Affording what's free and paying for choice: comparing the cost of public and private hospitalizations in urban Kerala

OBJECTIVE: To assess the cost of public and private hospitalizations in urban Kerala and discuss policy implications of social disparities in the economic burden of hospital care. METHODS: The NSSO survey on health care (1995-1996) for urban Kerala was analysed with regards to expenditure incurred by hospital episodes. Multilevel linear models were built to assess factors associated with levels of health expenditure. FINDINGS: Hospital care involves paying admission fees in 68% of cases of hospitalizations (98% in private and 20% in public sector) in urban Kerala. Poor households and those headed by casual workers show significantly lower levels of health expenditure and a higher proportion of health-related loss of income than other social groups. Although there is significant expenditure in both sectors for these groups, hospitalization on free public wards is associated with lower expenditure than other options. Factors linked with higher expenditure are: duration of stay; hospitalizations on paying public wards and in the private sector; hospitalizations for above poverty line households and hospitalizations for chronic illnesses. Expenditure for services bought from outside the hospital is important in the public sector. CONCLUSION: Hospitalization incurs significant expenditure in urban Kerala. Greater availability of free medical services in the public sector and financial protection against the cost of hospitalization are warranted.     

Outcomes-based resource allocation for indigenous health services: a model for northern Australia?

Wide differentials continue to exist in mortality rates and other health outcomes between Aboriginal and non-Aboriginal Australians. In the Northern Territory (NT), where Aborigines make up 24% of the population, the all-causes age-adjusted Standardised Mortality Ratio for Aborigines compared to non-Aborigines has remained above 3 since the late 1970s, with significant regional variations. During 1995 an expenditure analysis was undertaken for primary health care (PHC) services in different regions of the NT and compared to mortality ratios. At the same time a method for needs-based funding was being developed which could replace the existing historical funding arrangements. In the first instance, the application of a simplified version of this Resource Allocation Formula (RAF) resulted in a significant shift of resources for new prevention program funding to regions of relatively high mortality and low per capita PHC expenditure. However, developing RAFs to redistribute at the margin within the NT is likely to generate further inequities between losing NT programs and counterparts in other states. If outcomes-based resource allocation is to be meaningful nationally, the reference point for the RAF should be national average PHC expenditure rather than existing state averages. There is a need for a combined approach to outcomes-based planning which takes into account both the equity arguments of resource allocation models and efficacy arguments to maximise health gains. Some of these arguments are explored in this paper.     

A COMPARATIVE EXAMINATION OF THE AUSTRALIAN AND NEW ZEALAND HEALTH SYSTEMS

In both New Zealand and Australia the 1970s was a period of rapid escalation in health costs, and modest increases in utilisation, set against a background, particularly in the later years, of economic downturn and restrictions in government spending. As a consequence total expenditure on health care, as a proportion of gross domestic product, continued to rise throughout the decade, reaching 6.7 percent in New Zealand and 7.9 per cent in Australia by 1979. Much of this difference can be explained, statistically, by the higher level of national income per capita in Australia - the contrasting systems of financing and provision appear to be less significant. Other related explanatory factors include differences in the proportion of the labour force employed in the health sector; in the number of general practitioners per head of population; and in the rates of utilisation of both personal and hospital services.     

Avoidable mortality trends in Aboriginal and non‐Aboriginal populations in the Northern Territory, 1985‐2004

Objectives: To analyse rates of avoidable mortality in Aboriginal and non‐Aboriginal residents of the Northern Territory (NT) from 1985 to 2004, in order to assess the contribution of health care to life expectancy improvements. Methods: Australian Bureau of Statistics (ABS) death registration data for NT residents were used to identify ‘avoidable’ deaths, with further separation into three categories of conditions amenable to either medical care or health policy, and a category for ischaemic heart disease (IHD). A Poisson regression model was used to calculate the average annual change in avoidable mortality by sex and Aboriginality in the NT compared with Australia as a whole. Results: In the 20 years between 1985 and 2004, avoidable mortality rates fell 18.9% in NT Aboriginal people, 61.1% in NT non‐Aboriginal people and 59.5% in Australians overall. NT Aboriginal people continued to experience higher avoidable mortality than other Australians and the disparity increased over time. Most of the decline in avoidable mortality for Aboriginal Territorians occurred for conditions amenable to medical care. Conclusion: Medical care has made a significant contribution to improvements in Aboriginal life expectancy in the NT, however, reductions in avoidable mortality from IHD and conditions amenable to health policy have been variable. Implications: The results highlight the need for ongoing investment in comprehensive programs incorporating appropriate health policy interventions and management of chronic diseases.     

Toward a needs based mechanism for capitation purposes in Italy: the role of socioeconomic level in explaining differences in the use of health services

The paper investigated differences in the use of hospital care, out-patient care and pharmaceutical care in Piemonte, a region of northern Italy with 4,000,000 inhabitants, taking into account factors of need and supply, for capitation purposes. The study used a geographical design, with the municipalities as statistical units, and was based on integrated data from health and health service information systems, the population census and on the geographical distances among municipalities. Hierarchical regression models were fitted with the utilisation of services as the outcome variable and a set of direct and indirect factors of need and supply indicators as covariates. Higher health service consumption rates were observed for the most disadvantaged employment categories, in addition to the elderly. Distance from hospital was inversely correlated with the hospitalisation rate. A formula for determining capitation can be developed using age and indirect factors of need as weights.     

Fiscal decentralisation and infant mortality rate: the Colombian case

There is a paucity of research analysing the influence of fiscal decentralisation on health outcomes. Colombia is an interesting case study, as health expenditure there has been decentralising since 1993, leading to an improvement in health care insurance. However, it is unclear whether fiscal decentralisation has improved population health. We assess the effect of fiscal decentralisation of health expenditure on infant mortality rates in Colombia. Infant mortality rates for 1080 municipalities over a 10-year period (1998–2007) were related to fiscal decentralisation by using an unbalanced fixed-effect regression model with robust errors. Fiscal decentralisation was measured as the locally controlled health expenditure as a proportion of total health expenditure. We also evaluated the effect of transfers from central government and municipal institutional capacity. In addition, we compared the effect of fiscal decentralisation at different levels of municipal poverty. Fiscal decentralisation decreased infant mortality rates (the elasticity was equal to −0.06). However, this effect was stronger in non-poor municipalities (−0.12) than poor ones (−0.081). We conclude that decentralising the fiscal allocation of responsibilities to municipalities decreased infant mortality rates. However, this improved health outcome effect depended greatly on the socio-economic conditions of the localities. The policy instrument used by the Health Minister to evaluate municipal institutional capacity in the health sector needs to be revised.     

Utilización de servicios sanitarios por parte de las poblaciones inmigrante y nativa en la Comunidad Autónoma de la Región de Murcia

ObjectiveTo analyze the patterns of utilisation for three types of public health services (outpatient specialist visits, emergency visits and hospitalisations) in the Comunidad Autónoma de la Región de Murcia. We examine the differences between the average rates of utilization of these services among natives and non-Spanish immigrants, and whether these differences are due to differences in demographic structure, or to different behaviour between these groups.MethodsWe use econometric models for utilisation to exploit administrative records on health care utilisation and the well established Oaxaca decomposition method. This splits average rates of utilisation and/or average health expenditure into two components: the first one stands for the part of the difference that can be attributed to differential patterns of behaviour among the two groups; the second one represents the part of the difference in average expenditure that can be attributed to the fact that average demographic characteristics among both groups differ.ResultsThe rates of use of outpatient specialist visits, emergencies and hospital nights by the native population are greater than the corresponding rates for the immigrant population. For individuals aged between 20 to 40 years old, the utilisation rates of African and Latin-American females are higher than those for native females. The average health expenditure of native males is greater than that of immigrants. The difference is mainly due to different demographic features among the native and immigrant populations, except for the «rest of Europe» group, whose individuals show a different behaviour. In fact, among the 20 to 40 age group, the average health expenditure of native females equals that of Latin-American women, which is in turn below that of African females.ConclusionsIn this paper we show that the remarkable differences in the age-gender balance among different (in terms of nationality) groups of insured residents in Murcia has a considerable effect on consumption of health services and therefore on the average health care expenditure attributable to these groups.     

Estimating chronic disease prevalence among the remote Aboriginal population of the Northern Territory using multiple data sources

OBJECTIVE: To determine the prevalence rates of hypertension, diabetes, ischaemic heart disease (IHD), renal disease and chronic obstructive pulmonary disease (COPD), and their co-occurrence among the remote Aboriginal population of the Northern Territory (NT) in 2005. METHODS: Information from a primary care chronic disease register (CDR) and hospital inpatient database were linked to a population list by using a unique patient identifier. A capture-recapture method (CRM) and multivariate log-linear models were then applied to analyse the multiple datasets to estimate the prevalence rates for the selected diseases and case ascertainment in each data source. RESULTS: The NT remote Aboriginal communities had considerably higher prevalence rates across all five chronic diseases than national health survey figures. At ages 50 years and over, the prevalence rates for hypertension and renal disease were above 50%, diabetes 40%, COPD 30% and IHD above 20%. In terms of data completeness, CDR and hospital sources were both relatively incomplete, generally around 20-60%. The most common co-occurrences for the five chronic diseases were between hypertension, diabetes, IHD and renal disease. CONCLUSIONS AND IMPLICATIONS: The prevalence rates calculated using this method are comparable to estimates from rigorous small area studies, but are markedly higher than those from single clinical data sources. The results indicate that there is a considerable under-diagnosis of preventable chronic diseases in the Aboriginal communities.     

Resource allocation for public hospitals in Andhra Pradesh, India

The composition of the hospital sector has important implications for cost effectiveness accessibility and coverage. The classification of acute general hospitals is reviewed here with particular reference to India and Andhra Pradesh. Approaches to arrive at a norm for allocation of hospital expenditure among secondary and tertiary hospitals are discussed. The actual allocation of public sector hospital expenditures is analyzed with data from Andhra Pradesh. The shift in allocative emphasis away from hospitals and in favour of primary health care during the 1980s was found to have been equally shared by secondary and tertiary hospitals. The shares of recurrent (non-plan) expenditure to secondary and tertiary hospitals were 51% and 49% respectively. This can be compared to a derived norm of 66% and 33%. The opportunity that new investment funds (plan schemes) could have provided to rectify the expenditure bias against secondary level hospitals was missed as two-thirds of plan expenditure were also spent on tertiary level hospitals. The share of secondary hospital bed capacity was 45.5% against India's Planning Commission norm of 70%. Public spending strategies should explicitly consider what mix of hospital services is being financed as well as the balance between hospital and primary health care expenditures.     

Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability

STUDY OBJECTIVE: To examine the role of specialist outreach in supporting primary health care and overcoming the barriers to health care faced by the indigenous population in remote areas of Australia, and to examine issues affecting its sustainability. DESIGN: A process evaluation of a specialist outreach service, using health service utilisation data and interviews with health professionals and patients. SETTING: The Top End of Australia's Northern Territory, where Darwin is the capital city and the major base for hospital and specialist services. In the rural and remote areas outside Darwin there are many small, predominantly indigenous communities, which are greatly disadvantaged by a severe burden of disease and limited access to medical care. PARTICIPANTS: Seventeen remote health practitioners, five specialists undertaking outreach, five regional health administrators, and three patients from remote communities. MAIN RESULTS: The barriers faced by many remote indigenous people in accessing specialist and hospital care are substantial. Outreach delivery of specialist services has overcome some of the barriers relating to distance, communication, and cultural inappropriateness of services and has enabled an over fourfold increase in the number of consultations with people from remote communities. Key issues affecting sustainability include: an adequate specialist base; an unmet demand from primary care; integration with, accountability to and capacity building for a multidisciplinary framework centred in primary care; good communication; visits that are regular and predictable; funding and coordination that recognises responsibilities to both hospitals and the primary care sector; and regular evaluation. CONCLUSIONS: In a setting where there is a disadvantaged population with inadequate access to medical care, specialist outreach from a regional centre can provide a more equitable means of service delivery than hospital based services alone. A sustainable outreach service that is organised appropriately, responsive to local community needs, and has an adequate regional specialist base can effectively integrate with and support primary health care processes. Poorly planned and conducted outreach, however, can draw resources away and detract from primary health care.     

Context matters: Successes and challenges of intrapartum care scale-up in four districts of Afghanistan

Reducing preventable maternal mortality and achieving Sustainable Development Goal targets for 2030 will require increased investment in improving access to quality health services in fragile and conflict-affected states. This study explores the conditions that affect availability and utilisation of intrapartum care services in four districts of Afghanistan where mortality studies were conducted in 2002 and 2011. Information on changes in each district was collected through interviews with community members; service providers; and district, provincial and national officials. This information was then triangulated with programme and policy documentation to identify factors that affect the coverage of safe delivery and emergency obstetric care services. Comparison of barriers to maternal health service coverage across the four districts highlights the complexities of national health policy planning and resource allocation in Afghanistan, and provides examples of the types of challenges that must be addressed to extend the reach of life-saving maternal health interventions to women in fragile and conflict-affected states. Findings suggest that improvements in service coverage must be measured at a sub-national level, and context-specific service delivery models may be needed to effectively scale up intrapartum care services in extremely remote or insecure settings.     

The development of a Local Index of Need (LIN) and its use to explain variations in social services expenditure on mental health care in England

Wide variations in deprivation exist across England and it is likely that these variations translate into differences in the need for mental health care. Social Services Departments in England account for a substantial proportion of mental health expenditure. It is important that the distribution of expenditure reflects mental health needs. This paper's aims are to (1) describe the development of a new indicator of mental health needs, (2) use the index to explain variations in social services expenditure on mental health, and (3) compare the index with other established measures of need. A principal components analysis of sociodemographic variables considered to be indicators of need was used to produce four distinct factors for 148 Local Authority areas in England. A weighted sum of these factors was used to produce a single index. (Weights were the proportion of variance explained by each factor.) The index was used in a regression model to explain variations in spending on mental health care and was compared with (1) a model containing the four individual factors, (2) the current method of allocating resources, (3) the index used to allocate resources to primary care trusts, (4) the Mental Illness Needs Index (MINI), (5) four indices of deprivation produced by the Office of the Deputy Prime Minister, and (6) the average of the above four indices. The new index could explain 54% of variation, compared with 56% using the current method. The four-factor model could explain 66%, whilst the other models could explain between 37% and 20%. This new index has the advantage that it is not based on previous levels of utilisation or expenditure and yet still explains a comparable amount of variation as the current method. However, a disaggregated model containing individual factors may be preferable.     

Public hospital activity,expenditure and staffing levels for indigenous and nonindigenous settlements in remote Queensland

Abstract: Aborigines and Torres Strait Islanders who live in discrete communities have poor health. Their life expectancy is relatively low and the underlying rates of morbidity, mortality and hospitalisation are much higher than the Australian average. For Aborigines and Torres Strait Islanders in the remote communities, the mortality rate is some three times higher than that of the total population. By comparing remote Aboriginal and Torres Strait Islander communities with similarly remote nonindigenous settlements, the paper shows that there was greater hospital activity per person in remote Aboriginal and Torres Strait Islander communities. Paradoxically, whereas there was greater hospital activity in discrete indigenous communities, there was lower expenditure per person on hospital services. The paper finds also that there were fewer medical and nursing staff per person in remote Aboriginal and Torres Strait communities.     

Redistribution or horizontal equity in Hong Kong's mixed public-private health system: a policy conundrum

We examine the distributional characteristics of Hong Kong's mixed public-private health system to identify the net redistribution achieved through public spending on health care, compare the income-related inequality and inequity of public and private care and measure horizontal inequity in health-care delivery overall. Payments for public care are highly concentrated on the better-off whereas benefits are pro-poor. As a consequence, public health care effects significant net redistribution from the rich to the poor. Public care is skewed towards the poor in part not only because of allocation according to need but also because the rich opt out of the public sector and consume most of the private care. Overall, there is horizontal inequity favouring the rich in general outpatient care and (very marginally) inpatient care. Pro-rich bias in the distribution of private care outweighs the pro-poor bias of public care. A lesser role for private finance may improve horizontal equity of utilisation but would also reduce the degree of net redistribution through the public sector.     

The impact of reducing financial barriers on utilisation of a primary health care facility in Rwanda

Abstract

This study investigates the impact of subsidising community-based health insurance (mutuelle) enrolment, removing point-of-service co-payments, and improving service delivery on health facility utilisation rates in Mayange, a sector of rural Rwanda of approximately 25,000 people divided among five ‘imidugudu’ or small villages. While comprehensive service upgrades were introduced in the Mayange Health Centre between April 2006 and February 2007, utilisation rates remained similar to comparison sites. Between February 2007 and April 2007, subsidies for mutuelle enrolment established virtually 100% coverage. Immediately after co-payments were eliminated in February 2007, patient visits levelled at a rate triple the previous value. Regression analyses using data from Mayange and two comparison sites indicate that removing financial barriers resulted in about 0.6 additional annual visits for curative care per capita.

Although based on a single local pilot, these findings suggest that in order to achieve improved health outcomes, key short-term objectives include improved service delivery and reduced financial barriers. Based on this pilot, higher utilisation rates may be affected if broader swaths of the population are enrolled in mutuelle and co-payments are eliminated. Health leaders in Rwanda should consider further studies to determine if the impact of eliminating co-payments and increasing subsidies for mutuelle enrolment as seen in Mayange holds at greater levels of scale. Broader studies to better elucidate the impact of enrolment subsidies and co-payment subsidies on utilisation, health outcomes, and costs would also provide policy insights.     

政治体制对政府医疗卫生支出及健康产出的影响综述

大多数发展中国家的政府医疗卫生支出及健康产出长期处于较低水平,与发达国家有较大差距。这种差距并不能仅仅由经济因素解释,政府主导了卫生资源的分配,因此分析理性政府在公共资源分配中的激励问责机制尤为重要。本文分析了政治体制对政府提供医疗卫生服务的激励问责机制,综述了近年来有关政治体制影响政府医疗卫生支出及健康产出的实证研究。大量研究结果表明与非民主政治体制相比,民主政治体制在增加政府医疗卫生支出、提高健康产出方面有显著的积极作用。     

Financing health care in Bangladesh: Policy responses and challenges towards achieving universal health coverage

Bangladesh has attained notable progress in most of the health indicators, but still, health system of the country is suffering badly from poor funding. Issues like burden of out‐of‐pocket expenditure, low per capita share in health, inadequate service facilities, and financial barriers in reducing malnutrition are being overlooked due to inadequacy and inappropriate utilization of allocated funds. We aimed to review the current status of health care spending in Bangladesh in response to national health policy (NHP) and determine the future challenges towards achieving universal health coverage (UHC). National health policy suggested a substantial increase in budgetary allocation for health care, although government health care expenditures in proportion to total public spending plummeted down from 6.2% to 4.04% in the past 8 years. Overall, 67% of the health care cost is being paid by people, whereas global standard is below 32%. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. The country is experiencing demographic dividend with a concurrent rise of aged people, but there seems no financial protection schemes for the aged and working age populations. Such situation results in multiple obstacles in achieving financial risk protection as well as UHC. Policy makers must think effectively to develop and adapt systems in order to achieve UHC and ensure health for all.     

Use of general practice, diagnostic investigations and hospital services before and after cancer diagnosis - a population-based nationwide registry study of 127,000 incident adult cancer patients

ABSTRACT: BACKGROUND: Knowledge of patterns in cancer patients' health care utilisation around the time of diagnosis may guide health care resource allocation and provide important insights into this groups' demand for health care services. The health care need of patients with comorbid conditions far exceeds the oncology capacity and it is therefore important to elucidate the role of both primary and secondary care. The aim of this paper is to describe the use of health care services amongst incident cancer patients in Denmark one year before and one year after cancer diagnosis. METHODS: The present study is a national population-based case-control (1:10) registry study. All incident cancer patients (n=127,210) diagnosed between 2001 and 2006 aged 40 years or older were identified in the Danish Cancer Registry. Data from national health registries were provided for all cancer patients and for 1,272,100 controls. Monthly consultation frequencies, monthly proportions of persons receiving health services and three-month incidence rate ratios for one year before and one year after the cancer diagnosis were calculated. Data were analysed separately for women and men. RESULTS: Three months before their diagnosis, cancer patients had twice as many general practitioner (GP) consultations, ten to eleven times more diagnostic investigations and five times more hospital contacts than the reference population. The demand for GP services peaked one month before diagnosis, the demand for diagnostic investigations one month after diagnosis and the number of hospital contacts three months after diagnosis. The proportion of cancer patients receiving each of these three types of health services remained more than 10% above that of the reference population from two months before diagnosis until the end of the study period. CONCLUSIONS: Cancer patients' health service utilisation rose dramatically three months before their diagnosis. This increase applied to all services in general throughout the first year after diagnosis and to the patients' use of hospital contacts in particular. Cancer patients' heightened demand for GP services one year after their diagnosis highlights the importance of close coordination and communication between the primary and the secondary healthcare sector.     

清远市1999-2007年新生儿破伤风流行病学分析

目的探讨清远市新生儿破伤风（新破）发病情况及其影响因素和防制措施。方法采用描述性流行病学方法,对清远市1999—2007年新破专报系统的监测资料和个案调查材料进行统计分析。结果清远市1999—2007年共报告新破267例,年平均发病率0．80‰;死亡63例,年平均死亡率0．19‰;年平均病死率23．60％。报告发病率呈逐年下降趋势。病例主要集中在农村和边远山区。男、女要总发病率分别为1．08‰、0．46‰,差异有统计学意义（Х^2=8．734,P〈0.05）,男女性别比为2．84：1。在家中分娩的病例占94．70％;由未经培训的人员接生占93．63％;病例母亲94．01％未接种过破伤风类毒素,82．77％未接受过产前检查或不详;属计划外生育的病例占36．70％。结论产妇卫生知识缺乏和不安全接生是清远市新生儿破伤风发病的主要影响因素。普及住院分娩、新法接生,加强流动人口中育龄妇女的妇幼保健工作,育龄妇女接种破伤风类毒素是预防和消除新破的主要措施。