How much will coverage for universal access to comprehensive behavioral healthcare really cost?

The following article summarizes and reviews four recent research reports attempting to quantify how much a universally available, nondiscriminatory behavioral healthcare benefit would actually cost--per person per year. The author suggests that the cost differences between these reports primarily reflect different assumptions related to the expected behavioral healthcare delivery system and designs for behavioral healthcare benefits. Comprehensive behavioral healthcare delivered through well-managed benefit plans is likely to cost a little more than $200 per person per year, which would be much more affordable for our country than unmanaged comprehensive behavioral healthcare, which easily could cost in excess of $300 per person per year.     

An analysis of perceived access to health care in Europe: How universal is universal coverage?

The objective of this paper is to examine variations in perceptions of access to health care across and within 29 European countries. Using data from the 2008 round of the European Social Survey, we investigate the likelihood of an individual perceiving that they will experience difficulties accessing health care in the next 12 months, should they need it (N = 51,835). We find that despite most European countries having mandates for universal health coverage, individuals who are low income, in poor health, lack citizenship in the country where they reside, 20–30 years old, unemployed and/or female have systematically greater odds of feeling unable to access care. Focusing on the role of income, we find that while there is a strong association between low income and perceived access barriers across countries, within many countries, perceptions of difficulties accessing care are not concentrated uniquely among low-income groups. This implies that factors that affect all income groups, such as poor quality care and long waiting times may serve as important barriers to access in these countries. Despite commitments to move towards universal health coverage in Europe, our results suggest that there is still significant heterogeneity among individuals’ perceptions of access and important barriers to accessing health care.     

Towards universal health coverage: the role of within-country wealth-related inequality in 28 countries in sub-Saharan Africa

Objective

To measure within-country wealth-related inequality in the health service coverage gap of maternal and child health indicators in sub-Saharan Africa and quantify its contribution to the national health service coverage gap.

Methods

Coverage data for child and maternal health services in 28 sub-Saharan African countries were obtained from the 2000–2008 Demographic Health Survey. For each country, the national coverage gap was determined for an overall health service coverage index and select individual health service indicators. The data were then additively broken down into the coverage gap in the wealthiest quintile (i.e. the proportion of the quintile lacking a required health service) and the population attributable risk (an absolute measure of within-country wealth-related inequality).

Findings

In 26 countries, within-country wealth-related inequality accounted for more than one quarter of the national overall coverage gap. Reducing such inequality could lower this gap by 16% to 56%, depending on the country. Regarding select individual health service indicators, wealth-related inequality was more common in services such as skilled birth attendance and antenatal care, and less so in family planning, measles immunization, receipt of a third dose of vaccine against diphtheria, pertussis and tetanus and treatment of acute respiratory infections in children under 5 years of age.

Conclusion

The contribution of wealth-related inequality to the child and maternal health service coverage gap differs by country and type of health service, warranting case-specific interventions. Targeted policies are most appropriate where high within-country wealth-related inequality exists, and whole-population approaches, where the health-service coverage gap is high in all quintiles.     

Income-based disparities in health care utilisation under universal health coverage in Brazil, 2002–2003

Since Brazil's adoption of universal health care in 1988, the country's health care system has consisted of a mix of private providers and free public providers. We test whether income-based disparities in medical visits and medications remain in Brazil despite universal coverage using a nationally representative sample of over 48,000 households. Additional income is associated with less public sector utilisation and more private sector utilisation, both using simple correlations and regressions controlling for household characteristics and local area fixed effects. Importantly, the increase in private care use is greater than the drop in public care use. Also, income and unmet medical needs are negatively associated. These results suggest that access limitations remain for low-income households despite the availability of free public care.     

Does the distribution of health care benefits in Kenya meet the principles of universal coverage?

Background  

The 58^th World Health Assembly called for all health systems to move towards universal coverage where everyone has access to key promotive, preventive, curative and rehabilitative health interventions at an affordable cost. Universal coverage involves ensuring that health care benefits are distributed on the basis of need for care and not on ability to pay. The distribution of health care benefits is therefore an important policy question, which health systems should address. The aim of this study is to assess the distribution of health care benefits in the Kenyan health system, compare changes over two time periods and demonstrate the extent to which the distribution meets the principles of universal coverage.     

Influenza vaccination coverage among patients and healthcare workers in a university hospital during the 2006–2007 influenza season

Despite years of public health effort to increase vaccine uptake among populations recommended for influenza vaccination, immunization rates remain low among patients and healthcare workers (HCWs). The objective of this study was to report on influenza vaccination coverage of patients and HCWs for the same time period in 4 wards of a university hospital. A prospective cross-sectional study was conducted among patients and HCWs between December 11, 2006 and April 15, 2007 and individual factors associated with being vaccinated against influenza were assessed. Results indicated that older patients were significantly more vaccinated than younger patients. Physicians and residents were more likely to be vaccinated that the rest of staff, with possible differences between wards. Immunization of HCWs is a major issue in infection control in hospitals and long-term care facilities. However, the impact of influenza vaccination among HCWs in reducing hospital-acquired influenza and patient morbidity needs to be explored further.     

Comments on the article: “Syrian refugees in Lebanon: the search for universal health coverage”

This letter intends to clarify information and misconceptions found in the article “Syrian refugees in Lebanon: the search for universal health coverage” which was published June 1st, 2016, and to challenge the core notion of fragmentation as presented by the authors. It also highlights the fact that the article does not recognize the severe shortage in refugees health financing and unmet promises by the international community, and calls for immediate action and far greater support from that community to address the needs of refugees in Lebanon.     

India's “tryst” with universal health coverage: Reflections on ethnography in Indian health policymaking

In 2011, India stood at the crossroads of potentially major health reform. A High Level Expert Group (HLEG) on universal health coverage (UHC), convened by the Indian Planning Commission, proposed major changes in the structure and functioning of the country's health system. This paper presents reflections on the role of ethnography in policy-based social change for health in India, drawing from year-long participation in the aforementioned policy development process. It theorizes that international discourses have been (re)appropriated in the Indian case by recourse to both experience and evidence, resulting in a plurality of concepts that could be prioritized for Indian health reform. This articulation involved HLEG members exerting para-ethnographic labour and paying close attention to context, suggesting that ethnographic sensibilities can reside within the interactive and knowledge production practices among experts oriented toward policy change.     

A gap in formal long-term care use related to characteristics of caregivers and households,under the public universal system in Japan: 2001–2010

We investigated whether the universal provision of long-term care (LTC) under Japan's public system has equalized its use across households with different socio-economic characteristics, with a special focus on the gender and marital status of primary caregivers, and income. We used repeated cross-sectional data from national household surveys (2001, 2004, 2007, and 2010) and conducted multiple logistic regression analyses to obtain odds ratios of caregiver and household characteristics for service use, adjusting for recipients’ characteristics. The results showed that the patterns of service use have been consistently determined by caregivers’ gender and marital status over the period despite demographic changes among caregivers. The gap in service use first narrowed, then widened again across income levels after the global economic recession. The results indicate that the traditional gender-bound norms and capacity constraints on households’ informal care provision remained influential on decisions over service use, even after the universal provision of formal care. To improve equality of service utilization, the universal LTC system needs to meet diversifying needs of caregivers/recipients and their households, by overcoming barriers related to gender norms and economic disparity.     

Patients’ experience of using primary care services in the context of Indonesian universal health coverage reforms

Background

The World Health Organization (WHO) recommendation on universal coverage has been implemented in Indonesia as Jaminan Kesehatan Nasional (JKN). It was designed to provide people with equitable and high-quality health care by strengthening primary care as the gate-keeper to hospitals. However, during its first year of implementation, recruitment of JKN members was slow, and the referral rates from primary to secondary care remained high. Little is known about how the public views the introduction of JKN or the factors that influence their decision to enroll in JKN.

Aim

This research aimed to explore patients’ views on the implementation of JKN and factors that influence a person’s decision to enroll in the JKN scheme.

Methods

This study was informed by interpretative phenomenological analysis (IPA) methodology to understand patients’ views. The interview participants were purposively recruited using maximum variation criteria. The data were gathered using in-depth interviews and was conducted in Yogyakarta from October to December 2014. The interviews were transcribed, translated and analyzed using IPA analysis.

Result

Twenty three participants were interviewed from eight primary care clinics. Three superordinate themes: access, trust, and separation anxiety were identified which impacted on the uptake of JKN. Participants acknowledged that whilst primary care clinics were conveniently located, access was often complicated by long waiting times and short opening hours. Participants also expressed lower levels of trust with primary care doctors compared to hospital and specialist care. They also reported a sense of anxiety that the current JKN regulation might limit their ability to access the hospital service guaranteed in the past.

Discussion

This study identified patients’ views that could challenge the implementation of the gate-keeper role of primary care in Indonesia. While the patients valued the availability of medical care close to home, their lack of trust in primary care doctors and fear that they might lost the hospital care in the future appears to have impacted on the uptake of JKN. Unless targeted efforts are made to address these views through sustained public education and further capacity building in primary care, it is unlikely that the full potential of the JKN scheme in primary care will be realized.

     

Patients’ perspectives regarding hospital visits in the universal health coverage system of Thailand: a qualitative study

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.

     

Current issues with the immunization program in Japan: Can we fill the “vaccine gap”?

The "vaccine gap" is a term which has been used in Japan to indicate that the current immunization program is behind compared to the programs in other developed countries. The current national immunization program (NIP) which was established under the Japanese Immunization Law includes only six vaccines (eight targeted diseases), and the rest of available vaccines have been categorized as voluntary vaccines, which require out-of-pocket expense in order for the patients to receive them. This has led the vaccination rates for the voluntary vaccines remaining low, and the incidence of the target diseases remaining high. In addition, there are a few domestic rules that exist for immunizations including (1) subcutaneous injection is the standard method of vaccination, (2) the thigh is not considered to be the common site of vaccination in infants, and (3) the intervals of administration of inactivated and live vaccines are strictly determined by law. Along with the "vaccine gap" and the domestic rules, some movements to improve our current NIP are underway; including increased calls to change the NIP from civilians and professionals, the establishment of a group by the representatives from 13 medical professional societies asking the government to consider the immunization policy a "national policy" and seeking the establishment of a new and reorganized national immunization technical advisory group (NITAG). In addition, the Vaccination Subcommittee of Health Sciences Council was formed in the government to reform the current Immunization Law and NIP, which established a new national program for three voluntary vaccines funded by a temporary budget. We hope these new movements will fill the "vaccine gap" and that the NITAG will help ensure that vaccine policy becomes a national policy, and will provide necessary vaccinations without out-of-pocket expense to protect children in Japan from vaccine preventable diseases.     

Vaccination coverage among school children aged 14–15 years in the French department of Sarthe

Objectives

Vaccinations are the main pillar of primary prevention for infectious diseases. To guide and prioritize public health interventions, the Regional Health Agency has asked the Prevention, Vaccination, and Screening Center of the Sarthe department to assess vaccination coverage (VC) at the sub-departmental level. The main objective was to measure the VC among school children aged 14–15 years in Sarthe at the sub-departmental level.

Estimation of reproduction number and probable vector density of the first autochthonous dengue outbreak in Japan in the last 70 years

Objectives

The first autochthonous case of dengue fever in Japan since 1945 was reported on August 27, 2014. Infection was transmitted by Aedes albopictus mosquitoes in Tokyo’s Yoyogi Park. A total of 65 cases with no history of overseas travel and who may have been infected around the park were reported as of September 5, 2014. To quantify infection risk of the local epidemic, the reproduction number and vector density per person at the onset of the epidemic were estimated.

Methods

The estimated probability distribution and the number of female mosquitoes per person (MPP) were determined from the data of the initial epidemic.

Results

The estimated distribution R _0i for the initial epidemic was fitted to a Gamma distribution using location parameter 4.25, scale parameter 0.19, and shape parameter 7.76 with median 7.78 and IQR (7.21–8.40). The MPP was fitted to a normal distribution with mean 5.71 and standard deviation 0.53.

Conclusions

Both estimated reproduction number and vector density per person at the onset of the epidemic were higher than previously reported values. These results indicate the potential for dengue outbreaks in places with elevated vector density per person, even in dengue non-endemic countries. To investigate the cause of this outbreak, further studies will be needed, including assessments of social, behavioral, and environmental factors that may have contributed to this epidemic by altering host and vector conditions in the park.

     

Measles in the Nantes Teaching Hospital during the 2008-2009 epidemic

Objective

A recent measles epidemic in France incited us to report and describe measles cases requiring hospitalization, to raise the awareness of health professionals on under-diagnosis and frequent complications of this viral disease.

Design

We carried out a retrospective and epidemiologic study of measles cases recorded in the Nantes Teaching Hospital between August 2008 and September 2009. All these cases where confirmed by biological diagnosis and recorded by the Teaching Hospital virological laboratory.

Results

Thirteen cases of measles (11 adults and two children) were recorded during the study period. Adults were young (mean age 21.4 years); the oldest was 35 years old. We noted two severe cases with viral pneumonia and hypoxemia and one case with bacterial pneumonia. Two female patients were pregnant; one delivered prematurely, in the acute phase of measles, with no complication for the newborn. Two cases occurred in the nursing staff by documented nosocomial transmission. Sixty-nine percent of the patients were not vaccinated whereas the vaccinal status was not documented for 31%.

Conclusions

These cases underline the potential severity of this infection and the difficulty to diagnose measles at the early phase because of lack of awareness of medical staff. It will be necessary to reinforce prevention messages and promote measles vaccination in children as well as in young people and health workers.