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Purpose
Despite significant contribution by India’s informal sector, tattered conditions have inflated the burden of health shocks in many ways. This study tries to examine the economic burden of health shocks and its associated consequences on households whose members are involved in informal sector. We primarily focus on three objectives for our analysis: (1) compute distribution and magnitude of health shocks and health expenditure between formal and informal workers; (2) evaluate the incidence and intensity of catastrophic health expenditure (CHE), and measure its impoverishment effect; (3) estimate the major determinants of CHE for informal sector households.Methods
Underlying objectives have been estimated using standard catastrophic and impoverishment measures (poverty headcount and poverty gap) and Poisson, logit and Tobit multivariate regression models. For empirical analysis, data is exploited from the recent round of Indian Human Development Survey (IHDS-II), 2012.Results
We find that around 27% of households engaged in the informal sector spends more than 5% threshold on their health payment. We also find that OOP health expenditure pushes 7.12% informal sector households in poverty. Moreover, we also find that the impoverishment effect mainly rests on outpatient health expenditure and poverty deepening for informal sector households.Conclusion
Our findings indicate that informal sector workers are highly vulnerable to health shocks and economic burden in terms of high treatment costs and low insurance coverage. Further, we also show that workers engaged in the informal sector witness greater probability of incurring CHE and impoverishment. Results from the Tobit model suggests that various factors such as insurance coverage, severity of illness and others are crucial predictor of catastrophic spending.3.
Muttur Ranganathan Narayana 《Applied health economics and health policy》2016,14(6):673-690
Background
India’s High Level Expert Group on Universal Health Coverage in 2011 recommended a universal, public-funded and national health coverage policy. As a plausible forward-looking macroeconomic reform in the health sector, this policy proposal on universal health coverage (UHC) needs to be evaluated for age structure transition effect and fiscal sustainability to strengthen its current design and future implementation.Objective
Macroeconomic analyses of the long-term implications of age structure transition and fiscal sustainability on India’s proposed UHC policy.Methods
A new measure of age-specific UHC is developed by combining the age profile of public and private health consumption expenditure by using the National Transfer Accounts methodology. Different projections of age-specific public health expenditure are calculated over the period 2005–2100 to account for the age structure transition effect. The projections include changes in: (1) levels of the expenditure as gross domestic product grows, (2) levels and shape of the expenditure as gross domestic product grows and expenditure converges to that of developed countries (or convergence scenario) based on the Lee–Carter model of forecasting mortality rates, and (3) levels of the expenditure as India moves toward a UHC policy. Fiscal sustainability under each health expenditure projection is determined by using the measures of generational imbalance and sustainability gap in the Generational Accounting methodology.Results
Public health expenditure is marked by age specificities and the elderly population is costlier to support for their healthcare needs in the future. Given the discount and productivity growth rates, the proposed UHC is not fiscally sustainable under India’s current fiscal policies except for the convergence scenario. However, if the income elasticity of public expenditure on social welfare and health expenditure is less than one, fiscal sustainability of the UHC policy is attainable in all scenarios of projected public health expenditures. These new results strengthen the proposed UHC policy by accounting for age structure transition effect and justifying its sustainability within the framework of India’s current fiscal policies.Conclusion
The age structure transition effect is important to incorporate the age-specific cost and benefit of the proposed UHC policy, especially as India moves toward an ageing society. Fiscal sustainability is essential to ensure that the proposed UHC is implementable on a long-term basis and within the framework of current fiscal policies.4.
Ama de-Graft Aikins Mawuli Kushitor Kwadwo Koram Stella Gyamfi Gbenga Ogedegbe 《BMC public health》2014,14(Z2):S3
Background
The rising burden of chronic non-communicable diseases in low and middle income countries has major implications on the ability of these countries to achieve universal health coverage. In this paper we discuss the impact of cardiovascular diseases (CVD) on primary healthcare services in urban poor communities in Accra, Ghana.Methods
We review the evidence on the evolution of universal health coverage in Ghana and the central role of the community-based health planning services (CHPS) programme and the National Health Insurance Scheme in primary health care. We present preliminary findings from a study on community CVD knowledge, experiences, responses and access to services.Results
The rising burden of NCDs in Ghana will affect the achievement of universal health coverage, particularly in urban areas. There is a significant unmet need for CVD care in the study communities. The provision of primary healthcare services for CVD is not accessible, equitable or responsive to the needs of target communities.Conclusions
We consider these findings in the context of the primary healthcare system and discuss the challenges and opportunities for strengthening health systems in low and middle-income countries.5.
Background
Schizophrenia remains a priority condition in mental health policy and service development because of its early onset, severity and consequences for affected individuals and households.Aims and methods
This paper reports on an ‘extended’ cost-effectiveness analysis (ECEA) for schizophrenia treatment in India, which seeks to evaluate through a modeling approach not only the costs and health effects of intervention but also the consequences of a policy of universal public finance (UPF) on health and financial outcomes across income quintiles.Results
Using plausible values for input parameters, we conclude that health gains from UPF are concentrated among the poorest, whereas the non-health gains in the form of out-of-pocket private expenditures averted due to UPF are concentrated among the richest income quintiles. Value of insurance is the highest for the poorest quintile and declines with income.Conclusions
Universal public finance can play a crucial role in ameliorating the adverse economic and social consequences of schizophrenia and its treatment in resource-constrained settings where health insurance coverage is generally poor. This paper shows the potential distributional and financial risk protection effects of treating schizophrenia.6.
Background
A universal health coverage policy was implemented in Thailand in 2002 and led to an increase in accessibility to, and equity of, healthcare services. The Thai government and academics have focused on the large-scale aspects, including effectiveness and impacts, of universal health coverage over one decade. Here, we aimed to identify patients’ perspectives on hospital visits under universal health coverage.Methods
A qualitative study was carried out in four public hospitals in rural Thailand. We collected data through focus group discussions (FGDs) and in-depth interviews (IDIs). The semi-structured interview guide was designed to elicit perspectives on hospital visits among participants covered by the Universal Coverage Scheme, Social Security Scheme or Civil Servant Medical Benefit Scheme. Data were transcribed and analysed using a thematic approach.Results
Twenty-nine participants (mean age, 56.76?±?16.65 years) participated in five FGDs and one IDI. The emerging themes and sub-themes were identified. Factors influencing decisions to visit hospitals were free healthcare services, perception of serious illness, the need for special tests, and continuity of care. Long waiting times were barriers to hospital visits. Employees, who could not leave their work during office hours, could not access some services such as health check-ups. From the viewpoint of participants, public hospitals provided quality and equitable healthcare services. Nevertheless, shared decision making for treatment plans was not common.Conclusions
The factors and barriers to utilisation of healthcare services provide exploratory data to understand the healthcare-seeking behaviours of patients. Perceptions towards free services under universal health coverage are positive, but participation in decision making is rare. Future studies should focus on finding ways to balance the needs and barriers to hospital visits and to introduce the concept of shared decision making to both doctors and patients.7.
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Anders Wimo L. Fratiglioni B. -M. Sjölund A. Sköldunger C. Fagerström J. Berglund M. Lagergren 《The journal of nutrition, health & aging》2017,21(1):17-24
Objectives
Study formal and informal care of community-living older people in the Swedish National study of Aging and Care (SNAC).Design
Cross-sectional, population based cohort.Setting
Three areas in Sweden: Municipality of Nordanstig, Stockholm and Skåne County.Participants
3,338 persons ≥72 years.Measurements
Patterns and amounts of informal and formal care by cognition and area of residence.Results
73% received no care; 14% formal care; and 17% informal care (7% received both). In the whole study population, including those who used no care, individuals in small municipalities received 9.6 hours of informal care/month; in mid-size municipalities, 6.6; and in urban areas, 5.6. Users of informal care received 33.1 hours of informal care/month in small municipalities, 54.6 in mid-size municipalities and 36.1 in urban areas. Individuals with cognitive impairment received 14.1 hours of informal care/month, 2.7 times more than people with no/slight impairment. In the whole study population, individuals in small municipalities received an average of 3.2 hours of formal care/month; in mid-size municipalities 1.4; and in urban areas, 2.6. Corresponding figures for formal care users were 29.4 hours in small municipalities, 13.6 in mid-size municipalities and 16.7 in urban areas. Formal care users received 7.1 hours, and informal care users, 5.9 hours for each hour/month received by people in the study population as a whole.Conclusions
More informal than formal care was provided. Informal care is more frequent in small municipalities than urban areas and for those with than without cognitive impairment. The relationship between data on the whole population and the data on users or care indicates that population-based data are needed to avoid overestimates of care.9.
Background
The nursing sector is characterized by high sick leave and fluctuation rates due to work-related stress. There is a need to raise manager’s awareness in the care sector for goal-oriented operational health management.Objectives
Is a serious game a suitable instrument to change nursing care managers’ behaviors and attitudes and increase their knowledge regarding prevention and health promoting management behavior?Materials and methods
Preliminary investigation into the stress of care providers, evaluation of the initial situation in nursing care services, conception of a serious game including training concept, testing and evaluation in the field.Results
In most companies health promotion is not perceived as important (74%); thus, it is expected that “Serious Games for Health” (SGH) will be an effective and suitable instrument to train managers regarding preventive and health promoting management behavior.Conclusions
Operational health management should be anchored as a management task in the nursing care sector. The innovative educational concept “Stress-Rekord” can counteract multifactorial stress in the workplace.10.
Sarah King Josephine Exley Sarah Parks Sarah Ball Teresa Bienkowska-Gibbs Calum MacLure Emma Harte Katherine Stewart Jody Larkin Andrew Bottomley Sonja Marjanovic 《Quality of life research》2016,25(9):2245-2256
Purpose
Patient-reported data are playing an increasing role in health care. In oncology, data from quality of life (QoL) assessment tools may be particularly important for those with limited survival prospects, where treatments aim to prolong survival while maintaining or improving QoL. This paper examines the use and impact of using QoL measures on health care of cancer patients within a clinical setting, particularly those with brain cancer. It also examines facilitators and challenges, and provides implications for policy and practice.Design
We conducted a systematic literature review, 15 expert interviews and a consultation at an international summit.Results
The systematic review found no relevant intervention studies specifically in brain cancer patients, and after expanding our search to include other cancers, 15 relevant studies were identified. The evidence on the effectiveness of using QoL tools was inconsistent for patient management, but somewhat more consistent in favour of improving patient–physician communication. Interviews identified unharnessed potential and growing interest in QoL tool use and associated challenges to address.Conclusion
Our findings suggest that the use of QoL tools in cancer patients may improve patient–physician communication and have the potential to improve care, but the tools are not currently widely used in clinical practice (in brain cancer nor some other cancer contexts) although they are in clinical trials. There is a need for further research and stakeholder engagement on how QoL tools can achieve most impact across cancer and patient contexts. There is also a need for policy, health professional, research and patient communities to strengthen information exchange and debate, support awareness raising and provide training on tool design, use and interpretation.11.
Adrienne Clermont 《BMC public health》2017,17(4):734
Background
Inequality in healthcare across population groups in low-income countries is a growing topic of interest in global health. The Lives Saved Tool (LiST), which uses health intervention coverage to model maternal, neonatal, and child health outcomes such as mortality rates, can be used to analyze the impact of within-country inequality.Methods
Data from nationally representative household surveys (98 surveys conducted between 1998 and 2014), disaggregated by wealth quintile, were used to create a LiST analysis that models the impact of scaling up health intervention coverage for the entire country from the national average to the rate of the top wealth quintile (richest 20% of the population). Interventions for which household survey data are available were used as proxies for other interventions that are not measured in surveys, based on co-delivery of intervention packages.Results
For the 98 countries included in the analysis, 24–32% of child deaths (including 34–47% of neonatal deaths and 16–19% of post-neonatal deaths) could be prevented by scaling up national coverage of key health interventions to the level of the top wealth quintile. On average, the interventions with most unequal coverage rates across wealth quintiles were those related to childbirth in health facilities and to water and sanitation infrastructure; the most equally distributed were those delivered through community-based mass campaigns, such as vaccines, vitamin A supplementation, and bednet distribution.Conclusions
LiST is a powerful tool for exploring the policy and programmatic implications of within-country inequality in low-income, high-mortality-burden countries. An “Equity Tool” app has been developed within the software to make this type of analysis easily accessible to users.12.
Aim
Strength-based approaches draw on patients’ strengths and perspectives to partner with them in their own care, recovery and problem solving. The effectiveness of strength-based approaches to address complex health problems has a growing evidence base leading to its incorporation within universal services in many countries. However, practitioners’ understanding of implementation of strength-based approaches, such as how to agenda match, set goals and revise plans within universal services are under-researched. Maternity services are a key point of access to health services and women’s experiences of them have consequences for families’ future willingness to engage with public health provision. This study researched strength-based components of children’s services policy, Getting It Right For Every Child, in maternity care in Scotland.Subject and methods
Complex interventions, such as this policy, requires a methodology that captures complex dynamics. Consequently a realist-evaluation-informed case-study approach was adopted across three contrasting health boards comprised of: (1) interviews with women receiving maternity care with heightened risk profiles, (2) a sample of maternity care professionals responsible for implementing the policy and (3) document analysis of policy guidance and training materials.Results
Whilst midwives reported adopting more open approaches to raising sensitive issues with women, many midwives were unfamiliar with strength-based approaches and were not drawing upon them, in contrast to a perception amongst managers that training and implementation was common.Conclusion
These findings suggest implementation of strength-based approaches within universal services require further attention to training and embedding culture change.13.
Background
Equitable financing is a key objective of health care systems. Its importance is evidenced in policy documents, policy statements, the work of health economists and policy analysts. The conventional categorisations of finance sources for health care are taxation, social health insurance, private health insurance and out-of-pocket payments. There are nonetheless increasing variations in the finance sources used to fund health care. An understanding of the equity implications would help policy makers in achieving equitable financing.Objective
The primary purpose of this paper was to comprehensively assess the equity of health care financing in Malaysia, which represents a new country context for the quantitative techniques used. The paper evaluated each of the five financing sources (direct taxes, indirect taxes, contributions to Employee Provident Fund and Social Security Organization, private insurance and out-of-pocket payments) independently, and subsequently by combined the financing sources to evaluate the whole financing system.Methods
Cross-sectional analyses were performed on the Household Expenditure Survey Malaysia 1998/99, using Stata statistical software package. In order to assess inequality, progressivity of each finance sources and the whole financing system was measured by Kakwani's progressivity index.Results
Results showed that Malaysia's predominantly tax-financed system was slightly progressive with a Kakwani's progressivity index of 0.186. The net progressive effect was produced by four progressive finance sources (in the decreasing order of direct taxes, private insurance premiums, out-of-pocket payments, contributions to EPF and SOCSO) and a regressive finance source (indirect taxes).Conclusion
Malaysia's two tier health system, of a heavily subsidised public sector and a user charged private sector, has produced a progressive health financing system. The case of Malaysia exemplifies that policy makers can gain an in depth understanding of the equity impact, in order to help shape health financing strategies for the nation.14.
Sophie Witter Maria Paola Bertone Yotamu Chirwa Justine Namakula Sovannarith So Haja R. Wurie 《Conflict and health》2016,10(1):31
Background
Few studies look at policy making in the health sector in the aftermath of a conflict or crisis and even fewer specifically focus on Human Resources for Health, which is a critical domain for health sector performance. The main objective of the article is to shed light on the patterns and drivers of post-conflict policy-making. In particular, we explore whether the post -conflict period offers increased chances for the opening of ‘windows for opportunity’ for change and reform and the potential to reset health systems.Methods
This article uses a comparative policy analysis framework. It is based on qualitative data, collected using three main tools - stakeholder mapping, key informant interviews and document reviews - in Uganda, Sierra Leone, Cambodia and Zimbabwe.Results
We found that HRH challenges were widely shared across the four cases in the post-conflict period but that the policy trajectories were different – driven by the nature of the conflicts but also the wider context. Our findings suggest that there is no formula for whether or when a ‘window of opportunity’ will arise which allows health systems to be reset. Problems are well understood in all four cases but core issues – such as adequate pay, effective distribution and HRH management – are to a greater or lesser degree unresolved. These problems are not confined to post-conflict settings, but underlying challenges to addressing them – including fiscal space, political consensus, willingness to pursue public objectives over private, and personal and institutional capacity to manage technical solutions – are liable to be even more acute in these settings. The role of the MoH emerged as weaker than expected, while the shift from donor dependence was clearly not linear and can take a considerable time.Conclusions
Windows of opportunity for change and reform can occur but are by no means guaranteed by a crisis – rather they depend on a constellation of leadership, financing, and capacity. Recognition of urgency is certainly a facilitator but not sufficient alone. Post-conflict environments face particularly severe challenges to evidence-based policy making and policy implementation, which also constrain their ability to effectively use the windows which are presented.15.
Zubia Mumtaz Adrienne V. Levay Gian S. Jhangri Afshan Bhatti 《Health research policy and systems / BioMed Central》2015,13(Z1):S51
Background
In 2007, the Government of Pakistan introduced a new cadre of community midwives (CMWs) to address low skilled birth attendance rates in rural areas; this workforce is located in the private-sector. There are concerns about the effectiveness of the programme for increasing skilled birth attendance as previous experience from private-sector programmes has been sub-optimal. Indonesia first promoted private sector midwifery care, but the initiative failed to provide universal coverage and reduce maternal mortality rates.Methods
A clustered, stratified survey was conducted in the districts of Jhelum and Layyah, Punjab. A total of 1,457 women who gave birth in the 2 years prior to the survey were interviewed. χ2 analyses were performed to assess variation in coverage of maternal health services between the two districts. Logistic regression models were developed to explore whether differentials in coverage between the two districts could be explained by differential levels of development and demand for skilled birth attendance. Mean cost of childbirth care by type of provider was also calculated.Results
Overall, 7.9% of women surveyed reported a CMW-attended birth. Women in Jhelum were six times more likely to report a CMW-attended birth than women in Layyah. The mean cost of a CMW-attended birth compared favourably with a dai-attended birth. The CMWs were, however, having difficulty garnering community trust. The majority of women, when asked why they had not sought care from their neighbourhood CMW, cited a lack of trust in CMWs’ competency and that they wanted a different provider.Conclusions
The CMWs have yet to emerge as a significant maternity care provider in rural Punjab. Levels of overall community development determined uptake and hence coverage of CMW care. The CMWs were able to insert themselves into the maternal health marketplace in Jhelum because of an existing demand. A lower demand in Layyah meant there was less ‘space’ for the CMWs to enter the market. To ensure universal coverage, there is a need to revisit the strategy of introducing a new midwifery workforce in the private sector in contexts of low demand and marketing the benefits of skilled birth attendance.16.
Janessa M. Graves Jessica L. Mackelprang Celestina Barbosa-Leiker Mary E. Miller Angel Y. Li 《Quality of life research》2017,26(1):107-120
Purpose
This study investigated the association between work, work intensity, and quality of life (QOL) among adolescents in Washington State.Methods
Data from the 2010 Washington Healthy Youth Survey of public school students in 8, 10, and 12th grades were analyzed. Students were categorized as working or not working. Work intensity was classified by self-reported number of hours worked per week. Respondent QOL was measured using the Youth Quality of Life Instrument-Healthy Youth Survey Version (YQOL-HYS). Linear regression models evaluated the association between employment variables and scores on the YQOL-HYS.Results
In total, 27, 26, and 47 % of students in grades 8, 10, and 12 reported currently working, respectively. For 8th and 10th graders, working was significantly associated with lower QOL scores compared to non-working students. Across all grades, increased work intensity was associated with significantly lower QOL. Participation in after-school activities demonstrated a protective effect.Conclusions
While work is often a positive experience for adolescents, among younger teens and those who work many hours, employment during the school year may have a deleterious impact on QOL. Further research is necessary to better understand whether employment, particularly in early adolescence, may have negative ramifications on QOL among young workers.17.
Background
China is reforming the way it finances health care as it moves towards Universal Health Coverage (UHC) after the failure of market-oriented mechanisms for health care. Improving financing equity is a major policy goal of health care system during the progression towards universal coverage.Methods
We used progressivity analysis and dominance test to evaluate the financing channels of general taxation, pubic health insurance, and out-of-pocket (OOP) payments. In 2012 a survey of 8854 individuals in 3008 households recorded the socioeconomic and demographic status, and health care payments of those households.Results
The overall Kakwani index (KI) of China’s health care financing system is 0.0444. For general tax KI was ?0.0241 (95% confidence interval (CI): ?0.0315 to ?0.0166). The indices for public health schemes (Urban Employee Basic Medical Insurance, Urban Resident’s Basic Medical Insurance, New Rural Cooperative Medical Scheme) were respectively 0.1301 (95% CI: 0.1008 to 0.1594), ?0.1737 (95% CI: –0.2166 to ?0.1308), and ?0.5598 (95% CI: –0.5830 to ?0.5365); and for OOP payments KI was 0.0896 (95%CI: 0.0345 to 0.1447). OOP payments are still the dominant part of China’s health care finance system.Conclusion
China’s health care financing system is not really equitable. Reducing the proportion of indirect taxes would considerably improve health care financing equity. The flat-rate contribution mechanism is not recommended for use in public health insurance schemes, and more attention should be given to optimizing benefit packages during China’s progression towards UHC.18.
Background
This paper discusses the practices of organisations that cross the boundary between research and politics, to promote evidence-based policies and programmes.Methods
It uses the experience of a network of organisations in Africa to describe the methodology, challenges and successes of efforts to promote utilisation of research on the inter-connections between HIV/AIDS, food security and nutrition in South Africa. It emphasises that crossing the boundary between science and politics can be done systematically and is inevitable for any attempt that seeks influence policy making.Results
The paper reveals the complexity of the research-policy making interface and identifies key lessons for the practice of networking and engaging policy and decision-makers.Conclusion
The concept of boundary organisation is a helpful means to understand the methodological underpinnings of efforts to get research into policy and practice and to understand the ‘messy’ process of doing so.19.
Background
Strategic purchasing of health care services has become a key policy measure on the path to achieving universal health coverage. National provider payment systems for health services are typically characterized by mixes of provider payment methods with each method associated with distinct incentives for provider behaviours. Reaching incentive alignment across methods is critical to enhancing the effectiveness of strategic purchasing.Methods
A structured literature review was conducted to synthesize the evidence on how purposively aligned mixed provider payment systems affect health expenditure growth management, efficiency, and equity in access to services with a particular focus on coordinated and/or integrated care management.Results
The majority of the 37 reviewed articles focused on high-income countries with 74% from the US. Four categories of payment mixes were examined in this review: blended payment, bundled payment, cost-containment reward models, and aligned cost sharing mechanisms. Blended payment models generally reported moderate to no substantive reductions in expenditure growth, but increases in health system efficiency. Bundled payment schemes consistently report increases in efficiency and corresponding cost savings. Cost-containment rewards generated cost savings that can contribute to effective management of health expenditure growth. Evidence on aligned cost-sharing is scarce.Conclusion
There is lacking evidence on when and how mixed provider payment systems and cost sharing practices align towards achieving goals. A guiding framework for how to study and evaluate mixed provider payment systems across contexts is warranted. Future research should consider a conceptual framework explicitly acknowledging the complex nature of mixed provider payment systems.20.
Christine Cécile Leyns Jan De Maeseneer Sara Willems 《International journal for equity in health》2018,17(1):177