Assessing the equity and coverage policy sensitivity of financial protection indicators in Europe.

Progress towards universal health coverage is monitored by the incidence of catastrophic spending. Two catastrophic spending indicators are commonly used in Europe: Sustainable Development Goal (SDG) indicator 3.8.2 and the WHO Regional Office for Europe (WHO/Europe) indicator. The use of different indicators can cause confusion, especially if they produce contradictory results and policy implications. We use harmonised household budget survey data from 27 European Union countries covering 505,217 households and estimate the risk of catastrophic spending, conditional on household characteristics and the design of medicines co-payments. We calculate the predicted probability of catastrophic spending for particular households, which we call LISAs, under combinations of medicines co-payment policies and compare predictions across the two indicators. Using the WHO/Europe indicator, any combination of two or more protective policies (i.e. low fixed co-payments instead of percentage co-payments, exemptions for low-income households and income-related caps on co-payments) is associated with a statistically significant lower risk of catastrophic spending. Using the SDG indicator, confidence intervals for every combination of protective policies overlap with those for no protective policies. Although out-of-pocket medicines spending is a strong predictor of catastrophic spending using both indicators, the WHO/Europe indicator is more sensitive to medicines co-payment policies than the SDG indicator, making it a better indicator to monitor health system equity and progress towards UHC in Europe.

Monitoring progress towards universal health coverage in Europe: a descriptive analysis of financial protection in 40 countries.

Background: Ensuring that access to health care is affordable for everyone-financial protection-is central to universal health coverage (UHC). Financial protection is commonly measured using indicators of financial barriers to access (unmet need for health care) and financial hardship caused by out-of-pocket payments for health care (impoverishing and catastrophic health spending). We aim to assess financial hardship and unmet need in Europe and identify the coverage policy choices that undermine financial protection. Methods: We carry out a cross-sectional study of financial hardship in 40 countries in Europe in 2019 (the latest available year of data before COVID-19) using microdata from national household budget surveys. We define impoverishing health spending as out-of-pocket payments that push households below or further below a relative poverty line and catastrophic health spending as out-of-pocket payments that exceed 40% of a household's capacity to pay for health care. We link these results to survey data on unmet need for health care, dental care, and prescribed medicines and information on two aspects of coverage policy at country level: the main basis for entitlement to publicly financed health care and user charges for covered services. Findings: Out-of-pocket payments for health care lead to financial hardship and unmet need in every country in the study, particularly for people with low incomes. Impoverishing health spending ranges from under 1% of households (in six countries) to 12%, with a median of 3%. Catastrophic health spending ranges from under 1% of households (in two countries) to 20%, with a median of 6%. Catastrophic health spending is consistently concentrated in the poorest fifth of the population and is largely driven by out-of-pocket payments for outpatient medicines, medical products, and dental care-all forms of treatment that should be an essential part of primary care. The median incidence of catastrophic health spending is three times lower in countries that cover over 99% of the population than in countries that cover less than 99%. In 16 out of the 17 countries that cover less than 99% of the population, the basis for entitlement is payment of contributions to a social health insurance (SHI) scheme. Countries that give greater protection from user charges to people with low incomes have lower levels of catastrophic health spending. Interpretation: It is challenging to identify with certainty the coverage policy choices that undermine financial protection due to the complexity of the policies involved and the difficulty of disentangling the effects of different choices. The conclusions we draw are therefore tentative, though plausible. Countries are more likely to move towards UHC if they reduce out-of-pocket payments in a progressive way, decreasing them for people with low incomes first. Coverage policy choices that seem likely to achieve this include de-linking entitlement from payment of SHI contributions; expanding the coverage of outpatient medicines, medical products, and dental care; limiting user charges; and strengthening protection against user charges, particularly for people with low incomes. Funding: The European Union (DG SANTE and DG NEAR) and the Government of the Autonomous Community of Catalonia, Spain.

How resilient is health financing policy in Europe to economic shocks? Evidence from the first year of the COVID-19 pandemic and the 2008 global financial crisis.

The COVID-19 pandemic triggered an economic shock just ten years after the shock of the 2008 global financial crisis. Economic shocks are a challenge for health systems because they reduce government revenue at the same time as they increase the need for publicly financed health care. This article explores the resilience of health financing policy to economic shocks by reviewing policy responses to the financial crisis and COVID-19 in Europe. It finds that some health systems were weakened by responses to the 2008 crisis. Responses to the pandemic show evidence of lessons learnt from the earlier crisis but also reveal weaknesses in health financing policy that limit national preparedness to face economic shocks, particularly in countries with social health insurance schemes. These weaknesses highlight where permanent changes are needed to strengthen resilience in future: countries will have to find ways to reduce cyclicality in coverage policy and revenue-raising; increase the priority given to health in allocating public spending; and ensure that resources are used to meet equity and efficiency goals. Although many health systems are likely to face budgetary pressure in the years ahead, the experience of the 2008 crisis shows that austerity is not an option because it undermines resilience and progress towards universal health coverage.

Determinantes sociales de la salud y la calidad de vida en población adulta de Manizales, Colombia / Social determinants of health and quality of life of the adult population of Manizales, Colombia

Objetivo: Evaluar la asociación entre los determinantes sociales de la salud y la calidad de vida en una población adulta de la ciudad de Manizales. Métodos: Estudio descriptivo con una fase correlacional en un universo de 18 109 viviendas con una muestra de 440 seleccionadas a través de muestreo estratificado por afijación óptima. Como variable dependiente se midió la calidad de vida a través del formulario WHOQOL-BREF y como variables independientes se midieron los determinantes sociales de la salud estructurales e intermedios. La asociación entre las variables se midió a través de análisis bivariado mediante las pruebas U de Mann Whitney, t de Student, ANOVA y Kruskal Wallis. Resultados: La edad promedio fue de 49 años +/- 17,2 años, los ingresos mensuales mínimos del hogar fueron de 23 dólares y los ingresos máximos de 23 000 dólares, el 88,9 por ciento pertenecía al estrato socioeconómico alto. El 61,6 por ciento calificaron su calidad de vida como bastante buena. El análisis bivariado mostró asociación (p< 0,05) entre la escolaridad y la posición socioeconómica autopercibida con todas los dominios de calidad de vida así como entre los ingresos mensuales del hogar con la salud psicológica, relaciones sociales y el ambiente y la vinculación laboral con todos los dominios excepto las relaciones sociales. Conclusiones: Los determinantes sociales de la salud que se asociaron con la calidad de vida en todos sus dominios fueron la escolaridad y la posición socioeconómica autopercibida(AU)

Objective: To evaluate the association of social determinants of health and quality of life of the population in the city of Manizales, Colombia. Methods: Descriptive correlational study carried out in a sample of 440 households selected through optimal allocation stratified sampling from a universe of 18 109 households. The dependent variable was quality of life measured by using the WHOQOL-BREF and the independent variables were the structural and intermediate social determinants of health. The association of variables was measured though bivariate analysis using Mann-Whitney U, ANOVA, Student´s t and Kruskal Wallis tests. Results: The mean age was 49 ± 17.2 years; the minimum monthly household income was 23 and the maximum income was 23 000 US dollars, and 88.9 percent of the sample was rated as high socio-economic stratum. 61.6 percent rated pretty well their quality of life. The bivariate analysis showed association p< 0.05 between education and self-perceived socioeconomic status in all quality of life domains as well as between monthly household income and psychological health, social relations and working environment and links in all domains except for social relations. Conclusions: The social determinants of health associated with the quality of life in every domain were education and self-perceived socioeconomic status(AU)

Adaptación transcultural de mensajes de texto para autocuidado en gestantes

El objetivo de este trabajo fue adaptar transculturalmente mensajes de texto dirigidos a gestantes y sus acompañantes para dar herramientas a la academia en los procesos educativos. Se realizó adaptación transcultural en 4 fases: la primera partió de la revisión de textos traducidos al español por los docentes investigadores; luego se procedió a la revisión por parte de expertos; la tercera fase se articuló a partir de grupos focales con gestantes y acompañantes, y finalmente la elaboración de nuevos mensajes de acuerdo con guías y normas de atención en salud. En total, fueron revisados 170 mensajes en la primera fase: los expertos revisaron 107 dirigidos a gestantes, 37 a acompañantes, 18 sobre manejo de recién nacido, sobre estos se hicieron ajustes. El resultado de los grupos focales consolidó el proceso de claridad de los mensajes. El artículo propone una metodología para la adaptación transcultural que permite a la academia obtener mensajes que las gestantes requieren para fortalecer su autocuidado.

The objetive of this work was to adapt Cross-Culturally text messages aimed at pregnant women and their companions to give tools to the academy in educational processes. Cultural adaptation was performed in 4 phases: the first phase was the review of texts translated into Spanish by researchers; then peer review; the third phase was the execution of focus groups with pregnant women and their companions and finally the development of new messages according to guidelines and standards of health care. A total of 170 messages were reviewed in the first phase; the experts reviewed 107 aimed at pregnant women, 37 to companions and 18 related with newborn care. Adjustments were made upon these messages. The result of the focus groups consolidated the process of comprehension of the messages. The article proposes a methodology for cultural adaptation that allows the academy to get messages that pregnant women need to strengthen their self-care.

Objetivo: adaptar transcultural-mente as mensagens de texto para gravidas e seus companheiros para usar uma ferramenta académica nos processos educativos. Realizou-se adaptações transcultural em quatro fases: a primeira partiu na revisão da literatura traduzidos ao idioma espanhol pelos professores pesquisadores, depois a segunda atividade foi o processo de revisão por expertos na área; a terceira fase seleciona por meio de grupos focais com gravidas e companheiros, a última fase a elaboração de novas mensagens de acordo a guias e normas de atenção em saúde. No total, foram revisadas 170 mensagens na primeira fase: os expertos revisarão 107 textos para gravidas, 37 para seus companheiros, 18 sobre o recém-nascido, além disso o grupo focal consolidado o processo com facilidade das mensagens. O artigo propõe uma metodologia para a adaptação transcultural que permite a academia obter as mensagens que as gravides precisam para melhorar seu autocuidado.

Adaptación transcultural de mensajes de texto para autocuidado en gestantes / Cross-cultural adaptation of text messages for self-care in pregnant women / Adaptação transcultural de mensagens de texto para autocuidados em mulheres grávidas

El objetivo de este trabajo fue adaptar transculturalmente mensajes de texto dirigidos a gestantes y sus acompañantes para dar herramientas a la academia en los procesos educativos. Se realizó adaptación transcultural en 4 fases: la primera partió de la revisión de textos traducidos al español por los docentes investigadores; luego se procedió a la revisión por parte de expertos; la tercera fase se articuló a partir de grupos focales con gestantes y acompañantes, y finalmente la elaboración de nuevos mensajes de acuerdo con guías y normas de atención en salud. En total, fueron revisados 170 mensajes en la primera fase: los expertos revisaron 107 dirigidos a gestantes, 37 a acompañantes, 18 sobre manejo de recién nacido, sobre estos se hicieron ajustes. El resultado de los grupos focales consolidó el proceso de claridad de los mensajes. El artículo propone una metodología para la adaptación transcultural que permite a la academia obtener mensajes que las gestantes requieren para fortalecer su autocuidado.

The objective of this work was to cross-culturally adapt text messages addressed to pregnant women and their companions in order to provide tools to the academy in the educational processes. Cross-cultural adaptation was carried out in 4 phases: the first phase was based on the review of texts translated into Spanish by the research teachers; then the review was carried out by experts; the third phase was based on focus groups with pregnant women and their caregivers, and finally the elaboration of new messages in accordance with health care guidelines and norms. In total, 170 messages were reviewed in the first phase: the experts reviewed 107 messages addressed to pregnant women, 37 to those accompanying them, 18 on newborn management, and adjustments were made to these messages. The results of the focus groups consolidated the process of clarifying the messages. The article proposes a methodology for cross-cultural adaptation that allows the academy to obtain messages that pregnant women require to strengthen their self-care.

O objetivo deste trabalho foi adaptar transculturalmente mensagens de texto destinadas a mulheres grávidas e aos seus acompanhantes, a fim de fornecer ferramentas para a academia em processos educativos. A adaptação transcultural foi realizada em 4 fases: a primeira fase baseou-se na revisão dos textos traduzidos para espanhol pelos professores investigadores; em seguida, a revisão foi realizada por peritos; a terceira fase baseou-se em grupos de discussão com mulheres grávidas e seus acompanhantes e, por último, na elaboração de novas mensagens de acordo com as directrizes e normas de cuidados de saúde. No total, foram revistas 170 mensagens na primeira fase: os peritos reviram 107 mensagens dirigidas às mulheres grávidas, 37 aos seus acompanhantes e 18 sobre a gestão dos recém-nascidos, tendo sido efectuados ajustamentos a estas mensagens. Os resultados dos grupos de discussão consolidaram o processo de clarificação das mensagens. O artigo propõe uma metodologia de adaptação transcultural que permite à academia obter as mensagens de que as grávidas necessitam para reforçar o seu autocuidado.