Pakistan's path to universal health coverage: national and regional insights.

BACKGROUND: Universal Health Coverage (UHC) is a common health policy objective outlined in the Sustainable Development Goals. With provincial governments taking the initiative, Pakistan has implemented and extended UHC program amid a complex public health landscape. In this context, we assess Pakistan's progress toward achieving UHC at the national and subnational level. METHODS: We use data from the Demographic and Health Surveys and the Household Integrated Economic Survey to construct a UHC index at the national and subnational level for 2007, 2013, and 2018. Furthermore, we use Concentration Index (CI) and CI decomposition methodologies to assess the primary drivers of inequality in accessing medical services. Logistic regression and Sartori's two-step model are applied to examine the key determinants of catastrophic health expenditure (CHE). RESULTS: Our analysis underscores Pakistan's steady progress toward UHC, while revealing significant provincial disparities in UHC progress. Provinces with lower poverty rate achieve higher UHC index, which highlights the synergy of poverty alleviation and UHC expansion. Among the examined indicators, child immunization remains a key weakness that one third of the children are not fully vaccinated and one sixth of these not-fully-vaccinated children have never received any vaccination. Socioeconomic status emerges as a main contributor to disparities in accessing medical services, albeit with a declining trend over time. Household socioeconomic status is negatively correlated with CHE incidence, indicating that wealthier households are less susceptible to CHE. For individuals experiencing CHE, medicine expenditure takes the highest share of their health spending, registering a staggering 70% in 2018. CONCLUSION: Pakistan's progress toward UHC aligns closely with its economic development trajectory and policy efforts in expanding UHC program. However, economic underdevelopment and provincial disparities persist as significant hurdles on Pakistan's journey toward UHC. We suggest continued efforts in UHC program expansion with a focus on policy consistency and fiscal support, combined with targeted interventions to alleviate poverty in the underdeveloped provinces.

Modelling COVID-19 vaccination status and adherence to public health and social measures, Eastern Mediterranean Region and Algeria.

Objective: To study the link between coronavirus disease 2019 (COVID-19) vaccination status and adherence to public health and social measures in Members of the Eastern Mediterranean Region and Algeria. Methods: We analysed two rounds of a large, cross-country, repeated cross-sectional mobile phone survey in June-July 2021 and October-November 2021. The rounds included 14 287 and 14 131 respondents, respectively, from 23 countries and territories. Questions covered knowledge, attitudes and practices around COVID-19, and demographic, employment, health and vaccination status. We used logit modelling to analyse the link between self-reported vaccination status and individuals' practice of mask wearing, physical distancing and handwashing. We used propensity score matching as a robustness check. Findings: Overall, vaccinated respondents (8766 respondents in round 2) were significantly more likely to adhere to preventive measures than those who were unvaccinated (5297 respondents in round 2). Odds ratios were 1.5 (95% confidence interval, CI: 1.3-1.8) for mask wearing; 1.5 (95% CI: 1.3-1.7) for physical distancing; and 1.2 (95% CI: 1.0-1.4) for handwashing. Similar results were found on analysing subsamples of low- and middle-income countries. However, in high-income countries, where vaccination coverage is high, there was no significant link between vaccination and preventive practices. The association between vaccination status and adherence to public health advice was sustained over time, even though self-reported vaccination coverage tripled over 5 months (19.4% to 62.3%; weighted percentages). Conclusion: Individuals vaccinated against COVID-19 maintained their adherence to preventive health measures. Nevertheless, reinforcement of public health messages is important for the public's continued compliance with preventive measures.

Persistent inequalities in health care services utilisation in Brazil (1998-2019).

BACKGROUND: One of the primary objectives of the Brazilian health care system is to improve the health and well-being of all citizens. Since the establishment of the Unified Health System/Sistema Único de Saúde (SUS) in 1988, Brazil has made strides towards reducing inequalities in health care services utilisation. However, there are currently no comprehensive and up-to-date studies focused on inequalities in both curative and preventive health care services utilisation. METHODS: We evaluated data from the National Household Sample Survey and the Brazilian National Health Survey, which are two nationally representative studies that include findings from 1998, 2003, and 2008 and 2013 and 2019, respectively. We calculated Erreygers-corrected Concentration Indices (CInds) to evaluate the magnitude of socioeconomic-related inequalities associated with five indicators of health care services utilisation, including physician visits, hospital admissions, surgical procedures, Pap smears, and mammograms. The main factors associated with these inequalities were identified via a decomposition analysis of the calculated CInds. RESULTS: While the results of our analysis revealed persistent inequalities in health care services utilisation that favour the wealthy, we found that the overall magnitude of these inequalities decreased over time. The largest inequalities were observed in the utilisation of preventive care services (Pap smears and mammograms) and services available in the poorest regions of the country. Except for admissions for labour and delivery, our findings revealed that wealthier individuals were more likely to utilise hospital services; this represents a change from findings reported in previous years. Private health insurance coverage and individual socioeconomic status are significantly associated with inequalities in health care services utilisation throughout Brazil. CONCLUSIONS: Collectively, our findings suggest that we must continue to monitor potential inequalities in health care service utilisation to determine whether Brazilian policy objectives focused on improved health outcomes for all will ultimately be achieved.

Responsiveness of the healthcare system in the Kingdom of Saudi Arabia: evidence from a nationally representative survey.

BACKGROUND: Responsiveness is one of the widely used metrics in assessing the performance of healthcare systems. An analysis of the determinants of health care demand and supply and how the Saudi health system responds to the needs of patients (inpatient and outpatient) is needed; hence the need for this study. METHODS: We analysed data from the Saudi Health Systems Responsiveness survey - a nationally representative survey of 10,000 households interviewed in 2017. Using this dataset, we descriptively analysed the level of responsiveness of inpatient and outpatient services (using the standard World Health Organization (WHO) responsiveness dimensions). Based on a logit modelling approach, the relationship between responsiveness and its key determinants was analysed in terms of healthcare demand and supply. RESULTS: Over four fifths of respondents are satisfied with the level of inpatient and outpatient responsiveness. Furthermore, we find that those in bad health tend to show lower levels of satisfaction with inpatient and outpatient care. We also find some evidence that age, gender, and to some extent nationality act as correlates of health system responsiveness. Specifically, we find evidence that Saudi nationals are less satisfied with health services compared to foreign nationals. CONCLUSION: Based on these findings improving the responsiveness of public healthcare facilities would need to be prioritized. Focusing on patients in worse health and lower socio-economic status should also be one of the main priorities.

Evaluation of progress toward universal health coverage in Myanmar: A national and subnational analysis.

BACKGROUND: Universal health coverage (UHC) encompasses 2 main components: access to essential healthcare services and protection from financial hardship when using healthcare. This study examines Myanmar's efforts to achieve UHC on a national and subnational level. It is a primer of studying the concept of UHC on a subnational level, and it also establishes a baseline for assessing future progress toward reaching UHC in Myanmar. METHODS AND FINDINGS: The study uses the Demographic and Health Survey (2015) and the Myanmar Living Conditions Survey (MLCS; 2017) and adapts a previously developed UHC index to provide insights into the main barriers preventing the country's progress toward UHC. We find a negative correlation between the UHC index and the state/region poverty levels. The equity of access analysis reveals significant pro-rich inequity in access to all essential healthcare services. Socioeconomic status and limited availability of healthcare infrastructure are the main driving forces behind the unequal access to interventions that are crucial to achieving UHC by 2030. Finally, financial risk protection analysis shows that the poor are less likely to use healthcare services, and, once they do, they are at a greater risk of suffering financial catastrophe. Limitations of this study revolve around its correlational, rather than causal, nature. CONCLUSIONS: We suggest a 2-pronged approach to help Myanmar achieve UHC: Government and state authorities should reduce the financial burden of seeking healthcare, and, coupled with this, significant investment in and expansion of health infrastructure and the health workforce should be made, particularly in the poorer and more remote states.

Covid-19 and non-communicable diseases: evidence from a systematic literature review.

BACKGROUND: Since early 2020, the Covid-19 pandemic has engulfed the world. Amidst the growing number of infections and deaths, there has been an emphasis of patients with non-communicable diseases as they are particularly susceptible to the virus. The objective of this literature review is to systematize the available evidence on the link between non-communicable diseases and Covid-19. METHODS: We have conducted a systematic review of the literature on Covid-19 and non-communicable diseases from December, 2019 until 15th of November, 2020. The search was done in PubMed and in doing so we used a variety of searching terms in order to isolate the final set of papers. At the end of the selection process, 45 papers were selected for inclusion in the literature review. RESULTS: The results from the review indicate that patients with certain chronic illnesses such as diabetes, hypertension (and other cardiovascular diseases), chronic respiratory illnesses, chronic kidney and liver conditions are more likely to be affected by Covid-19. More importantly, once they do get infected by the virus, patients with chronic illnesses have a much higher likelihood of having worse clinical outcomes (developing a more severe form of the disease or dying) than an average patient. There are two hypothesized channels that explain this strong link between the chronic illnesses enumerated above and Covid 19: (i) increased ACE2 (angiotensin-converting enzyme 2) receptor expressions, which facilitates the entry of the virus into the host body; and (ii) hyperinflammatory response, referred to as "cytokine storm". Finally, the literature review does not find any evidence that diabetes or hypertension related medications exacerbate the overall Covid-19 condition in chronic illness patients. CONCLUSIONS: Thus, the evidence points out to 'business as usual' disease management model, although with greater supervision. However, given the ongoing Covid-19 vulnerabilities among people with NCDs, prioritizing them for the vaccination process should also figure high on the agenda on health authorities.

Inequality in healthcare use among older people in Colombia.

BACKGROUND: Since the early 1990s, Colombia has made great strides in extending healthcare coverage to its population. In order to measure the impact of these efforts, it is important to assess whether the introduction of universal health coverage has translated into equitable access to healthcare in the country, particularly for the elderly. Thus, in this study we assessed the inequality in utilization of health services among elderly patients in Colombia. In addition, we identified the determinants of healthcare utilization. METHODS: We analyzed the 2015 Colombian health, well-being and aging study (SABE). To classify determinants of healthcare use into predisposing, enabling and need factors, we employed the Anderson framework of healthcare utilization. Use of outpatient, inpatient and preventive health services constituted the dependent variables. We performed multivariate logistic regressions, estimated concentration indexes (CI) and performed decomposition analyses of the CIs to determine the contribution of various determinants to inequality of healthcare utilization. RESULTS: The study sample included 23,694 adults over 60-years-old. Wealth quintile, urban dwelling, health insurance type and multimorbidity predicted the utilization of all types of healthcare services except for hospitalization. Aside from inpatient care, pro-rich inequality in utilization of healthcare services was present. Wealth quintile and type of health insurance were the largest contributors to pro-rich inequality in use of preventive services. CONCLUSIONS: While there has been progress in health insurance coverage for the elderly in Colombia, there are still equality challenges in the delivery of healthcare, especially for preventive and outpatient care. These inequalities are driven by individual characteristics such as wealth, urban residence, type of health insurance carried, and presence of multimorbidity. To address this issue, the Colombian health system should extend health insurance coverage to uninsured populations, as well as reduce barriers of access to healthcare services among poorest and the rural population receiving subsidized insurance.

Equity of access to maternal health interventions in Brazil and Colombia: a retrospective study.

BACKGROUND: Reducing maternal mortality is a top priority in Latin American countries. Despite the progress in maternal mortality reduction, Brazil and Colombia still lag behind countries at similar levels of development. METHODS: Using data from the Demographic Health Survey, this study quantified and compared, by means of concentration indices, the socioeconomic-related inequity in access to four key maternal health interventions in Brazil and Colombia. Decomposition analysis of the concentration index was used for two indicators - skilled attendance at birth and postnatal care in Brazil. RESULTS: Coverage levels of the four key maternal health interventions were similar in the two countries. More specifically, we found that coverage of some of the interventions (e.g. ante-natal care and skilled birth assistance) was higher than 90% in both countries. Nevertheless, the concentration index analysis pointed to significant pro-rich inequities in access in all four key interventions in both countries. Interestingly, the analysis showed that Colombia fared slightly better than Brazil in terms of equity in access of the interventions studied. Finally, the decomposition analysis for the presence of a skilled attendant at birth and postnatal care in Brazil underlined the significance of regional disparities, wealth inequalities, inequalities in access to private hospitals, and inequalities in access to private health insurance. CONCLUSIONS: There are persistent pro-rich inequities in access to four maternal health interventions in both Brazil and Colombia. The decomposition analysis conducted on Brazilian data suggests the existence of disparities in system capacity and quality of care between the private and the public health services, resulting in inequities of access to maternal health services.

Decision-making criteria among European patients: exploring patient preferences for primary care services.

BACKGROUND: Health economics preference-based techniques, such as discrete choice experiments (DCEs), are often used to inform public health policy on patients' priorities when choosing health care. Although there is general evidence about patients' satisfaction with general-practice (GP) care in Europe, to our knowledge no comparisons are available that measure patients' preferences in different European countries, and use patients' priorities to propose policy changes. METHODS: A DCE was designed and used to capture patients' preferences for GP care in Germany, England and Slovenia. In the three countries, 841 eligible patients were identified across nine GP practices. The DCE questions compared multiple health-care practices (including their 'current GP practice'), described by the following attributes: 'information' received from the GP, 'booking time', 'waiting time' in the GP practice, 'listened to', as well as being able to receive the 'best care' available for their condition. Results were compared across countries looking at the attributes' importance and rankings, patients' willingness-to-wait for unit changes to the attributes' levels and changes in policy. RESULTS: A total of 692 respondents (75% response rate) returned questionnaires suitable for analysis. In England and Slovenia, patients were satisfied with their 'current practice', but they valued changes to alternative practices. All attributes influenced decision-making, and 'best care' or 'information' were more valued than others. In Germany, almost all respondents constantly preferred their 'current practice', and other factors did not change their preference. CONCLUSION: European patients have strong preference for their 'status quo', but alternative GP practices could compensate for it and offer more valued care.

The diabetes-obesity-hypertension nexus in Qatar: evidence from the World Health Survey.

BACKGROUND: As countries develop economically, an "epidemiological transition" occurs whereby a set of chronic diseases increasingly becomes a country's health challenge. Against this background, this paper examines the most common conditions associated with the prevalence of diabetes in Qatar, with a specific focus on the diabetes-obesity-hypertension nexus. METHODS: We analyzed data from the World Health Organization's World Health Survey conducted in the State of Qatar in 2006. The survey included demographic, anthropometric, and blood chemistry measurements. Using multivariate logistical regression analysis, we assessed the most common conditions associated with diabetes, using both objective and subjective measures of diabetes. The objective measures relied on random blood sugar tests, and the subjective measure included respondents who affirmatively answered the question on diabetes diagnosis. We repeated our analysis on respondents who had blood glucose levels high enough to be considered diabetic/glucose intolerant but did not answer affirmatively on the question of diabetes diagnosis. RESULTS: WHEN USING THE OBJECTIVE MEASURE OF DIABETES, THE FOLLOWING CONDITIONS APPEARED SIGNIFICANT: obesity (OR = 1.5, 95% CI = 1.2 - 1.9), higher income (OR = 1.4, 95% CI = 1.0 - 1.9), high cholesterol (OR = 1.4, 95% CI = 1.0 - 1.9), having Qatari origin (OR = 1.3, 95% CI = 1.0 - 1.7), and increasing systolic blood pressure (SBP) 120-139 mmHg (OR = 1.5, 95% CI = 1.2 - 2.0), SBP 140-159 mmHg (OR = 2.2, 95% CI = 1.6 - 3.1), SBP > 160 mmHg (OR = 3.2, 95% CI = 2.0 - 5.3). Similar results were obtained using the subjective measure of diabetes as a dependent variable. When applied to the group of respondents that included pre-diabetics and those who did not know they were diabetic, obesity and hypertension appeared as the only statistically significant explanatory variables. CONCLUSION: High prevalence of diabetes, hypertension, and especially obesity is documented among residents of Qatar. Further steps are required to tackle the most common conditions associated with the rising diabetes epidemic in the country, which might also pose significant fiscal challenges in the future.

Insights from a modelling analysis of COVID-19 vaccination in the Eastern Mediterranean Region.

Background: Understanding the main determinants of COVID-19 vaccine uptake is critical to increasing vaccine coverage. This is particularly important for COVID-19 vaccine uptake, which has been affected by both demand and supply issues. Aim: To understand the links between vaccine uptake and demand and supply issues in the WHO Eastern Mediterranean and UNICEF Middle East and North Africa regions. Methods: We collected data through 2 rounds of a repeated cross-sectional phone survey from 11 000 individuals across 16 low- and middle-income countries. We used logit modelling to distil the main characteristics of the 4 vaccination categories (vaccinated, unvaccinated but willing, unvaccinated and undecided, and unvaccinated and unwilling) while also considering vaccine availability. We conducted sub-regional analysis to account for differences in level of development between the low- and middle-income countries. Results: Despite the increase in vaccination coverage from 60.9% at the end of 2021 to 78.3% by August 2022, about 9% were not willing and were not vaccinated during the two rounds of interviews. Our modelling analysis revealed that positive beliefs about safety, effectiveness and side effects of the COVID-19 vaccines were associated with increased odds of being vaccinated or willingness to be vaccinated. Those who did not believe in the safety of the vaccines were less likely to be vaccinated than those who believed in the safety of the vaccines (OR: 0.56; 95% CI: 0.46-0.67). By contrast, negative beliefs about the COVID-19 vaccines increased the probability of being unwilling to be vaccinated. Conclusion: The results from this research offer useful insights into tackling the supply and demand related barriers to COVID-19 vaccination uptake and provides lessons for future health threats.

Multidimensional Poverty and Risk of Atherosclerotic Cardiovascular Disease: A U.S. National Study.

Background: Poverty is associated with atherosclerotic cardiovascular disease (ASCVD). While poverty can be evaluated using income, a unidimensional poverty metric inadequately captures socioeconomic adversity. Objectives: The aim of the study was to examine the association between a multidimensional poverty measure and ASCVD. Methods: Survey data from the National Health Interview Survey was analyzed. Four poverty dimensions were used: income, education, self-reported health, and health insurance status. A weighted deprivation score (c i ) was calculated for each person. The multidimensional poverty index was computed for various cutoffs, k, for total population, and by ASCVD status. The association between multidimensional poverty and ASCVD was examined using Poisson regression. Area under receiver operator characteristics curve analysis was performed to compare the multidimensional poverty measure with the income poverty measure as a classification tool for ASCVD. Results: Among the 328,164 participants, 55.0% were females, the mean age was 46.3 years, 63.1% were non-Hispanic Whites, and 14.1% were non-Hispanic Blacks. Participants with ASCVD (7.95%) experienced greater deprivation at each multidimensional poverty cutoff, k, compared to those without ASCVD. In adjusted models, higher burden of multidimensional poverty was associated with up to 2.4-fold increased prevalence of ASCVD (c i  = 0.25, adjusted prevalence ratio [aPR] = 1.66, P < 0.001; c i  = 0.50, aPR = 1.99; c i  = 0.75, aPR = 2.29; P < 0.001; c i  = 1.00, aPR = 2.38, P < 0.001). Multidimensional poverty exhibited modestly higher discriminant validity, compared to income poverty (area under receiver operator characteristics = 0.62 vs 0.58). Conclusions: There is an association between the multidimensional poverty and ASCVD. Multidimensional poverty index demonstrates slightly better discriminatory power than income alone. Future validation studies are warranted to redefine poverty's role in health outcomes.

Corruption, inequality and population perception of healthcare quality in Europe.

BACKGROUND: Evaluating the quality of healthcare and patient safety using general population questionnaires is important from research and policy perspective. Using a special wave of the Eurobarometer survey, we analysed the general population's perception of health care quality and patient safety in a cross-country setting. METHODS: We used ordered probit, ordinary least squares and probit analysis to estimate the determinants of health care quality, and ordered logit analysis to analyse the likelihood of being harmed by a specific medical procedure. The models used population weights as well as country-clustered standard errors. RESULTS: We found robust evidence for the impact of socio-demographic variables on the perception of quality of health care. More specifically, we found a non-linear impact of age on the perception of quality of health care and patient safety, as well as a negative impact of poverty on both perception of quality and patient safety. We also found robust evidence that countries with higher corruption levels were associated with worse perceptions of quality of health care. Finally, we found evidence that income inequality affects patients' perception vis-à-vis safety, thus feeding into the poverty/health care quality nexus. CONCLUSIONS: Socio-demographic factors and two macro variables (corruption and income inequality) explain the perception of quality of health care and likelihood of being harmed by adverse events. The results carry significant policy weight and could explain why targeting only the health care sector (without an overall reform of the public sector) could potentially be challenging.

Preventable mortality in the Russian Federation: a retrospective, regional level study.

Background: Avoidable mortality, including both treatable and preventable deaths, is frequently used as an indicator of health system performance. Whilst the term treatable mortality refers to deaths that might be averted by medical interventions, preventable mortality generally reflects the impact of system-wide health policies. The concept of preventable mortality has not been evaluated extensively in the Russian Federation, particularly at the regional or sub-national (oblast) level. Methods: We calculated total preventable mortality as well as individual rates for males and females in each oblast using data from the Russian Fertility and Mortality Database (RusFMD) and computed the contributions of specific preventable causes of death to the overall rates. We also evaluated the relationship between preventable mortality and its main correlates during the years 2014-2018 using panel fixed effects modelling with variables that reflected both, behavioural risk factors and access to health care. Findings: Overall preventable mortality in the Russian Federation has been on a downward trend. Whilst 548 preventable deaths per 100,000 person-years were reported in the year 2000, only 301 per 100,000 person-years were reported in 2018. Whilst mortality due to cancer, cardiovascular, and alcohol-related diseases has declined (albeit unevenly) amongst both males and females, deaths resulting from complications of diabetes and human immunodeficiency virus infection have increased. Our findings also revealed significant heterogeneity in preventable mortality at the oblast level. For example, in 2018, deaths due to preventable causes were concentrated primarily in Siberia and the Far East. Smoking and the availability of nurses were identified as significant correlates of preventable mortality at the oblast level. Interpretations: Efforts designed to strengthen the current health care system, notably those serving the rural and less densely populated oblasts, might reduce the rate of preventable mortality in Russia. These efforts might be coupled with an ongoing focus on programs designed to reduce smoking. Funding: None.

HIV in the Russian Federation: mortality, prevalence, risk factors, and current understanding of sexual transmission.

BACKGROUND: Although HIV infection in the Russian Federation was historically concentrated among marginalized populations (people who inject drugs, sex workers, MSM, and the prison population), recent evidence suggests that it has become a more generalized epidemic. The objective of our research was to explore how these trends in HIV prevalence and HIV-related mortality compare across Russia. METHODS: We calculated HIV-associated mortality for both male and female individuals in each region (oblast) of the Russian Federation using data from the Russian Fertility and Mortality Database (RusFMD). Using current data on HIV prevalence, we computed the correlation between HIV prevalence and HIV-associated mortality. We also used oblast-level data to examine the associations between HIV prevalence and the risk factors most commonly associated with HIV infection. RESULTS: Over the past 20 years, the Russian Federation has experienced a rapid increase in HIV-associated mortality in both male and female individuals. Our findings revealed significant heterogeneity, with higher rates of HIV-associated mortality reported in oblasts in the Siberian and Ural Federal Districts. There is a strong correlation (0.8) between HIV-associated mortality and virus prevalence. These findings confirm that there are regional disparities in access and adherence to antiretroviral therapy (ART), as indicated by the low correlation (-0.4) between virus prevalence and access to ART coverage. The results from our modeling analysis revealed that, in addition to the factors most commonly associated with this disease (e.g. intravenous drug use), knowledge about sexual transmission of HIV in the general population has a broad impact on its prevalence at the oblast level. CONCLUSION: Interventions that reduce HIV prevalence, for example, opioid substitution therapy and needle-sharing programs for people who inject drugs, as well as the increased availability of educational and preventive programs may halt the spread of HIV across the Russian Federation. Similarly, increased access to treatment could help in reducing HIV-related mortality.

Inequalities in unmet need for health care services and medications in Brazil: a decomposition analysis.

Background: Unmet need is a metric used to assess the performance of health care systems throughout the world. One of the primary objectives of the Brazilian health care system is to identify ways to improve the health outcomes of all citizens. To accomplish this challenging goal, the health care system in Brazil will need to identify and eliminate barriers and provide timely and adequate access to health care services to all. Methods: This study assessed the performance of the Brazilian health care system by focusing on the unmet need for health care services and medications. We evaluated the Brazilian National Health Survey data collected in 2013 and 2019 to determine the magnitude of socioeconomic-related inequalities associated with unmet health care needs. Primary contributing factors were identified via decomposition analysis of the calculated concentration indices (CInds). Findings: Despite the availability of universal health care, 3.8% and 7.5% of the population in Brazil reported unmet needs for health care services and medications, respectively in the 2019 survey. Although the overall unmet need for medications remained unchanged between 2013 and 2019, CInd analysis revealed significant pro-poor inequalities with respect to unmet needs for both health care services and medications. The overall magnitude of these inequalities was higher in the poorer regions of the country. The use of private health insurance as well as individual health and socioeconomic status contributed significantly to the inequalities associated with unmet needs for health care services and medication throughout Brazil. Interpretations: Policy interventions should focus on improving access to health care services, extending coverage to include pharmaceuticals, and targeting both financial and non-financial barriers to obtaining care, particularly those experienced by the poor and vulnerable populations in Brazil. Funding: None.

COVID-19 Vaccination Personas in Yemen: Insights from Three Rounds of a Cross-Sectional Survey.

We used three rounds of a repeated cross-sectional survey on COVID-19 vaccination conducted throughout the entire territory of Yemen to: (i) describe the demographic and socio-economic characteristics associated with willingness to be vaccinated; (ii) analyse the link between beliefs associated with COVID-19 vaccines and willingness to be vaccinated; and (iii) analyse the potential platforms that could be used to target vaccine hesitancy and improve vaccine coverage in Yemen. Over two-thirds of respondents were either unwilling or unsure about vaccination across the three rounds. We found that gender, age, and educational attainment were significant correlates of vaccination status. Respondents with better knowledge about the virus and with greater confidence in the capacity of the authorities (and their own) to deal with the virus were more likely to be willing to be vaccinated. Consistent with the health belief model, practising one (or more) COVID-19 preventative measures was associated with a higher willingness to get a COVID-19 vaccination. Respondents with more positive views towards COVID-19 vaccines were also more likely to be willing to be vaccinated. By contrast, respondents who believed that vaccines are associated with significant side effects were more likely to refuse vaccination. Finally, those who relied on community leaders/healthcare workers as a trusted channel for obtaining COVID-19-related information were more likely to be willing to be vaccinated. Strengthening the information about the COVID-19 vaccination (safety, effectiveness, side effects) and communicating it through community leaders/healthcare workers could help increase the COVID-19 vaccine coverage in Yemen.

COVID-19 Vaccination Personas in Syria: Evidence from a Cross-Sectional Survey.

Achieving a high level of COVID-19 vaccination coverage in a conflict-affected setting is challenging. The objective of this paper is to shed further light on the main determinants of vaccination coverage using a large, cross-sectional sample (October-November 2022) of over 17,000 adults in Syria. We find evidence that certain demographic and socioeconomic characteristics describe a core set of vaccination personas. Men, older respondents, and those who are more educated and trust information received from healthcare authorities are more likely to be vaccinated. Healthcare workers in this sample are highly vaccinated. Furthermore, respondents with more positive views towards COVID-19 vaccines are also more likely to be willing to be vaccinated. By contrast, respondents who believe that vaccines are associated with significant side effects are also more likely to refuse vaccination. In addition, younger respondents and women, as well as those with a lower level of education, are more likely to refuse to be vaccinated. Respondents with a neutral attitude towards vaccines are also more likely to be undecided, whereas respondents who are refusing to get vaccinated are more likely to trust the information received from private doctors, private clinics, as well as social media and, more broadly, the internet.

Financial Risk Protection and Unmet Healthcare Need in Russia.

BACKGROUND: Achieving universal health coverage (UHC) includes financial risk protection. To date, catastrophic healthcare expenditure (CHE), the impoverishing effect of out-of-pocket (OOP) healthcare payments, and unmet healthcare need are the most widely used indicators for assessing the financial risk protection of a healthcare system. This study aimed to estimate the Russian healthcare system's financial risk protection by focusing on CHE, OOP and unmet healthcare need. METHODS: The study used eight waves of the Russia Longitudinal Monitoring Survey (RLMS) (2010-2017) to analyze the financial risk protection of the Russian healthcare system. Commonly used indicators - CHE, both incidence and intensity, the impoverishing effect of CHE and unmet need -were used. RESULTS: We found low incidence and intensity of CHE in the Russian Federation. Our results are robust to various definitions of CHE (eg, as a share of total household expenditure or total household income). Furthermore, the impoverishing effect of OOP healthcare payments remains limited, despite the most recent economic slowdown (2014- 2016). This could be explained by a noticeable reduction in CHE during the crisis years, as postponing healthcare was adopted as a coping mechanism, particularly among households heavily affected by the crisis. CONCLUSION: As stressed by the UHC framework, our findings suggest that CHE only partly captures inefficiencies and inequities in coverage, because one tenth of households forwent medical care for medicines and certain services. As spending on medicines and dental care are the main drivers of CHE, policy interventions should focus on extending coverage for pharmaceutical and dental care and target financial barriers to seeking care, particularly for the poor and vulnerable.

Financial protection in health among the middle-aged and elderly: Evidence from the Greek economic recession.

Since the late 2000s, the Greek economy has entered a long period of recession, with reforms and retrenchment in health care being among the main public policy priorities. This study investigates the extent to which financial protection in health has changed among older households during the Greek crisis. We focus on the middle-aged and elderly, the heavy users of health services, who have faced a substantial health and financial burden during the crisis. Our analysis shows that the headcount and overshoot of catastrophic health expenditure (CHE) substantially increased from 2007 to 2015, suggesting that financial protection has eroded to a great extent. Prior to the crisis, CHE was mainly due to inpatient care, followed by outpatient care and medicines. However, the contribution of spending for outpatient medicines to CHE substantially increased during the study period. The headcount of CHE rose across all socioeconomic groups we examined, with low-income households and households with chronic patients being disproportionately affected. In 2007, we do not report signs of socioeconomic inequalities in the risk of CHE. On the contrary, our results show that households of low socioeconomic status are more likely to incur CHE in 2015, revealing substantial inequalities in the risk of CHE. This finding raises significant distributional and equity concerns. Strengthening financial protection among older households is an imperative challenge for the Greek health system, and several policy responses need to be adopted towards this direction.