Health for some? The effects of user fees in the Volta Region of Ghana

This paper reports key findings and conclusions from a 1996 study of user fees and exemptions in the Volta Region of Ghana. A variety of data sources and methods were used, including interviews with patients and managers, community-based focus group discussions, analysis of facility records and analyses of previous household survey data. Official fee levels and exemption categories were established in 1985. While this legislation made provision for drug fees to be 'at cost' and thus to be revised in line with inflation, other official fees have not been adjusted since 1985. In the face of declining real levels of budget allocations and decreased supplies of essential consumables from the Central medical stores, facility managers have established their own pricing and fee collection systems. This has been allowed by the Ministry of Health, but the decentralized nature of fee setting and collection practices has made it very difficult for the Ministry to monitor the effects of fees. The study found that facility managers have been very active in setting and collecting fees and using the revenues to purchase essential inputs. The level of revenues being mobilized accounts for between two-thirds and four-fifths of the non-salary operating budget of government health facilities, and virtually all of the resources for non-salary operating expenses in mission hospitals. Official exemptions are largely non-functional. Less than one in 1000 patient contacts were granted exemption in 1995. With estimates that between 15 and 30% of the population lives in poverty, the failure of exemptions to function means that fees are preventing access for the poor, or are imposing significant financial hardships on this part of the population. Health facilities in the Volta Region have achieved a kind of 'sustainable inequity', with fees enabling service provision to continue, while concurrently preventing part of the population from using these services.     

The State Children's Health Insurance Program: has it reduced the percentage of uninsured children?

Recent data indicate that the percentage of children in the United States who are uninsured is declining. Although many factors have contributed to that decline, this study assesses the role of public health insurance, specifically the State Children's Health Insurance Program (SCHIP), in reducing the percentage of uninsured children without health insurance from 1998-2000 and whether Medicaid and SCHIP crowd out exists. While this research confirms a significant decline in the percentage of uninsured children since SCHIP began enrolling children in 1998, other factors, including the poverty rate, the percentage of children on Medicaid, geographic region and race had a greater impact in explaining that result than SCHIP. Lastly, the data findings are consistent with research suggesting crowd out does exist.     

Side effects of generic competition?

This study examined the relationship between generic drug market shares and the number of reported side effects. Yearly time-series data for the number of reported side effects and information on market shares, prices, and quantities from 1972 to 1996 were used in this study. Poisson and negative binomial regression models were used in the statistical analysis. The results show that increased generic market share increases the number of reported side effects for all estimated models. When studying the relationship at the substance level, increasing generic market shares increases the number of side effects for 7 of the 15 substances. Generic substitution laws and measures to increase generic competition may thus have unintended consequences since these results show a positive relationship between generic market shares and reported side effects.     

Are pleiotropic effects of statins real?

The clinical benefits of statins are strongly related to their low density lipoprotein-cholesterol (LDL-C) lowering properties. However, because mevalonic acid (MVA), the product of 3-hydroxy-3-methyl-3-glutaryl coenzyme A (HMG-CoA) reductase reaction, is the precursor not only of cholesterol but also of nonsteroidal isoprenoid compounds, the inhibition of HMG-CoA reductase may result in pleiotropic effects, independent of their hypocholesterolemic properties. The discrimination between the pleiotropic from LDL-C lowering effects may potentially be more evident during the early phase of treatment since plasma MVA levels drop up to 70% within 1-2 hours while a reduction of LDL-C, detectable after 24 hours, became significant after 6-7 days. Therefore, the deprivation of circulating MVA-derived isoprenoids in the early phase of treatment could be the main mechanism responsible for the atheroprotective effect of statins. This early window of protection in the absence of LDL-C lowering suggests that the anti-inflammatory and the pleiotropic properties of statins may have clinical importance. Therefore, acute coronary syndromes could represent a clinical condition for addressing the early benefits of statins therapy, ie, within 24 h of the event, independent of LDL-C lowering.     

Health Status of Mexican-Origin Persons: Do Proxy Measures of Acculturation Advance our Understanding of Health Disparities?

Objectives This paper compares select health status indicators between the U.S. and Mexico, and within the Mexican-origin population using proxy measures of acculturation. Methods Statistical data were abstracted and a Medline literature review conducted of English-language epidemiologic articles on Mexican-origin groups published during 1976–2005. Results U.S.-born Mexican-Americans have higher morbidity and mortality compared to Mexico-born immigrants. Mexico has lower healthcare resources, life expectancy, and circulatory system and cancer mortality rates, but similar infant immunization rates compared to the U.S. Along the U.S.-Mexico border, the population on the U.S. side has better health status than the Mexican side. The longer in the U.S., the more likely Mexican-born immigrants engage in behaviors that are not health promoting. Conclusions Researchers should consider SEP, community norms, behavioral risk and protective factors when studying Mexican-origin groups. It is not spendingtime in the U.S. that worsens health outcomes but rather changes in health promoting behaviors.     

The Causal Effect of Education on Health: What is the Role of Health Behaviors?

We investigate the causal effect of education on health and the part of it that is attributable to health behaviors by distinguishing between short‐run and long‐run mediating effects: whereas, in the former, only behaviors in the immediate past are taken into account, in the latter, we consider the entire history of behaviors. We use two identification strategies: instrumental variables based on compulsory schooling reforms and a combined aggregation, differencing, and selection on an observables technique to address the endogeneity of both education and behaviors in the health production function. Using panel data for European countries, we find that education has a protective effect for European men and women aged 50+. We find that the mediating effects of health behaviors—measured by smoking, drinking, exercising, and the body mass index—account in the short run for around a quarter and in the long run for around a third of the entire effect of education on health. Copyright © 2015 John Wiley & Sons, Ltd.     

What are the health effects of fat?

In order to answer the question which health benefits are to be expected from dietary fat, we have to differentiate between different kinds of fat with varying fatty acid composition. Saturated fatty acids are commonly judged to have a negative health impact as they lead to increased serum cholesterol levels and a higher risk of coronary heart disease. Therefore, all recommendations stress the importance to limit the intake of saturated fatty acids. Monounsaturated fatty acids, on the other hand, have a positive impact on the serum lipid profile, lead to decreased LDL-oxidation and favorably influence the metabolism of diabetics. However, it is essential that monounsaturated fatty acids be mainly supplied by plant oils like rape seed or olive oil and not by foods that are simultaneously rich in saturated fatty acids. Concerning polyunsaturated fatty acids, it is important to increase the supply of n-3 fatty acids (ratio of n-6:n-3: about 5:1) as there is substantial evidence for their protective effects. If the fatty acid composition of the diet is optimized, even a total dietary fat content of 35% of total energy intake can be adequate as long as there is enough physical activity and the diet is rich in plant-derived foods like vegetables, fruits, cereals, potatoes, beans and legumes.     

Is the risk of lung cancer reduced among eczema patients?

Persons with a history of eczema have been shown to have a reduced risk of lung cancer, but the evidence has been inconclusive because of the small size of previous studies and their limited ability to control for confounding by smoking. The objective of this study was to determine the role of eczema in relation to lung cancer while overcoming the limitations of previous investigations. Study subjects included 2,854 cases and 3,116 population and hospital controls recruited during 1998-2001 from 16 areas in the Czech Republic, Hungary, Poland, Romania, Russia, Slovakia, and the United Kingdom. Odds ratios were calculated for self-reported history of eczema via multivariate logistic regression modeling. The odds ratio for a history of eczema was 0.61 (95% confidence interval: 0.48, 0.76) after control for age, sex, study center, and cumulative tobacco smoking. There was no heterogeneity in the results by sex or age at onset of eczema. Subjects reporting use of medication for eczema had a lower odds ratio than subjects not reporting such use. This study provides further evidence for an inverse association between history of eczema and lung cancer risk, which is unlikely to be due to chance, bias, or confounding.