivery time and waiting time (for emergency department crowding) spent in different residential areas of Xi'an City in the process of emergency. Meanwhile, the vulnerable regions of gaining emergency medical resources are identified through the comprehensive analysis of the three stages of emergency. Results: The studies show that the residents in built-up area are more convenient to get ambulance service and arrive at care hospitals than those in suburban areas, but they may face greater hospital crowdedness. Although suburban residents are faced with low hospital crowdedness, they spend more time on getting ambulances and going to care hospitals. The accessibility of emergency medical resources varies greatly among residents in different regions, with 5.38% of the residents were identified in the high-risk area distributing in suburban residential areas in the south of the city center, 21.92% in the medium risk area in the southern mountainous areas and the periphery of the core suburban areas of the city, and 46.11% in the low-risk area which are mainly distributed in built-up areas in gaining emergency medical services. Conclusions: Obviously, getting an ambulance and arriving at the nearest hospital quickly shows that it is conducive to access to emergency resources. However, the impact of hospital emergency crowding can not be ignored, especially in the area surrounded by high-grade hospitals in the central area of the city. In considering the spatial layout of emergency stations and emergency hospitals, the dislocation distribution of hospitals at different levels should be reasonably adjusted to balance the equity of residents in obtaining emergency medical resources. [ABSTRACT FROM AUTHOR]

Background: Access to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers' access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV). Methods: We used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates. Results: Compared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) while ASR under the EHC model did not differ from ASR with regular access in any of the outcomes. The comparison between EHC and HV model showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). GP and emergency department utilization, unmet needs and avoidable hospitalization did not show significant differences in any of the fully adjusted models. Conclusion: ASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Potential patterns of differences in GP utilization, unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies. [ABSTRACT FROM AUTHOR]

Background: Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context. Methods: Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups. Results: Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018. Conclusions: Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results. [ABSTRACT FROM AUTHOR]

Background: Most existing research on rural–urban health inequalities focuses on disparities in service access and health outcomes based on region. This paper examines rural–urban disparities in maternal healthcare utilization and delivery modes based on household registration (hukou) status to understand the role of state institutions in producing healthcare disparities in China. Methods: Utilizing administrative data from the Public Maternal Health Insurance scheme, we analyzed 54,733 live births in City A (2015–2019) and 25,849 live births in City B (2018–2019) in Guangdong Province in China. We constructed regression models using hukou status (rural versus urban) as the explanatory variable. Results: While there is no statistically significant difference in rural and urban mothers' probability of obtaining the minimum recommended number of prenatal care checkups in City A (OR = 0.990 [0.950, 1.032]), mothers with rural hukou status have a lower probability of obtaining the minimum recommended number of visits in City B than their counterparts with urban hukou (OR = 0.781 [0.740, 0.825]). The probability of delivering in tertiary hospital is lower among mothers with rural hukou than among those with urban hukou in both cities (City A: OR = 0.734 [0.701, 0.769]; City B: OR = 0.336 [0.319, 0.354]). Mothers with rural hukou are more likely to have a Cesarean section than those with urban hukou in both cities (City A: OR = 1.065 [1.027, 1.104]; City B: OR = 1.127 [1.069, 1.189]). Compared with mothers with urban hukou, mothers with rural hukou incurred 4 % (95 % CI [-0.046, -0.033]) and 9.4 % (95 % CI [-0.120, -0.068]) less in total medical costs for those who delivered via Cesarean section and 7.8 % (95 % CI [-0.085, -0.071]) and 19.9 % (95 % CI [-0.221, -0.177]) less for those who delivered via natural delivery in City A and City B, respectively. Conclusions: Rural hukou status is associated with younger age, no difference or lower probability of having a minimum number of prenatal checkups, higher likelihood of delivering in nontertiary hospitals, increased Cesarean delivery rates, and lower medical cost for delivery in these two Chinese cities. Evaluating how hukou status influences maternal healthcare in Chinese cities is important for devising targeted public policies to promote more equitable maternal health services. [ABSTRACT FROM AUTHOR]

Background: Health outcomes in India are characterized by pervasive inequities due to deeply entrenched socio-economic gradients amongst the population. Therefore, it is imperative to investigate these systematic disparities in health, however, evidence of inequities does not commensurate with its policy objectives in India. Thus, our paper aims to examine the magnitude of and trends in horizontal inequities in self-reported morbidity and untreated morbidity in India over the period of 2004 to 2017–18. Methods: The study used cross-sectional data from nationwide healthcare surveys conducted in 2004, 2014 and 2017–18 encompassing sample size of 3,85,055; 3,35,499 and 5,57,887 individuals respectively. Erreygers concentration indices were employed to discern the magnitude and trend in horizontal inequities in self-reported morbidity and untreated morbidity. Need standardized concentration indices were further used to unravel the inter-regional and intra-regional income related inequities in outcomes of interest. Additionally, regression based decomposition approach was applied to ascertain the contributions of both legitimate and illegitimate factors in the measured inequalities. Results: Estimates were indicative of profound inequities in self-reported morbidity as inequity indices were positive and significant for all study years, connoting better-off reporting more morbidity, given their needs. These inequities however, declined marginally from 2004(HI: 0.049, p< 0.01) to 2017–18(HI: 0.045, P< 0.01). Untreated morbidity exhibited pro-poor inequities with negative concentration indices. Albeit, significant reduction in horizontal inequity was found from 2004(HI= − 0.103, p< 0.01) to 2017–18(HI = − 0.048, p< 0.01) in treatment seeking over the years. The largest contribution of inequality for both outcomes stemmed from illegitimate variables in all the study years. Our findings also elucidated inter-state heterogeneities in inequities with high-income states like Andhra Pradesh, Kerala and West Bengal evincing inequities greater than all India estimates and Northeastern states divulged equity in reporting morbidity. Inequities in untreated morbidity converged for most states except in Punjab, Chhattisgarh and Himachal Pradesh where widening of inequities were observed from 2004 to 2017–18. Conclusions: Pro-rich and pro-poor inequities in reported and untreated morbidities respectively persisted from 2004 to 2017–18 despite reforms in Indian healthcare. Magnitude of these inequities declined marginally over the years. Health policy in India should strive for targeted interventions closing inequity gap. [ABSTRACT FROM AUTHOR]

Background: Following the 2008 economic crisis many countries implemented austerity policies, including reducing public spending on health services. This paper evaluates the trends and equity in the use of health services during and after that period in Spain – a country with austerity policies – and in Germany – a country without restriction on healthcare spending. Methods: Data from several National Surveys in Spain and several waves of the Socio-Economic Panel in Germany, carried out between 2009 and 2017, were used. The dependent variables were number of doctor's consultations and whether or not a hospital admission occurred. The measure of socioeconomic position was education. In each year, the estimates were made for people with and without pre-existing health problems. First, the average number of doctor's consultations and the percentage of respondents who had had been hospitalized were calculated. Second, the relationship between education and use of those health services was estimated by calculating the difference in consultations using covariance analysis – in the case of number of consultations – and by calculating the percentage ratio using binomial regression – in the case of hospitalization. Results: The annual mean number of consultations went down in both countries. In Spain the average was 14.2 in 2009 and 10.4 in 2017 for patients with chronic conditions; 16.6 and 13.5 for those with a mental illness; and 6.4 and 5.9 for those without a defined illness. In Germany, the averages were 13.8 (2009) and 12.9 (2017) for the chronic group; 21.1 and 17.0 for mental illness; and 8.7 and 7.5 with no defined illness. The hospitalization frequency also decreased in both countries. The majority of the analyses presented no significant differences in relation to education. Conclusion: In both Spain and Germany, service use decreased between 2009 and 2017. In the first few years, this reduction coincided with a period of austerity in Spain. In general, we did not find socioeconomic differences in health service use. [ABSTRACT FROM AUTHOR]

Background: China issued strict nationwide guidelines to combat the COVID-19 outbreak in January 2020 and gradually loosened the restrictions on movement in early March. Little is known about how these disease control measures affected the 600 million people who live in rural China. The goal of this paper is to document the quarantine measures implemented in rural China outside the epicenter of Hubei Province and to assess the socioeconomic effect of the measures on rural communities over time. Methods: We conducted three rounds of interviews with informants from 726 villages in seven provinces, accounting for over 25% of China's overall rural population. The survey collected data on rural quarantine implementation; COVID-19 infections and deaths in the survey villages; and effects of the quarantine on employment, income, education, health care, and government policies to address any negative impacts. The empirical findings of the work established that strict quarantine measures were implemented in rural villages throughout China in February. Results: There was little spread of COVID-19 in rural communities: an infection rate of 0.001% and zero deaths reported in our sample. However, there were negative social and economic outcomes, including high rates of unemployment, falling household income, rising prices, and disrupted student learning. Health care was generally accessible, but many delayed their non-COVID-19 health care due to the quarantine measures. Only 20% of villagers received any form of local government aid, and only 11% of villages received financial subsidies. There were no reports of national government aid programs that targeted rural villagers in the sample areas. Conclusions: By examining the economic and social effects of the COVID-19 restrictions in rural communities, this study will help to guide other middle- and low-income countries in their containment and restorative processes. Without consideration for economically vulnerable populations, economic hardships and poverty will likely continue to have a negative impact on the most susceptible communities. [ABSTRACT FROM AUTHOR]

Introduction: This paper aimed at estimating the resources required to implement a community Score Card by a typical rural district health team in Uganda, as a mechanism for fostering accountability, utilization and quality of maternal and child healthcare service. Methods: This costing analysis was done from the payer's perspective using the ingredients approach over five quarterly rounds of scoring between 2017 and 2018. Expenditure data was obtained from project records, entered and analyzed in Microsoft excel. Two scale-up scenarios, scenario one (considered cost inputs by the MakSPH research teams) and scenario two (considering cost inputs based on contextual knowledge from district implementing teams), were simulated to better understand the cost implications of integrating the Community Score Card (CSC) into a district health system. Results: The total and average cost of implementing CSC for five quarterly rounds over a period of 18 months were USD 59,962 and USD 11,992 per round of scoring, respectively. Considering the six sub-counties (including one Town Council) in Kibuku district that were included in this analysis, the average cost of implementating the CSC in each sub-county was USD 1998 per scoring round. Scaling-up of the intervention across the entire district (included 22 sub-counties) under the first scenario would cost a total of USD 19,003 per scoring round. Under the second scaleup scenario, the cost would be lower at USD 7116. The total annual cost of scaling CSC in the entire district would be USD 76,012 under scenario one compared to USD 28,465 under scenario two. The main cost drivers identified were transportation costs, coordination and supervision costs, and technical support to supplement local implementers. Conclusion: Our analysis suggests that it is financially feasible to implement and scale-up the CSC initiative, as an accountability tool for enhancing service delivery. However, the CSC design and approach needs to be embedded within local systems and implemented in collaboration with existing stakeholders so as to optimise costs. A comprehensive economic analysis of the costs associated with transportation, involvement of the district teams in coordination, supervision as well as provision of technical support is necessary to determine the cost-effectiveness of the CSC approach. [ABSTRACT FROM AUTHOR]

Background: The National Health Mission (NHM), the largest ever publicly funded health programme worldwide, used over half of the national health budget in India and primarily aimed to improve maternal and child health in the country. Though large scale public health investment has improved the health care utilization and health outcomes across states and socio-economic groups in India, little is known on the equity concern of NHM. In this context, this paper examines the utilization pattern and net benefit of public subsidy for institutional delivery by the level of care in India. Methods: Data from the most recent round of the National Family Health Survey (NFHS 4), conducted during 2015–16, was used in the study. A total of 148,645 last birth delivered in a health centre during the 5 years preceding the survey were used for the analyses. Out-of-pocket (OOP) payment on delivery care was taken as the dependent variable and was analysed by primary care and secondary level of care. Benefits Incidence Analysis (BIA), descriptive statistics, concentration index (CI), and concentration curve (CC) were used to do the analysis. Results: Institutional delivery from the public health centres in India is pro-poor and has a strong economic gradient. However, about 28% mothers from richest wealth quintile did not pay for delivery in public health centres compared to 16% among the poorest wealth quintile. Benefit incidence analyses suggests a pro-poor distribution of institutional delivery both at primary and secondary level of care. In 2015–16, at the primary level, about 32.29% of subsidies were used by the poorest, 27.22% by poorer, 20.39% by middle, 13.36% by richer and 6.73% by the richest wealth quintile. The pattern at the secondary level was similar, though the magnitude was lower. The concentration index of institutional delivery in public health centres was − 0.161 [95% CI, − 0.158, − 0.165] compared to 0.296 [95% CI, 0.289, 0.303] from private health centres. Conclusion: Provision and use of public subsidy for institutional delivery in public health centres is pro-poor in India. Improving the quality of service in primary health centres is recommended to increase utilisation and reduce OOP payment for health care in India. [ABSTRACT FROM AUTHOR]

Background: Most studies on health disparities deal with the occurrence of disease, but little is known about inequalities in the utilization of mental health services. This paper examines social inequalities in the utilization of outpatient psychotherapy within a health care system where there are low financial barriers to health care and a lack of specific health policies to address access to psychotherapeutic services. Methods: Registry data of German statutory health insurance for the year 2013 were used (total population: N = 746,963; 10,711 women and men with psychotherapy). Logistic regression analyses were performed to estimate the effects of three socio-economic (SES) indicators on the utilization of psychotherapy. Results: Utilization of psychotherapy by SES status did not correspond to the social structure of the insured population. Social disparities that disadvantaged less privileged women and men were found; this applied to education, income and occupational position. The most pronounced differences were found for education. In contrast, effects of income were rather small. These findings must be interpreted against the backdrop of the absence of financial barriers to outpatient psychotherapy in Germany. Conclusions: A marked degree of psychotherapy under-utilization was found for lower SES groups. Psychotherapists should pay increased attention to clients with lower socio-economic position. Enhancing mental health literacy, as well as reducing the stigma of mental illness, is crucial for increasing the usage of psychotherapeutic services of those who need it most. Relevant health policy is needed to reduce the barriers to, and consequently increase psychotherapy utilization. [ABSTRACT FROM AUTHOR]

Background: The objective of this paper is to analyse whether the recent recession has altered health care utilisation patterns of different income groups in Spain. Methods: Based on information concerning individuals 'income and health care use, along with health need indicators and demographic characteristics (provided by the Spanish National Health Surveys from 2006/07 and 2011/12), econometric models are estimated in two parts (mixed logistic regressions and truncated negative binominal regressions) for each of the public health services studied (family doctor appointments, appointments with specialists, hospitalisations, emergencies and prescription drug use). Results: The results show that the principle of universal access to public health provision does not in fact prevent a financial crisis from affecting certain income groups more than others in their utilisation of public health services. Conclusions: Specifically, in relative terms the recession has been more detrimental to low-income groups in the cases of specialist appointments and hospitalisations, whereas it has worked to their advantage in the cases of emergency services and family doctor appointments. [ABSTRACT FROM AUTHOR]

Background: Inequalities in demographic, socio-economic and health status for China labor force place them at greater health risks, and marginalized them in the utilization of healthcare services. This paper identifies the inequalities which limit the utilization of health services among China labor force, and provides a reference point for health policy. Methods: Data were collected from 23,505 participants aged 15 to 65, from the 2014 China Labor Force Dynamic Survey (a nationwide cross-sectional survey covering 29 provinces with a multi-stage cluster, and stratified, probability sampling strategy) conducted by Sun Yat-sen University. Logistic regression models were used to study the effects of demographic (age, gender, marital status, type of hukou and migration status), socio-economic (education, social class and insurance) and health status (self-perceived general health and several chronic illnesses) variables on the utilization of health services (two-week visiting and hospitalization during the past 12 months). Goodness of fit was assessed using Hosmer-Lemeshow test. Discrimination ability was assessed based on the area under the receiver operating curve (AUC). Results: Migrants with more than 1 (OR 2.80, 95% CI 1.01 ~ 7.82) or none chronic illnesses (OR 1.26, 95% CI 1.01 ~ 7.82) are more likely to be two week visiting to the clinic than non-migrants; migrants with none chronic illnesses (OR 0.61, 95% CI 0.45 ~ 0.82) are less likely to be in hospitalization during the past 12 months than non-migrants. Female, elder, hukou of non-agriculture, higher education level, higher social class, purchasing more insurance and poorer selfperceived health were predictors for more utilization of health service. More insurance benefited more two-week visiting (OR 1.12, 95% CI 1.06 ~ 1.17) and hospitalization during the past 12 months (OR 1.12, 95% CI 1.07 ~ 1.18) for individuals with none chronic illness but not ≥1 chronic illnesses. All models achieved good calibration (Hosmer-Lemeshow test's P range of 0.258-0.987) and discrimination (AUC range of 0.626-0.725). Conclusions: This study has shown that there are inequalities of demographic, socio-economic and health status in the utilization of health services for China labor force. Prudent health policy with equitable utilization of health services eliminating mentioned inequalities should be a priority in shaping China's healthcare system reform. [ABSTRACT FROM AUTHOR]

Background: China has since the beginning of this millennium engaged in substantial Universal Health Coverage (UHC) reforms. This paper adds evidence on how equity in level of health service utilization changed after UHC reforms. Methods: Our study was based on household survey data from 30 counties in Sichuan province in 2004 and 2011. We introduce an unusual outcome variable, namely level of healthcare utilization. Concentration index (CI) was used to measure income based inequality in level of healthcare utilization. Horizontal index (HI) was used to assess whether inequalities are inequitable. We decomposed the concentration index to measure the factors contributing to inequality in level of utilization. Oaxaca type decomposition was applied to control whether identified changes were attributable to changed inequality or to other factors. Results: Pro-rich inequity in level of healthcare utilization increased after UHC reforms. Overall, a higher proportion of users sought services at county hospitals or higher in 2011 compared with 2004. Richer users were considerably more likely than the poor to seek care at hospitals rather than at clinics or health centers, and the pro-rich inequality in level of healthcare utilization was highly inequitable. Insurance enrollment became the main driver of pro-rich inequity in level of healthcare utilization after reforms, while health needs became less important for determining level of care, all disfavoring low income groups. Conclusions: Assessments of equity should pay attention to inequalities in level of healthcare utilization. Our results indicate that in China, wide insurance coverage is insufficient to ensure equity in level of healthcare utilization. On the contrary, type of insurance enrollment has become a main driver of inequity in level of utilization. Hence, equalizing health insurance schemes would be of crucial importance in order to improve health equity in China. Moreover, UHC reforms should strengthen the primary sector and limit non-needs based use of high-level hospitals in order to promote equitable use of healthcare services. [ABSTRACT FROM AUTHOR]

Background: The inequity of healthcare utilization in rural China is serious, and the urban-rural segmentation of the medical insurance system intensifies this problem. To guarantee that the rural population enjoys the same medical insurance benefits, China began to establish Urban and Rural Resident Basic Medical Insurance (URRBMI) nationwide in 2016. Against this backdrop, this paper aims to compare the healthcare utilization inequity between URRBMI and New Cooperative Medical Schemes (NCMS) and to analyze whether the inequity is reduced under URRBMI in rural China. Methods: Using the data from a national representative survey, the China Health and Retirement Longitudinal Study (CHARLS), which was conducted in 2015, a binary logistic regression model was applied to analyze the influence of income on healthcare utilization, and the decomposition of the concentration index was adopted to compare the Horizontal inequity index (HI index) of healthcare utilization among the individuals insured by URRBMI and NCMS. Results: There is no statistically significant difference in healthcare utilization between URRBMI and NCMS, but in outpatient utilization, there are significant differences among different income groups in NCMS; high-income groups utilize more outpatient care. The Horizontal inequity indexes (HI indexes) in outpatient utilization for individuals insured by URRBMI and NCMS are 0.024 and 0.012, respectively, indicating a pro-rich inequity. Meanwhile, the HI indexes in inpatient utilization under the two groups are − 0.043 and − 0.028, respectively, meaning a pro-poor inequity. For both the outpatient and inpatient care, the inequity degree of URRBMI is larger than that of NCMS. Conclusions: This paper shows that inequity still exists in rural areas after the integration of urban-rural medical insurance schemes, and there is still a certain gap between the actual and the expected goal of URRBMI. Specifically, compared to NCMS, the pro-rich inequity in outpatient care and the pro-poor inequity in inpatient care are more serious in URRBMI. More chronic diseases should be covered and moral hazard should be avoided in URRBMI. For the vulnerable groups, special policies such as reducing the deductible and covering these groups with catastrophic medical insurance could be considered. [ABSTRACT FROM AUTHOR]

Objective: By analyzing the gap of hospitalization service among floating population covered by different medical insurance in Jiangsu Province, this paper aimed to understand the current situation of hospitalized health service utilization (HHSU) among floating population, and to provide policy suggestions for improving HHSU of floating population with different health insurance. Methods: The data of this study were obtained from "the National Dynamic Monitoring Survey of Floating Population in 2014". A total of 12,000 samples of floating population in Jiangsu Province were selected. 57.15% for men and 42.85% for women; 46.95% for those under 30 years old, 39.67% for 30 to 45 years old, 13.38% for over the age of forty-five. Using descriptive statistical analysis, chi-square test, exploratory factor analysis, logistic regression and stepwise multiple linear regression, the paper analyzed the difference of HHSU of floating population with different medical insurance in 2014. This study divided basic medical insurance into 3 categories: MIUE (Medical Insurance of Urban Employee), other medical insurances (including new rural cooperative medical system and the medical insurance for urban residents) and no medical insurance. Results: The hospitalization rate of floating population with MIUE (89.95%) was higher than the rate of floating population with other medical insurances (74.76%) and the gap is 15.19%. It was also higher than the rate of floating population with no medical insurance (67.57%) and the gap is 22.38%. (chi-square = 24.958, p = 0.000). 15.34% of floating population with MIUE spent more than 1600 dollars during hospitalization. It was lower than floating population with other medical insurances (16.19%) and no medical insurance (21.62%). The gaps respectively were 0.85 and 6.28% (chi-square = 10.000, p = 0.040). There existed significant differences among hospitalization medical expenses that floating population with different basic medical insurances spent. (chi-square = 225.206, p = 0.000) The type of basic medical insurance had statistical significance on whether the patients were hospitalized (p = 0.003) and whether they were hospitalized (p = 0.014). Logistic regression analysis results showed that "Social structure" (Education, Hukou, Insurance status and Work status) were significantly associated with Should be hospitalized but not and "Education" were significantly associated with Inpatient facilities selection. The stepwise multiple linear regression results presented that "Demography" and "Floating area" influenced In-hospital medical cost and "Social structure" and "Gender" influenced Reimbursement of in-hospital medical cost. Conclusion: Medical insurance type affects the hospitalization health service utilization of floating population, including Should be hospitalized but not and Reimbursement of in-hospital medical cost. [ABSTRACT FROM AUTHOR]

Background: Although health strategies and policies have addressed equitable distribution of health care in Mongolia, few studies have been conducted on this topic. Rapid socio-economic changes have recently occurred; however, there is no evidence as to how horizontal inequity has changed. The aim of this paper is to evaluate income related-inequalities in health care utilizations and their changes between 2007/2008 and 2012 in Mongolia. Methods: The data used in this study was taken from the nationwide cross-sectional data sets, the Household Socio-Economic Survey, collected in 2007/2008 and 2012 by the National Statistical Office of Mongolia. We employed the Erreygers' concentration index to measure inequality in health service utilization. Horizontal inequity was estimated by a difference between actual and predicted use of health services using the indirect standardization method. Results: The results show that the concentration indices for tertiary level, private outpatient and inpatient services were significantly positive, the contrary for family group practice/soum hospital outpatient services, in both years. After controlling for need, pro-rich inequity (p < 0.01) was observed in the tertiary level, private outpatient, and general inpatient, services in both years. Pro-poor inequity (p < 0.01) existed in family group practice/soum hospital outpatient services in both years. Degrees of inequity in tertiary level hospital and private hospital outpatient services became more pro-rich, whereas in family group practice/soum hospital outpatient services became more pro-poor from 2007/2008 to 2012. Pro-rich inequity in inpatient services remained the same from 2007/2008 to 2012. Conclusions: Equitable distribution of health care has been well documented in health strategies and policies; however, the degree of inequity in delivery of health services has a tendency to increase in Mongolia. Therefore, there is a need to consider implementation issues of the strategies and refocus on policy prioritizations. It is necessary to strengthen primary health care services, particularly by diminishing obstacles for lower income and higher need groups. [ABSTRACT FROM AUTHOR]

Introduction: This paper assesses both patients' perspectives on the differences in primary care quality between traditional Tibetan medicine (TTM) hospitals and western medicine (WM) hospitals and the efficacy of the government's investment in these two Prefecture-level primary care structures in Tibet. Method: A validated Tibetan version of the Primary Care Assessment Tool (PCAT-T) was used to collect data on 692 patients aged over 18 years old, who reported the sampling site was their regular source of health care. T-tests were performed to compare the separate and total primary care attributes between WM hospitals and TTM hospitals. Multiple linear regression analysis was conducted to examine the association of the health care setting with primary care attributes while controlling for socio-demographic, health service use and health status characteristics. Results: Compared to WM hospitals, the results showed that TTM hospitals had patients who were older (15.8 % versus 8.4 % over 60 years); with lower education levels (66.0 % versus 35.8 % with below junior high school ) and income levels (46.9 % versus 26.5 % with annual household income below 30,000RMB); more likely to be married (79.2 % versus 60.5 %); made less frequent health care visits; and had higher self-rated health status. Overall, patients assessed the primary care performance in TTM hospitals significantly higher (80.0) than WM hospitals (74.63). There were no differences in health care assessment by patient gender, age, income, education, marital status and occupation. Conclusions: TTM patients reported better primary care experiences than patients using WM hospitals, which validated the government's investment in traditional Tibetan medicine. [ABSTRACT FROM AUTHOR]

Background: Older persons report poor health status and greater need for healthcare. However, there is limited research on older persons' healthcare disparities in Uganda. Therefore, this paper aimed at investigating factors associated with older persons' healthcare access in Uganda, using a nationally representative sample. Methods: We conducted secondary analysis of data from a sample of 1602 older persons who reported being sick in the last 30 days preceding the Uganda National Household Survey. We used frequency distributions for descriptive data analysis and chi-square tests to identify initial associations. We fit generalized linear models (GLM) with the poisson family and the log link function, to obtain incidence risk ratios (RR) of accessing healthcare in the last 30 days, by older persons in Uganda. Results: More than three quarters (76%) of the older persons accessed healthcare in the last 30 days. Access to healthcare in the last 30 days was reduced for older persons from poor households (RR = 0.91, 95% CI: 0.83-0.99); with some walking difficulty (RR = 0.90, 95% CI: 0.83-0.97); or with a lot of walking difficulty (RR = 0.84, 95% CI: 0.75-0.95). Conversely, accessing healthcare in the last 30 days for older persons increased for those who earned wages (RR = 1.08, 95% CI: 1.00-1.15) and missed work due to illness for 1-7 days (RR =1.19, 95% CI: 1.10-1.30); and 8-14 days (RR = 1.19, 95% CI: 1.07-1.31). In addition, those who reported non-communicable diseases (NCDs) such as heart disease, hypertension or diabetes (RR= 1.09, 95% CI: 1.01-1.16); were more likely to access healthcare during the last 30 days. Conclusion: In the Ugandan context, health need factors (self-reported NCDs, severity of illness and mobility imitations) and enabling factors (household wealth status and earning wages in particular) were the most important determinants of accessing healthcare in the last 30 days among older persons. [ABSTRACT FROM AUTHOR]

Introduction Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health - a difference in health - is inequitable. Empirically operationalizing definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question - whether unexplained health inequality is unfair - determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity. Methods We use the American sample of the 2002-03 Joint Canada/United States Survey of Health and measure health by the Health Utilities Index (HUI). We model variation in the observed HUI by demographic, socioeconomic, health behaviour, and health care variables using Ordinary Least Squares. We estimate unfair HUI by standardizing fairness, removing the fair component from the observed HUI. We consider health inequality due to factors amenable to policy intervention as unfair. We contrast estimates of inequity using two fairness- standardization methods: direct (considering unexplained inequality as ethically acceptable) and indirect (considering unexplained inequality as unfair). We use the Gini coefficient to quantify inequity. Results Our analysis shows that about 75% of the variation in the observed HUI is unexplained by the model. The direct standardization results in a smaller inequity estimate (about 60% of health inequality is inequitable) than the indirect standardization (almost all inequality is inequitable). Conclusions The choice of the fairness-standardization method is ethical and influences the empirical health inequity results considerably. More debate and analysis is necessary regarding which treatment of the unexplained inequality has the stronger foundation in equity considerations. [ABSTRACT FROM AUTHOR]

Introduction In Hong Kong, migrants arriving from Mainland China often have multiple roles and responsibilities while adapting to new lives in their host destination. This paper explored the factors that contribute to the inequity in health services utilisation experienced by these migrants; and, identified the elements that could constitute an effective health delivery model to address the service gap. Methods Site visits and a focus group discussion (n = 13) were held with both public and private health providers before a number of innovative health delivery models were formulated. They were then circulated among the panel in two further rounds of Delphi survey (n = 11) from March- April 2012 to systematically collect opinions and select the most endorsed health service models to serve this target population. Results Focus group members perceived that most migrants were unaware of, or even ignored, their own physical and mental health needs, and had low utilisation of healthcare services, because of their pre-occupation with daily chores and hardship as well as differing health values, practices and expectations. They further identified that the structural issues such as the healthcare setting or the operation of current service provisions had failed to meet migrants' health needs. Consequently, four new service models that incorporated professional advice and empowerment, which were identified as the two most important elements, were put forward. Thus, the model of having a nurse with social work training, supported by volunteer groups, was selected as the best option to familiarise and empower patients within the labyrinth of local healthcare services. Conclusion Implementation of a social empowerment model by way of targeted support and specific health information is recommended. Further evaluation of this model is needed to understand its effectiveness for improving health literacy and health status in this disadvantaged group in the long term. [ABSTRACT FROM AUTHOR]

Background: Several studies have demonstrated that self-rated health status is affected by socioeconomic variables. However, there is little knowledge about whether perceived economic resources affect people's health. The purpose of this study is to examine the relationship between self-rated health status and different measures of income. Specifically, the effect of both objective income and perceived economic resources are estimated for a very large sample of households in Italy. By estimating this relationship, this paper aims at filling the previously mentioned gap. Methods: The data used are from the 2015 European Health Interview Survey and were collected using information from approximately 16,000 households in 562 Italian municipalities. Ordinary and generalized ordered probit models were used in estimating the effects of a set of covariates, among others measures of income, on the self-rated health status. Results: The results suggest that the subjective income, measured by the perceived economic resources, affects the probability of reporting a higher self-rate health status more than objective income. The results also indicate that other variables, such as age, educational level, presence/absence of chronic disease, and employment status, affect self-rated health more significantly than objective income. It is also found that males report more frequently higher rating than females. Conclusions: Our analysis demonstrates that perceived income affects significantly self-rated health. While self-perceived economic resources have been used to assess economic well-being and satisfaction, they can also be used to assess stress levels and related health outcomes. Our findings suggest that low subjective income adversely affects subjective health. Therefore, it is important to distinguish between effects of income and individuals' perceptions of their economic resources or overall financial situation on their health. From a gender perspective, our results show that females are less likely to have high rating than males. However, as females perceive an improved economic situation, on the margin, the likelihood of a higher self-rated health increases compared to males. [ABSTRACT FROM AUTHOR]

Introduction: The community score card (CSC) is a participatory monitoring and evaluation tool that has been employed to strengthen the mutual accountability of health system and community actors. In this paper we describe the influence of the CSC on selected maternal and newborn service delivery and utilization indicators. Methods: This was a mixed methods study that used both quantitative and qualitative data collection methods. It was implemented in five sub-counties and one town council in Kibuku district in Uganda. Data was collected through 17 key informant interviews and 10 focus group discussions as well as CSC scoring and stakeholder meeting reports. The repeated measures ANOVA test was used to test for statistical significance. Qualitative data was analyzed manually using content analysis. The analysis about the change pathways was guided by the Wild and Harris dimensions of change framework. Results: There was an overall improvement in the common indicators across sub-counties in the project area between the 1st and 5th round scores. Almost all the red scores had changed to green or yellow by round five except for availability of drugs and mothers attending Antenatal care (ANC) in the first trimester. There were statistically significant differences in mean scores for men escorting their wives for ante natal care (ANC) (F(4,20) = 5.45, P = 0.01), availability of midwives (F(4,16) =5.77, P < 0.01), availability of delivery beds (F(4,12) =9.00, P < 0.01) and mothers delivering from traditional birth attendants (TBAs), F(4,16) = 3.86, p = 0.02). The qualitative findings suggest that strengthening of citizens' demand, availability of resources through collaborative problem solving, increased awareness about targeted maternal health services and increased top down performance pressure contributed to positive changes as perceived by community members and their leaders. Conclusions and recommendations: The community score cards created opportunities for community leaders and communities to work together to identify innovative ways of dealing with the health service delivery and utilization challenges that they face. Local leaders should encourage the availability of safe spaces for dialogue between communities, health workers and leaders where performance and utilization challenges can be identified and solutions proposed and implemented jointly. [ABSTRACT FROM AUTHOR]

Introduction: In Africa, a majority of women bring their infant to health services for immunization, but few are checked in the postpartum (PP) period. The Missed opportunities for maternal and infant health (MOMI) EU-funded project has implemented a package of interventions at community and facility levels to uptake maternal and infant postpartum care (PPC). One of these interventions is the integration of maternal PPC in child clinics and infant immunization services, which proved to be successful for improving maternal and infant PPC. Aim: Taking stock of the progress achieved in terms of PPC with the implementation of the interventions, this paper assesses the economic cost of maternal PPC services, for health services and households, before and after the project start in Kaya health district (Burkina Faso). Methods: PPC costs to health services are estimated using secondary data on personnel and infrastructure and primary data on time allocation. Data from two household surveys collected before and after one year intervention among mothers within one year PP are used to estimate the household cost of maternal PPC visits. We also compare PPC costs for households and health services with or without integration. We focus on the costs of the PPC intervention at days 6–10 that was most successful. Results: The average unit cost of health services for days 6–10 maternal PPC decreased from 4.6 USD before the intervention in 2013 (Jan-June) to 3.5 USD after the intervention implementation in 2014. Maternal PPC utilization increased with the implementation of the interventions but so did days 6–10 household mean costs. Similarly, the household costs increased with the integration of maternal PPC to BCG immunization. Conclusion: In the context of growing reproductive health expenditures from many funding sources in Burkina Faso, the uptake of maternal PPC led to a cost reduction, as shown for days 6–10, at health services level. Further research should determine whether the increase in costs for households would be deterrent to the use of integrated maternal and infant PPC. [ABSTRACT FROM AUTHOR]

The author talks about challenge of health inequality in Brazil and progress made in the same field. Topics discussed include a paper showing non-communicable diseases as more common in people of lower social position, implementation of the Brazilian Unified Health System that has eliminated inequalities and need of development of systems to monitor health inequalities and social determinants.

Background: The Chinese government has now achieved universal coverage of medical insurance through two systems: the Basic Medical Insurance System for Urban Employees (BMISUE) and the Basic Medical Insurance System for Urban and Rural Residents (BMISURR). This paper aims to identify the impact of China's current medical insurance system on equity in the use of health services by the floating elderly population from two aspects: institutional differences and geographical disparity. Methods: The data used in the study are from the China Migrants Dynamic Survey (CMDS) conducted by the National Health and Wellness Council of China. This study uses the Logit model to estimate the impact of the medical insurance system on the utilization of health services and the Propensity Score Matching (PSM) method to further test the robustness of the results. Results: The study found that the type of medical insurance does not affect health services utilization by the floating elderly population in China. However, for those participating in the same medical insurance, participation in different regions will significantly affect the use of health service resources. For the BMISURR, when the place of the insurance is the same as the place of residence, the proportion of the floating elderly population that will see a doctor when they are sick will increase by 4.80%. For the BMISUE, when the place of the insurance is the same as the place of residence, the proportion of the floating elderly population that will see a doctor when they are sick will increase by 10.30%. Conclusions: The difference between the place of insurance and the place of residence results in the unbalanced utilization of health services by the floating elderly population participating in the same medical insurance system. [ABSTRACT FROM AUTHOR]

Background: Ensuring equitable access to medical care with financial risk protection has been at the center of achieving universal health coverage. In this paper, we assess the levels and trends of inequalities in medical care utilization and household catastrophic health spending (HCHS) at the national and sub-national levels in Rwanda. Methods: Using the Rwanda Integrated Living Conditions Surveys of 2005, 2010, 2014, and 2016, we applied multivariable logit models to generate the levels and trends of adjusted inequalities in medical care utilization and HCHS across the four survey years by four socio-demographic dimensions: poverty, gender, education, and residence. We measured the national- and district-level inequalities in both absolute and relative terms. Results: At the national level, after controlling for other factors, we found significant inequalities in medical care utilization by poverty and education and -in HCHS by poverty in all four years. From 2005 to 2016, inequalities in medical care utilization by the four dimensions did not change significantly, while the inequality in HCHS by poverty was reduced significantly. At the district level, inequalities in both medical care utilization and HCHS were larger than zero in all four years and decreased over time. Conclusions: Poverty and poor education were significant contributors to inequalities in medical care utilization and HCHS in Rwanda. Policies or interventions targeting poor households or households headed by persons receiving no education are needed in order to effectively reduce inequalities in medical care utilization and HCHS. [ABSTRACT FROM AUTHOR]

Background: Despite the wealth of frameworks on social determinants of health (SDOH), two current limitations include the relative superficial description of factors affecting health and a lack of focus on measuring health equity. The Health Equity Measurement Framework (HEMF) addresses these gaps by providing a more encompassing view of the multitude of SDOH and drivers of health service utilisation and by guiding quantitative analysis for public health surveillance and policy development. The objective of this paper is to present the HEMF, which was specifically designed to measure the direct and indirect effects of SDOH to support improved statistical modelling and measurement of health equity. Methods: Based on a framework synthesis, the HEMF development involved initially integrating theoretical components from existing SDOH and health system utilisation frameworks. To further develop the framework, relevant publications on SDOH and health equity were identified through a literature review in major electronic databases. White and grey literatures were critically reviewed to identify strengths and gaps in the existing frameworks in order to inform the development of a unique health equity measurement framework. Finally, over a two-year period of consultation, scholars, health practitioners, and local policy influencers from municipal and provincial governments provided critical feedback on the framework regarding its components and causal relationships. Results: This unified framework includes the socioeconomic, cultural, and political context, health policy context, social stratification, social location, material and social circumstances, environment, biological factors, health-related behaviours and beliefs, stress, quality of care, and healthcare utilisation. Alongside the HEMF's self-exploratory diagram showing the causal pathways in-depth, a number of examples are provided to illustrate the framework's usefulness in measuring and monitoring health equity as well as informing policy-making. Conclusions: The HEMF highlights intervention areas to be influenced by strategic public policy for any organisation whose purview has an effect on health, including helping non-health sectors (such as education and labour) to better understand how their policies influence population health and perceive their role in health equity promotion. The HEMF recognises the complexity surrounding the SDOH and provides a clear, overarching direction for empirical work on health equity. [ABSTRACT FROM AUTHOR]

Background: Benefit Incidence Analysis (BIA) is used to understand the distribution of health care utilization and spending in comparison to income distribution. The results can illustrate how effectively governments allocate limited resources towards meeting the needs of the poor. In analyzing the distribution of public spending on inpatient, outpatient, and deliveries, this paper represents the most recent BIA completed in India. Methods: In order to conduct the BIA statistical analysis for this project, 2014 utilization data from the most recently completed Indian National Sample Survey (NSS) was used. Unit costs were estimated for primary care, hospital inpatient, hospital outpatient, and deliveries. Concentration curves and concentration indices were estimated both at the national and state levels. Analyses were reported for overall utilization, as well as for the gross and net benefits for inpatient, outpatient, and deliveries. Results: According to the results, utilization of government inpatient and delivery services is pro-poor. When gross and net benefits are included in the analysis, services become more equal and less pro-poor. Gross benefits, which are measured with state-level unit costs, are virtually equal for all services. Although there are some pro-poor gross benefits trends for national outpatient services, the results also show that the equality of national gross benefits trends hides a significant disparity across Indian States. While a number of Indian States have outpatient gross benefits that are pro-poor, few show pro-poor benefits for inpatient and delivery services. Net benefits, which considers both unit costs for each respective service, and out-of-pocket (OOP) expenditures, trend similarly to gross benefits. In addition, those who use public facilities spend considerable OOP to supplement government services. Conclusions: This BIA reveals that government spending on public health care has not resulted in significantly pro-poor services. While some progress has been made relative to deliveries and outpatient services, inpatient stays are not pro-poor. In addition, national results mask significant disparities across Indian states. [ABSTRACT FROM AUTHOR]

Background: In resource-constrained health systems medical travel is a common alternative to seeking unavailable health services. This paper was motivated by the need to understand better the impact of such travel on households and health systems. Methods: We used primary data from 344 subsidized and 471 non-subsidized inbound medical travellers during June to December 2013 drawn from the North, Centre and South regions of the Maldives where three international airports are located. Using a researcher-administered questionnaire to acquire data, we calculated annual out-of-pocket (OOP) spending on health, food and non-food items among households where at least one member had travelled to another country for medical care within the last year and estimated the poverty head count using household income as a living standard measure. Results: Most of the socio demographic indicators, and costs of treatment abroad among Maldivian medical travellers were similar across different household income levels with no statistical difference between subsidized and non-subsidized travellers (p value: 0.499). The government subsidy across income quintiles was also similar indicating that the Maldivian health financing structure supports equality rather than being equity-sensitive. There was no statistical difference in OOP expenditure on medical care abroad and annual OOP expenditure on healthcare was similar across income quintiles. Diseases of the circulatory system, eye and musculoskeletal system had the most impoverishing effect – diseases for which half of the patients, or less, did not receive the public subsidy. Annually, 6 and 14% of the medical travellers in the Maldives fell into poverty ($2 per day) before and after making OOP payments to health care. Conclusion: Evidence of a strong association between predominant public financing of medical travel and equality was found. With universal eligibility to the government subsidy for medical travel, utilization of treatment abroad, medical expenditures abroad and OOP expenditures on health among Maldivian medical travellers were similar between the poor and the rich. However, we conclude mixed evidence on the linkages between public financing of medical travel and impoverishment which needs to be further explored with comparison of impoverishment levels between households with and without medical travel. [ABSTRACT FROM AUTHOR]