Health insurance coverage and use of selected preventive services by working-age women, BRFSS, 2006

Access to healthcare and participation in preventive screening are important to the well-being of women. Using 2006 Behavioral Risk Factor Surveillance System (BRFSS) data, we examined the prevalence of health insurance coverage among working-age women and their use of selected preventive health screening. These data were also used to determine these women's access to services and the extent to which cost was a barrier. Overall, 17.3% of working-age women reported not having health insurance coverage, and lack of coverage varied widely among the states. Those without coverage were significantly more likely to report having neither routine health examinations nor a regular provider, to report cost as a barrier to access, and to be less likely to get screened for breast, cervical, and colorectal cancers during the specified time intervals. Future research and programs need to address the public health issues of unmet healthcare needs and health insurance coverage of U.S. women.     

Healthcare-seeking patterns among immigrants in Portugal

Equity of access to health services is a major concern as it is an important precondition for positive health outcomes. However, inequities in use of health services among immigrant populations persist. Despite the increasing research in the field, patterns of healthcare seeking among immigrant populations and its associated factors are not fully understood. This study aimed to investigate healthcare-seeking patterns among immigrants in Portugal and identify factors associated with utilisation of health services. A cross-sectional study was conducted between October 2008 and May 2009 with a sample of 1,375 immigrants residing in the Lisbon region. Data were collected through a structured questionnaire applied by trained interviewers. Two stepwise logistic regressions were conducted to identify which factors were associated with utilisation of the National Health Service (NHS) and with healthcare seeking for the first time in Portugal at the Primary Health Care service, estimated by calculating odds ratios and 95% confidence intervals. Among participants, around 77% reported having used the NHS; 50% sought health-care for the first time at the Primary Health Care service and 33% at the emergency room. Lower odds of having used the NHS were associated with being male, Brazilian or eastern European compared with being African, and undocumented. Lower odds of having sought health-care for the first time at the Primary Health Care service were associated with being male and undocumented. These results suggest that further efforts are needed to tackle inequalities in access to care and promote the utilisation of health services, particularly among the more vulnerable immigrant groups. Increasing appropriate utilisation of health services, including the primary and preventive care services, may lead to better health outcomes. Immigrants' involvement and participation should be incorporated into the development of health strategies to improve access and utilisation of healthcare services.     

Youth experiences in accessing sexual healthcare services in Vietnam

Poor sexual and reproductive health outcomes among youth are reflective of the many barriers members of this group face in accessing health services. This study provides an in-depth account of the unique challenges that young people face in accessing sexual healthcare services in Vietnam. We surveyed 130 men and women aged 18–24 years at two major reproductive health sites in Ho Chi Minh City. We identified and explored seven domains: health insurance status, modern contraception use, HIV/STI testing, cervical cancer screening, unintended pregnancy, reproductive coercion and the patient-provider relationship. Attitudes towards the national health insurance system suggest that it does not facilitate access to healthcare. Despite widespread and affordable services, fears, fallacies and fixed social mores created formidable barriers for unmarried youth to access sexual and reproductive health services in Vietnam.     

Royal Society of Tropical Medicine and Hygiene meeting at Manson House,London 17 January 2002. Cervical cancer in developing countries

The public health importance of cervical cancer is now increasingly appreciated as a means to improve the general health of women in many developing countries. Developing countries account for 80% of the world burden, mostly due to the lack of effective control programmes. Infection with oncogenic types of human papillomaviruses (HPV) has been established as the central cause for cervical cancer. Thus, vaccination against HPV is a potentially useful strategy for prevention, but this may take several years to become a reality. Currently, early detection and treatment is the most effective approach to control cervical cancer. Cervical cancer may be controlled through improving awareness and accessibility to diagnostic and treatment services. Cytology-based screening is beyond the capacity of health services in many developing countries, hence, alternative methods to cytology are being investigated. Visual inspection of the cervix after application of 3-5% acetic acid (VIA) seems to be a promising screening test, with a similar sensitivity to that of cytology, but lower specificity. Currently, it is being evaluated for its cost-effectiveness in reducing cervical cancer incidence and mortality in randomized trials. Information from the ongoing studies will be valuable for evolving cervical cancer control policies and programmes in low-resource settings.     

Impact of Community‐based Health Insurance on Access and Financial Protection: Evidence from Three Randomized Control Trials in Rural India

Since the 1990s, community‐based health insurance (CBHI) schemes have been proposed to reduce the financial consequences of illness and enhance access to healthcare in developing countries. Convincing evidence on the ability of such schemes to meet their objectives is scarce. This paper uses randomized control trials conducted in rural Uttar Pradesh and Bihar (India) to evaluate the effects of three CBHI schemes on healthcare utilization and expenditure. We find that the schemes have no effect on these outcomes. The results suggest that CBHI schemes of the type examined in this paper are unlikely to have a substantial impact on access and financial protection in developing countries. Copyright © 2015 John Wiley & Sons, Ltd.     

An in-depth and updated perspective on determinants of cervical cancer screening among central Appalachian women

Although cervical cancer rates in the U.S. have declined sharply, certain groups remain at elevated risk, including Appalachian women. To establish culturally-relevant cervical cancer prevention programs requires a comprehensive, current understanding of the factors which influence women's decisions to undergo Pap tests. Since most studies that found low rates of Pap test use in Appalachia were carried out decades ago, an in-depth update is warranted. Local, trained interviewers conducted interviews with rarely or never screened Appalachian women from Kentucky and West Virginia. Sessions were tape recorded, transcribed, and content analyzed. Participants (N = 25) suggested the following positive influences on obtaining screening: having an orientation toward the use of preventive health services; having health insurance and access to a good medical environment; and maintaining a flexible enough schedule to keep appointments. Screening barriers included: fear of subjecting oneself to medical scrutiny because of obesity or being a smoker; inadequate health care access such as clinician shortages, scarcity of specialty providers, long travel time to services, and clinic schedules that do not accommodate working women; and lack of providers' recommendations. Rarely mentioned were some previously reported factors including male relatives' refusal to permit Pap tests, concern over privacy, and lack of belief in Pap tests.     

Field based evidence of enhanced healthcare utilization among persons insured by micro health insurance units in Philippines

Underutilization of healthcare is common among rural and low-income population segments in countries with lower income or inequitable income distribution. Micro health insurance units (MIUs) are created by informal sector groups because people cannot access health insurance or are dissatisfied with the programmes they can access. The policy choice to support MIUs relies on evidence that affiliation with these schemes increases healthcare utilization. This article examines new evidence of the association between affiliation with MIUs and healthcare utilization. We analyzed field data collected in 6 MIUs in the Philippines in 2002 (through a household survey encompassing 890 insured- and 1063 uninsured households). The two cohorts did not differ in demographic parameters, and differed only marginally in income and education levels, both higher amongst the insured. Insured persons reported higher hospitalization rates, higher rates of professionally-attended deliveries, lower rates of delivery at home, a higher frequency of primary-care physician encounters, a higher rate of diagnosed chronic diseases, and better drug compliance among chronically ill. Increased utilization by the insured is not due to adverse selection, judging by two facts: morbidity of the two cohorts, as assessed by a proxy indicator (the reported number of episodes of illness) did not differ; and rates of deliveries were even slightly higher among the uninsured. We conclude that MIUs in the Philippines can alleviate underutilization of heath care.     

Adding value and equity to primary healthcare through partnership working to establish a viable community health workers’ programme in Namibia

Community health worker (CHW?) programmes have been criticized on two fronts: either as being inappropriate for effectively improving healthcare in impoverished societies, or as being fraught with relationship problems between partners. This paper uses an example from Namibia to suggest that both these criticisms can be overcome: the first by clarifying the objectives of a CHW programme, the second by careful planning. It is concluded that CHW programmes do have a legitimate and important role to play in the delivery of primary healthcare in developing countries. In particular, at a small incremental cost, they can reduce inequalities in access to and utilization of formal healthcare services by deprived communities.     

Identification of Unmet Healthcare Needs: A National Survey in Thailand

Objectives:This study examined demographic factors hampering access to healthcare at hospitals and suggests policy approaches to improve healthcare management in Thailand.Methods:The data for the study were drawn from a health and welfare survey conducted by the National Statistical Office of Thailand in 2017. The population-based health and welfare survey was systematically carried out by skilled interviewers, who polled 21 519 384 individuals. The independent variables related to demographic data (age, sex, religion, marital status, education, occupation, and area of residence), chronic diseases, and health insurance coverage. The dependent variable was the degree of access to healthcare. Multiple logistic regression analysis was subsequently performed on the variables found to be significant in the univariate analysis. Results:Only 2.5% of the population did not visit a hospital when necessary for outpatient-department treatment, hospitalization, or the provision of oral care. The primary reasons people gave for not availing themselves of the services offered by government hospitals when they were ill were—in descending order of frequency—insufficient time to seek care, long hospital queues, travel inconvenience, a lack of hospital beds, unavailability of a dentist, not having someone to accompany them, and being unable to pay for the transportation costs. Multiple logistic regression analysis showed that failure to access the health services provided at hospitals was associated with demographic, educational, occupational, health welfare, and geographic factors. Conclusions:Accessibility depends not only on health and welfare benefit coverage, but also on socioeconomic factors and the degree of convenience associated with visiting a hospital.     

Incentives for voluntary health insurance in a national health system: Evidence from Italy

ObjectivesThe paper evaluates the extent to which the government's policy to encourage the purchase of voluntary health insurance (VHI) may have led to income-related horizontal inequity in access to health care in a universal health care system (NHS).MethodsAd hoc tax return data for the universe of Italian taxpayers for years 2009-2016 are used to estimate the tax benefits granted to taxpayers who hold VHI, the redistributive impact, and the public budget effect. The income elasticity of tax benefits is estimated using tax return data and considering some taxpayers’ characteristics (income class, gender, age, and geographic area). Standard inequality indices are computed to assess income-related horizontal inequity in access to health care.ResultsTax incentives, especially those granted to employer-paid health insurance, have a sizeable impact on tax revenue and introduce into the Italian NHS significant income-related horizontal and vertical inequity in access to health care. The results suggest a distributional profile of tax incentives that is highly concentrated in favor of wealthier taxpayers.ConclusionOur analysis adds novel evidence that may contribute to the current debate on whether and to what extent countries in which all citizens have access to free healthcare and equal standards of healthcare services should subsidize VHI, especially when the coverage doubles the healthcare services provided by universal public insurance. We show that VHI reduces tax revenues and introduces disparities among citizens in terms of access to healthcare services.     

Differences in access to health care services among adults in rural America by rural classification categories and age

Objective: To study differences in excess to health care services between different population groups in rural areas of the United States. Design: Using data from the 1994 National Health Interview Survey and the 1991 Area Resource File, we examined the differences in excess with seven measures: having a regular source of care, having a usual place of care, having health insurance coverage, delaying medical care because of cost for all rural residents; number of doctor visits, number of hospital discharges and length of hospital stay per discharge for those who reported their health as being either poor or fair. Rural residents were classified by ages and grouped into four rural classification categories that were characterised along two dimensions: adjacent to a metropolitan statistical area (MSA) (yes/no) and inclusion of a city of at least 10 000 people (yes/no). Setting: Rural areas Subjects: Rural populations. Results: Residents aged 18–24 years had the worst access to services and the residents aged 65 years and over had the best access to services when measured by regular source of care, a usual place of care and health insurance status. Compared to those aged 50–64 years, residents aged 25–49 years were less likely to report having health insurance and more likely to report delaying seeking medical care because of costs. Rural residents who lived in a county adjacent to an MSA generally were less limited in access than those who lived in a county not adjacent to an MSA. Conclusions: Rural America is not a homogeneous entity in many aspects of the access to health care services.     

高端医疗服务发展的国际经验与启示

高端医疗服务业是健康服务业发展的关键领域,但由于公立医院特需服务不断扩张、社会办医政策存"玻璃门"等原因,我国高端医疗服务业的发展尚处于初期阶段。事实上,高端医疗服务业在部分国家(特别是发达国家)已经初具规模,并在发展基础、运营模式、保障体系等方面积累了比较丰富的经验。本研究介绍了英国、美国、德国、新加坡、澳大利亚和印度发展高端医疗服务业的经验:建立国家安全网医院起兜底作用,实行分层定价和差异化补贴政策,借助商业健康保险,运用公私合作模式,优先发展若干领域。并结合我国实际情况,提出我国发展高端医疗服务业的启示:在确保基本医疗服务的前提下,实行有差别的支付政策;推广商业健康保险,拓展公私合作,确定发展高端医疗的优先领域。     

Patient-Held Maternal and/or Child Health Records: Meeting the Information Needs of Patients and Healthcare Providers in Developing Countries?

Though improvements in infant and maternal mortality rates have occurred over time, women and children still die every hour from preventable causes. Various regional, social and economic factors are involved in the ability of women and children to receive adequate care and prevention services. Patient-held maternal and/or child health records have been used for a number of years in many countries to help track health risks, vaccinations and other preventative health measures performed. Though these records are primarily designed to record patient histories and healthcare information and guide healthcare workers providing care, because the records are patient-held, they also allow families a greater ability to track their own health and prevention strategies.A literature search was performed to answer these questions: (1) What are maternal information needs regarding pregnancy, post-natal and infant healthcare, especially in developing countries? (2) What is known about maternal information seeking behavior in developing countries? (3) What is the history and current state of maternal and/or child patient-held healthcare records, do they provide for the information needs of the healthcare provider and what are the effects and outcomes of patient-held records in general and for maternal and/or child health in particular?Specific information needs of pregnant women and mothers are rarely studied. The small numbers of maternal information behavior results available indicate that mothers, in general, prefer to receive health information directly from their healthcare provider as opposed to from other sources (written, etc.) Overall, in developing countries, patient-held maternal and/or child healthcare records have a mostly positive effect for both patient and care provider. Mothers and children with records tend to have better outcomes in healthcare and preventative measures. Further research into the information behaviors of pregnant women and mothers to determine the extent of reliance on interpersonal information seeking is recommended before expending significant resources on enhanced patient-held maternal and/or child healthcare records including storage on mobile devices. In particular, research is needed to explore the utility of providing targeted health messages to mothers regarding their own health and that of their children; this might best be accomplished through mobile technologies.     

Determinants of influenza vaccination in hard-to-reach urban populations

OBJECTIVE: Influenza vaccination rates among disadvantaged minority and hard-to-reach populations are lower than in other groups. We assessed the barriers to influenza vaccination in disadvantaged urban areas. METHODS: We conducted a cross-sectional study, using venue-based sampling, collecting data on residents of eight neighborhoods throughout East Harlem and the Bronx, New York City. RESULTS: Of 760 total respondents, 461 (61.6%) had received influenza vaccination at some point in their life. In multivariable models, having access to routine medical care, receipt of health or social services, having tested positive for HIV, and current interest in receiving influenza vaccination were significantly associated with having received influenza vaccination in the previous year. Of participants surveyed, 79.6% were interested in receiving an influenza vaccination at the time of survey. Among participants who had never previously received influenza vaccination in the past, 73.4% were interested in being vaccinated; factors significantly associated with an interest in being vaccinated were minority race, lower annual income, history of being homeless, being uninsured/underinsured, and not having access to routine medical care. CONCLUSIONS: Participants who are unconnected to health or social services or government health insurance are less likely to have been vaccinated in the past although these persons are willing to receive vaccine if it were available.     

Survey in sub-Saharan Africa shows substantial support for government efforts to improve health services

Public opinion can play an important role in shaping health policy alternatives and outcomes. However, little is known about how citizens in developing countries evaluate government performance in the health sector. Through a survey conducted in 2008 in twenty sub-Saharan African countries, we examined public priorities and perceptions of government efforts to improve health services. In sixteen of these countries, health was one of the top five priorities the public thought the government should address. A staggering proportion of citizens in most of the sampled countries reported having gone without medicines or medical treatment in the previous year, and going without health care was most strongly correlated with views on health services. By contrast, greater access to health care was associated with more positive impressions of government efforts to improve health services. Population health indicators, such as life expectancy and childhood mortality, were not correlated with citizens' evaluation of government efforts. Results suggest that improving access to health care will be a key factor in improving perceptions of government performance.     

Perceived access in a managed care environment: determinants of satisfaction.

With increasing competition in the local and regional healthcare markets, and growing interest in assessing the effectiveness of services and patient outcomes, satisfaction measures are becoming prominent in evaluating the performance of the healthcare system. This study examines the independent effect of predisposing, enabling and medical need factors on perceived access to care with particular focus on insurance plans. A survey questionnaire is developed to investigate access limitations at three levels: (1) the health plan, (2) the individual provider(s) and (3) the healthcare organization. In addition, shortage of providers, residents' perceptions of their health status, satisfaction with access to care and socio-demographic indicators are incorporated into the analysis. Multivariate logistic regression is used to assess the independent effects of the above factors on a dichotomous dependent variable--residents' overall satisfaction with access to healthcare services. The most salient determinants of overall satisfaction with access to care were the type of health insurance plan, cost of insurance premiums, co-payments, difficulty with obtaining referrals, self-rated general health, the opportunity cost of taking time to see a provider (measured by the loss of hourly wages), marital status and the age factor over 80 years.     

异地医保实时结算的支付模式研究

针对跨省异地就医实时结算的支付模式难以界定的现状,分析了处理跨省异地医保实时医保结算时必须解决的3项关键问题,提出了可供选择的解决方案,为实现跨省异地就医医保实时结算进行了有益的探索。课题的实施对于推动跨省卫生协同服务水平的提高具有重大意义。     

Public health insurance and mortality in the older population: Evidence from the Irish Longitudinal Study on Ageing

Most developed countries provide publicly-financed insurance for many health services for their populations although there is considerable variation across countries in the types of services covered, eligible population groups and whether co-payments are levied. The Irish healthcare system, with a complex mix of public and private financing of healthcare services, offers a useful case study for an examination of the impact of type of health insurance cover on population health. In this paper, we investigate the extent to which type of health insurance cover is associated with all-cause, cause-specific, and amenable mortality using data on a representative survey of the population aged 50+ from the Irish Longitudinal Study on Ageing (TILDA) matched to administrative data on death registrations. The results show that those without public or private health insurance have a higher risk of all-cause and cancer mortality. However, there is no evidence that type of health insurance cover affects mortality risk from causes that are considered amenable to healthcare intervention, although this analysis was based on a much smaller sample size. This analysis provides important evidence for a country that is implementing reforms to its financing and delivery structures in order to move towards a system of universal healthcare.