Health care financing in Hong Kong: a case for tax‐based financing

With the new government of the Hong Kong Special Administrative Region currently conducting a review of Hong Kong's health care financing system, this article argues that the existing tax‐based system not only works well at present, but is also sustainable in the future. The performance of the system is analysed in terms of cost, health outcomes and access. The arguments for change are discussed, and the case for maintaining the status quo is presented. The author concludes that the way forward would be to fine tune the existing system rather than to replace it with other systems which are known to have higher transaction costs and more serious supply‐side moral hazards. Copyright © 1999 John Wiley & Sons, Ltd.     

Individual and collective exposure to political violence: Palestinian adolescents coping with conflict

BACKGROUND: We conducted a survey of Palestinian adolescents in school. We hypothesized that collective and individual exposures to violence would both negatively affect adolescents' mental health. We also anticipated that the negative effect of collective exposures on mental health would be less than that of individual exposures. Our analysis was designed to test these hypotheses. METHODS: A representative sample of 3415 students of 10th and 11th grades from the Ramallah District of the West Bank participated in the survey. The primary independent variables were scales of individual and collective exposures to trauma/violence (ETV) by the Israeli military and settlers. Factor analysis revealed several sub-scales. Outcome measures were constructed and included: a binary measure of depressive-like states, and emotional, depressive-like state, and somatic scales. Several variables were identified as possible covariates: gender, age, school-type, residence, employment status of father, and identity documents held. RESULTS: Logistic and multiple regression analyses revealed a strong relationship between ETV and adolescents' mental health, with both individual and collective exposures having independent effects. There was a higher prevalence of depressive-like symptoms among girls compared with boys, and in adolescents living in Palestinian refugee camps compared with those living in cities, towns and villages. CONCLUSION: The findings confirmed our hypothesis that both individual and collective ETV independently affect the mental health of adolescents. Contrary to expectations, individual exposures did not consistently have a greater negative effect on health outcomes than collective exposures, although the sub-scale of direct personal exposures to violence consistently showed the strongest effect among sub-scales. The results emphasize the importance of going beyond individual experiences and including the health outcomes of collective violation when analyzing violent and traumatic contexts.     

Catastrophic payments for health care in Asia

Out-of-pocket (OOP) payments are the principal means of financing health care throughout much of Asia. We estimate the magnitude and distribution of OOP payments for health care in fourteen countries and territories accounting for 81% of the Asian population. We focus on payments that are catastrophic, in the sense of severely disrupting household living standards, and approximate such payments by those absorbing a large fraction of household resources. Bangladesh, China, India, Nepal and Vietnam rely most heavily on OOP financing and have the highest incidence of catastrophic payments. Sri Lanka, Thailand and Malaysia stand out as low to middle income countries that have constrained both the OOP share of health financing and the catastrophic impact of direct payments. In most low/middle-income countries, the better-off are more likely to spend a large fraction of total household resources on health care. This may reflect the inability of the poorest of the poor to divert resources from other basic needs and possibly the protection of the poor from user charges offered in some countries. But in China, Kyrgyz and Vietnam, where there are no exemptions of the poor from charges, they are as, or even more, likely to incur catastrophic payments.     

Normalising the abnormal: Palestinian youth and the contradictions of resilience in protracted conflict

This qualitative study explores the construct of resilience by Palestinian youth in the 10th to 12th grades at school living in and around Ramallah in the West Bank. We look at how adolescents themselves interpret and give meaning to the concept of resilience in dehumanising and abnormal conditions. The aim is to 'problematise' the construct to go beyond quantitative research and objective inquiry. Focus groups were conducted with 321 male and female Palestinian students in 15 schools in Ramallah and the surrounding villages. This study presents findings that are consistent with previous research on the value of supportive relationships such as families and friends. Political participation and education are vital to a sense of identity and political resistance. However, a key finding reveals the normalisation of everyday life in fostering resiliency within abnormal living conditions. Palestinian youth, nonetheless, paint a picture of resilience that reveals contradictions and tensions. This study underlines the fluid and dynamic nature of resilience. Despite the desire for order, Palestinian young people complain of emotional distress and boredom. Feelings of desperation are intermingled with optimism. We also argue that the concept of resilience developed in predominantly Western settings ignores a local idiom of communal care and support. International and local organisations providing psychosocial care rely on trauma programmes based on a Western style of counselling. An over-emphasis on individualised intervention overlooks the notion of collective resiliency and fails to build on existing social capital within communities. Policy-makers should do more than 'tweak' preconceived projects to fit the cultural context or to replicate them from one conflict area to another. We should also keep in mind that the search for psychological well-being and justice are not mutually exclusive.     

Equity in health care financing in Palestine: the value-added of the disaggregate approach

This paper analyzes the redistributive effect and progressivity associated with the current health care financing schemes in the Occupied Palestinian Territory, using data from the first Palestinian Household Health Expenditure Survey conducted in 2004. The paper goes beyond the commonly used "aggregate summary index approach" to apply a more detailed "disaggregate approach". Such an approach is borrowed from the general economic literature on taxation, and examines redistributive and vertical effects over specific parts of the income distribution, using the dominance criterion. In addition, the paper employs a bootstrap method to test for the statistical significance of the inequality measures. While both the aggregate and disaggregate approaches confirm the pro-rich and regressive character of out-of-pocket payments, the aggregate approach does not ascertain the potential progressive feature of any of the available insurance schemes. The disaggregate approach, however, significantly reveals a progressive aspect, for over half of the population, of the government health insurance scheme, and demonstrates that the regressivity of the out-of-pocket payments is most pronounced among the worst-off classes of the population. Recommendations are advanced to improve the performance of the government insurance schemes to enhance its capacity in limiting inequalities in health care financing in the Occupied Palestinian Territory.     

Reproductive decisions in the lives of West Bank Palestinian women: Dimensions and contradictions

Palestinian women have one of the highest fertility rates in the world, averaging 4.38 births per woman. However, Palestinian fertility patterns are distinct from those of other developing nations, in that high fertility rates coexist alongside high levels of education and low levels of infant mortality – both of which have been established elsewhere as predictors of low total fertility rates. This study explores the dimensions and context of the contradictions between fertility predictors and rates, isolating main factors that shape Palestinian reproductive behaviour. Furthermore, while this study addresses factors that influence the high fertility in the Palestinian Territories, it also addresses factors that contribute to the steady decline of this trend. In-depth interviews were conducted with Palestinian women in urban refugee communities and key informant interviews with experts on Palestinian reproductive health. The findings indicate that five factors shape women's reproductive behaviour: (1) the fear of losing one's children in the ongoing conflict; (2) socio-economic factors including poverty and density of space; (3) the marital relationship; (4) religious values; and (5) generational differences. These results highlight the influence of socio-political conditions on reproductive behaviour and the significance of women's agency in manoeuvring their fertility outcomes.     

Redistributive effects of Swedish health care finance

This paper investigates the redistributive effects of the Swedish health care financing system in 1980 and 1990 for four different financial sources: county council taxes, payroll taxes, direct payments and state grants. The redistributive effects are decomposed into vertical, horizontal and ‘reranking’ segments for each of the four financial sources. The data used are based on probability samples of the Swedish population, from the Level of Living Survey (LNU) from 1981 and 1991. The paper concludes that the Swedish health care financing system is weakly progressive, although direct payments are regressive. There is some horizontal inequity and ‘reranking’, which mainly comes from the county council taxes, since those tax rates vary for each county council. The implication is that, to some extent, people with equal incomes are treated unequally. Copyright © 1998 John Wiley & Sons, Ltd.     

The impact of vouchers on the use and quality of health care in developing countries: A systematic review

Abstract

One approach to delivering healthcare in developing countries is through voucher programmes, where vouchers are distributed to a targeted population for free or subsidised health care. Using inclusion/exclusion criteria, a search of databases, key journals and websites review was conducted in October 2010. A narrative synthesis approach was taken to summarise and analyse five outcome categories: targeting, utilisation, cost efficiency, quality and health outcomes. Sub-group and sensitivity analyses were also performed. A total of 24 studies evaluating 16 health voucher programmes were identified. The findings from 64 outcome variables indicates: modest evidence that vouchers effectively target specific populations; insufficient evidence to determine whether vouchers deliver healthcare efficiently; robust evidence that vouchers increase utilisation; modest evidence that vouchers improve quality; no evidence that vouchers have an impact on health outcomes; however, this last conclusion was found to be unstable in a sensitivity analysis. The results in the areas of targeting, utilisation and quality indicate that vouchers have a positive effect on health service delivery. The subsequent link that they improve health was found to be unstable from the data analysed; another finding of a positive effect would result in robust evidence. Vouchers are still new and the number of published studies is limiting.     

Access to health care resources in the UK: the case of care for arthritis

The paper uses new and detailed data from a population sample of individuals with arthritis to examine the impact of objective measures of need for treatment and individual measures of socio-economic position on the distribution of public and private health care. The quality of the data and the range of explanatory factors are more detailed than previously used to study of the allocation of NHS care. The results indicate that broadly the NHS appears to meet its equity goal of equal care for equal medical need, though there is evidence that education increases the amount of resources received. The results also show the importance of the interaction between the public and private sectors in the UK.     

Extensions to decomposition of the redistributive effect of health care finance

The total redistributive effect (RE) of health-care finance has been decomposed into vertical, horizontal and reranking effects. The vertical effect has been further decomposed into tax rate and tax structure effects. We extend this latter decomposition to the horizontal and reranking components of the RE. We also show how to measure the vertical, horizontal and reranking effects of each component of the redistributive system, allowing analysis of the RE of health-care finance in the context of that system. The methods are illustrated with application to the RE of health-care financing in Canada.     

Local inequality and departures from publicly provided health care in Canada

This paper examines the relationship between changes in income inequality and the provision of resources in a health care system (the public‐private mix). Specifically, we investigate whether increases in income inequality, as separate from overall income levels and growth, have changed the availability of both private clinics and privately financed physicians in a context where the dominant market player is the public system. Our findings provide reasonable evidence that increases in income inequality have led to substantial increases in both. We find that moving from median level of inequality across neighborhoods to the top 1% level of inequality increases the probably of a private clinic by 40% and the probability of having physicians who have opted out of the public system by 170%.     

Informal payment for health care and the theory of 'INXIT'

Informal payments are known to be widespread in the post-communist health care systems of Central and Eastern Europe. However, their role and nature remains contentious, with the debate characterized by much polemic. This paper steps back from this debate to examine the theoretical basis for understanding the persistence of informal payments. The authors develop a cognitive behavioural model of informal payment, which draws on the theory of government failure and extends Hirschman's theory of 'exit, voice, loyalty', the behavioural responses to 'decline in firms, organizations and states'. It is argued that informal payment represents another possible behavioural reaction: 'inxit', which becomes important when the channels of exit and voice are blocked. The theory is applied to explain informal payments in Hungary, but can be shown to be relevant to other countries facing similar issues. The paper examines the proposed policies to tackle informal payments, and on the basis of the theory of 'inxit' it advocates that solutions should contain an appropriate balance between exit and voice to optimize the chances of maintaining a good standard of public services.     

Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status

PURPOSE Long-term shifts in specialty choice and health workforce policy have raised concern about the future of primary care in the United States. The objective of this study was to examine current use of primary and specialty care across the US population for policy-relevant subgroups, such as disadvantaged populations and persons with chronic illness.METHODS Data from the Medical Expenditure Panel Survey from 2004 were analyzed using a probability sample patients or other participants from the noninstitutionalized US population in 2004 (N = 34,403). The main and secondary outcome measures were the estimates of the proportion of Americans who accessed different types of primary care and specialty physicians and midlevel practitioners, as well as the fraction of ambulatory visits accounted for by the different clinician types. Data were disaggregated by income, health insurance status, race/ethnicity, rural or urban residence, and presence of 5 common chronic diseases.RESULTS Family physicians were the most common clinician type accessed by adults, seniors, and reproductive-age women, and they were second to pediatricians for children. Disadvantaged adults with 3 markers of disadvantage (poverty, disadvantaged minority, uninsured) received 45.6% (95% CI, 40.4%–50.7%) of their ambulatory visits from family physicians vs 30.5% (95% CI, 30.0%–32.1%) for adults with no markers. For children with 3 vs 0 markers of disadvantage, the proportion of visits from family physicians roughly doubled from 16.5% (95% CI, 14.4%–18.6%) to 30.1% (95% CI, 18.8%–41.2%). Family physicians constitute the only clinician group that does not show income disparities in access. Multivariate analyses show that patterns of access to family physicians and nurse-practitioners are more equitable than for other clinician types.CONCLUSIONS: Primary care clinicians, especially family physicians, deliver a disproportionate share of ambulatory care to disadvantaged populations. A diminished primary care workforce will leave considerable gaps in US health care equity. Health care workforce policy should reflect this important population-level function of primary care.     

Improving health equity through health care systems research

Objective

To describe health equity research priorities for health care delivery systems and delineate a research and action agenda that generates evidence-based solutions to persistent racial and ethnic inequities in health outcomes.

Data Sources and Study Setting

This project was conducted as a component of the Agency for Healthcare Research and Quality's (AHRQ) stakeholder engaged process to develop an Equity Agenda and Action Plan to guide priority setting to advance health equity. Recommendations were developed and refined based on expert input, evidence review, and stakeholder engagement. Participating stakeholders included experts from academia, health care organizations, industry, and government.

Study Design

Expert group consensus, informed by stakeholder engagement and targeted evidence review.

Data Collection/Extraction Methods

Priority themes were derived iteratively through (1) brainstorming and idea reduction, (2) targeted evidence review of candidate themes, (3) determination of preliminary themes; (4) input on preliminary themes from stakeholders attending AHRQ's 2022 Health Equity Summit; and (5) and refinement of themes based on that input. The final set of research and action recommendations was determined by authors' consensus.

Principal Findings

Health care delivery systems have contributed to racial and ethnic disparities in health care. High quality research is needed to inform health care delivery systems approaches to undo systemic barriers and inequities. We identified six priority themes for research; (1) institutional leadership, culture, and workforce; (2) data-driven, culturally tailored care; (3) health equity targeted performance incentives; (4) health equity-informed approaches to health system consolidation and access; (5) whole person care; (6) and whole community investment. We also suggest cross-cutting themes regarding research workforce and research timelines.

Conclusions

As the nation's primary health services research agency, AHRQ can advance equitable delivery of health care by funding research and disseminating evidence to help transform the organization and delivery of health care.     

Public health challenges in the political economy of conflict: the case of Syria

Recent uprisings in the Arab world and a full‐scale war in Syria are widely viewed as popular demand for political voice against repressive regimes. However, growing economic inequalities and serious economic dysfunction played a role as trigger for conflict than is commonly accepted. Tunisia, Egypt and Syria all implemented policies of liberalization over the past two decades, leading to the worsening of living standards for the majority. The various forms of liberalization played a significant role in embedding social division and discontent whose outcomes affected other countries of the region with the onset of market reforms in nascent welfare states. Egypt, for example, was viewed by the World Bank as an economic ‘best performer’, despite regular riots over food prices, job losses and land expropriation for tourism. Tunisia was praised by donors just prior to the uprising (in 2010), for ‘weathering well’ the global economic downturn through ‘sound macroeconomic management’. In Syria, the market economy made its mark over the 90s, but macroeconomic adjustment policies were implemented in a bilateral agreement with the European Union and approved by the International Monetary Fund in 2003. The economic stabilization programme that followed had limited concern for social impacts such as jobs losses, price rises and national debt, which ultimately caused immense hardship for the population at large, acting as a trigger for the initial uprising in 2011, prior to its transformation into a fully blown conflict. This article focuses on reforms implemented in the health sector and sets these in the context of the current political economy of Syria. It suggests that a protective approach to public health services during and in the aftermath of conflict may increase the possibilities of reconstruction and reconciliation between warring sides. Copyright © 2015 John Wiley & Sons, Ltd.     

Thirty years of national health insurance in South Korea: lessons for achieving universal health care coverage

South Korea introduced mandatory social health insurance forindustrial workers in large corporations in 1977, and extendedit incrementally to the self-employed until it covered the entirepopulation in 1989. Thirty years of national health insurancein Korea can provide valuable lessons on key issues in healthcare financing policy which now face many low- and middle-incomecountries aiming to achieve universal health care coverage,such as: tax versus social health insurance; population andbenefit coverage; single scheme versus multiple schemes; purchasingand provider payment method; and the role of politics and politicalcommitment. National health insurance in Korea has been successfulin mobilizing resources for health care, rapidly extending populationcoverage, effectively pooling public and private resources topurchase health care for the entire population, and containinghealth care expenditure. However, there are also challengesposed by the dominance of private providers paid by fee-for-service,the rapid aging of the population, and the public-private mixrelated to private health insurance.