Health benefits of reduced patient cost sharing in Japan

Objective

To assess the effect on out-of-pocket medical spending and physical and mental health of Japan’s reduction in health-care cost sharing from 30% to 10% when people turn 70 years of age.

Methods

Study data came from a 2007 nationally-representative cross-sectional survey of 10 293 adults aged 64 to 75 years. Physical health was assessed using a 16-point scale based on self-reported data on general health, mobility, self-care, activities of daily living and pain. Mental health was assessed using a 24-point scale based on the Kessler-6 instrument for nonspecific psychological distress. The effect of reduced cost sharing was estimated using a regression discontinuity design.

Findings

For adults aged 70 to 75 years whose income made them ineligible for reduced cost sharing, neither out-of-pocket spending nor health outcomes differed from the values expected on the basis of the trend observed in 64- to 69-year-olds. However, for eligible adults aged 70 to 75 years, out-of-pocket spending was significantly lower (P < 0.001) and mental health was significantly better (P < 0.001) than expected. These differences emerged abruptly at the age of 70 years. Moreover, the mental health benefits were similar in individuals who were and were not using health-care services (P = 0.502 for interaction). The improvement in physical health after the age of 70 years in adults eligible for reduced cost-sharing tended to be greater than in non-eligible adults (P = 0.084).

Conclusion

Reduced cost sharing was associated with lower out-of-pocket medical spending and improved mental health in older Japanese adults.     

Progress and challenges of the rural cooperative medical scheme in China

Problem

During China’s transition to a market economy in the 1980s and 1990s, the rural population faced substantial barriers to accessing health care and encountered heavier financial burdens than urban residents in paying for necessary health services.

Approach

In 2003, China started to implement a rural cooperative medical scheme (RCMS), mainly through government subsidies. The scheme operates at the county level and offers a modest benefit package.

Local setting

In spite of rapid economic growth since the early 1980s, income disparities in China have increased, particularly between rural and urban populations. In response, the government has put greater emphasis on social development, including health system development. Examples are the prioritization of improved access to health services and the reduction of the burden of payment for necessary services.

Relevant changes

After 10 years of implementation, the RCMS now provides coverage to the entire rural population and has substantially improved access to health care. Yet despite a drop in out-of-pocket payments as a proportion of total health expenditure, paying for necessary services continues to cause financial hardship for many rural residents.

Lessons learnt

In its first decade, the RCMS made progress through political mobilization, government subsidies, the readiness of the health-care delivery system, and the availability of a monitoring and evaluation system. Further improving the RCMS will require a focus on cost containment, quality improvement and making the scheme portable.     

The Effect of Parity on Expenditures for Individuals with Severe Mental Illness

Objective

To determine whether comprehensive behavioral health parity leads to changes in expenditures for individuals with severe mental illness (SMI), who are likely to be in greatest need for services that could be outside of health plans'' traditional limitations on behavioral health care.

Data Sources/Study Setting

We studied the effects of a comprehensive parity law enacted by Oregon in 2007. Using claims data, we compared expenditures for individuals in four Oregon commercial plans from 2005 through 2008 to a group of commercially insured individuals in Oregon who were exempt from parity.

Study Design

We used difference-in-differences and difference-in-difference-in-differences analyses to estimate changes in spending, and quantile regression methods to assess changes in the distribution of expenditures associated with parity.

Principal Findings

Among 2,195 individuals with SMI, parity was associated with increased expenditures for behavioral health services of $333 (95 percent CI $67, $615), without corresponding increases in out-of-pocket spending. The increase in expenditures was primarily attributable to shifts in the right tail of the distribution.

Conclusions

Oregon''s parity law led to higher average expenditures for individuals with SMI. Parity may allow individuals with high mental health needs to receive services that may have been limited without parity regulations.     

Implementation of information and communication technologies for health in Bangladesh

Problem

Bangladesh has yet to develop a fully integrated health information system infrastructure that is critical to guiding policy development and planning.

Approach

Initial pilot telemedicine and eHealth programmes were not coordinated at national level. However, in 2011, a national eHealth policy was implemented.

Local setting

Bangladesh has made substantial improvements to its health system. However, the country still faces public health challenges with limited and inequitable access to health services and lack of adequate resources to meet the demands of the population.

Relevant changes

In 2008, eHealth services were introduced, including computerization of health facilities at sub-district levels, internet connections, internet servers and an mHealth service for communicating with health-care providers. Health facilities at sub-district levels were provided with internet connections and servers. In 482 upazila health complexes and district hospitals, an mHealth service was set-up where an on-duty doctor is available for patients at all hours to provide consultations by mobile phone. A government operated telemedicine service was initiated and by 2014, 43 fully equipped centres were in service. These centres provide medical consultations by qualified physicians to patients visiting rural and remote community clinics and union health centres.

Lessons learnt

Despite early pilot interventions and successful implementation, progress in adopting eHealth strategies in Bangladesh has been slow. There is a lack of common standards on information technology for health, which causes difficulties in data management and sharing among different databases. Limited internet bandwidth and the high cost of infrastructure and software development are barriers to adoption of these technologies.     

Improving patient access to specialized health care: the Telehealth Network of Minas Gerais, Brazil

Problem

The Brazilian population lacks equitable access to specialized health care and diagnostic tests, especially in remote municipalities, where health professionals often feel isolated and staff turnover is high. Telehealth has the potential to improve patients’ access to specialized health care, but little is known about it in terms of cost-effectiveness, access to services or user satisfaction.

Approach

In 2005, the State Government of Minas Gerais, Brazil, funded the establishment of the Telehealth Network, intended to connect university hospitals with the state’s remote municipal health departments; support professionals in providing tele-assistance; and perform tele-electrocardiography and teleconsultations. The network uses low-cost equipment and has employed various strategies to overcome the barriers to telehealth use.

Local setting

The Telehealth Network connects specialists in state university hospitals with primary health-care professionals in 608 municipalities of the large state of Minas Gerais, many of them in remote areas.

Relevant changes

From June 2006 to October 2011, 782 773 electrocardiograms and 30 883 teleconsultations were performed through the network, and 6000 health professionals were trained in its use. Most of these professionals (97%) were satisfied with the system, which was cost-effective, economically viable and averted 81% of potential case referrals to distant centres.

Lessons learnt

To succeed, a telehealth service must be part of a collaborative network, meet the real needs of local health professionals, use simple technology and have at least some face-to-face components. If applied to health problems for which care is in high demand, this type of service can be economically viable and can help to improve patient access to specialized health care.     

COBRA ARRA Subsidies: Was the Carrot Enticing Enough?

Objective

To help preserve continuity of health insurance coverage during the recent recession, the American Recovery and Reinvestment Act provided a 65 percent Consolidated Omnibus Budget Reconciliation Act (COBRA) premium subsidy for workers laid off in 2008–2010. We examined COBRA enrollment levels with the subsidy and the health, access, and financial consequences of enrollment decisions.

Study Design/Data Collection

Telephone interviews linked with health system databases for 561 respondents who were laid off in 2009 and eligible for the COBRA subsidy (80 percent response rate).

Principal Findings

Overall, 38 percent reported enrolling in COBRA and 54 percent reported having some gaps in insurance coverage since being laid off. After adjustments, we found that those who had higher cost-sharing, who had higher incomes, were older, or were sicker were more likely to enroll in COBRA. COBRA enrollees less frequently reported access problems or that their health suffered because of poor access, but they reported greater financial stress due to health care spending.

Conclusion

Despite the substantial subsidy, a majority of eligible individuals did not enroll in COBRA, and many reported insurance coverage gaps. Nonenrollees reported more access problems and that their health worsened. Without a mandate, subsidies may need to be widely publicized and larger to encourage health insurance enrollment among individuals who suffer a negative income shock.     

Monitoring service delivery for universal health coverage: the Service Availability and Readiness Assessment

Objective

To describe the Service Availability and Readiness Assessment (SARA) and the results of its implementation in six countries across three continents.

Methods

The SARA is a comprehensive approach for assessing and monitoring health service availability and the readiness of facilities to deliver health-care interventions, with a standardized set of indicators that cover all main programmes. Standardized data-collection instruments are used to gather information on a defined set of selected tracer items from public and private health facilities through a facility sample survey or census. Results from assessments in six countries are shown.

Findings

The results highlight important gaps in service delivery that are obstacles to universal access to health services. Considerable variation was found within and across countries in the distribution of health facility infrastructure and workforce and in the types of services offered. Weaknesses in laboratory diagnostic capacities and gaps in essential medicines and commodities were common across all countries.

Conclusion

The SARA fills an important information gap in monitoring health system performance and universal health coverage by providing objective and regular information on all major health programmes that feeds into country planning cycles.     

Free versus subsidised healthcare: options for fee exemptions,access to care for vulnerable groups and effects on the health system in Burkina Faso

Background

The many forms of healthcare fee exemptions implemented in Burkina Faso since the 2000s have varied between total exemption (free) and cost subsidisation. This article examines both options, their contextual variations and the ways in which they affect access to healthcare for vulnerable people as well as the operation of the health system. This research is part of an interdisciplinary regional program on the elimination of user fees for health services in West Africa (Burkina Faso, Mali and Niger).

Method

A conceptual framework and a chronological review of policy interventions are used as references to summarise the results of the three qualitative studies presented. Historical reference points are used to describe the emergence of healthcare fee exemption policies in Burkina Faso and the events that influenced their adoption. The joint analysis of opinions on options for fee exemption focuses on the different types of repercussions on access to healthcare and the operation of the health system.

Results

In conjunction with the twists and turns of the gradual development of a national health policy and in response to international recommendations, healthcare fee exemptions have evolved since colonisation. The limitations of the changes introduced with cost recovery and the barriers to healthcare access for the poorest people led to the adoption of the current sectorial fee exemptions. The results provide information on the reasons for the changes that have occurred over time. The nuanced perspectives of different categories of people surveyed about fee exemption options show that, beyond the perceived effects on healthcare access and the health system, the issue is one of more equitable governance.

Conclusions

In principle, the fee exemption measures are intended to provide improved healthcare access for vulnerable groups. In practice, the negative effects on the operation of the health system advocate for reforms to harmonise the changes to multifaceted fee exemptions and the actual needs to promote effectiveness and sustainability.

     

The impact of health insurance in Africa and Asia: a systematic review

Objective

To evaluate the impact of health insurance on resource mobilization, financial protection, service utilization, quality of care, social inclusion and community empowerment in low- and lower-middle-income countries in Africa and Asia.

Methods

A systematic search for randomized controlled trials, quasi-experimental and observational studies published before the end of 2011 was conducted in 20 literature databases, reference lists of relevant studies, web sites and the grey literature. Study quality was assessed with a quality grading protocol.

Findings

Inclusion criteria were met by 159 studies – 68 in Africa and 91 in Asia. Most African studies reported on community-based health insurance (CBHI) and were of relatively high quality; social health insurance (SHI) studies were mostly Asian and of medium quality. Only one Asian study dealt with private health insurance (PHI). Most studies were observational; four had randomized controls and 20 had a quasi-experimental design. Financial protection, utilization and social inclusion were far more common subjects than resource mobilization, quality of care or community empowerment. Strong evidence shows that CBHI and SHI improve service utilization and protect members financially by reducing their out-of-pocket expenditure, and that CBHI improves resource mobilization too. Weak evidence points to a positive effect of both SHI and CBHI on quality of care and social inclusion. The effect of SHI and CBHI on community empowerment is inconclusive. Findings for PHI are inconclusive in all domains because of insufficient studies.

Conclusion

Health insurance offers some protection against the detrimental effects of user fees and a promising avenue towards universal health-care coverage.     

Socioeconomic inequalities in the access to and quality of health care services

OBJECTIVE

To assess the inequalities in access, utilization, and quality of health care services according to the socioeconomic status.

METHODS

This population-based cross-sectional study evaluated 2,927 individuals aged ≥ 20 years living in Pelotas, RS, Southern Brazil, in 2012. The associations between socioeconomic indicators and the following outcomes were evaluated: lack of access to health services, utilization of services, waiting period (in days) for assistance, and waiting time (in hours) in lines. We used Poisson regression for the crude and adjusted analyses.

RESULTS

The lack of access to health services was reported by 6.5% of the individuals who sought health care. The prevalence of use of health care services in the 30 days prior to the interview was 29.3%. Of these, 26.4% waited five days or more to receive care and 32.1% waited at least an hour in lines. Approximately 50.0% of the health care services were funded through the Unified Health System. The use of health care services was similar across socioeconomic groups. The lack of access to health care services and waiting time in lines were higher among individuals of lower economic status, even after adjusting for health care needs. The waiting period to receive care was higher among those with higher socioeconomic status.

CONCLUSIONS

Although no differences were observed in the use of health care services across socioeconomic groups, inequalities were evident in the access to and quality of these services.     

The role of drug vendors in improving basic health-care services in Nigeria

Objective

To characterize patent and proprietary medicine vendors and shops in Nigeria and to assess their ability to help improve access to high-quality, primary health-care services.

Methods

In 2013 and 2014, a census of patent and proprietary medicine shops in 16 states of Nigeria was carried out to determine: (i) the size and coverage of the sector; (ii) the basic characteristics of shops and their staff; and (iii) the range of products stocked for priority health services, particularly for malaria, diarrhoea and family planning. The influence of the medical training of people in charge of the shops on the health-care products stocked and registration with official bodies was assessed by regression analysis.

Findings

The number of shops per 100 000 population was higher in southern than in northern states, but the average percentage of people in charge with medical training across local government areas was higher in northern states: 52.6% versus 29.7% in southern states. Shops headed by a person with medical training were significantly more likely to stock artemisinin-based combination therapy, oral rehydration salts, zinc, injectable contraceptives and intrauterine contraceptive devices. However, these shops were less likely to be registered with the National Association of Patent and Proprietary Medicine Dealers and more likely to be registered with the regulatory body, the Pharmacist Council of Nigeria.

Conclusion

Many patent and proprietary medicine vendors in Nigeria were medically trained. With additional training and oversight, they could help improve access to basic health-care services. Specifically, vendors with medical training could participate in task-shifting interventions.     

Estimation of maternal and child mortality one year after user-fee elimination: an impact evaluation and modelling study in Burkina Faso

Objective

To estimate the impact on maternal and child mortality after eliminating user fees for pregnant women and for children less than five years of age in Burkina Faso.

Methods

Two health districts in the Sahel region eliminated user fees for facility deliveries and curative consultations for children in September 2008. To compare health-care coverage before and after this change, we used interrupted time series, propensity scores and three independent data sources. Coverage changes were assessed for four variables: women giving birth at a health facility, and children aged 1 to 59 months receiving oral rehydration salts for diarrhoea, antibiotics for pneumonia and artemesinin for malaria. We modelled the mortality impact of coverage changes in the Lives Saved Tool using several scenarios.

Findings

Coverage increased for all variables, however, the increase was not statistically significant for antibiotics for pneumonia. For estimated mortality impact, the intervention saved approximately 593 (estimate range 168–1060) children’s lives in both districts during the first year. This lowered the estimated under-five mortality rate from 235 deaths per 1000 live births in 2008 to 210 (estimate range 189–228) in 2009. If a similar intervention were to be introduced nationwide, 14 000 to 19 000 (estimate range 4000–28 000) children''s lives could be saved annually. Maternal mortality showed a modest decrease in all scenarios.

Conclusion

In this setting, eliminating user fees increased use of health services and may have contributed to reduced child mortality.     

Using Quantile Regression to Examine Health Care Expenditures during the Great Recession

Objective

To examine the association between the Great Recession of 2007–2009 and health care expenditures along the health care spending distribution, with a focus on racial/ethnic disparities.

Data Sources/Study Setting

Secondary data analyses of the Medical Expenditure Panel Survey (2005–2006 and 2008–2009).

Study Design

Quantile multivariate regressions are employed to measure the different associations between the economic recession of 2007–2009 and health care spending. Race/ethnicity and interaction terms between race/ethnicity and a recession indicator are controlled to examine whether minorities encountered disproportionately lower health spending during the economic recession.

Principal Findings

The Great Recession was significantly associated with reductions in health care expenditures at the 10th–50th percentiles of the distribution, but not at the 75th–90th percentiles. Racial and ethnic disparities were more substantial at the lower end of the health expenditure distribution; however, on average the reduction in expenditures was similar for all race/ethnic groups. The Great Recession was also positively associated with spending on emergency department visits.

Conclusion

This study shows that the relationship between the Great Recession and health care spending varied along the health expenditure distribution. More variability was observed in the lower end of the health spending distribution compared to the higher end.     

The Institutional Effects of Incarceration: Spillovers From Criminal Justice to Health Care

Context

This study examines the spillover effects of growth in state-level incarceration rates on the functioning and quality of the US health care system.

Methods

Our multilevel approach first explored cross-sectional individual-level data on health care behavior merged to aggregate state-level data regarding incarceration. We then conducted an entirely aggregate-level analysis to address between-state heterogeneity and trends over time in health care access and utilization.

Findings

We found that individuals residing in states with a larger number of former prison inmates have diminished access to care, less access to specialists, less trust in physicians, and less satisfaction with the care they receive. These spillover effects are deep in that they affect even those least likely to be personally affected by incarceration, including the insured, those over 50, women, non-Hispanic whites, and those with incomes far exceeding the federal poverty threshold. These patterns likely reflect the burden of uncompensated care among former inmates, who have both a greater than average need for care and higher than average levels of uninsurance. State-level analyses solidify these claims. Increases in the number of former inmates are associated simultaneously with increases in the percentage of uninsured within a state and increases in emergency room use per capita, both net of controls for between-state heterogeneity.

Conclusions

Our analyses establish an intersection between systems of care and corrections, linked by inadequate financial and administrative mechanisms for delivering services to former inmates.     

Financial barriers to HIV treatment in Yaound��, Cameroon: first results of a national cross-sectional survey

Objective

To assess the extent to which user fees for antiretroviral therapy (ART) represent a financial barrier to access to ART among HIV-positive patients in Yaoundé, Cameroon.

Methods

Sociodemographic, economic and clinical data were collected from a random sample of 707 HIV-positive patients followed up in six public hospitals of the capital city (Yaoundé) and its surroundings through face-to-face interviews carried out by trained interviewers independently from medical staff and medical questionnaires filled out by prescribing physicians. Logistic regression models were used to identify factors associated with self-reported financial difficulties in purchasing ART during the previous 3 months.

Findings

Of the 532 patients treated with ART at the time of the survey, 20% reported financial difficulty in purchasing their antiretroviral drugs during the previous 3 months. After adjustment for socioeconomic and clinical factors, reports of financial difficulties were significantly associated with lower adherence to ART (odds ratio, OR: 0.24; 95% confidence interval, CI: 0.15–0.40; P < 0.0001) and with lower CD4+ lymphocyte (CD4) counts after 6 months of treatment (OR: 2.14; 95% CI: 1.15–3.96 for CD4 counts < 200 cells/µl; P = 0.04).

Conclusion

Removing a financial barrier to treatment with ART by eliminating user fees at the point of care delivery, as recommended by WHO, could lead to increased adherence to ART and to improved clinical results. New health financing mechanisms based on the public resources of national governments and international donors are needed to attain universal access to drugs and treatment for HIV infection.     

Availability of essential health services in post-conflict Liberia

Objective

To assess the availability of essential health services in northern Liberia in 2008, five years after the end of the civil war.

Methods

We carried out a population-based household survey in rural Nimba county and a health facility survey in clinics and hospitals nearest to study villages. We evaluated access to facilities that provide index essential services: artemisinin combination therapy for malaria, integrated management of childhood illness, human immunodeficiency virus (HIV) counselling and testing, basic emergency obstetric care and treatment of mental illness.

Findings

Data were obtained from 1405 individuals (98% response rate) selected with a three-stage population-representative sampling method, and from 43 of Nimba county’s 49 health facilities selected because of proximity to the study villages. Respondents travelled an average of 136 minutes to reach a health facility. All respondents could access malaria treatment at the nearest facility and 55.9% could access HIV testing. Only 26.8%, 14.5%, and 12.1% could access emergency obstetric care, integrated management of child illness and mental health services, respectively.

Conclusion

Although there has been progress in providing basic services, rural Liberians still have limited access to life-saving health care. The reasons for the disparities in the services available to the population are technical and political. More frequently available services (HIV testing, malaria treatment) were less complex to implement and represented diseases favoured by bilateral and multilateral health sector donors. Systematic investments in the health system are required to ensure that health services respond to current and future health priorities.     

Monitoring access to out-of-hours care services in Scotland - a review

Objectives

Changes in the contractual responsibilities of primary care practitioners and health boards have resulted in a plethora of arrangements relating to out-of-hours healthcare services. Rather than being guaranteed access to a GP (usually either their own or another through a local GP co-operative), patients have a number of alternative routes to services. Our objective was to identify and assess the availability and adequacy of relevant standards, responsibilities and information systems in Scotland to monitor the impact of contractual changes to out-of-hours healthcare services on equity of access.

Design

Cross-sectional study.

Setting

All providers of primary care out-of-hours services in Scotland.

Participants

Not applicable.

Main outcome measures

First, identification and policy review of current standards and performance monitoring systems, data and information, primarily through directly contacting national and local organizations responsible for monitoring out-of-hours care, supplemented by literature searches to highlight specific issues arising from the review; and second, mapping of data items by out-of-hours provider type to identify overlap and significant gaps.

Results

In Scotland, data monitoring systems have not kept pace with changes in the organization of out-of-hours care, so the impact on access to services for different population groups is unknown. There are significant gaps in information collected with respect to workforce, distribution of services, service utilisation and clinical outcomes.

Conclusions

Since 2004 there have been major changes to the way patients access out-of-hours healthcare in the UK. In Scotland, none of the current systems provide information on whether the new services satisfy the key NHS principle of equity of access. There is an urgent need for a comprehensive review of data standards and systems relating to out-of-hours care in order to monitor and evaluate inputs, processes and outcomes of care not least in respect of access and fairness of distribution of resources.