Search

Setting: Research capacity is weakest in low and middle-income countries (LMICs) where operational research is highly relevant and needed. Structured Operational Research and Training Initiative (SORT IT) courses have been developed to train participants to conduct and publish operational research and influence policy and practice. Twenty courses were completed in Asia, Africa, Europe and the South Pacific between 2009 and 2014. Objectives: In the 20 completed SORT IT courses, to assess where the research was conducted, who was trained, who became facilitators in subsequent courses and course outcomes. Design: A cohort study of completed SORT IT courses Results: There were 236 participants (41% female) including 64 nationalities who conducted research in 59 countries, mostly from Asia and Africa (mean course duration = 9.7 months). Most participants (68%) were from government health programs and non-governmental agencies. A total of 213(90%) participants completed all milestones successfully with 41(19%) becoming subsequent course facilitators, 88% of whom were from LMICs. Of 228 manuscripts submitted to scientific journals, 197(86%) were either published or in press; in 86%, the principal investigator (first author) was a LMIC national. Papers were published in 23 scientific journals (impact factor 0.5–4.4) and covered 21 disease categories (median publication time = 5.7 months). Published papers (186) had 94,794 cumulative article views/downloads. Article views/downloads for immediate open access articles were double those from closed access journals. Conclusion: The SORT IT model has been effective in training personnel to produce relevant operational research in LMICs. It merits continued commitment and support for further scale-up and development. [ABSTRACT FROM AUTHOR]

In this paper, we aim to establish a mathematical model to design a maximizing social welfare intervention mechanism of healthcare service goods in China. The intervention mechanism is helpful to facilitate the adoption of the healthcare service goods. We consider a research problem that regulates the supply chain system for healthcare service goods by an intervention mechanism, and two intervention strategies composed of demand-growth strategy and subsidy strategy are used to the combination of intervention mechanism. Then this paper presents a new method based on fuzzy set and bilevel programming to design the intervention mechanism. To demonstrate the effectiveness of the proposed model, we conduct a case study for Wudang personalized health package and verify our model by the specific result analysis, the result indicates that our joint intervention mechanism is helpful to achieve the target and increase social welfare. [ABSTRACT FROM AUTHOR]

Background: Resource allocation decisions for disease categories can be informed by proper estimates of the magnitude and distribution of total spending. In the backdrop of a high burden of Non-Communicable Diseases and Injuries (NCDI) in India, and a paucity of estimates on government spending on NCDI, this paper attempts to analyse public sector expenditure on NCDI spending in India. Methods: Various recent budget documents of the Centre and States/Union Territories have been used to extract expenditure on NCDI. The aggregates thus arrived at have been analysed to estimate aggregate and state level per capita spending. State level spending have been compared against disease burden using DALYs. Patterns of spending on NCDI across states were also analysed together with state level poverty to observe possible patterns. Findings: The total spending on NCDI by the government is low at less than 0.5% of GDP. NCDI spending is little more than one-fourth of total health spending of the country and most spending takes place at the state level (80%). The Ministry of Health and Family Welfare’s share in Central spending on NCDI is around 65%, and currently it spends 20% of its total health spending on NCDI. The gap between spending and DALYs is the most for the economically vulnerable states. Also, the states with high poverty levels also have low per capita expenditure on NCDI Interpretation: India does not depend on donor funding for health. It will have to step up domestic funding to address the increasing disease burden of NCDIs and to reduce the high out-of-pocket expenditure on NCDI. Policies on NCDI need to focus on UHC, service integration and personnel gaps. [ABSTRACT FROM AUTHOR]

This paper examines the relationship between body composition and earnings in a developing country setting. We use body mass index, waist circumference and hip circumference. Exploiting the panel structure of our longitudinal survey, we find that along with BMI, waist circumference is related to higher earnings in Indonesia. [ABSTRACT FROM AUTHOR]

Objectives: Little is known about the gender and age differences associated with the effects of economic fluctuations on hospitalization for cardiovascular diseases. This paper investigates the impact of economic fluctuations on hospitalization for ischemic heart disease (IHD), stroke, and hypertension by age and gender between January 1996 and December 2012 in Taiwan. Methods: We adopted a multiple-input time series analysis to examine the strength of the immediate and latent effects of the 17-year quarterly unemployment rates (UR), air pollution exposure (APE), gross domestic product (GDP), per capita consumption expenditure in cigarette and alcohol (ECA), and per capita healthcare expenditure (HE) on the adjusted quarterly incidence rate of hospitalization. The data used in this paper were retrieved from the National Health Insurance Research Database and the website of the Directorate-General of Budget, Accounting and Statistics (DGBAS), Executive Yuan. Results: Our findings indicate that higher UR increased IHD hospitalization in young men and women and middle-aged women but reduced stroke hospitalization in young men. Higher APE increased IHD hospitalization in young men but reduced it for young women, increased stroke hospitalization in old men and middle-aged women but reduced it for young men, and increased hypertension hospitalization in middle-aged men and young women. Higher ECA reduced IHD hospitalization in middle-aged men, increased stoke hospitalization in middle-aged and old men and middle-aged women. Higher HE reduced IHD hospitalization in old men, young and old women, reduced stroke hospitalization in old women, and reduced hypertension hospitalization in young and middle-aged women. Conclusions: Overall, we found that the economic fluctuations caused increased harmful effects in certain population subgroups but also brought some soothing effects to some groups. [ABSTRACT FROM AUTHOR]

Objective: This paper reflected on the prevalence of hypertension and diabetes in Bangladesh, which is spreading rapidly in low-income countries. The rationale of constructing more health centers for addressing NCDs was assessed in this paper by determining the relationship between prevalence of NCDs, particularly hypertension and diabetes, and distance to health facilities. Methods: From BDHS (Bangladesh Health and Demographic Survey) 2011 data set, 7544 samples were analyzed to demonstrate association between Non-communicable diseases (NCD) and distance from respondents’ home to health facilities like hospitals, community clinics, pharmacies or doctors’ chambers, and community facilities like market, post office or cinema hall. Bivariate analysis was conducted between accessibility to health facilities and prevalence of the diseases. The causal relationship between the spatial effects and the prevalence of the diseases were analyzed by applying Generalized Linear Mixed Model (GLMM) was fitted. Results: Fitting linear mixed effect models, we found that hypertension and diabetes react differently with various spatial effects. Distance from home to hospital had significant effect (P < 0.001) on hypertension showing people living further from the facilities or town centers seemed to be less hypertensive, whereas diabetes showed no such affiliation. Conclusion: Higher prevalence of diabetes (40.9%) over hypertension (26.5%) in people aging 35 or higher, have appeared to have caused the difference, which concluded that each non-communicable disease should be dealt to its own merit for policy making instead considering as a group of diseases. [ABSTRACT FROM AUTHOR]

Motivation: Proper management of fecal sludge has significant positive health and environmental externalities. Most research on managing onsite sanitation so far either simulates the costs of, or the welfare effects from, managing sludge in situ in pit latrines. Thus, designing management strategies for onsite rural sanitation is challenging, because the actual costs of transporting sludge for treatment, and sources for financing these transport costs, are not well understood. Methods: In this paper we calculate the actual cost of sludge management from onsite latrines, and identify the contributions that latrine owners are willing to make to finance the costs. A spreadsheet-based model is used to identify a cost-effective transport option, and to calculate the cost per household. Then a double-bound contingent valuation method is used to elicit from pit-latrine owners their willingness-to-pay to have sludge transported away. This methodology is employed for the case of a rural subdistrict in Bangladesh called Bhaluka, a unit of administration at which sludge management services are being piloted by the Government of Bangladesh. Results: The typical sludge accumulation rate in Bhaluka is calculated at 0.11 liters/person/day and a typical latrine will need to be emptied approximately once every 3 to 4 years. The costs of emptying and transport are high; approximately USD 13 per emptying event (circa 14% of average monthly income); household contributions could cover around 47% of this cost. However, if costs were spread over time, the service would cost USD 4 per year per household, or USD 0.31 per month per household—comparable to current expenditures of rural households on telecommunications. Conclusion: This is one of few research papers that brings the costs of waste management together with financing of that cost, to provide evidence for an implementable solution. This framework can be used to identify cost effective sludge management options and private contributions towards that cost in other (context-specific) administrative areas where onsite sanitation is widespread. [ABSTRACT FROM AUTHOR]

Several publicly financed health insurance schemes have been launched in India with the aim of providing universalizing health coverage (UHC). In this paper, we report the impact of publicly financed health insurance schemes on health service utilization, out-of-pocket (OOP) expenditure, financial risk protection and health status. Empirical research studies focussing on the impact or evaluation of publicly financed health insurance schemes in India were searched on PubMed, Google scholar, Ovid, Scopus, Embase and relevant websites. The studies were selected based on two stage screening PRISMA guidelines in which two researchers independently assessed the suitability and quality of the studies. The studies included in the review were divided into two groups i.e., with and without a comparison group. To assess the impact on utilization, OOP expenditure and health indicators, only the studies with a comparison group were reviewed. Out of 1265 articles screened after initial search, 43 studies were found eligible and reviewed in full text, finally yielding 14 studies which had a comparator group in their evaluation design. All the studies (n-7) focussing on utilization showed a positive effect in terms of increase in the consumption of health services with introduction of health insurance. About 70% studies (n-5) studies with a strong design and assessing financial risk protection showed no impact in reduction of OOP expenditures, while remaining 30% of evaluations (n-2), which particularly evaluated state sponsored health insurance schemes, reported a decline in OOP expenditure among the enrolled households. One study which evaluated impact on health outcome showed reduction in mortality among enrolled as compared to non-enrolled households, from conditions covered by the insurance scheme. While utilization of healthcare did improve among those enrolled in the scheme, there is no clear evidence yet to suggest that these have resulted in reduced OOP expenditures or higher financial risk protection. [ABSTRACT FROM AUTHOR]

Background: Leprosy remains a disease of concern in many countries including Nepal. To achieve the target of elimination, the WHO strategy promotes comprehensive education of patients, healthcare workers (HCWs), and the public on leprosy-related issues. However most educational programs are based on the concerns of HCWs and not on patients’ needs. The objective of this paper is to explore the educational needs of leprosy affected patients in Nepal and compare them to the needs perceived by HCWs. Methodology/principal findings: Semi directive interviews were conducted with patients and HCWs. The data was analyzed using the basic interpretative qualitative framework. The study was conducted in two leprosy referral centers, one university hospital and one primary health care center: Lalgadh Leprosy Hospital and Services Centre, Anandaban Hospital and its satellite clinic in Patan, B. P. Koirala Institute of Health Sciences in Dharan, and the Itahari primary health care centre. The results show that there remains a lack of knowledge regarding the disease (origins, manifestations, prevention and treatment) contributing to late care seeking behavior and high levels of stigma, with an important psychological and financial stress for patients. All of the HCWs displayed a good understanding of patients’ difficulties and needs and acknowledged the key role of patient education. However, they expressed several challenges in managing patients due to lack of time, human resources and training in patient education. Conclusions/significance: Further efforts need to be made to increase patients’ general knowledge of the disease in order to motivate them to seek healthcare earlier and change their perception of the disease to reduce stigma. HCWs need proper training in patient education and counseling for them to acquire the necessary skills required to address the different educational needs of their patients. The use of lay and peer counselors would be an option to address the workload and lack of time expressed by HCWs. [ABSTRACT FROM AUTHOR]

Introduction: Public health spending in India has been traditionally one of the lowest globally. Punjab is one of the states with highest proportion of out-of-pocket expenditures for healthcare in India. We undertook this study to produce the sub-national health accounts (SNHA) for Punjab state in India. Methodology: We used System of Health Accounts (SHA) 2011 framework for preparing health accounts for Punjab state. Data on health spending by government was obtained from concerned public sector departments both at state and central level. Estimates on Out-of-Pocket Expenditures (OOPE) expenditure were derived from National Sample Survey (NSS) 71st round data, Consumer Expenditure Survey (CES) data and Pharmatrac. Primary surveys were done for assessing health expenditure data by firms and non-governmental organizations. All estimates of healthcare expenditures reported in our paper pertain to 2013–14, and are reported in both Indian National Rupee (INR) and United States Dollar (US $),using average conversion rate of INR 60.50 per US $. Results: In 2013–14, the current health expenditures (CE) in Punjab was INR 134,680million (US $ 2245 million) which was 4.02% of its gross state domestic product (GSDP).However, public spending on health was 0.95% of GSDP i.e. 21% of the total health expenditure (THE), while 79% was private expenditure. In per capita terms, THE in Punjab was INR 4963 (US $ 82.03). In terms of functions, medical goods (41.6%) and curative care (37%) consumed larger share of expenditure in the Punjab state. Households spent 52% of expenditures for medicines and other pharmaceutical goods. Risk pooling mechanisms are being adopted to a lesser extent in the state. Conclusion: The healthcare in Punjab is largely financed through private OOPE. Currently, public health spending in Punjab is inadequate to meet the healthcare demands of population, which is less than 1% of state’s GSDP. Monitoring public resources is very important for better resource allocations. Health Accounts production is useful in order to assess future trends and impact of health financing policies on goals of universal health coverage and should be made a part of routine monitoring system both at national and sub-national level. [ABSTRACT FROM AUTHOR]

Background: This paper describes the association between workplace violence and job satisfaction among physicians and nurses in Macau. Convenience sampling was sourced from six health centers under the Macau Health Bureau. Methods: This study uses a cross-sectional self-administrative survey. The study used case studies research instruments for workplace violence in the health sector by country (from the ILO, ICN, WHO, PSI), the Minnesota Satisfaction Questionnaire and Perceived Stress Scale. The data collection period spanned from August to December, 2014. Data analysis: Multiple logistic regression examines levels of intrinsic and extrinsic satisfaction in physicians and nurses and significant correlates affecting their job satisfaction. Results: A total of 720 (14.9% physicians) participants were recruited. 57.2% of participants reported physical and psychological workplace violence in the preceding year. The most common forms of workplace violence were verbal abuse (53.4%), physical assault (16.1%), bullying / harassment (14.2%), sexual harassment (4.6%) and racial harassment (2.6%). Nurses were at a significantly higher risk of physical assault and verbal abuse compared to physicians. Patients, patients’ relatives, and colleagues were the main perpetrators. Worry about WPV, on-call duty and shift work, experience of bullying and verbal abuse and employment sector emerged as significant correlates affecting the intrinsic and extrinsic job satisfaction of physicians and nurses. Frontline staff, aged 30 and 39, coming from an ethnic minority, and perceived stress were significant correlates affecting nurses’ job satisfaction. Conclusions: WPV remains a significant concern in healthcare settings in Macau. Stakeholders should legally enforce a zero-tolerance policy towards WPV within healthcare workplaces. WPV is detrimental to healthcare professionals’ mental wellbeing, risking irreversible physical and psychological harm for its victims. [ABSTRACT FROM AUTHOR]

Due to difficulties in accurately predicting the emergency timing and the magnitude of a disaster, operations for perishable emergency inventory planning often encounter expiration and shortage problems. In order to ease the expiration problem in emergency medicine preparation inventories, this paper investigates an emergency medicine closed-loop supply chain for returning unused items from an ERC (Emergency Reserve Center) to a hospital. To assure that the return strategy is meaningful, we propose a critical parameter that we term the latest return time, after which the remaining emergency medicine in the ERC cannot be returned to the hospital. In addition, the short lifetime of emergency products and uncertainty about demand time and demand quantity are also considered in this emergency inventory planning system. In analyzing the optimal ordering policies, we find that the two threshold values for the predefined return time, which affect the total costs, are not monotonous; rather, the direction of their effect is first down, then up, and then down again, which means that a better predefined value of the latest return time can be determined by minimizing total costs. By studying and comparing decentralized and centralized decisions, we find that the centralized decision system works better to control expiration and costs. Therefore, we design a coordination mechanism for the cooperation between the ERC and the hospital. Our analysis shows that we should not ignore the emergency uncertainty and perishability of emergency items. [ABSTRACT FROM AUTHOR]

This paper uses two nationally representative sets of medical claims data from medical assistance and universal public health insurance systems to examine how medical assistance system assignment affects short-term inpatient health care provision. In Japan, the medical assistance system, which is part of a public assistance system, provides medical care services for its beneficiaries without imposing any financial burdens, such as copayments or advance premium payments. These circumstances can lead to inpatient costs, as physicians may provide more treatments because there is a financial incentive. Because the assignment of public assistance in Japan is not random but is subject to means testing by the local government, I employ the instrumental variable model to control the potential correlation. I find that medical expenditure is significantly higher for medical assistance patients than for universal public health insurance patients, with an arc elasticity of approximately 0.20. This elasticity is slightly greater than that found for inpatient care in the randomized RAND Health Insurance Experiment and recent empirical studies on low-income populations. In addition, the elasticities for patients who receive medication, treatment and surgery are greater. [ABSTRACT FROM AUTHOR]

Introduction: There is an evidence of increasing inpatient expenditure for decedents. Estimates used to assess the economic burden of out-of-pocket (OOP) healthcare expenditure provide an underestimation for inpatient decedent cases. The aims of this paper are to study the trend and pattern of inpatient decedent expenditure and decipher the reasons behind the increasing cost in India. Methods: Using three rounds of national level National Sample Survey (NSS) data on morbidity & healthcare conducted during 1995–2015 in India, total and component-wise cost of dying was estimated by the socio-demographic characteristics and types of diseases. Generalised linear model was employed to find the changing effect of inpatient decedents on inpatient expenditure on three-time points. Results: More than half among inpatient decedents were elderly. Mean inpatient expenditure for neoplasm, circulatory system-related diseases and external causes of mortality and morbidity increased substantially during these two decades. Mean decedent inpatient expenditure become double, diagnostic and bed charges increased by 243%, 323% respectively during 2004–05 to 2014–15. During 2014–15 average decedents aged 15–59 years spent ₹53599 in last twelve month of their life. Controlling all other potential factors, the inpatient expenditure among decedents increased substantially between 1995–96 and 2014–15. Discussion: Out-of-pocket inpatient health expenditure widened between survivor and decedents in between 1995–2014. Increase in the proportion of elderly, proportion of non-communicable and lifestyle-related diseases, expenses on drugs, diagnostics, bed charges largely private sector expenses were the leading reasons for increasing inpatient decedent expenditure. Age-based risk adjustment and modification of end-of-life care are strongly required, future social insurance based on the health-based value of out-of-pocket expenditure rather than their pure consumption value need to be designed to tackle the burden. [ABSTRACT FROM AUTHOR]

Background: The Philippines has built an extensive decentralised network of Animal Bite Treatment Centers (ABTCs) to help bite victims receive timely rabies post-exposure prophylaxis (PEP) at little cost. This study surveyed patients in the community and at ABTCs of three provinces to assess animal bite/scratch incidence, health-seeking behaviour and PEP-related out-of pocket expenses (OOPE). Methodology and principal findings: During community surveys in 90 barangays (neighbourhoods), 53% of households reported at least one animal bite /scratch injury over the past 3 years, similar across urban and rural barangays. Overall bite/scratch incidences in 2016–17 were 67.3, 41.9 and 48.8 per 1,000 population per year for Nueva Vizcaya, Palawan and Tarlac respectively. Incidences were around 50% higher amongst those under 15 years of age, compared to -those older than 15. Household awareness of the nearest ABTCs was generally over 80%, but only 44.9% sought proper medical treatment and traditional remedies were still frequently used. The proportion of patients seeking PEP was not related to the distance or travel time to the nearest ABTC. For those that did not seek medical treatment, most cited a lack of awareness or insufficient funds and almost a third visited a traditional healer. No deaths from bite/scratch injuries were reported. A cohort of 1,105 patients were interviewed at six ABTCs in early 2017. OOPE varied across the ABTCs, from 5.53 USD to 37.83 USD per patient, primarily dependent on the need to pay for immunization if government supplies had run out. Overall, 78% of patients completed the recommended course, and the main reason for non-completion was a lack of time, followed by insufficient funds. Dog observation data revealed that 85% of patients were not truly exposed to rabies, and education in bite prevention might reduce provoked bites and demand for PEP. An accompanying paper details the ABTC network from the health provider’s perspective. [ABSTRACT FROM AUTHOR]

Background: Around 63% of total health care expenditure in Bangladesh is mitigated through out of pocket payment (OOP). Heavy reliance on OOP at the time of care seeking poses great threat for financial impoverishment of the households. Households employ different strategies to cope with the associated financial hardship. Objective: The aim of this paper is to understand the determinants of hardship financing in coping with OOP adopted for health care seeking of under five childhood illnesses in rural setting of Bangladesh. Methods: A community based cross sectional survey was conducted during August to October, 2014 in 15 low performing sub-districts of northern and north-east regions of Bangladesh. Of the 7039 mothers of under five children surveyed, 1895 children who suffered from illness and sought care for their illness episodes were reported in this study. Descriptive statistics and ordinal regression analysis were conducted. Results: A total number of 7,039 under five children reported to have suffered illness by their mothers. Among these children 37% suffered from priority illness. Care was sought for 88% children suffering from illnesses. Among them 26% went to a public or private sector medically trained provider. 5% of households incurred illness cost more than 10% of the household’s monthly expenditure. The need for assistance was higher among those compared to others (31% vs 13%). Different financing mechanisms adopted to meet OOP are loan with interest (6%), loan without interest (9%) and financial help from relatives (6%) Need for financial assistance varied from 19% among households in the lowest quintile to 9% in the highest wealth. Ordinal regression analysis revealed that burden of hardship financing increases by 2.17 times when care is sought from a private trained provider compared to care seeking from untrained provider (CI: 1.49, 3.17). Similarly, for families that incur a health care expenditure that is more than 10% of their total monthly expenditure (CI:1.46, 3.88), the probability of falling into more severe financial burden increases by 2.4 times. We also found severity of the hardship financing to be around half for households with monthly income of more than BDT 7500 (OR = 0.56, CI: 0.37, 0.86). The burden increased by 2.10 times for households with a deficit (CI: 1.53, 2.88) between their monthly income and expenditure. The interaction between family income and severity of illness showed to significantly affect the scale of hardship financing. Children suffering from priority illness belonging to poor households were found have two times (CI: 1.09, 3.47) higher risks of suffering from hardship financing. Conclusion and policy implications: Findings from this study will help the policy makers to identify the target groups and thereby design effective health financing programs. [ABSTRACT FROM AUTHOR]

This paper examines the effect of maternal socio-economic status in the household, such as their autonomy, ability, freedom and bargaining power, on child birth registration in India using the nationally representative India Human Development Survey-II (IHDS-II), 2011–12. We have estimated a multilevel mixed effects model which accounts for the hierarchical structure of the data and allows us to examine the effects of unobserved ‘district’ and ‘community’ characteristics along with individual child level characteristics on probability of birth registration. The results show that between-districts and between individuals differences share a considerably high and an almost equal proportion of the variations in probability of birth registration in India. At individual child level, mother’s socio-economic status such as her ability to move around independently and her exposure to outside world, significantly raise the probability of birth registration. More importantly, the marginal effects of the maternal autonomy indicators: mother’s ability to move around freely and her control over resources, on birth registration vary across districts in India. Other variables such as institutional birth, mother’s antenatal care seeking behaviour, caste, religion, household wealth and parental education are significant determinants of birth registration. [ABSTRACT FROM AUTHOR]

With the ongoing demographic and epidemiological transition, cancer is emerging as a major public health concern in India. This paper uses nationally representative household survey to examine the overall prevalence and economic burden of cancer in India. The age-standardized prevalence of cancer is estimated to be 97 per 100,000 persons with greater prevalence in urban areas. The evidence suggests that cancer prevalence is highest among the elderly and also among females in the reproductive age groups. Cancer displays a significant socioeconomic gradient even after adjusting for age-sex specifics and clustering in a multilevel regression framework. We find that out of pocket expenditure on cancer treatment is among the highest for any ailment. The average out of pocket spending on inpatient care in private facilities is about three-times that of public facilities. Furthermore, treatment for about 40 percent of cancer hospitalization cases is financed mainly through borrowings, sale of assets and contributions from friends and relatives. Also, over 60 percent of the households who seek care from the private sector incur out of pocket expenditure in excess of 20 percent of their annual per capita household expenditure. Given the catastrophic implications, this study calls for a disease-based approach towards financing such high-cost ailment. It is suggested that universal cancer care insurance should be envisaged and combined with existing accident and life insurance policies for the poorer sections in India. In concluding, we call for policies to improve cancer survivorship through effective prevention and early detection. In particular, greater public health investments in infrastructure, human resources and quality of care deserve priority attention. [ABSTRACT FROM AUTHOR]

Background: No study of obesity risk for people in developed countries has conducted a multi-dimensional analysis of the association of socioeconomic status with obesity. In this paper, we investigated if education functions as either a confounder or an effect modifier in the association of another socioeconomic status indicator with obesity. Methods: This cross-sectional study analyzed data of an adult population sample (10,905 men and 14,580 women) from the Korea National Health and Nutrition Examination Survey (2010–2014). The study performed multivariate logistic regression analyses for three education levels and four indicators of socioeconomic status (i.e., marital status, residential area, occupation, and income). Results: The overall prevalence of obesity was 38.1% in men and 29.1% in women (p < 0.001). In men, while education functioned as an effect modifier in the association between marital status and obesity (p for interaction = 0.006), it functioned as both a confounder (p < 0.001) and an effect modifier (p for interaction < 0.001) in the association between residential area and obesity. In contrast, in women, education functioned as a confounder in the association of residential area with obesity (p = 0.010). However, it functioned as both a confounder (p < 0.001) and an effect modifier (p for interaction = 0.012) in the association between income and obesity. A prediction showed that unlike in women, education was positively associated with obesity risk for some socioeconomic indicator groups in men; for example, in a rural resident group, a higher level of education increased the probability of being obese by 19.7%. Conclusions: The present study suggests the need to examine sex-specific studies regarding the role of education on the association between other socioeconomic status indicators and obesity. This should be considered in planning education policies to reduce the risk of obesity. [ABSTRACT FROM AUTHOR]

The Hospital Authority (HA) is a statutory body managing all the public hospitals and institutes in Hong Kong (HK). In recent decades, Hong Kong Hospital Authority (HKHA) has been making efforts to improve the healthcare services, but there still exist some problems like unfair resource allocation and poor management, as reported by the Hong Kong medical legislative committee. One critical consequence of these problems is low healthcare efficiency of hospitals, leading to low satisfaction among patients. Moreover, HKHA also suffers from the conflict between limited resource and growing demand. An effective evaluation of HA is important for resource planning and healthcare decision making. In this paper, we propose a two-phase method to evaluate HA efficiency for reducing healthcare expenditure and improving healthcare service. Specifically, in Phase I, we measure the HKHA efficiency changes from 2000 to 2013 by applying a novel DEA-Malmquist index with undesirable factors. In Phase II, we further explore the impact of some exogenous factors (e.g., population density) on HKHA efficiency by Tobit regression model. Empirical results show that there are significant differences between the efficiencies of different hospitals and clusters. In particular, it is found that the public hospital serving in a richer district has a relatively lower efficiency. To a certain extent, this reflects the socioeconomic reality in HK that people with better economic condition prefers receiving higher quality service from the private hospitals. [ABSTRACT FROM AUTHOR]

Background: While women and girls face special risks from lack of access to sanitation facilities, their ability to participate and influence household-level sanitation is not well understood. This paper examines the association between women's decision-making autonomy and latrine construction in rural areas of Odisha, India. Methods: We conducted a mixed-method study among rural households in Puri district. This included a cross sectional survey among 475 randomly selected households. These were classified as either having a functional latrine, a non-functional latrine or no latrine at all. We also conducted 17 in-depth interviews and 9 focus group discussions among household members of these three categories of households. Results: Decisions on the construction of household level sanitation facilities were made exclusively by the male head in 80% of households; in 11% the decision was made by men who consulted or otherwise involved women. In only 9% of households the decision was made by women. Households where women were more involved in general decision making processes were no more likely to build a latrine, compared to households where they were excluded from decisions. Qualitative research revealed that women’s non-involvement in sanitation decision making is attributed to their low socio-economic status and inability to influence the household’s financial decisions. Female heads lacked confidence to take decisions independently, and were dependent on their spouse or other male family members for most decisions. The study revealed the existence of power hierarchies and dynamics within households, which constrained female’s participation in decision-making processes regarding sanitation. Conclusions: Though governments and implementers emphasize women’s involvement in sanitation programmes, socio-cultural factors and community and household level dynamics often prevent women from participating in sanitation-related decisions. Measures are needed for strengthening sanitation policies and effective implementation of programmes to address gender power relations and familial relationships that influence latrine adoption and use. [ABSTRACT FROM AUTHOR]

Objective: The world population is aging rapidly and the well-being of older people is of great interest. Therefore, this study investigates the determinants of life satisfaction among the oldest-old (i.e. individuals aged 80 or over) in China. Materials and methods: We use the 2011/2012 Chinese Longitudinal Healthy Longevity Survey data (n = 6530) for this paper. Logistic regression is used to analyse the effects of socio-demographic, economic, health, instrumental activities of daily living, family and community factors on life satisfaction and depression among the oldest-old in China. Results: Our analysis confirms the significance of many factors affecting life satisfaction among the oldest-old in China. Factors that are correlated with life satisfaction include respondent’s sex, education, place of residence, self-rated health status, cognitive ability (using mini mental state examination), regular physical examination, perceived relative economic status, access to social security provisions, commercialized insurances, living arrangements, and number of social services available in the community (p<0.05 for all these variables). Although life satisfaction is negatively associated with instrumental activities of daily living (β = -0.068, 95%CI = -.093—.043), and depression (β = -0.463, 95%CI = -.644—.282), the overall effect of self-rated health status is positive (p<0.001). This confirms the primacy of health as the determinant of well-being among the oldest-old. Conclusions: Majority of the oldest-old in China rated their life satisfaction as good or very good. Our findings show that health and economic status are by far the most significant predictors of life satisfaction. Our finding on the primacy of health and relative income as determinants of well-being among the oldest-old, and the greater influence of self-rated health status over objective health measures is consistent with the findings of many past studies. Our results suggest that efforts should be directed at enhancing family support as well as health and social service provisions in the community to improve life satisfaction of older people. [ABSTRACT FROM AUTHOR]

Purpose: Diabetes mellitus (DM) is a global pandemic metabolic disorder. In recent years, the amount of medical resources required for the treatment of diabetes has increased as diabetes rates have gradually risen. The combined effects of individual and neighbourhood socio-economic status (SES) on DM survival rates are still not clear, especially in patients of working age. In this paper, we aim to analyze the combined effects of neighbourhood and individual SES on DM survival rates in patients of working age in Taiwan. Methods: The study of 23,781 people who were diagnosed with DM by using population—based study between 2002 and 2006. Each sample was followed up for 4 years or as a sensor case. We defined Individual SES and neighbourhood SES by each patient’s job category and household income which characterized as advantaged or disadvantaged. Then we compared the survival rates by SES group used Cox proportional hazards model for adjust risk factors. Results: The 4-year overall survival rates of diabetic patients were worst for those with low individual SES who living in advantaged neighbourhoods. After adjustment for patient characteristics, DM patients with high individual SES living in disadvantaged neighbourhoods had the same risk of mortality as those patients with high individual SES living in advantaged neighbourhoods (hazard ratio: 1.11; 95% confidence interval [CI]: 0.81–1.51). The study found that DM patients with low individual SES who live in disadvantaged areas had a greater risk of mortality than those with high SES (odds ratio: 2.57; 95% CI: 2.04–3.24). There were significant differences in survival rates between patients with high individual SES and patients with low individual SES. In contrast, the results did not statistically significant differences in survival rates between advantaged and disadvantaged neighbourhood SES groups. Conclusion: DM patients with low individual SES had the worst survival rate, regardless of whether they were living in a high or low SES neighbourhood area. The competitive cause of death, i.e., the fact that complications, rather than DM itself, are often the cause of death, may be the reason for the inverse relationship found between the effects of individual SES and neighbourhood SES on DM survival. We conclude that the socio-economic gradient in survival among DM patients may be the result of differences in access to medical treatment and attributes related to individual SES. [ABSTRACT FROM AUTHOR]

Out-of-pocket spending at out-patient departments (OPD) by households is relatively less analyzed compared to hospitalization expenses in India. This paper provides new evidence on the levels and drivers of expenditure on out-patient care, as well as choice of providers, using household survey data from 8 districts in 3 states of India. Results indicate that the economically vulnerable spend more on OPD as a proportion of per capita consumption expenditure, out-patient care remains overwhelmingly private and switches of providers—while not very prevalent—is mostly towards private providers. A key result is that choice of public providers tend to lower OPD spending significantly. It indicates that an improvement in the overall quality and accessibility of government facilities still remain an important tool that should be considered in the context of financial protection. [ABSTRACT FROM AUTHOR]

The aim of this research is to explore factors influencing the management decisions to adopt human resource information system (HRIS) in the hospital industry of Bangladesh—an emerging developing country. To understand this issue, this paper integrates two prominent adoption theories—Human-Organization-Technology fit (HOT-fit) model and Technology-Organization-Environment (TOE) framework. Thirteen factors under four dimensions were investigated to explore their influence on HRIS adoption decisions in hospitals. Employing non-probability sampling method, a total of 550 copies of structured questionnaires were distributed among HR executives of 92 private hospitals in Bangladesh. Among the respondents, usable questionnaires were 383 that suggesting a valid response rate of 69.63%. We classify the sample into 3 core groups based on the HRIS initial implementation, namely adopters, prospectors, and laggards. The obtained results specify 5 most critical factors i.e. IT infrastructure, top management support, IT capabilities of staff, perceived cost, and competitive pressure. Moreover, the most significant dimension is technological dimension followed by organisational, human, and environmental among the proposed 4 dimensions. Lastly, the study found existence of significant differences in all factors across different adopting groups. The study results also expose constructive proposals to researchers, hospitals, and the government to enhance the likelihood of adopting HRIS. The present study has important implications in understanding HRIS implementation in developing countries. [ABSTRACT FROM AUTHOR]

Background: With declines in development assistance for health and growing interest in country ownership, donors are increasingly faced with the task of transitioning health programs to local actors towards a path to sustainability. Yet there is little available guidance on how to measure and evaluate the success of a transition and its subsequent effects. This study assesses the transition of the Avahan HIV/AIDS prevention program in India to investigate how preparations for transition affected continuation of program activities post-transition. Methods: Two rounds of two surveys were conducted and supplemented by data from government and Avahan Computerized Management Information Systems (CMIS). Exploratory factor analysis was used to develop two measures: 1) transition readiness pre-transition, and 2) institutionalization (i.e. integration of initial program systems into organizational procedures and behaviors) post-transition. A fixed effects model was built to examine changes in key program delivery outcomes over time. An ordinary least square regression was used to assess the relationship between transition readiness and sustainability of service outcomes both directly, and indirectly through institutionalization. Results: Transition readiness data revealed 3 factors (capacity, alignment and communication), on a 15-item scale with adequate internal consistency (alpha 0.73). Institutionalization was modeled as a unidimensional construct, and a 12-item scale demonstrated moderate internal consistency (alpha 0.60). Coverage of key populations and condom distribution were sustained compared to pre-transition levels (p<0.01). Transition readiness, but not institutionalization, predicted sustained outcomes post-transition. Transition readiness did not necessarily lead to institutionalization of key program elements one year after transition. Conclusion: Greater preparedness prior to transition is important to achieve better service delivery outcomes post-transition. This paper illustrates a methodology to measure transition readiness pre-transition to identify less ready organizations or program components in advance, improving the likelihood of service sustainability. Further research is needed around the conceptualization and development of measures of institutionalization and its effects on long-term program sustainability. [ABSTRACT FROM AUTHOR]

Objective: The paper examines whether out-of-pocket health care expenditure also has regional discrepancies, comparing to the equity between urban and rural areas, and across households. Method: Sampled data were derived from Urban Household Survey and Rural Household Survey data for 2011/2012 for Anhui Province, and 11049 households were included in this study. The study compared differences in out-of-pocket expenditure on health care between regions (urban vs. rural areas) and years (2011 vs. 2012) using two-sample t-test, and also investigated the degree of inequality using Lorenz and concentration curves. Result: Approximately 5% and 8% of total household consumption expenditure was spent on health care for urban and rural populations, respectively. In 2012, the wealthiest 20% of urban and rural population contributed 49.7% and 55.8% of urban and rural total health expenditure respectively, while the poorest 20% took only 4.7% and 4.4%. The concentration curve for out-of-pocket expenditure in 2012 fell below the corresponding concentration curve for 2011 for both urban and rural areas, and the difference between curves for rural areas was greater than that for urban areas. Conclusion: A substantial and increasing gap in health care expenditures existed between urban and rural areas in Anhui. The health care financing inequality merits ample attention, with need for policymaking to focus on improving the accessibility to essential health care services, particularly for rural and poor residents. This study may provide useful information on low income areas of China. [ABSTRACT FROM AUTHOR]

Background: A recent report by the Institute for Health Metrics and Evaluation (IHME) highlights that mental health receives little attention despite being a major cause of disease burden. This paper extends previous assessments of development assistance for mental health (DAMH) in two significant ways; first by contrasting DAMH against that for other disease categories, and second by benchmarking allocated development assistance against the core disease burden metric (disability-adjusted life year) as estimated by the Global Burden of Disease Studies. Methods: In order to track DAH, IHME collates information from audited financial records, project level data, and budget information from the primary global health channels. The diverse set of data were standardised and put into a single inflation adjusted currency (2015 US dollars) and each dollar disbursed was assigned up to one health focus areas from 1990 through 2015. We tied these health financing estimates to disease burden estimates (DALYs) produced by the Global Burden of Disease 2015 Study to calculated a standardised measure across health focus areas—development assistance for health (in US Dollars) per DALY. Findings: DAMH increased from USD 18 million in 1995 to USD 132 million in 2015, which equates to 0.4% of total DAH in 2015. Over 1990 to 2015, private philanthropy was the most significant source (USD 435 million, 30% of DAMH), while the United States government provided USD 270 million of total DAMH. South and Southeast Asia received the largest proportion of funding for mental health in 2013 (34%). DAMH available per DALY in 2013 ranged from USD 0.27 in East Asia and the Pacific to USD 1.18 in the Middle East and North Africa. HIV/AIDS received the largest ratio of funds to burden—approximately USD150 per DALY in 2013. Mental and substance use disorders and its broader category of non-communicable disease received less than USD1 of DAH per DALY. Interpretation: Combining estimates of disease burden and development assistance for health provides a valuable perspective on DAH resource allocation. The findings from this research point to several patterns of unproportioned distribution of DAH, none more apparent than the low levels of international investment in non-communicable diseases, and in particular, mental health. However, burden of disease estimates are only one input by which DAH should be determined. [ABSTRACT FROM AUTHOR]

Introduction: This research article reports on factors influencing initial voluntary uptake of community-based health insurance (CBHI) schemes in low- and middle-income countries (LMIC), and renewal decisions. Methods: Following PRISMA protocol, we conducted a comprehensive search of academic and gray literature, including academic databases in social science, economics and medical sciences (e.g., Econlit, Global health, Medline, Proquest) and other electronic resources (e.g., Eldis and Google scholar). Search strategies were developed using the thesaurus or index terms (e.g., MeSH) specific to the databases, combined with free text terms related to CBHI or health insurance. Searches were conducted from May 2013 to November 2013 in English, French, German, and Spanish. From the initial search yield of 15,770 hits, 54 relevant studies were retained for analysis of factors influencing enrolment and renewal decisions. The quantitative synthesis (informed by meta-analysis) and the qualitative analysis (informed by thematic synthesis) were compared to gain insight for an overall synthesis of findings/statements. Results: Meta-analysis suggests that enrolments in CBHI were positively associated with household income, education and age of the household head (HHH), household size, female-headed household, married HHH and chronic illness episodes in the household. The thematic synthesis suggests the following factors as enablers for enrolment: (a) knowledge and understanding of insurance and CBHI, (b) quality of healthcare, (c) trust in scheme management. Factors found to be barriers to enrolment include: (a) inappropriate benefits package, (b) cultural beliefs, (c) affordability, (d) distance to healthcare facility, (e) lack of adequate legal and policy frameworks to support CBHI, and (f) stringent rules of some CBHI schemes. HHH education, household size and trust in the scheme management were positively associated with member renewal decisions. Other motivators were: (a) knowledge and understanding of insurance and CBHI, (b) healthcare quality, (c) trust in scheme management, and (d) receipt of an insurance payout the previous year. The barriers to renewal decisions were: (a) stringent rules of some CBHI schemes, (b) inadequate legal and policy frameworks to support CBHI and (c) inappropriate benefits package. Conclusion and Policy Implications: The demand-side factors positively affecting enrolment in CBHI include education, age, female household heads, and the socioeconomic status of households. Moreover, when individuals understand how their CBHI functions they are more likely to enroll and when people have a positive claims experience, they are more likely to renew. A higher prevalence of chronic conditions or the perception that healthcare is of good quality and nearby act as factors enhancing enrolment. The perception that services are distant or deficient leads to lower enrolments. The second insight is that trust in the scheme enables enrolment. Thirdly, clarity about the legal or policy framework acts as a factor influencing enrolments. This is significant, as it points to hitherto unpublished evidence that governments can effectively broaden their outreach to grassroots groups that are excluded from social protection by formulating supportive regulatory and policy provisions even if they cannot fund such schemes in full, by leveraging people’s willingness to exercise voluntary and contributory enrolment in a community-based health insurance. [ABSTRACT FROM AUTHOR]

Background: India has recently introduced telemedicine initiatives to enhance access to specialized care at a low cost for the pediatric HIV patients, who face multiple challenges due to growing disease burden and limited preparedness of the health system to address it. There are limited evidences on the cost-effectiveness of these interventions. This study was undertaken in Maharashtra, a province, located in the western region of the country, to inform policy regarding the effectiveness of this programme. The objective was to estimate the unit cost of ART services for pediatric HIV patients and examine the efficiency in the use of resource and treatment compliance resulting from telemedicine initiatives in pediatric HIV compared to usual ART services. Methods: We selected 6 ART centers (3 from linked centers linked to Pediatric HIV Centre of Excellence (PCoE) and 3 from non-linked centers) randomly from three high, middle and low ART centers, categorized on the basis of case load in each arm. A bottom up costing methodology was adopted to understand the unit cost of services. Loss to follow up and timeliness of the visits were compared between the two arms and were linked to the cost. Results: The average cost per-visit was INR 1803 in the linked centers and that for the non-linked centers was INR 3412. There has been 5 percentage point improvement in lost to follow-up in the linked centers compared to non-linked centers against a back-drop of a reduction in per-pediatric patient cost of INR 557. The linkage has resulted in increase in timeliness of the visits in linked centers compared to non-linked centers. Discussion and conclusion: The telemedicine linkage led to an increase in the case load leading to a decrease in cost. The evidence on efficiency in the use of resource and improvement in treatment compliance as suggested by this study could be used to scale up this initiative. [ABSTRACT FROM AUTHOR]

Objective: We examined the incremental cost-effectiveness between two mHealth programs, implemented from 2011 to 2015 in rural Bangladesh: (1) Comprehensive mCARE package as an intervention group and (2) Basic mCARE package as a control group. Methods: Both programs included a core package of census enumeration and pregnancy surveillance provided by an established cadre of digitally enabled community health workers (CHWs). In the comprehensive mCARE package, short message service (SMS) and home visit reminders were additionally sent to pregnant women (n = 610) and CHWs (n = 70) to promote the pregnant women’s care-seeking of essential maternal and newborn care services. Economic costs were assessed from a program perspective inclusive of development, start-up, and implementation phases. Effects were calculated as disability adjusted life years (DALYs) and the number of newborn deaths averted. For comparative purposes, we normalized our evaluation to estimate total costs and total newborn deaths averted per 1 million people in a community for both groups. Uncertainty was assessed using probabilistic sensitivity analyses with Monte Carlo simulation. Results: The addition of SMS and home visit reminders based on a mobile phone-facilitated pregnancy surveillance system was highly cost effective at a cost per DALY averted of $31 (95% uncertainty range: $19–81). The comprehensive mCARE program had at least 88% probability of being highly cost-effective as compared to the basic mCARE program based on the threshold of Bangladesh’s GDP per capita. Conclusion: mHealth strategies such as SMS and home visit reminders on a well-established pregnancy surveillance system may improve service utilization and program cost-effectiveness in low-resource settings. [ABSTRACT FROM AUTHOR]

Introduction: Tobacco smoking is often more prevalent among those with lower socio-economic status (SES) in high-income countries, which can be driven by the inequalities in initiation and cessation of smoking. Smoking is a leading contributor to socio-economic disparities in health. To date, the evidence for any socio-economic inequality in smoking cessation is lacking, especially in low- and middle-income countries (LMICs). This study examined the association between cessation behaviours and SES of smokers from eight LMICs. Methods: Data among former and current adult smokers aged 18 and older came from contemporaneous Global Adult Tobacco Surveys (2008–2011) and the International Tobacco Control Surveys (2009–2013) conducted in eight LMICs (Bangladesh, Brazil, China, India, Mexico, Malaysia, Thailand and Uruguay). Adjusted odds ratios (AORs) of successful quitting in the past year by SES indicators (household income/wealth, education, employment status, and rural-urban residence) were estimated using multivariable logistic regression controlling for socio-demographics and average tobacco product prices. A random effects meta-analysis was used to combine the estimates of AORs pooled across countries and two concurrent surveys for each country. Results: Estimated quit rates among smokers (both daily and occasional) varied widely across countries. Meta-analysis of pooled AORs across countries and data sources indicated that there was no clear evidence of an association between SES indicators and successful quitting. The only exception was employed smokers, who were less likely to quit than their non-employed counterparts, which included students, homemakers, retirees, and the unemployed (pooled AOR≈0.8, p<0.10). Conclusion: Lack of clear evidence of the impact of lower SES on adult cessation behaviour in LMICs suggests that lower-SES smokers are not less successful in their attempts to quit than their higher-SES counterparts. Specifically, lack of employment, which is indicative of younger age and lower nicotine dependence for students, or lower personal disposable income and lower affordability for the unemployed and the retirees, may be associated with quitting. Raising taxes and prices of tobacco products that lowers affordability of tobacco products might be a key strategy for inducing cessation behaviour among current smokers and reducing overall tobacco consumption. Because low-SES smokers are more sensitive to price increases, tobacco taxation policy can induce disproportionately larger decreases in tobacco consumption among them and help reduce socio-economic disparities in smoking and consequent health outcomes. [ABSTRACT FROM AUTHOR]

Background: We undertook this study to assess the incremental cost per quality adjusted life year (QALY) gained with the use of pan-genotypic sofosbuvir (SOF) + velpatasvir (VEL) for HCV patients, as compared to the current treatment regimen under the universal free treatment scheme in Punjab state. Methodology: A Markov model depicting natural history of HCV was developed to simulate the progression of disease. Three scenarios were compared: I (Current Regimen)—use of SOF + daclatasvir (DCV) for non-cirrhotic patients and ledipasvir (LDV) or DCV with SOF ± ribavirin (RBV) according to the genotype for cirrhotic patients; II—use of SOF + DCV for non-cirrhotic patients and use of SOF+VEL for compensated cirrhotic patients (with RBV in decompensated cirrhosis patients) and III—use of SOF+VEL for both non-cirrhotic and compensated cirrhotic patients (with RBV in decompensated cirrhosis patients). The lifetime costs, life-years and QALYs were assessed for each scenario, using a societal perspective. All the future costs and health outcomes were discounted at an annual rate of 3%. Finally, the incremental cost per QALY gained was computed for each of scenario II and III, as compared to scenario I and for scenario III as compared to II. In addition, we evaluated the lifetime costs and QALYs among HCV patients for each of scenario I, II and III against the counterfactual of ‘no universal free treatment scheme’ scenario which involves patients purchasing care in routine setting of from public and private sector. Results: Each of the scenarios I, II and III dominate over the no universal free treatment scheme scenario, i.e. have greater QALYs and lesser costs. The use of SOF+VEL only for cirrhotic patients (scenario II) increases QALYs by 0.28 (0.03 to 0.71) per person, and decreases the cost by ₹ 5,946 (₹ 1,198 to ₹ 14,174) per patient, when compared to scenario I. Compared to scenario I, scenario III leads to an increase in QALYs by 0.44 (0.14 to 1.01) per person, and is cost-neutral. While the mean cost difference between scenario III and I is—₹ 2,676 per patient, it ranges from a cost saving of ₹ 14,835 to incurring an extra cost of ₹ 3,456 per patient. For scenario III as compared II, QALYs increase by 0.16 (0.03 to 0.36) per person as well as costs by ₹ 3,086 per patient which ranges from a cost saving of ₹ 1,264 to incurring an extra cost of ₹ 6,344. Shift to scenario II and III increases the program budget by 5.5% and 60% respectively. Conclusion: Overall, the use of SOF+VEL is highly recommended for the treatment of HCV infection. In comparison to the current practice (scenario I), scenario II is a dominant option. Scenario III is cost-effective as compared to scenario II at a threshold of one-time GDP per capita. If budget is an important constraint, velpatasvir should be given to HCV infected cirrhotic patients. However, if no budget constraint, universal use of velpatasvir for HCV treatment is recommended. [ABSTRACT FROM AUTHOR]

Background: Expanding public health insurance seeks to attain several desirable objectives, including increasing access to healthcare services, reducing the risk of catastrophic healthcare expenditures, and improving health outcomes. The extent to which these objectives are met in a real-world policy context remains an empirical question of increasing research and policy interest in recent years. Methods: We reviewed systematically empirical studies published from July 2010 to September 2016 using Medline, Embase, Econlit, CINAHL Plus via EBSCO, and Web of Science and grey literature databases. No language restrictions were applied. Our focus was on both randomised and observational studies, particularly those including explicitly attempts to tackle selection bias in estimating the treatment effect of health insurance. The main outcomes are: (1) utilisation of health services, (2) financial protection for the target population, and (3) changes in health status. Findings: 8755 abstracts and 118 full-text articles were assessed. Sixty-eight studies met the inclusion criteria including six randomised studies, reflecting a substantial increase in the quantity and quality of research output compared to the time period before 2010. Overall, health insurance schemes in low- and middle-income countries (LMICs) have been found to improve access to health care as measured by increased utilisation of health care facilities (32 out of 40 studies). There also appeared to be a favourable effect on financial protection (26 out of 46 studies), although several studies indicated otherwise. There is moderate evidence that health insurance schemes improve the health of the insured (9 out of 12 studies). Interpretation: Increased health insurance coverage generally appears to increase access to health care facilities, improve financial protection and improve health status, although findings are not totally consistent. Understanding the drivers of differences in the outcomes of insurance reforms is critical to inform future implementations of publicly funded health insurance to achieve the broader goal of universal health coverage. [ABSTRACT FROM AUTHOR]

Introduction: The National Rural Health Mission (NRHM) was launched in India in 2005 to address the health needs of under-served populations in rural areas, and to support universal access to care. Despite this initiative, unaccredited informal providers (IPs) often remain patients’ first point of contact, which has led to inconsistencies in treatment, and has compromised the quality of care. Aim: To explore the factors that influence patients’ decisions about healthcare providers in rural areas of central India. Methods: Nine focus group discussions (FGDs) were held in nine villages in central India. Framework analysis using an inductive approach was used to analyse the data. Results: The crosscutting theme across the discussions was not choice but need—the need for affordable and accessible health care regardless of the provider’s qualification. Results highlighted that IPs play a pivotal role in villagers’ lives. Formal healthcare services were accessed infrequently, and mainly when a condition was judged severe or possibly even fatal. Even then, affordability was carefully weighed. Villagers’ distance from formal providers contributed to high cost and low preference of formal providers. When opting for IPs, familiarity and trust were more important to villagers than qualifications. IPs have operated in rural communities in India for a long time and have adapted their services to meet the needs, preferences, social norms, and economic conditions of villagers. Conclusion: IPs have captured a niche and are often the first contact point in rural settings even when patients ultimately are diagnosed and treated by trained doctors. Merely tackling the undersupply of qualified doctors is not effective or sufficient to impact on the rural healthcare system: the strong and prevalent influence of IPs needs to be addressed also. [ABSTRACT FROM AUTHOR]

Caesarean section (CS) can prevent maternal and neonatal mortality and morbidity. However, it involves risks and high costs that can be a burden, especially in low and middle income countries. The aim of this study is to assess its magnitude and correlates among women of reproductive age in the urban and rural areas of Vietnam. We analyzed microdata from the national Multiple Indicator Cluster Survey (MICS) conducted in 2014 by using a representative sample of households at the national level in both urban and rural areas. A total of 1,350 women who delivered in institutional settings in the two years preceding the survey were included. Frequency and percentage distributions of the variables were performed. Bivariate and multivariate logistic regression analyses were undertaken to identify the factors associated with CS. Odds ratios with a 95% confidence interval were used to ascertain the direction and strength of the associations. The overall CS rate among the women who delivered in healthcare facilities in Vietnam has rapidly increased and reached a high level (29.2%). After controlling for significant characteristics, living in urban areas doubles the likelihood of undergoing a CS (OR = 1.98; 95% CI 1.48 to 2.67). Maternal age at delivery over 35 years is a major positive correlate of CS. Beyond this common phenomenon, different distinct lines of socioeconomic and demographic cleavage operate in urban compared with rural areas. The differences regarding the correlates of CS according to the place of residence suggest that specific measures should be taken in each setting to allow women to access childbirth services that are appropriate to their needs. [ABSTRACT FROM AUTHOR]

Background: In the Philippines, one in four pregnancies are unintended and 610 000 unsafe abortions are performed each year. This study explored the association between missed opportunities to provide family planning counseling, quality of counseling and its impact on utilization of effective contraception in the Philippines. Methods: One-hundred-one nationally representative health facilities were randomly selected from five levels of the health system. Sexually-active women 18–49 years old, wanting to delay or limit childbearing, attending primary care clinics between April 24 and August 8, 2017 were included. Data on contraceptive use, counseling and availability were collected using interviews and facility assessments. Effective contraceptive methods were defined as those with rates of unintended pregnancy of less than 10 per 100 women in first year of typical use. Findings: 849 women were recruited of whom 51.1% currently used effective contraceptive methods, 20.6% were former effective method users and 28.3% had never used an effective method. Of 1664 cumulative clinic visits reported by women in the previous year, 72.6% had a missed opportunity to receive family planning counseling at any visit regardless of level of facility, with 83.7% having a missed counseling opportunity on the day of the interview. Most women (55.9%) reported health concerns about modern contraception, with 2.9% receiving counseling addressing their concerns. Only 0.6% of former users and 2.1% never-users said they would consider starting a modern contraceptive in the future. Short and long acting reversible contraceptive methods were available in 93% and 68% of facilities respectively. Conclusions: Missed opportunities to provide family planning counseling are widespread in the Philippines. Delivery of effective contraceptive methods requires that wider legal, policy, social, cultural, and structural barriers are addressed, coupled with systems approaches for improving availability and quality of counseling at all primary health care contacts. [ABSTRACT FROM AUTHOR]

Background: Malaysia is widely credited to have achieved universal health coverage for citizens. However, the accessibility of healthcare services to migrant workers is questionable. Recently, medical fees for foreigners at public facilities were substantially increased. Mandatory health insurance only covers public hospital admissions and excludes undocumented migrants. This study explores barriers to healthcare access faced by documented and undocumented migrant workers in Malaysia. Methods: We use qualitative data from 17 in-depth interviews conducted with key informants from civil society organisations, trade unions, academia, medical professionals, as well as migrant workers and their representatives. We interviewed doctors working in public hospitals and private clinics frequented by migrants. Data were analysed using thematic analysis. Results: We found that healthcare services in Malaysia are often inaccessible to migrant workers. Complex access barriers were identified, many beyond the control of the health sector. Major themes include affordability and financial constraints, the need for legal documents like valid passports and work permits, language barriers, discrimination and xenophobia, physical inaccessibility and employer-related barriers. Our study suggests that government mandated insurance for migrant workers is insufficient in view of the recent increase in medical fees. The perceived close working relationship between the ministries of health and immigration effectively excludes undocumented migrants from access to public healthcare facilities. Language barriers may affect the quality of care received by migrant workers, by inadvertently resulting in medical errors, while preventing them from giving truly informed consent. Conclusions: We propose instituting migrant-friendly health services at public facilities. We also suggest implementing a comprehensive health insurance to enable healthcare access and financial risk protection for all migrant workers. Non-health sector solutions include the formation of a multi-stakeholder migration management body towards a comprehensive national policy on labour migration which includes health. [ABSTRACT FROM AUTHOR]

Persistent barriers to universal access to medicines are limited social protection in the event of illness, inadequate financing for essential medicines, frequent stock-outs in the public sector, and high prices in the private sector. We argue that greater coherence between human rights law, national medicines policies, and universal health coverage schemes can address these barriers. We present a cross-national content analysis of national medicines policies from 71 countries published between 1990–2016. The World Health Organization’s (WHO) 2001 guidelines for developing and implementing a national medicines policy and all 71 national medicines policies were assessed on 12 principles, linking a health systems approach to essential medicines with international human rights law for medicines affordability and financing for vulnerable groups. National medicines policies most frequently contain measures for medicines selection and efficient spending/cost-effectiveness. Four principles (legal right to health; government financing; efficient spending; and financial protection of vulnerable populations) are significantly stronger in national medicines policies published after 2004 than before. Six principles have remained weak or absent: pooling user contributions, international cooperation, and four principles for good governance. Overall, South Africa (1996), Indonesia and South Sudan (2006), Philippines (2011–2016), Malaysia (2012), Somalia (2013), Afghanistan (2014), and Uganda (2015) include the most relevant texts and can be used as models for other settings. We conclude that WHO’s 2001 guidelines have guided the content and language of many subsequent national medicines policies. WHO and national policy makers can use these principles and the practical examples identified in our study to further align national medicines policies with human rights law and with Target 3.8 for universal access to essential medicines in the Sustainable Development Goals. [ABSTRACT FROM AUTHOR]

We systematically review the health-financing mechanisms, revenue rising, pooling, purchasing, and benefits, in the Association of Southeast Asian Nations (ASEAN) and the People’s Republic of China, and their impact on universal health coverage (UHC) goals in terms of universal financial protection, utilization/equity and quality. Two kinds of sources are reviewed: 1) academic articles, and 2) countries’ health system reports. We synthesize the findings from ASEAN countries and China reporting on studies that are in the scope of our objective, and studies that focus on the system (macro level) rather than treatment/technology specific studies (micro level).The results of our review suggest that the main sources of revenues are direct/indirect taxes and out of pocket payments in all ASEAN countries and China except for Brunei where natural resource revenues are the main source of revenue collection. Brunei, Indonesia, Philippines, Malaysia, and Viet Nam have a single pool for revenue collection constituting a national health insurance. Cambodia, China, Lao, Singapore, and Thailand have implemented multiple pooling systems while Myanmar has no formal arrangement. Capitation, Fee-for-Service, DRGs, Fee schedules, Salary, and Global budget are the methods of purchasing in the studied countries. Each country has its own definition of the basic benefit package which includes the services that are perceived as essential for the population health. Although many studies provide evidence of an increase in financial protection after reforming the health-financing mechanisms in the studied countries, inequity in financial protection continue to exist. Overall, the utilization of health care among the poor has increased as a consequence of the implementation of government subsidized health insurance schemes which target the poor in most of the studied countries. Inappropriate policies and provider payment mechanisms impact on the quality of health care provision. We conclude that the most important factors to attain UHC are to prioritize and include vulnerable groups into the health insurance scheme. Government subsidization for this kind of groups is found to be an effective method to achieve this goal. The higher the percentage of government expenditure on health, the greater the financial protection is. At the same time, there is a need to weigh the financial stability of the health-financing system. A unified health insurance system providing the same benefit package for all, is the most efficient way to attain equitable access to health care. Capacity building for both administrative and health service providers is crucial for sustainable and good quality health care. [ABSTRACT FROM AUTHOR]

Background: Donor funding for HIV/AIDS services is declining in Cambodia, and domestic resources need to be mobilized to sustain and expand these services. However, the cost of delivering HIV/AIDS services is not well studied in Cambodia. This study aims to assess the costs of delivering HIV/AIDS services, identify the major components of costs, and sources of funding. Methods: Four of the six highest HIV burden provinces were selected at random for this study. Within each province, four health centers and two hospitals were selected for detailed data collection. A mix of top-down and bottom-up methods were used to assess the costs for HIV testing and antiretroviral therapy (ART) from the provider perspective. We assessed the differences in the quantity and prices of inputs between health facilities of the same type to identify cost-drivers. Results: The average cost per visit for HIV testing was $8.92 at health centers and $14.03 at referral hospitals. Differences in the number of visits per staff were the primary determinant of differences in the cost per visit. First-line ART costed about $250 per patient per year, and the number of patients per staff was an important cost driver. Second-line ART costed from $500 to $716 per patient per year, on average, across the types of facilities, with the quantity and mix of second-line antiretroviral drugs being an important cost driver. Inpatient care at referral and provincial hospitals in total represented less than 2 percent of costs of outpatient ART. Discussion: Costs are similar to neighboring countries, but over 50% of the costs of ART are financed by donors. Cambodia now is scaling up social health insurance coverage; the data from this study could serve as one input when setting reimbursement rates for HIV/AIDS services to help ensure that providers are adequately reimbursed for their services. [ABSTRACT FROM AUTHOR]