Equity of the HIV epidemic response in 13 African countries.

For over 25 years, new programs to attempt to stem the HIV epidemic have been developed in Africa by country governments as well as external donors. These programs and activities have built and operated facilities, trained clinicians, financed drugs and commodities, supported and helped finance government health planning and operations, and contributed in other ways. Who has benefited from this massive mobilization? While some single country and narrowly focused studies have been done, the issue of equity of HIV programs for vulnerable populations has not been examined in a large set of countries. Using Population-based HIV Impact Assessment (PHIA) data, we examine equity of the HIV programs in 13 African countries to determine if vulnerable groups (such as those with low wealth, rural populations, young adults, and females) have achieved comparable levels of access to HIV program services. In contrast, we also compare the equity of the HIV response to rural and low-wealth populations with the equity of corresponding domestic health systems using Demographic and Health Survey data.This study found that in over half of the countries, the HIV response indicators were equitable for vulnerable population segments including the low-wealth population (in seven countries) and rural population segment (in nine countries). In no country was the domestic health system equitable for these two groups. However, HIV programming does show some clear patterns of inequity for low-wealth and rural populations in some countries. For gender and young adults, the HIV response indicators show that in all 13 countries men and young adults are consistently underserved relative to their counterparts.

Zirconium-based metallic glass and zirconia coatings to inhibit bone formation on titanium.

Surface-modified commercially pure titanium (Cp-Ti) with zirconium (Zr)-based thin film metallic glasses (Zr-TFMGs) and ZrO2 thin films were surgically implanted into the tibiae of rats; the bone formation was analyzed to examine the performance of the coatings as a biomaterial. Zr-TFMGs and ZrO2 thin films were coated on Cp-Ti substrates to monitor the control of assimilation in vitro and in vivo. The microstructural and elemental analyses were carried out for the as deposited thin films by x-ray diffraction (XRD), transmission electron microscopy and x-ray photoelectron spectroscopy. TFMG- and ZrO2-coated Ti specimens were immersed in simulated body fluid (SBF) for a period of 21 days to evaluate the calcium phosphate precipitation in vitro. XRD, x-ray photoelectron spectroscopy and scanning electron microscopy/energy dispersive x-ray spectroscopy were used to quantify the mineralization on the coated Zr-TFMG and ZrO2. In vitro corrosion studies showed that the Zr-based TFMG and ZrO2 coatings sustained in the SBF, exhibited superior corrosion resistance to the bare crystalline Ti substrate. Wettability studies showed TFMG and ZrO2 coatings with a hydrophobic nature, and the TFMG-coated SBF-submerged specimens showed a hydrophilic nature. The in vitro cell viability of MC3T3-E1 cells showed good cell proliferation and low cytotoxicity. The calcification deposits were evaluated by staining with alizarin red S, which showed a lower calcium formation on Zr-TFMG compared to ZrO2. The present work also aims to assess the assimilation behavior of Cp-Ti, Zr-TFMG and ZrO2 in vivo by inserting the coated specimen in the femur of rats. After post-implantation of 8 weeks, specimens were examined by micro-CT evaluation. The bone contact ratios as calculated were 72.75%, 15.32% and 38.79%. Consequently, the bone affinity was Cp-Ti wire >ZrO2-coated Ti wire >Zr48Cu36Ag8Al8-coated Ti wire.

Health expenditures, health outcomes and the role of good governance.

This paper examines the relationship between country health spending and selected health outcomes (infant mortality and child mortality), using data from 133 low and middle-income countries for the years 1995, 2000, 2005, and 2006. Health spending has a significant effect on reducing infant and under-5 child mortality with an elasticity of 0.13 to 0.33 for infant mortality and 0.15 to 0.38 for under-5 child mortality in models estimated using fixed effects methods (depending on models employed). Government health spending also has a significant effect on reducing infant and child mortality and the size of the coefficient depends on the level of good governance achieved by the country, indicating that good governance increases the effectiveness of health spending. This paper contributes to the new evidence pointing to the importance of investing in health care services and the importance of governance in improving health outcomes.

The income elasticity of health care spending in developing and developed countries.

To date, international analyses on the strength of the relationship between country-level per capita income and per capita health expenditures have predominantly used developed countries' data. This study expands this work using a panel data set for 173 countries for the 1995-2006 period. We found that health care has an income elasticity that qualifies it as a necessity good, which is consistent with results of the most recent studies. Furthermore, we found that health care spending is least responsive to changes in income in low-income countries and most responsive to in middle-income countries with high-income countries falling in the middle. Finally, we found that 'Voice and Accountability' as an indicator of good governance seems to play a role in mobilizing more funds for health.

Pathways of health technology diffusion: the United States and low-income countries.

In the United States, the complex process of getting health care technologies into practice takes place in a competitive health system that is driven by technological innovation. Federal, state, and local governments' roles in the diffusion process are limited. In low-income countries, where competitive markets are not as prominent, diffusing medical innovations requires an alternative understanding of how new technologies are adopted. This paper describes how, in low-income countries, the lack of functioning markets serves as a barrier to the transfer of necessary health technologies, and why governments must act as stewards in promoting technologies there.

Does funding from donors displace government spending for health in developing countries?

The notable increases in funding from various donors for health over the past several years have made examining the effectiveness of aid all the more important. We examine the extent to which donor funding for health substitutes for--rather than complements--health financing by recipient governments. We find evidence of a strong substitution effect. The proportionate decrease in government spending associated with an increase in donor funding is largest in low-income countries. The results suggest that aid needs to be structured in a way that better aligns donors' and recipient governments' incentives, using innovative approaches such as performance-based aid financing.

Factors determining choice of health care provider in Jordan.

This paper examines factors influencing a patient's choice of provider for outpatient health care services in Jordan. Factors including demographic, socioeconomic, insurance status, quality of care, household size and cost of health care were studied using a multinomial logit model applied to a sample of 1031 outpatients from the Jordan heathcare utilization and expenditure survey, 2000. The patient's socioeconomic and demographic characteristics affected provider choice. Insurance was not statistically significant in choosing Ministry of Health facilities over other providers. Patients utilizing the public sector were price sensitive, and therefore any attempt to improve accessibility to health care services in Jordan should take this into consideration.

Health reform for children: the Egyptian experience with school health insurance.

In June 1992, the People's Assembly of Egypt passed Law 99 expanding health insurance to cover all school children. This was one of the most important initiatives undertaken in recent years by the Ministry of Health, and it effectively increased the number of beneficiaries covered by the Health Insurance Organization (HIO) from 3.75 million in 1988 to about 14 million in 1993. This paper first examines the policy processes for the introduction of this innovation in Egypt's health system. Next, the paper discusses the implementation and consequences of the new policy in terms of coverage, financing, benefits, and delivery of services, along with data on utilization and expenditures. Several important lessons derive from this analysis. First, major reform efforts are possible when there is a strong political commitment and the proposed program and solutions are acceptable to the key stakeholders. Second, compromises and trade-offs are essential to construct a politically feasible and ethically acceptable reform initiative. Third, while these trade-offs might yield short-term gains, the trade-offs in the long term may undermine the reform's capacity to achieve the anticipated equity enhancements and can potentially undermine the financial sustainability of the reform.