Effects of expanding a non-contributory health insurance scheme on out-of-pocket healthcare spending by the poor in Turkey.

INTRODUCTION: Insufficient or no health insurance creates financial access barriers to healthcare services, especially for vulnerable populations. The Green Card scheme, a non-contributory government-funded health insurance scheme for the poor in Turkey, was expanded in 2003-2006 and has provided citizens with extended benefits. We study the effects of this expansion of the Green Card scheme on out-of-pocket healthcare expenditures for low-income households. METHODS: We use difference-in-differences study design to examine the causal impact of having a Green Card on financial protection in terms of out-of-pocket health expenditures and catastrophic expenditures for the poor in Turkey. In addition, we implement quantile regression analysis to examine how the benefits expansion affects the poor who have the largest out-of-pocket expenditures and are in the upper tail of the health spending distribution. RESULTS: We find that the expansion of benefits coverage leads to significant reductions in annualised out-of-pocket healthcare expenditures for dental care, diagnostics services, pharmaceuticals and total medical spending. We show that the decline in spending by Green Card beneficiaries corresponds to about 33% as per cent of total per-household medical spending. Quantile regression analysis shows that the scheme is even more effective at reducing expenditures for those people facing large health expenditures. The scheme reduces the incidence of catastrophic expenditures by nearly 50% among those with the largest annual out-of-pocket expenditures. CONCLUSIONS: Increasing benefits coverage for a non-contributory insurance programme leads to financial protection for the poor by reducing out-of-pocket and catastrophic health expenditures. It is even more effective at reducing out-of-pocket health spending for those whose health expenditures that lie on the high end of healthcare spending distribution.

Genetic and Environmental Contributions to Behavioral Stability and Change in Children 6-36 months of Age Using Louisville Twin Study Data.

The Infant Behavior Record (IBR) from the Bayley Scales of Infant Development has been used to study behavioral development since the 1960s. Matheny (1983) examined behavioral development at 6, 12, 18, and 24 months from the Louisville Twin Study (LTS). The extracted temperament scales included Task Orientation, Affect-Extraversion, and Activity. He concluded that monozygotic twins were more similar than same-sex dizygotic twins on these dimensions. Since this seminal work was published, a larger LTS sample and more advanced analytical methods are available. In the current analyses, Choleksy decomposition was applied to behavioral data (n = 1231) from twins 6-36 months. Different patterns of genetic continuity vs genetic innovations were identified for each IBR scale. Single common genetic and shared environmental factors explained cross-age twin similarity in the Activity scale. Multiple shared environmental factors and a single genetic factor coming on line at age 18 months contributed to Affect-Extraversion. A single shared environmental factor and multiple genetic factors explained cross-age twin similarity in Task Orientation.

Twin Differentiation of Cognitive Ability Through Phenotype to Environment Transmission: The Louisville Twin Study.

The Louisville Twin Study is one of the most intensive twin studies of cognitive ability. The repeated measurements of the twins are ideal for testing developmental twin models that allow for the accumulation of gene-environment correlation via a (P⇒E) transmission process to explain twins' divergence in mean ability level over time. Using full-scale IQ scores from 566 pairs of twins (MZ = 278; DZ = 288), we tested whether a P⇒E transmission model provided better representation of actual developmental processes than a genetic simplex model. We also addressed whether the induced gene-environment correlation alters the meaning of the latent nonshared environmental factors with a simple numerical method for interpreting nonshared environmental factors in the context of P⇒E transmission. The results suggest that a P⇒E model provided better fit to twins' FSIQ data than a genetic simplex model and the meaning of the nonshared environment was preserved in the context of P⇒E.

Applying Biometric Growth Curve Models to Developmental Synchronies in Cognitive Development: The Louisville Twin Study.

Biometric latent growth curve models were applied to data from the LTS in order to replicate and extend Wilson's (Child Dev 54:298-316, 1983) findings. Assessments of cognitive development were available from 8 measurement occasions covering the period 4-15 years for 1032 individuals. Latent growth curve models were fit to percent correct for 7 subscales: information, similarities, arithmetic, vocabulary, comprehension, picture completion, and block design. Models were fit separately to WPPSI (ages 4-6 years) and WISC-R (ages 7-15). Results indicated the expected increases in heritability in younger childhood, and plateaus in heritability as children reached age 10 years. Heritability of change, per se (slope estimates), varied dramatically across domains. Significant genetic influences on slope parameters that were independent of initial levels of performance were found for only information and picture completion subscales. Thus evidence for both genetic continuity and genetic innovation in the development of cognitive abilities in childhood were found.

Determinants of malaria diagnostic uptake in the retail sector: qualitative analysis from focus groups in Uganda.

BACKGROUND: In Uganda, as in most other malaria-endemic countries, presumptive treatment for malaria based on symptoms without a diagnostic blood test is still very common. While diagnostic testing in public sector facilities is increasing, many people in Uganda who suspect malaria visit private sector outlets to purchase medications. Increasing the availability and uptake of rapid diagnostic tests (RDTs) for malaria in private outlets could help increase diagnostic testing for malaria but raises questions about the patient demand for and valuation of testing that are less critical for public sector introduction. METHODS: In preparation for a behaviour change campaign to encourage and sustain the demand for RDTs in drug shops, eight focus group discussions with a total of 84 community members were conducted in six districts across Uganda's Eastern Region in November-December 2011. Focus groups explored incentives and barriers to seeking diagnosis for malaria, how people react to test results and why, and what can be done to increase the willingness to pay for RDTs. RESULTS: Overall, participants were very familiar with malaria diagnostic testing and understood its importance, yet when faced with limited financial resources, patients preferred to spend their money on medication and sought testing only when presumptive treatment proved ineffective. While side effects did seem to be a concern, participants did not mention other potential costs of taking unnecessary or ineffective medications, such as money wasted on excess drugs or delays in resolution of symptoms. Very few individuals were familiar with RDTs. CONCLUSION: In order to boost demand, these results suggest that private sector RDTs will have to be made convenient and affordable and that targeted behaviour change campaigns should strive to increase the perceived value of diagnosis.

Access to subsidized ACT and malaria treatment--evidence from the first year of the AMFm program in six districts in Uganda.

OBJECTIVE: To determine the effect of the Affordable Medicines Facility for malaria (AMFm) launched in April 2011 in Uganda on the use of Artemisinin Combination Therapies (ACTs) for malaria treatment. METHODS: 2398 households across six districts in Eastern Uganda were monitored through monthly survey visits from April 2011 to April 2012. During each visit, health seeking modules were completed for any morbidity episode reported by the household. Additional surveys were conducted with 114 licensed drug shops in the same districts in April 2011 and April 2012. Changes in drug shops' stocking and pricing of ACTs, as well as changes in households' treatment behaviour and drug usage were analysed. RESULTS: The fraction of licensed drug shops reporting that an ACT was one of their top five bestselling antimalarial drugs increased from 32% to 84% (Δ=0.517, 95% Confidence Intervals (CI) [0.407, 0.628], P<0.001). The fraction of children under the age of 5 with fevers getting an ACT increased from 37% to 47% (Δ=0.103, 95% CI [0.070, 0.136], P<0.001), and the fraction of ACT treatments among patients getting any antimalarial increased from 51% to 65% (Δ=0.145, 95% CI [0.121, 0.169], P<0.001). The observed changes were particularly large among poorer households, and were smallest for households from the highest wealth quintile. CONCLUSIONS: The study results suggest that, during its first year of implementation in Uganda, the AMFm achieved its main objective of increasing the availability and use of ACTs. Estimates of the impact of the AMFm on ACT use for children under 5 imply that the program should be considered highly cost-effective under current World Health Organization (WHO) guidelines. The overall results look promising, but larger and longer term studies will be needed to assess the health impact and cost-effectiveness of the program.

Feasibility of distributing rapid diagnostic tests for malaria in the retail sector: evidence from an implementation study in Uganda.

BACKGROUND: Despite the benefits of malaria diagnosis, most presumed malaria episodes are never tested. A primary reason is the absence of diagnostic tests in retail establishments, where many patients seek care. Malaria rapid diagnostic tests (RDTs) in drug shops hold promise for guiding appropriate treatment. However, retail providers generally lack awareness of RDTs and training to administer them. Further, unsubsidized RDTs may be unaffordable to patients and unattractive to retailers. This paper reports results from an intervention study testing the feasibility of RDT distribution in Ugandan drug shops. METHODS AND FINDINGS: 92 drug shops in 58 villages were offered subsidized RDTs for sale after completing training. Data on RDT purchases, storage, administration and disposal were collected, and samples were sent for quality testing. Household surveys were conducted to capture treatment outcomes. Estimated daily RDT sales varied substantially across shops, from zero to 8.46 RDTs per days. Overall compliance with storage, treatment and disposal guidelines was excellent. All RDTs (100%) collected from shops passed quality testing. The median price charged for RDTs was 1000USH ($0.40), corresponding to a 100% markup, and the same price as blood slides in local health clinics. RDTs affected treatment decisions. RDT-positive patients were 23 percentage points more likely to buy Artemisinin Combination Therapies (ACTs) (p = .005) and 33.1 percentage points more likely to buy other antimalarials (p<.001) than RDT-negative patients, and were 5.6 percentage points more likely to buy ACTs (p = .05) and 31.4 percentage points more likely to buy other antimalarials (p<.001) than those not tested at all. CONCLUSIONS: Despite some heterogeneity, shops demonstrated a desire to stock RDTs and use them to guide treatment recommendations. Most shops stored, administered and disposed of RDTs properly and charged mark-ups similar to those charged on common medicines. Results from this study suggest that distributing RDTs through the retail sector is feasible and can reduce inappropriate treatment for suspected malaria.

Group differences in IQ are best understood as environmental in origin.

Responds to the comments by J. P. Rushton (see record 2012-24333-012); M. A. Woodley and G. Meisenberg (see record 2012-24333-013); and J. D. Mayer, D. R. Caruso, A. T. Panter, and P. Salovey (see record 2012-24333-014) on the present authors' original article, "Intelligence: New findings and theoretical developments" (see record 2011-30298-001). Here, the authors address the concerns raised by Rushton and by Woodley and Meisenberg, and conclude by agreeing with Mayer et al's claim that many types of abilities can be thought of as intelligence of a kind. They note, however, that it has proved hard to show that measures of emotional intelligence or social intelligence contribute to behavior we would want to call intelligent over and above their correlation with conventional IQ tests.

Intelligence: new findings and theoretical developments.

We review new findings and new theoretical developments in the field of intelligence. New findings include the following: (a) Heritability of IQ varies significantly by social class. (b) Almost no genetic polymorphisms have been discovered that are consistently associated with variation in IQ in the normal range. (c) Much has been learned about the biological underpinnings of intelligence. (d) "Crystallized" and "fluid" IQ are quite different aspects of intelligence at both the behavioral and biological levels. (e) The importance of the environment for IQ is established by the 12-point to 18-point increase in IQ when children are adopted from working-class to middle-class homes. (f) Even when improvements in IQ produced by the most effective early childhood interventions fail to persist, there can be very marked effects on academic achievement and life outcomes. (g) In most developed countries studied, gains on IQ tests have continued, and they are beginning in the developing world. (h) Sex differences in aspects of intelligence are due partly to identifiable biological factors and partly to socialization factors. (i) The IQ gap between Blacks and Whites has been reduced by 0.33 SD in recent years. We report theorizing concerning (a) the relationship between working memory and intelligence, (b) the apparent contradiction between strong heritability effects on IQ and strong secular effects on IQ, (c) whether a general intelligence factor could arise from initially largely independent cognitive skills, (d) the relation between self-regulation and cognitive skills, and (e) the effects of stress on intelligence.

Black Americans reduce the racial IQ gap: evidence from standardization samples.

It is often asserted that Black Americans have made no IQ gains on White Americans. Until recently, there have been no adequate data to measure trends in Black IQ. We analyzed data from nine standardization samples for four major tests of cognitive ability. These data suggest that Blacks gained 4 to 7 IQ points on non-Hispanic Whites between 1972 and 2002. Gains have been fairly uniform across the entire range of Black cognitive ability.