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Background: The transformation from the quantity of labor supply to the quality of labor supply is an important measure to improve the self-development of migrant workers. Method: Based on the 2018 China Floating Population Dynamic Monitoring Survey data, this paper uses the 2SLS model based on instrumental variable estimation to analyze the impact of urban and rural integrated medical insurance on the quality of migrant workers' labor supply. Results: The study found that: First, urban and rural integrated medical insurance can significantly improve the quality of labor supply for migrant workers. Even with different instrumental variables and the use of propensity score matching for counterfactual inferences, the findings remain robust. Second, the impact of urban–rural integrated medical insurance on the quality of labor supply for migrant workers has nonlinear characteristics. At the low quantile, the impact of urban–rural integrated medical insurance on the quality of labor supply for migrant workers showed a downward trend, but with the increase of the quantile, the impact of urban and rural integrated medical insurance continued to increase, showing a U-shaped trend. Conclusion: Urban–rural integrated medical insurance can not only directly reduce the labor time of migrant workers and ease the labor burden of migrant workers, but also indirectly improve the quality of labor supply for migrant workers through the intermediary role of promoting the availability of public services such as family contracted doctor services and health education. [ABSTRACT FROM AUTHOR]

Background: Publicly Funded Health Insurance Schemes (PFHIS) are intended to play a role in achieving Universal Health Coverage (UHC). In countries like India, PFHISs have low penetrance and provide limited coverage of services and of family members within households, which can mean that women lose out. Gender inequities in relation to financial risk protection are understudied. Given the emphasis being placed on achieving UHC for all in India, this paper examined intersecting gender inequalities and changes in PFHIS coverage in southern India, where its penetrance is greater and of longer duration. Data and methods: This study used the fourth (NFHS-4, 2015–16) and fifth (NFHS-5, 2019–21) rounds of India's National Family Health Survey for five southern states: namely, Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, and Telangana. The World Health Organization's Health Equity Assessment Toolkit (HEAT) Plus and Stata were used to analyse PFHIS coverage disaggregated by seven dimensions of inequality. Ratios and differences for binary dimensions; Between Group Variance and Theil Index for unordered dimensions; Absolute and Relative Concentration Index (RCI) for ordered dimensions were computed separately for women and men. Results: Overall, PFHIS coverage increased significantly (p < 0.001) among women and men in Andhra Pradesh, and Kerala from NFHS-4 to NFHS-5. Overall, men had higher PFHIS coverage than women, especially in Andhra Pradesh, Tamil Nadu, and Telangana in both surveys. In both absolute and relative terms, PFHIS coverage was concentrated among older women and men across all states; age-related inequalities were higher among women than men in both surveys in Andhra Pradesh, Kerala, and Telengana. The magnitude of education-related inequalities was twice as high as among women in Telangana (RCINFHS-4: -12.23; RCINFHS-5: -9.98) and Andhra Pradesh (RCINFHS-4: -8.05; RCINFHS-5: -7.84) as compared to men in Telangana (RCINFHS-4: -5.58; RCINFHS-5: -2.30) and Andhra Pradesh (RCINFHS-4: -4.40; RCINFHS-5: -3.12) and these inequalities remained in NFHS-5, suggesting that lower education level women had greater coverage. In the latter survey, a high magnitude of wealth-related inequality was observed in women (RCINFHS-4: -15.78; RCINFHS-5: -14.36) and men (RCINFHS-4: -20.42; RCINFHS-5: -13.84) belonging to Kerala, whereas this inequality has decreased from NFHS-4 to NFHS-5., again suggestive of greater coverage among poorer populations. Caste-related inequalities were higher in women than men in both surveys, the magnitude of inequalities decreased between 2015–16 and 2019–20. Conclusions: We found gender inequalities in self-reported enrolment in southern states with long-standing PFHIS. Inequalities favoured the poor, uneducated and elderly, which is to some extend desirable when rolling out a PFHIS intended for harder to reach populations. However, religion and caste-based inequalities, while reducing, were still prevalent among women. If PFHIS are to truly offer financial risk protection, they must address the intersecting marginalization faced by women and men, while meeting eventual goals of risk pooling, indicated by high coverage and low inequality across population sub-groups. [ABSTRACT FROM AUTHOR]

Background: The continuing impetus for universal health coverage has given rise to publicly funded health insurance schemes in lower-middle income countries. However, there is insufficient understanding of how universal health coverage schemes impact gender equality and equity. This paper attempts to understand why utilization of a publicly funded health insurance scheme has been found to be lower among women compared to men in a southern Indian state. It aims to identify the gender barriers across various social institutions that thwart the policy objectives of providing financial protection and improved access to inpatient care for women.Methods: A qualitative study on the Chief Minister's Comprehensive Health Insurance Scheme was carried out in urban and rural impoverished localities in Tamil Nadu, a southern state in India. Thirty-three women and 16 men who had a recent history of hospitalization and 14 stakeholders were purposefully interviewed. Transcribed interviews were content analyzed based on Naila Kabeer's Social Relations Framework using gender as an analytical category.Results: While unpacking the navigation pathways of women to utilize publicly funded health insurance to access inpatient care, gender barriers are found operating at the household, community, and programmatic levels. Unpaid care work, financial dependence, mobility constraints, and gender norms emerged as the major gender-specific barriers arising from the household. Exclusions from insurance enrollment activities at the community level were mediated by a variety of social inequities. Market ideologies in insurance and health, combined with poor governance by State, resulted in out-of-pocket health expenditures, acute information asymmetry, selective availability of care, and poor acceptability. These gender barriers were found to be mediated by all four institutions-household, community, market, and State-resulting in lower utilization of the scheme by women.Conclusions: Health policies which aim to provide financial protection and improve access to healthcare services need to address gender as a crucial social determinant. A gender-blind health insurance can not only leave many pre-existing gender barriers unaddressed but also accentuate others. This paper stresses that universal health coverage policy and programs need to have an explicit focus on gender and other social determinants to promote access and equity. [ABSTRACT FROM AUTHOR]

Background: Over 150 million people, mostly from low and middle-income countries (LMICs) suffer from catastrophic health expenditure (CHE) every year because of high out-of-pocket (OOP) payments. In Tanzania, OOP payments account for about a quarter of the total health expenditure. This paper compares healthcare utilization and the incidence of CHE among improved Community Health Fund (iCHF) members and non-members in central Tanzania. Methods: A survey was conducted in 722 households in Bahi and Chamwino districts in Dodoma region. CHE was defined as a household health expenditure exceeding 40% of total non-food expenditure (capacity to pay). Concentration index (CI) and logistic regression were used to assess the socioeconomic inequalities in the distribution of healthcare utilization and the association between CHE and iCHF enrollment status, respectively. Results: 50% of the members and 29% of the non-members utilized outpatient care in the previous month, while 19% (members) and 15% (non-members) utilized inpatient care in the previous twelve months. The degree of inequality for utilization of inpatient care was higher (insured, CI = 0.38; noninsured CI = 0.29) than for outpatient care (insured, CI = 0.09; noninsured CI = 0.16). Overall, 15% of the households experienced CHE, however, when disaggregated by enrollment status, the incidence of CHE was 13% and 15% among members and non-members, respectively. The odds of iCHF-members incurring CHE were 0.4 times less compared to non-members (OR = 0.41, 95%CI: 0.27–0.63). The key determinants of CHE were iCHF enrollment status, health status, socioeconomic status, chronic illness, and the utilization of inpatient and outpatient care. Conclusion: The utilization of healthcare services was higher while the incidence of CHE was lower among households enrolled in the iCHF insurance scheme relative to those not enrolled. More studies are needed to establish the reasons for the relatively high incidence of CHE among iCHF members and the low degree of healthcare utilization among households with low socioeconomic status. [ABSTRACT FROM AUTHOR]

Background: Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). While evidence suggests that SHI is a promising strategy for achieving UHC, low-income countries often struggle to implement and sustain SHI systems. It is therefore important to understand how SHI enrollees use health insurance and how it affects their health-seeking behavior. This paper examines how SHI affects patient decision-making regarding when and where to seek care in Kenya and Ghana, two countries with established SHI systems in sub-Saharan Africa.Methods: This paper draws from two datasets collected under the African Health Markets for Equity (AHME) program. One dataset, collected in 2013 and 2017 as part of the AHME qualitative evaluation, consists of 106 semi-structured clinic exit interviews conducted with patients in Ghana and Kenya. This data was analyzed using an inductive, thematic approach. The second dataset was collected internally by the AHME partner organizations. It derives from a cross-sectional survey of social franchise clients at three social franchise networks supported by AHME. Data collection took place from February - May 2018 and in December 2018.Results: Many clients appreciated that insurance coverage made healthcare more affordable, reported seeking care more frequently when covered with SHI. Clients also noted that the coverage gave them access to a wider variety of providers, but rarely sought out SHI-accredited providers specifically. However, clients sometimes were charged for services that should have been covered by insurance. Due to a lack of understanding of SHI benefits, clients rarely knew they had been charged inappropriately.Conclusions: Clients and providers would benefit from education on what is included in the SHI package. Providers should be monitored and held accountable for charging clients inappropriately; in Ghana this should be accompanied by reforms to make government financing for SHI sustainable. Since clients valued provider proximity and both Kenya and Ghana have a dearth of providers in rural areas, both countries should incentivize providers to work in these areas and prioritize accrediting rural facilities into SHI schemes to increase accessibility and reach. [ABSTRACT FROM AUTHOR]

An increasingly number of low- and middle-income countries have developed and implemented a national policy towards universal coverage of healthcare for their citizens over the past decade. Among them is China which has expanded its population coverage by health insurance from around 29.7% in 2003 to over 90% at the end of 2010. While both central and local governments in China have significantly increased financial inputs into the two newly established health insurance schemes: new cooperative medical scheme (NCMS) for the rural population, and urban resident basic health insurance (URBMI), the cost of healthcare in China has also been rising rapidly at the annual rate of 17.0%% over the period of the past two decades years. The total health expenditure increased from 74.7 billion Chinese yuan in 1990 to 1998 billion Chinese yuan in 2010, while average health expenditure per capital reached the level of 1490.1 Chinese yuan per person in 2010, rising from 65.4 Chinese yuan per person in 1990. The repaid increased population coverage by government supported health insurance schemes has stimulated a rising use of healthcare, and thus given rise to more pressure on cost control in China. There are many effective measures of supply-side and demand-side cost control in healthcare available. Over the past three decades China had introduced many measures to control demand for health care, via a series of copayment mechanisms. The paper introduces and discusses new initiatives and measures employed to control cost escalation of healthcare in China, including alternative provider payment methods, reforming drug procurement systems, and strengthening the application of standard clinical paths in treating patients at hospitals, and analyses the impacts of these initiatives and measures. The paper finally proposes ways forward to make universal health coverage in China more sustainable. [ABSTRACT FROM AUTHOR]

Background: Understanding the health policy formulation process over the years has focused on the content of policy to the neglect of context. This had led to several policy initiatives having a still birth or ineffective policy choices with sub-optimal outcomes when implemented. Sometimes, the difficulty has been finding congruence between different values and interests of the various stakeholders. How can policy initiators leverage the various subtle mechanisms that various players draw on to leverage their interests during policy formulation. This paper attempts to conceptualise these levers of policy formulation to enhance an understanding of this field of work based on lived experience. Methodology: This is a qualitative participant observation case study based on retrospective recollection of the policy process and political levers involved in developing the Ghana National Health Insurance Scheme. The study uses a four-concept framework which is agenda setting, symbols manipulation, constituency preservation and coalition building to capture the various issues, negotiations and nuanced approaches used in arriving at desired outcomes. Results: Technical experts, civil society, academicians and politicians all had significant influence on setting the health insurance agenda. Each of these various stakeholders carefully engaged in ways that preserved their constituency interests through explicit manoeuvres and subtle engagements. Where proposals lend themselves to various interpretations, stakeholders were quick to latch on the contentious issues to preserve their constituency and will manipulate the symbols that arise from the proposals to their advantage. Where interests are contested and the price of losing out will leave government worse off which will favour its political opponent, it will push for divergent interests outside parliamentary politics through intense negotiations to build coalitions so a particular policy may pass. Conclusions: This paper has examined the policy environment and the political leverages in retrospect at arriving at Ghana's health insurance policy and design. New perspectives have been brought to the dynamics of the interactions of the 3 streams of problem, policy and politics. It provides lessons which suggest that in understanding the policy process, it is important that actors engage with the content as well as the context to understand viewpoints that may be expressed by interest groups. This will empower policy proponents to achieve easier results and limit the frustrations associated with the policy process. There are no straight and determined pathways for achieving outcomes so appreciating the evidence and basis for design, negotiation process and building coalitions along the way are skills to be mastered. [ABSTRACT FROM AUTHOR]

Background: Out of pocket payments are the predominant method of financing healthcare in many developing countries, which can result in impoverishment and financial catastrophe for those affected. In 2010, WHO estimated that approximately 100 million people are pushed below the poverty line each year by payments for healthcare. Micro health insurance (MHI) has been used in some countries as means of risk pooling and reducing out of pocket health expenditure. A systematic review was conducted to assess the extent to which MHI has contributed to providing financial risk protection to low-income households in developing countries, and suggest how the findings can be applied in the Pakistani setting.Methods: We conducted a systematic search for published literature using the search terms "Community based health insurance AND developing countries", "Micro health insurance AND developing countries", "Mutual health insurance AND developing countries", "mutual OR micro OR community based health insurance" "Health insurance AND impact AND poor" "Health insurance AND financial protection" and "mutual health organizations" on three databases, Pubmed, Google Scholar and Science Direct (Elsevier). Only those records that were published in the last ten years, in English language with their full texts available free of cost, were considered for inclusion in this review. Hand searching was carried out on the reference lists of the retrieved articles and webpages of international organizations like World Bank, World Health Organization and International Labour Organization.Results: Twenty-three articles were eligible for inclusion in this systematic review (14 from Asia and 9 from Africa). Our analysis shows that MHI, in the majority of cases, has been found to contribute to the financial protection of its beneficiaries, by reducing out of pocket health expenditure, catastrophic health expenditure, total health expenditure, household borrowings and poverty. MHI also had a positive safeguarding effect on household savings, assets and consumption patterns.Conclusion: Our review suggests that MHI, targeted at the low-income households and tailored to suit the cultural and geographical structures in the various areas of Pakistan, may contribute towards providing protection to the households from catastrophe and impoverishment resulting from health expenditures. This paper emphasizes the need for further research to fill the knowledge gap that exists about the impact of MHI, using robust study designs and impact indicators. [ABSTRACT FROM AUTHOR]

Background: Women who have migrated often encounter difficulties in accessing healthcare and experience inequitable sexual and reproductive health outcomes in destination countries. These health inequities include contraceptive access and use. To better understand what influences contraceptive access and use, this scoping review set out to synthesize the evidence on contraceptive access and use and on associated interventions among women with migratory experience in high-income countries (HICs) in Europe, North America and Australasia. Methods: The scientific databases PubMed, Web of Science and CINAHL were searched for peer-reviewed quantitative, qualitative and mixed method articles published between January 2000 and June 2023. Articles were included if they reported on studies exploring contraceptive use to prevent pregnancies among women of reproductive age with migratory experience living in HICs. Two researchers independently screened and extracted data from the articles. Findings were categorized by patient and health system level factors according to Levesque et al.'s framework of access to health care. Results: A total of 68 articles were included, about half (n = 32) from North America. The articles focused on the individual level rather than the health system level, including aspects such as women's contraceptive knowledge, the influence of culture and religion on accessing and using contraception, partner involvement, and differing health insurance coverage. On the health system level, the articles highlighted lack of information on contraceptive services, cultural (in)adequacy of services and communication aspects, contraceptives' side effects, as well as geographic availability and cost of services. The review further identified three articles reporting on interventions related to contraceptive counselling. Conclusions: There is a lack of knowledge regarding how health systems impose obstacles to contraceptive services for women with migratory experience on an organizational level, as research has focused heavily on the individual level. This review's findings may serve as a foundation for further research and advances in policy and practice, specifically recommending early provision of health system related information and contraceptive education, engagement of male partners in contraceptive discourses, cultural competency training for healthcare professionals, and strengthening of interpretation services for contraceptive counselling. [ABSTRACT FROM AUTHOR]

Introduction: Identifying and exploiting stewardship and financing challenges in Iran's health insurance system as an ecosystem is essential to achieving predetermined goals. This study aimed to determine the challenges and strategies in the Iranian health insurance ecosystem to provide relevant evidence to healthcare managers and policymakers to improve its functions and perform necessary reforms. Method: This qualitative study was conducted at the national level in Iran. Data were collected using semi-structured interviews and analyzed using the directed content analysis method. The study participants included managers and experts in health insurance and faculty of universities of medical sciences, who were selected by purposive sampling. Results: The challenges and strategies expressed by participants were categorized into two functions: stewardship and financing. Four main themes, ten subthemes, 22 challenges, and 24 strategies were identified in the stewardship function, along with three main themes, 12 subthemes, 17 challenges, and 16 strategies in the financing function. The major challenge in the Iranian health insurance ecosystem was the complexity and conflict of interests between multiple actors with different roles, which led to fragmentation, diverse structures, and a gap between other functions and objectives, hindering the effective functioning of the ecosystem. Conclusion: In order to deal with the challenges of the health insurance ecosystem, it is suggested to create a coherent insurance system through a single utility system, and by paying more attention to health-oriented services, the health insurance ecosystem becomes a health-oriented system instead of being treatment-oriented. In addition, in order to strengthen the governance of the country's health insurance ecosystem, the number of actors with multiple roles should be reduced and the roles of the actors should be clarified and separated in order to prevent conflicts of interest and structural corruption in this ecosystem. [ABSTRACT FROM AUTHOR]

Introduction: Hypertension is highly prevalent in India, but the proportion of patients achieving blood pressure control remains low. Efforts have been made to expand health insurance coverage nationwide with the aim of improving overall healthcare access. It is critical to understand the role of health insurance coverage in improving hypertension care. Methods: We used secondary data from the nationally representative sample of adults aged 15–49 years from the 2015–2016 National Family Health Survey (NFHS) in India. We defined the hypertension care cascade as four successive steps of (1) screened, (2) diagnosed, (3) treated, and (4) controlled, and operationalized these variables using blood pressure measurements and self-reports. We employed household fixed effect models that conceptually matched people with and without insurance within the household, to estimate the impact of insurance coverage on the likelihood of reaching each care cascade step, while controlling for a wide range of additional individual-level variables. Results: In all 130,151 included individuals with hypertension, 20.4% reported having health insurance. For the insured hypertensive population, 79.8% (95% Confidence Interval: 79.3%-80.3%) were screened, 49.6% (49.0%-50.2%) diagnosed, 14.3% (13.9%-14.7%) treated, and 7.9% (7.6%-8.2%) controlled, marginally higher than the percentages for the uninsured 79.8% (79.5%-80.0%), 48.2% (47.9%-48.6%), 13.3% (13.1%-13.5%), and 7.5% (7.4%-7.7%) for each cascade step, respectively. From the household fixed effects model, health insurance did not show significant impact on the hypertension care cascade, with the estimated relative risks of health insurance 0.97 (0.93–1.02), 0.97 (0.91–1.03), 0.95 (0.77–1.30), and 0.97 (0.65–1.10) for each cascade step, respectively. We further performed stratified analyses by sociodemographic and behavioral risk factors and a sensitivity analysis with district fixed effects, all of which yielded results that confirmed the robustness of our main findings. Conclusions: Health insurance did not show significant impact on improving hypertension care cascade among young and middle-aged adults with hypertension in India. Innovative strategies for overcoming practical barriers to healthcare services in addition to improving financial access are needed to address the large unmet need for hypertension care. [ABSTRACT FROM AUTHOR]

Background: Workplace cancer screening programs are determined as part of an employee's benefits package and health checkups are perceived positively. However, the current status of workplace cancer screening programs in Japan is unavailable. This study aimed to assess the adherence to national guidelines for colorectal, breast, and cervical cancer screenings in the workplace among Japanese enterprises and identify factors associated with excessive or inadequate screenings. Methods: A cross-sectional study design was employed. Data were obtained from a survey conducted by the "Corporate Action to Promote Cancer Control" between November and December 2022 among registered partner enterprises in Japan. The survey included questions on background characteristics, cancer screening practices, and intervention approaches. The analysis included 432 enterprises that provided complete responses regarding colorectal, breast, and cervical cancer screenings. Results: The guideline-adherence rates for colorectal, breast, and cervical cancer screenings in the workplace were 12.7%, 3.0%, and 8.8%, respectively. Enterprises had lower adherence to screening guidelines than local governments. Colorectal (70.8%) and breast (67.1%) cancer screenings were predominantly categorized as "overscreening" and cervical (60.6%) cancer screening, as "underscreening." Factors such as enterprise scale, health insurance associations, and the number of interventional approaches were significantly associated with increased "overscreening" (101–1000: β = 0.13, p = 0.01; ≥ 1000: β = 0.17, p < 0.01; health insurance association: β = 0.23, p < 0.01; and approaches: β = 0.42, p < 0.01) and reduced "underscreening" (101–1000: β = -0.13, p = 0.01; ≥ 1000: β = -0.17, p < 0.01; health insurance association: β = -0.18, p < 0.01; and approaches: β = -0.48, p < 0.01). Conclusion: Adherence to national guidelines for colorectal, breast, and cervical cancer screenings in the workplace was suboptimal among Japanese enterprises. Therefore, appropriate cancer screening measures and interventions to ensure guideline adherence and optimization of screening benefits while minimizing potential harms should be expeditiously implemented. [ABSTRACT FROM AUTHOR]

Background: Malaria is Ghana's most endemic disease; occurring across most parts of the country with a significant impact on individuals and the health system as whole. Treatment seeking for malaria care takes various forms. The National Health Insurance Scheme (NHIS) was introduced in 2004 to promote access to health services to mitigate the negative impact of the user fee regime. Ten years on, national coverage is less than 40% of the total population and patients continue to make direct payments for health services. This paper analyses the care-seeking behaviour of households for treatment of malaria in Ghana under the NHI policy. Method: Using a cross-sectional survey of household data collected from three districts in Ghana covering the 3 ecological zones namely the coastal, forest and savannah, a multinomial logit model is estimated. The sample consists of 365 adults and children reporting being ill with malaria in the last four weeks prior to the study. Results: Out of the total, 58% were insured and 71% of them sought care from a formal health facility. Among the insured, 15% chose informal care compared to 48% among the uninsured. The results from the multinomial logit estimations show that health insurance and travel time to health facility are significant determinants of health care demand. The results show that the insured are 6 times more likely to choose regional/district hospitals: 5 times more likely to choose health centres/clinics and 7 times more likely to choose private hospitals/clinics over informal care when compared with the uninsured. Individual characteristics such as age, education and wealth status were significant determinants of health care provider choice for specific categories of health facilities. Conclusion: Overall, for malaria care the uninsured are more likely to choose informal care compared to the insured for the treatment of malaria. [ABSTRACT FROM AUTHOR]

Background: The Family Physician Programme is a key health reform in Iran that faces significant challenges in urban areas, particularly in Mazandaran and Fars provinces The study aims to critically evaluate the challenges encountered in the Urban Family Physician Program, with a particular focus on the perspectives of insurance organizations. Methods: A qualitative approach was adopted, involving semi-structured interviews with 22 experts and managers from basic health insurance funds. Snowball sampling facilitated participant selection, and interviews proceeded until saturation. Data analysis utilized content analysis and Atlas-T software, adhering to COREQ criteria. Results: Implementation problems of the urban family physician program were categorized into ten Categories and 22 Subcategories, including financing, stewardship, human resources, structure, culture, information system, payment, monitoring and control, the function of insurance organizations, and implementation. Conclusion: The urban family physician program's implementation challenges, as viewed by health insurance organizations, underscore the necessity for strategic decision-making in financing, payment models, electronic system integration, structural adjustments, comprehensive monitoring, evaluation, cultural considerations, and appropriate devolution to insurance entities. [ABSTRACT FROM AUTHOR]

Background: Health-seeking behavior (HSB) involves any action or inaction taken by individuals who perceive themselves to have a health problem or illness aimed at finding appropriate medical treatments. Studies suggest a positive relationship between the availability and quality of health services and their utilization. This study aimed to identify the factors influencing health-seeking behavior among Sudanese immigrants in Saudi Arabia, to improve healthcare access and health outcomes. Method: A cross-sectional study was conducted targeting Sudanese residents of the Kingdom of Saudi Arabia (KSA). Participants were recruited using convenient sampling. A self-administered questionnaire was distributed electronically. A total of 494 participants were recruited for the study. Results: This study showed that the majority of the participants (66.6%) visited a primary healthcare center when faced with a medical problem. However, the prevalence of self-medication in the past three months was 45.7%. Significant factors influencing health-seeking behavior included age (OR [95% CI]: 1.032 [1.000-1.066]) and lack of health insurance (OR = 1.01, 95% CI [1.00-1.02], p = 0.019). Conclusions: This study emphasizes the importance of understanding healthcare-seeking behavior among immigrant groups, particularly Sudanese immigrants in Saudi Arabia. It highlights the significance of insurance as a determinant of healthcare-seeking behavior and calls for reforming current policies to reduce disparities in accessing healthcare services. [ABSTRACT FROM AUTHOR]

Background: Migrants have complex health needs but face multiple barriers to accessing health care. In France, permanent healthcare access offices (PASSs), as specific primary health care facilities (SPHCs), provide care to people without health insurance coverage. Once these patients obtain health insurance, they are referred to common ambulatory general practice. The aim of this study was to explore migrants' experiences and strategies for seeking common primary care after having been treated by an SPHC. Methods: We conducted a qualitative study based on grounded theory between January and April 2022. We held semi-structured interviews with migrants who had consulted a PASS. Two researchers performed an inductive analysis. Results: We interviewed 12 migrants aged 22 to 65 to confirm data saturation. The interviewees relied on "referents": professional referents (to be properly treated for specific health problems), guides (to find their way through the healthcare system), or practical referents (to address practical issues such as translation, travel needs, or medical matters). Those who considered the PASS to be a referent expressed disappointment and incomprehension at the time of discharge. Referral procedures and the first encounter with common ambulatory general practice were decisive in whether the interviewees accessed and stayed in a coordinated primary care pathway. The perceived quality of care depended on a feeling of being considered and listened to. For interviewees who received first-time services from an ambulatory general practice, the way in which they were referred to and their first experience with an ambulatory GP could influence their adherence to care. Conclusions: The conditions of transition from SPHCs to common ambulatory general practice can impact migrants' adherence to a coordinated primary care pathway. Referral can improve these patients' care pathways and ease the transition from a PASS to ambulatory care. Healthcare professionals at SPHCs should pay special attention to vulnerable migrants without previous experience in ambulatory general practice and who depend on referents in their care pathways. For these patients, adapted referral protocols with further individual support and empowerment should be considered. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular diseases (CVDs) are the leading cause of death in Indonesia, accounting for 38% of the total mortality in 2019. Moreover, healthcare spending on CVDs has been at the top of the spending under the National Health Insurance (NHI) implementation. This study analyzed the association between the presence of CVDs with or without other chronic disease comorbidities and healthcare costs among adults (> 30 years old) and if the association differed between NHI members in the subsidized group (poorer) and non-subsidized households group (better-off) in Indonesia. Methods: This retrospective cohort study analyzed the NHI database from 2016–2018 for individuals with chronic diseases (n = 271,065) ascertained based on ICD-10 codes. The outcome was measured as healthcare costs in USD value for 2018. We employed a three-level multilevel linear regression, with individuals at the first level, households at the second level, and districts at the third level. The outcome of healthcare costs was transformed with an inverse hyperbolic sine to account for observations with zero costs and skewed data. We conducted a cross-level interaction analysis to analyze if the association between individuals with different diagnosis groups and healthcare costs differed between those who lived in subsidized and non-subsidized households. Results: The mean healthcare out- and inpatient costs were higher among patients diagnosed with CVDs and multimorbidity than patients with other diagnosis groups. The predicted mean outpatient costs for patients with CVDs and multimorbidity were more than double compared to those with CVDs but no comorbidity (USD 119.5 vs USD 49.1, respectively for non-subsidized households and USD 79.9 vs USD 36.7, respectively for subsidized households). The NHI household subsidy status modified relationship between group of diagnosis and healthcare costs which indicated a weaker effect in the subsidized household group (β = -0.24, 95% CI -0.29, -0.19 for outpatient costs in patients with CVDs and multimorbidity). At the household level, higher out- and inpatient costs were associated with the number of household members with multimorbidity. At the district level, higher healthcare costs was associated with the availability of primary healthcare centres. Conclusions: CVDs and multimorbidity are associated with higher healthcare costs, and the association is stronger in non-subsidized NHI households. Households' subsidy status can be construed as indirect socioeconomic inequality that hampers access to healthcare facilities. Efforts to combat cardiovascular diseases (CVDs) and multimorbidity should consider their distinct impacts on subsidized households. The effort includes affirmative action on non-communicable disease (NCD) management programs that target subsidized households from the early stage of the disease. [ABSTRACT FROM AUTHOR]

Background: The study uncovers micro and macro socioeconomic disparities in terms of health behavior, disease perception, and reception of information. Furthermore, findings shed light on the possible role of health insurance on access to information, disease perception and the adoption of preventive behaviors in the context of a public health emergency such as the COVID-19 pandemic. Methods: This study employed a cross-sectional design using the Philippine Demographic and Health Survey (DHS). With a total of 29,809 respondents, it evaluated the individual or household and systemwide socioeconomic determinants of four different outcomes: receipt of information, disease perception, uptake of free preventive services, and treatment-seeking behavior. In addition to logistic regression models with the socioeconomic variables as the independent variables, models for the evaluation of the moderating effect of insurance ownership were fitted. Predicted probabilities were reported for the analysis of moderating effects. Results: Findings show that individual and householdsocioeconomic determinants affected health-behavior and access to or receipt of information pertinent to the COVID-19 pandemic. Both education and wealth affected the receipt of information such that individuals in more advantaged socioeconomic positions were at least 30% more likely to have received information on COVID-19. Wealth was also associated to treatment-seeking behavior. Regional differences were seen across all dependent variables. Moreover, the study provides evidence that ownership of insurance can close education-based gaps in the uptake of free vaccination and COVID-19 testing. Conclusion: It is imperative that targeted efforts be maximized by utilizing existing strategies and mechanisms to reach the marginalized and disadvantaged segments of the population. Health insurance may give off added benefits that increase proficiency in navigating through the healthcare system. Further research may focus on examining pathways by which health insurance or social policies may be used to leverage responses to public health or environmental emergencies. [ABSTRACT FROM AUTHOR]

Background: Functional disability is an emerging public health concern that has an impact on the health and quality of life of older adults. If functional disability recognized early, it will be possible to support them to live independently. Although functional disability is extensively researched in developed countries; studies are scarce in Sub-Saharan Africa, particularly Ethiopia. Therefore, this study aims to assess the prevalence and associated factors of functional disability in activities of daily living among older adults in Gondar town, Ethiopia. Methods: A community-based cross-sectional study was conducted from April to June 2022. Multistage sampling techniques were used to recruit 607 older adults aged 60 years and older. A pre-tested interview-administered questionnaire was used to assess functional disability in basic activities of daily living and instrumental activities of daily living using the Katz Index and Lawton scale, respectively. Bivariate and multivariable logistic regression models were employed. The findings of the study were presented by descriptive statistics and an adjusted odds ratio with 95% CI was used to determine statistical significance. Results: The prevalence of functional disability in basic activities of daily living and instrumental activities of daily living among older adults was 34.5% and 54.4, respectively. Age 80 and older [AOR = 2.41, CI (1.41–4.10)], low-income status [AOR = 2.58, CI (1.50–4.46)], multimorbidity [AOR = 2.97, CI (1.92–4.60)], depression [AOR = 2.97, CI (1.63–5.40)], and low level of physical activity [AOR = 3.31, CI (2.11–5.17)] were associated with basic activities of daily living. Age 80 and older (AOR = 3.11, CI = 1.94-5.00), multimorbidity [AOR = 3.06, CI (2.10–4.46)], and depression [AOR = 3.52, CI (2.10–4.46)] were associated with instrumental activities of daily living. Conclusion and recommendations: Our study finding revealed that functional disability affects a large number of older adult residents. The age group of 80 years and older, low-income status, a low level of physical activity, multimorbidity, and depression were associated with basic and instrumental activities of daily living. Therefore, health interventions designed to increase older adults' level of physical activity, management of multimorbidity, and depression, more care for elders 80 years and older, and supporting older adults financially for health insurance coverage could be an important strategy to reduce functional disability among older adults. [ABSTRACT FROM AUTHOR]

Background: General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification. Methods: Qualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke's thematic analysis approach. Results: Our results indicate that GPs' sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs' opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs' available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence. Conclusion: Our study suggests that GPs' decisions about sickness certification is largely driven by patient preferences. The GPs' gatekeeping function is limited to negotiations about grade and duration of absence spells. [ABSTRACT FROM AUTHOR]

Background: Prolonged sitting is ubiquitous in modern society and linked to several diseases. Height-adjustable desks are being used to decrease worksite based sitting time (ST). Single-desk sit-to-stand workplaces exhibit small ST reduction potential and short-term loss in performance. The aim of this paper is to report the study design and methodology of an ACTIVE OFFICE trial.Design: The study was a 1-year three-arm, randomized controlled trial in 18 healthy Austrian office workers. Allocation was done via a regional health insurance, with data collection during Jan 2014 - March 2015. Participants were allocated to either an intervention or control group. Intervention group subjects were provided with traditional or two-desk sit-to-stand workstations in either the first or the second half of the study, while control subjects did not experience any changes during the whole study duration. Sitting time and physical activity (IPAQ-long), cognitive performance (text editing task, Stroop-test, d2R test of attention), workload perception (NASA-TLX) and physiological parameters (salivary cortisol, heartrate variability and body weight) were measured pre- and post-intervention (23 weeks after baseline) for intervention and control periods. Postural changes and sitting/standing time (software logger) were recorded at the workplace for the whole intervention period.Discussion: This study evaluates the effects of a novel two-desk sit-to-stand workplace on sitting time, physical parameters and work performance of healthy office based workers. If the intervention proves effective, it has a great potential to be implemented in regular workplaces to reduce diseases related to prolonged sitting.Trial Registration: ClinicalTrials.gov Identifier: NCT02825303 , July 2016 (retrospectively registered). [ABSTRACT FROM AUTHOR]

An amendment to this paper has been published and can be accessed via the original article. [ABSTRACT FROM AUTHOR]

As the main force and practice subject of rural revitalisation, farmers' health is intricately linked to agricultural production and the rural economy. This study utilizes open data from the 2015 China Nutrition and Health Survey and employs the Least Absolute Shrinkage and Selection Operator (LASSO) method to explore the factors influencing farmers' self-assessment of health. The findings reveal that education level, proactive nutrition knowledge seeking, healthy dietary preferences and habits, and the use of clean cooking fuel positively impact farmers' health self-assessment. Conversely, age, history of illness or injury, and participation in medical insurance negatively affect their self-assessment. Furthermore, factors influencing farmers' health self-assessment exhibit heterogeneity across regions. Our findings suggest that promoting health education, disseminating nutritional dietary knowledge, and enhancing rural household infrastructure play an important role in improving farmers' self-evaluation of health. Therefore, policymakers should design more targeted health interventions and infrastructure improvement plans based on farmers' self-assessment of health and the level of regional economic development. [ABSTRACT FROM AUTHOR]

Purpose: Medical insurance fraud has caused huge losses to countries around the world, and public reporting has become an important means to combat medical insurance fraud. The attitude of medical insurance fraud whistleblowers affects people's reporting behavior, and understanding people's attitude toward medical insurance fraud whistleblowers provides a basis for further improving the system and policy of public participation in medical insurance fund supervision. Methods: We adopted the questionnaire method to conduct a national cross-sectional survey of the Chinese public and analyzed the data using Chi-square tests, Fisher's exact tests, and binary logistic regression models. Results: A total of 837 respondents were included, and 81.8% of the population had a supportive attitude toward medical insurance fraud whistleblowers, with gender, whether they had used medical insurance reimbursement, and present life satisfaction being statistically significant (P < 0.05). Conclusion: The public is generally supportive of medical insurance fraud whistleblowers, and women, those who have used medical insurance for reimbursement, and those who are satisfied with their lives are more likely to be supportive of medical insurance fraud whistleblowers. [ABSTRACT FROM AUTHOR]

Introduction: Young and middle-aged people are important participants in the fight against health insurance fraud. The study aims to investigate the differences in their willingness to report health insurance fraud and the factors influencing it when it occurs in familiar or unfamiliar healthcare settings. Methods: Data were obtained from a validated questionnaire from 828 young and middle-aged people. McNemar's test was used to compare the public's willingness to report under the two scenarios. Chi-square tests and multiple logistic regression analysis were used to analyze the determinants of individuals' willingness to report health insurance fraud in different scenarios. Results: Young and middle-aged people were more likely to report health insurance fraud in a familiar healthcare setting than in an unfamiliar one (McNemar's χ²=26.51, P < 0.05). Their sense of responsibility for maintaining the security of the health insurance fund, the government's openness about fraud cases, and the perception of their ability to report had significant positive effects on the public's willingness to report in both settings (P < 0.05). In a familiar healthcare setting, the more satisfied the public is with government measures to protect whistleblowers, the more likely they are to report (OR = 1.44, P = 0.025). Those who perceive the consequences of health insurance fraud to be serious are more likely to report than those who perceive the consequences to be less serious (OR = 1.61, P = 0.042). Conclusion: Individuals are more likely to report health insurance fraud in familiar healthcare settings than in unfamiliar ones, in which their awareness of the severity of the consequences of health insurance fraud and their perceived risk after reporting it play an important role. The government's publicizing of fraud cases and enhancing the public's sense of responsibility and ability to maintain the safety of the health insurance fund may be a way to increase their willingness to report, regardless of whether they are familiar with the healthcare setting or not. [ABSTRACT FROM AUTHOR]

Background: Ethiopia aims to achieve universal healthcare using health insurance. To do so, it has been implementing community-based health insurance since 2011. However, the retention of members by the scheme has not yet been evaluated nationally. The systematic review and meta-analysis aimed to evaluate the dropout rate and associated factors among the scheme's beneficiaries in Ethiopia. Methods: On December 19, 2022, searches were conducted in Scopus, Hinari, PubMed, Semantic Scholar, and Google Scholar. Searches were also conducted on the general web and electronic repositories, including the Ethiopian Health Insurance Service, the International Institute for Primary Health Care-Ethiopia, and various higher education institutions. The Joanna Briggs Institute's tools and the "preferred reporting items for systematic reviews and meta-analyses 2020 statement" were used to evaluate bias and frame the review, respectively. Data were analyzed using Stata 17 and RevMan 5. To assess heterogeneity, we conducted subgroup analysis and used a random model to calculate odds ratios with a p value less than 0.05 and a 95% CI. Results: In total, 14 articles were included in the qualitative synthesis, of which 12 were selected for the quantitative analysis. The pooled estimate revealed that the dropout rate of beneficiaries from the scheme was 34.0% (95% CI: 23-44%), provided that the renewal rate was 66.0%, and was found to be influenced by socio-demographic, health status, length of enrolment, knowledge, attitude, the scheme, and health service-related variables. The southern and Oromia regions reported the lowest and highest dropout rates, with 27.0% (95% CI: 24-29%) and 48.0% (95% CI: 18-78%), respectively. The dropout rates increased from 12.3% in 2012–2015 to 34.4% in 2020–2021. Conclusion: More than one-third of the scheme's beneficiaries were found to have dropped out, and this has been found to increase over time, dictating that a community-based strategy and intervention, from the supply, insurer, and demand sides, seem indispensable in minimizing this huge dropout rate. [ABSTRACT FROM AUTHOR]

Background Tobacco use over the life-course threatens to increase disease burden in older adulthood, including lower income countries like Ghana. This paper describes demographic, socioeconomic, health risks and life satisfaction indices related to tobacco use among older adults in Ghana. Methods This work was based on the World Health Organization's multi-country Study on global AGEing and adult health (SAGE), conducted in six countries including Ghana. Wave one of SAGE in Ghana was conducted in 2007-2008 as collaboration between WHO and the University of Ghana Medical School through the Department of Community Health. A nationally representative sample of 4305 older adults aged 50 years and above were interviewed. Associations between tobacco consumption and sociodemographic, socioeconomic, health risk and life satisfaction were evaluated using chi-square and odds ratio (OR). Logistic regression analyses, adjusted for age, sex and other variables, were conducted to determine predictors of tobacco consumption in older persons. Results Overall prevalence of current daily smokers among older adults in Ghana was 7.6%. Tobacco use (i.e. ever used tobacco) was associated with older males, (AOR = 1.10, CI 1.05-1.15), older adults residing in rural locations (AOR = 1.37, CI 1.083-1.724), and older adults who used alcohol (AOR = 1.13, CI 0.230-2.418). Tobacco use was also associated (although not statistically significant per p-values) with increased self-reporting of angina, arthritis, asthma, chronic lung disease, depression, diabetes, hypertension, and stroke. Older adults who used tobacco and with increased health risks, tended to be without health insurance (AOR = 1.41, CI 1.111-1.787). Satisfaction with life and daily living was much lower for those who use tobacco. Regional differences existed in tobacco use; the three northern regions (Upper East, Northern and Upper West) had higher proportions of tobacco use among older adults in the country. Quitting tobacco use was higher in the 70+ years age group, in women, among urban residents and in those with at least secondary education. Quitting tobacco use also increased with increasing income levels. Conclusions Tobacco use among older adults in Ghana was associated with older men living in rural locations, chronic ill-health and reduced life satisfaction. A high proportion of older adults have stopped using tobacco, demonstrating the possibilities for effective public health interventions. Health risk reduction strategies through targeted anti-smoking health campaigns, improvement in access to health and social protection (such as health insurance) will reduce health risks among older persons who use tobacco. [ABSTRACT FROM AUTHOR]

One of the challenges to maintain an agenda for universal coverage and equitable health system is to develop effective structuring and management of health financing. Global experiences with different systems of health financing suggests that a strong public role in health financing is essential for health systems to protect the poor and health systems with the strongest state role are likely the more equitable and achieve better aggregate health outcomes. Using Malaysia as a case study, this paper seeks to evaluate the progress and capacity of a middle income country in terms of health financing for universal coverage, and also to highlight some of the key underlying health systems challenges. The WHO Health Financing Strategy for the Asia Pacific Region (2010-2015) was used as the framework to evaluate the Malaysian healthcare financing system in terms of the provision of universal coverage for the population, and the Malaysian National Health Accounts (2008) provided the latest Malaysian data on health spending. Measuring against the four target indicators outlined, Malaysia fared credibly with total health expenditure close to 5% of its GDP (4.75%), out-of-pocket payment below 40% of total health expenditure (30.7%), comprehensive social safety nets for vulnerable populations, and a tax-based financing system that fundamentally poses as a national riskpooled scheme for the population. Nonetheless, within a holistic systems framework, the financing component interacts synergistically with other health system spheres. In Malaysia, outmigration of public health workers particularly specialist doctors remains an issue and financing strategies critically needs to incorporate a comprehensive workforce compensation strategy to improve the health workforce skill mix. Health expenditure information is systematically collated, but feedback from the private sector remains a challenge. Service delivery-wise, there is a need to enhance financing capacity to expand preventive care, in better managing escalating healthcare costs associated with the increasing trend of non-communicable diseases. In tandem, health financing policies need to infuse the element of cost-effectiveness to better manage the purchasing of new medical supplies and equipment. Ultimately, good governance and leadership are needed to ensure adequate public spending on health and maintain the focus on the attainment of universal coverage, as well as making healthcare financing more accountable to the public, particularly in regards to inefficiencies and better utilisation of public funds and resources. [ABSTRACT FROM AUTHOR]

Background: Most European health care systems are suffering from the impact of demographic change. In short, aging of society is leading to higher costs of treatment per capita, while reproduction rates below 2.1 children per woman lead to a reduced number of younger people to provide for the necessary contributions into the health insurance system. This research paper addresses the questions what impact the demographic development will have on one particular spending area, what are pharmaceutical expenditure in two of Europe's largest health care systems, Germany and France, and what the implications are for pharmaceutical companies. Methods: The research is based on publicly available data from German and French health ministries, the OECD, and institutes which focus on projection of demographic development in those countries. In a first step, data was clustered into age groups, and average spending on pharmaceuticals was allocated to that. In the second step, these figures were extrapolated, based on the projected change in the demographic structure of the countries from 2004 until 2050. This leads to a deeper understanding of demand for pharmaceutical products in the future due to the demographic development as a single driving factor. Results: - Pharmaceutical expenses per head (patient) will grow only slightly until 2050 (0.5% p.a. in both countries). - Demographic change alone only provides for a slowly growing market for pharmaceutical companies both in Germany and in France, but for a relevant change in the consumption mix of pharmaceutical products, based on a shift of relevance of different age groups. Conclusions: Despite demographic changes pharmaceutical expenses per head (patient) and the overall pharmaceutical markets will grow only slightly until 2050 in Germany as well as in France. Nevertheless, the aging of society implies different challenges for pharmaceutical companies and also for the health care system. Companies have to cope with the shift of relevance of different age groups and within the health care system new options for financing the slowly growing expenses have to be found. [ABSTRACT FROM AUTHOR]

Background: A total of 12.7 million Mexicans reside as migrants in the United States, of whom only 45% have health insurance in this country while access to health insurance by migrants in Mexico is fraught with difficulties. Health insurance has been shown to impact the use of health care in both countries. This paper quantifies hospitalizations by migrants who return from the US seeking medical care in public and private hospitals in the US-Mexico border area and in communities of origin. The proportion of bed utilization and the proportion of hospitalizations in Mexico out of the total expected by migrants in the US were estimated. Methods: The universe included 48 Ministry of Health and 47 private hospitals serving municipalities of high or very high migration in Mexico, where 17% of remittance-receiving households are located, as well as 15 public and 159 private hospitals in 10 Mexican cities along the border with the US. Hospitals were sampled through various methods to include 27% of beds. Patients and staff were interviewed and data triangulated to quantify migrants that returned to Mexico seeking medical care. Official hospital discharge statistics and secondary data from migration databases and published statistics were analyzed to identify bed occupancy, general migrant hospitalization rates and the size of the migrant population that maintains close relationships with households in communities of origin. Results: Up to 1609 migrants were admitted to public hospitals (76.6%) and 492 to private hospitals (23.4%) serving municipalities of high and very high migration intensity in 2008. Up to 0.90% of public hospital capacity was used. In the border area up to 908 and 2416 migrants were admitted to public (27.3%) and private (72.7%) hospitals, respectively. Up to 1.18% of public hospital capacity was used. Between 2.4% and 20.4% of the expected hospitalization needs of migrants with dependent households are satisfied through these services. The most common diagnostic categories mentioned across hospitals were traumatisms, complications of diabetes and elective surgery, in that order. Private hospitals mention elective surgeries as the main diagnostic category followed by complications of diabetes. Conclusions: Hospitals in communities of origin in Mexico are devoting few resources to respond to hospitalization needs of migrants in the US. Currently no hospital programs exist to stimulate migrant demand or to cater to their specific needs. Registering migratory history in clinical and administrative records can be readily implemented. Developing bi-national referral networks and insuring migrants in the US within current Mexican federal programs could greatly increase migrant access to hospitals. [ABSTRACT FROM AUTHOR]

Background: In contrast to the considerable body of literature concerning the disabilities of the general population, little information exists pertaining to the disabilities of the farm population. Focusing on the disability issue to the insurants in the Farmers' Health Insurance (FHI) program in Taiwan, this paper examines the associations among socio-demographic characteristics, insured factors, and the introduction of the national health insurance program, as well as the types and payments of disabilities among the insurants. Methods: A unique dataset containing 1,594,439 insurants in 2008 was used in this research. A logistic regression model was estimated for the likelihood of received disability payments. By focusing on the recipients, a disability payment and a disability type equation were estimated using the ordinary least squares method and a multinomial logistic model, respectively, to investigate the effects of the exogenous factors on their received payments and the likelihood of having different types of disabilities. Results: Age and different job categories are significantly associated with the likelihood of receiving disability payments. Compared to those under age 45, the likelihood is higher among recipients aged 85 and above (the odds ratio is 8.04). Compared to hired workers, the odds ratios for self-employed and spouses of farm operators who were not members of farmers' associations are 0.97 and 0.85, respectively. In addition, older insurants are more likely to have eye problems; few differences in disability types are related to insured job categories. Conclusions: Results indicate that older farmers are more likely to receive disability payments, but the likelihood is not much different among insurants of various job categories. Among all of the selected types of disability, a highest likelihood is found for eye disability. In addition, the introduction of the national health insurance program decreases the likelihood of receiving disability payments. The experience in Taiwan can be valuable for other countries that are in an initial stage to implement a universal health insurance program. [ABSTRACT FROM AUTHOR]

Background: Universal social medical insurance coverage is viewed as a major factor in promoting social integration, but insufficient evidence exists on the integration of elderly rural migrants (ERM), generally aged 60 years and above, in low- and middle-income countries. To address this problem, we explore the relationship between the location of social medical insurance (SMI), such as a host city, and social integration in the context of Chinese ERM. Methods: This study is based on data from the 2017 National Internal Migrant Dynamic Monitoring Survey in China. The study participants were Chinese ERM. An integration index was constructed to measure the degree of social integration in a multi-dimensional manner using a factor analysis method. This study used descriptive statistics and one-way analysis of variance to explore the differences in social integration between ERM with SMI from host cities and hometowns. Stepwise multiple linear regression analysis was used to test the correlation between SMI location and social integration level in the overall sample. Finally, the results were verified by propensity score matching. Results: It was found that 606 (18.2%) of the insured ERM chose host city SMI, while 2727 (81.8%) chose hometown SMI. The level of social integration was lower among ERM with hometown SMI (-1.438 ± 32.795, F = 28.311, p ≤ 0.01) than those with host city SMI (6.649 ± 34.383). Among the dimensions of social integration, social participation contributed more than other factors, with a contribution rate of 45.42%. Host city SMI increased the probability of the social integration index by 647% among ERM (k-nearest neighbor caliper matched (n = 4, caliper = 0.02), with a full sample ATT value of 6.47 (T = 5.32, SE = 1.48, p < 0.05)). Conclusions: ERM with host city SMI have a higher social integration level than those with hometowns SMI. That is, host city SMI positively affects social integration. Policymakers should focus on the access of host city SMI for ERM. Removing the threshold of host city SMI coverage for ERM can promote social integration. [ABSTRACT FROM AUTHOR]

Background: At the beginning of the COVID-19 pandemic in the United States in the spring of 2020, many Americans avoided the healthcare system, while those with COVID-19 symptoms were faced with decisions about seeking healthcare services for this novel virus. Methods: Using a probability sample (n = 1088) from the Michigan adult population of PCR-confirmed COVID-19 cases who were diagnosed prior to July 31, 2020, we used logistic regression to examine sociodemographic and symptom severity predictors of care-seeking behaviors. The analyses examined three different outcomes: (1) whether respondents sought care and, among those who sought care, whether they sought care from (2) a primary care provider or (3) an emergency room. Final models were adjusted for sex, age, race and ethnicity, income, education, marital status, living arrangement, health insurance, and self-reported symptom severity. Results: We found that participants ages 65 and older had 4.00 times higher odds of seeking care than 18-34-year-olds (95% CI: 2.21, 7.24), while adults reporting very severe symptoms had roughly 15 times higher odds of seeking care than those with mild symptoms (95% CI: 7.73, 27.01). Adults who were non-Hispanic Black or were uninsured had lower odds of seeking care from a primary care physician versus seeking care from other locations in comparison to adults who were non-Hispanic White or were privately insured, respectively (non-Hispanic Black: aOR = 0.27, 95% CI: 0.16, 0.44; Uninsured: aOR = 0.19, 95% CI: 0.09, 0.42). Conversely, adults who were older or reported more severe symptoms had higher odds of seeking care from an emergency room versus other locations in comparison to adults who were younger or reported less severe symptoms (Age 65+: aOR = 2.96, 95% CI: 1.40, 6.28; Very Severe Symptoms: aOR = 6.63, 95% CI: 3.33, 13.20). Conclusions: Our results suggest differential utilization of healthcare services early in the COVID-19 pandemic. Further analyses are needed to examine the reasons for these differences. [ABSTRACT FROM AUTHOR]

Background: The pre-referral history of patients with low back pain referred to secondary care is poorly documented, and it is unclear whether it complies with clinical guideline recommendations; specifically, whether they have received appropriate treatment in primary care. This study describes the patient population referred to a spine clinic at a Danish hospital and investigates whether they have received an adequate course of treatment in primary care before referral. Furthermore, a possible association between primary care treatment and socioeconomic factors is estimated. Methods: We examined self-reported data from 1035 patients with low back pain of at least eight weeks duration referred to secondary care at a medical spine clinic using a cross-sectional design. As an approximation to national clinical guidelines, the definition of an adequate course of treatment in primary care was at least five visits to a physiotherapist or chiropractor prior to referral. Results: Patients were on average 53 years old, and 56% were women. The average Oswestry Disability Index score was 36, indicating a moderate level of disability. Nearly half of the patients reported pain for over a year, and 75% reported pain below knee level. Prior to referral, 33% of the patients had not received an adequate course of treatment in primary care. Based on multiple logistic regression with the three socioeconomic variables, age and sex in the model, those who were unemployed had an odds ratio of 2.35 (1.15–4.79) for not receiving appropriate treatment compared to employed patients. Similarly, the odds ratio for patients without vs. with health insurance was 1.71 (1.17–2.50). No significant association was observed with length of education. Conclusions: Despite national clinical guidelines recommending management for low back pain in primary care, one third of the patients had not received an adequate course of treatment before referral to secondary care. Moreover, the high probability of not having received recommended treatment for patients who were unemployed or lacked health insurance indicates an economic obstacle to adequate care. Therefore, reconsidering the compensation structure for the treatment of back pain patients is imperative to mitigate health inequality within low back pain management. [ABSTRACT FROM AUTHOR]

Background: As vaccines for COVID-19 became available, many countries introduced an obligation in 2021 for employees to prove their COVID-19 status at work, known in Germany as the 3G rule (vaccinated, recovered, tested). In view of the controversial debate, there was concern that employees might try to avoid providing mandatory COVID-19 certificates by taking sick leave. The aim of this study was to investigate whether mandatory COVID-19 tests in the workplace led to such an evasive response. Method: For an empirical panel analysis, we collected data from official sources and combined aggregated health insurance data on sick leave, epidemiological data on laboratory-confirmed COVID-19 infections, and vaccination rates for the German states from September 2021 to January 2022. We used a regional panel data analysis to estimate the impact of the mandatory COVID-19 certificates at the workplace on workers' sick leave. The regional vaccination rate reflected differences in treatment intensity. Results: This study contributes to the limited evidence on the potential impact of introducing mandatory COVID-19 certificates at the workplace on sickness absence rates. In fact, our results showed that after controlling for infection rates, a one percentage point lower vaccination rate led to a 0.021 percentage point increase in the sickness absence rate when the 3G rule came into effect. This effect was measured with high statistical precision. In addition, in robustness checks, we controlled for a number of other possible influencing factors that may have affected sickness behaviours, such as time-varying labour market situations. However, the results remained robust. Conclusions: The results of our empirical panel analysis implied that mandatory COVID-19 certificates in the workplace led to evasive responses and to additional days of sick leave of a relevant magnitude. Testing obligations were meant to help contain the epidemic. However, when introducing controversial obligations, it is important to consider evasive responses and to design the rules appropriately and communicate them convincingly. [ABSTRACT FROM AUTHOR]

Background: Population ageing presents considerable challenges for the attainment of universal health coverage (UHC), especially in countries where such coverage is still in its infancy. Ghana presents an important case study on the effectiveness of policies aimed at achieving UHC in the context of population ageing in low and middle-income countries. It has witnessed a profound recent demographic transition, including a large increase in the number of older adults, which coincided with the development and implementation of a National Health Insurance Scheme (NHIS), designed to help achieve UHC. The objective of this paper is to examine the community, household and individual level determinants of NHIS enrolment among older adults aged 50-69 and 70 plus. The latter are exempt from NHIS premium payments.Methods: Using the Ghanaian Living Standards Survey from 2012 to 2013, determinants of NHIS enrolment for individuals aged 50-69 and 70 plus living in rural Ghana are examined through the application of multilevel regression analysis.Results: Previous studies have mainly focused on the enrolment of young and middle aged adults and considered mainly demographic and socio-economic factors. The novel inclusion of spatial barriers within this analysis demonstrates that levels of NHIS enrolment are determined in part by the community provision of healthcare facilities. In addition, the findings imply that insurance enrolment increases with household expenditure even for those aged 70 plus who are exempt from the NHIS premium payment.Conclusion: Adequate and appropriate infrastructure as well as health insurance is vital to ensure movement to UHC in low and middle income countries. Overall, the results confirm that there remain significant inequalities in enrolment by expenditure quintile that future policy reform will need to address. [ABSTRACT FROM AUTHOR]

Objective: The Andersen' s Behavioral Model was used to explore the impact of various factors on the utilization of health services. The purpose of this study is to establish a provincial-level proxy framework for the utilization of health services from a spatial perspective, based on the influencing factors of the Andersen' s Behavioral Model. Method: Provincial-level health service utilization was estimated by the annual hospitalization rate of residents and the average number of outpatient visits per year from China Statistical Yearbook 2010–2021. Exploring the relevant influencing factors of health service utilization using the spatial panel Durbin model. Spatial spillover effects were introduced to interpret the direct and indirect effects influenced by the proxy framework for predisposing, enabling, and need factors on health services utilization. Results: From 2010 − 2020, the resident hospitalization rate increased from 6.39% ± 1.23% to 15.57% ± 2.61%, and the average number of outpatient visits per year increased from 1.53 ± 0.86 to 5.30 ± 1.54 in China. For different provinces, the utilization of health services is uneven. The results of the Durbin model show that locally influencing factors were statistically significantly related to an increase in the resident hospitalization rate, including the proportion of 65-year-olds, GDP per capita, percentage of medical insurance participants, and health resources index, while statistically related to the average number of outpatient visits per year, including the illiteracy rate and GDP per capita. Direct and indirect effects decomposition of resident hospitalization rate associated influencing factors demonstrated that proportion of 65-year-olds, GDP per capita, percentage of medical insurance participants, and health resources index not only affected local resident hospitalization rate but also exerted spatial spillover effects toward geographical neighbors. The illiteracy rate and GDP per capita have significant local and neighbor impacts on the average number of outpatient visits. Conclusion: Health services utilization was a variable varied by region and should be considered in a geographic context with spatial attributes. From the spatial perspective, this study identified the local and neighbor impacts of predisposing factors, enabling factors, and need factors that contributed to disparities in local health services utilization. [ABSTRACT FROM AUTHOR]

Background: Regular breast screening is one of the most effective ways to detect early signs of breast cancer but travel distance to cancer-diagnostic facilities can affect breast screening attendance. Yet, limited studies have examined the impact of distance to cancer-diagnostic facilities on clinical breast screening behaviour among women in sub-Saharan Africa (SSA). This study examined the influence of travel distance to a health facility on clinical breast screening behaviour in five SSA countries: Namibia, Burkina Faso, Cote D'Ivoire, Kenya, and Lesotho. The study further assessed variations in clinical breast screening behaviour across diverse socio-demographic characteristics of women. Methods: A sample of 45,945 women was drawn from the most recent Demographic and Health Surveys (DHS) for the included countries. The DHS uses 2-stage stratified cluster sampling to select nationally representative samples of women (15–49) and men (15–64) via a cross-sectional design. Proportions and binary logistic regression were used to examine associations between the women's socio-demographic characteristics and breast screening attendance. Results: The overall proportion of survey participants who underwent clinical breast cancer screening was 16.3%. Travel distance to a health facility had a significant (p < 0.001) impact on clinical breast screening behaviour as 18.5% of participants who self-reported distance as "not a big problem" attended clinical breast screening compared to 10.8% who self-reported distance as "a big problem". The study further found that various socio-demographic factors were significantly associated with breast cancer screening uptake, including age, education level, media exposure, wealth status, parity, contraceptive use, health insurance coverage, and marital status. The multivariate analysis controlling for other factors confirmed the strong association between distance to health facilities and screening uptake. Conclusions: The study found that travel distance is a significant factor affecting clinical breast screening attendance among women in the selected SSA countries. Furthermore, the likelihood of breast screening attendance varied depending on different women's characteristics. It is crucial to prioritise breast screening interventions, particularly among the disadvantaged women identified in this study, to achieve maximum public health benefits. [ABSTRACT FROM AUTHOR]

Background: With a number of vaccines against COVID-19 now widely available globally, it is opportune to determine what tips the decision to get vaccinated. In most countries like the Philippines where the government provides these vaccines for free to all its citizens, their COVID-19 vaccine awareness and COVID-19 information sources as well as their socio-demographic profile were considered as primary factors that could possibly affect vaccination decisions. Participants' income level was considered as a possible financial consideration that can affect vaccination decision as transport to vaccination sites might entail costs to them. Methods: This study used a cross sectional survey design wherein participants came from all regions of the Philippines. An online questionnaire was voluntarily answered by Filipinos aged 18–80 years of age. Results: A total of 2,268 participated in the survey with 1,462 having complete responses which were included in the analysis. Those who are younger, with higher educational attainment, with public health insurance, with employers requiring vaccination, high awareness about COVID-19 vaccination, and high vaccine confidence are more likely to get vaccinated. On the other hand, those with long-standing illness and those residing outside the national capital region are less likely to get vaccinated. Conclusion: Vaccination decisions among Filipinos are determined by their age, educational attainment, health insurance, employer requirement, high awareness of the disease, and a high level of vaccine confidence. [ABSTRACT FROM AUTHOR]