Progress towards universal health coverage and inequalities in infant mortality: an analysis of 4·1 million births from 60 low-income and middle-income countries between 2000 and 2019.

BACKGROUND: Expanding universal health coverage (UHC) might not be inherently beneficial to poorer populations without the explicit targeting and prioritising of low-income populations. This study examines whether the expansion of UHC between 2000 and 2019 is associated with reduced socioeconomic inequalities in infant mortality in low-income and middle-income countries (LMICs). METHODS: We did a retrospective analysis of birth data compiled from Demographic and Health Surveys (DHSs). We analysed all births between 2000 and 2019 from all DHSs available for this period. The primary outcome was infant mortality, defined as death within 1 year of birth. Logistic regression models with country and year fixed effects assessed associations between country-level progress to UHC (using WHO's UHC service coverage index) and infant mortality (overall and by wealth quintile), adjusting for infant-level, mother-level, and country-level variables. FINDINGS: A total of 4 065 868 births to 1 833 011 mothers were analysed from 177 DHSs covering 60 LMICs between 2000 and 2019. A one unit increase in the UHC index was associated with a 1·2% reduction in the risk of infant death (AOR 0·988, 95% CI 0·981-0·995; absolute measure of association, 0·57 deaths per 1000 livebirths). An estimated 15·5 million infant deaths were averted between 2000 and 2019 because of increases in UHC. However, richer wealth quintiles had larger associated reductions in infant mortality from UHC (quintile 5 AOR 0·983, 95% CI 0·973-0·993) than poorer quintiles (quintile 1 0·991, 0·985-0·998). In the early stages of UHC, UHC expansion was generally beneficial to poorer populations (ie, larger reductions in infant mortality for poorer households [infant deaths per 1000 per one unit increase in UHC coverage: quintile 1 0·84 vs quintile 5 0·59]), but became less so as overall coverage increased (quintile 1 0·64 vs quintile 5 0·57). INTERPRETATION: Since UHC expansion in LMICs appears to become less beneficial to poorer populations as coverage increases, UHC policies should be explicitly designed to ensure lower income groups continue to benefit as coverage expands. FUNDING: UK National Institute for Health and Care Research.

The impact of health on economic growth: A narrative literature review.

The nexus between health and economic growth is a dynamic and complex relationship. This article reviews the empirical evidence that has sought to assess the causal impact of health on growth, understood as growth in GDP per capita, and focusing on cross-country and selected single country studies. The review largely provides evidence in favour of a positive effect of population health on economic growth. However, the multitude of the factors at play and the possible bidirectional relationship between health and growth pose a challenge for the quantification of the effect and for the relative importance of the underlying mechanisms. There is notable heterogeneity between studies in the magnitude and, in some cases, even in the sign of the effect. The evidence suggests that the health-growth relationship may depend on three main factors: the sample composition (i.e. a country's demographic stage or GDP per capita); the health dimension considered (e.g. health improvements at different life stages may affect productivity differently); and the model specification (e.g. whether or not initial life expectancy is controlled for in the analysis or the quality of the instrument). These findings advocate for a policy approach that integrates health considerations into economic strategies and emphasizes intersectoral collaboration to maximize the economic returns from improved health outcomes.

Exploring the association between primary care efficiency and health system characteristics across European countries: a two-stage data envelopment analysis.

BACKGROUND: Primary care is widely seen as a core component of resilient and sustainable health systems, yet its efficiency is not well understood and there is a lack of evidence about how primary care efficiency is associated with health system characteristics. We examine this issue through the lens of diabetes care, which has a well-established evidence base for effective treatment and has previously been used as a tracer condition to measure health system performance. METHODS: We developed a conceptual framework to guide the analysis of primary care efficiency. Using data on 18 European countries during 2010-2016 from several international databases, we applied a two-stage data envelopment analysis to estimate (i) technical efficiency of primary care and (ii) the association between efficiency and health system characteristics. RESULTS: Countries varied widely in terms of primary care efficiency, with efficiency scores depending on the range of population characteristics adjusted for. Higher efficiency was associated with bonus payments for the prevention and management of chronic conditions, nurse-led follow-up, and a financial incentive or requirement for patients to obtain a referral to specialist care. Conversely, lower efficiency was associated with higher rates of curative care beds and financial incentives for patients to register with a primary care provider. CONCLUSIONS: Our results underline the importance of considering differences in population characteristics when comparing country performance on primary care efficiency. We highlight several policies that could enhance the efficiency of primary care. Improvements in data collection would enable more comprehensive assessments of primary care efficiency across countries, which in turn could more effectively inform policymaking.

The impact of economic sanctions on health and health systems in low-income and middle-income countries: a systematic review and narrative synthesis.

INTRODUCTION: Economic sanctions restrict customary commercial and financial ties between states to induce change in political constitution or conduct of the targeted country. Although the stated goals of sanctions often include humanitarian objectives, prospective procedures for health risk assessment are not regularly incorporated in their implementation. Moreover, past experience suggests that the burden of economic isolation may fall on the civilian population. We present key findings from a WHO-sponsored evidence review on the impact of economic sanctions on health and health systems in low-income and middle-income countries, aiming at comprehensive coverage and explicit consideration of issues of causality and mechanisms. METHODS: Broad searches of PubMed and Google Scholar (1970-2021) were designed to retrieve published and grey English-language literature expected to cut across disciplines, terminology and research methods. Studies providing an impact estimate were rated by a structured assessment based on ROBINS-I risk of bias domains, synthesised via vote counting and contextualised into the broader literature through a thematic synthesis. RESULTS: Included studies (185) were mostly peer-reviewed, mostly single-country, largely coming from medicine and public health, and chiefly concerned with three important target countries-Iraq, Haiti and Iran. Among studies providing impact estimates (31), most raised multiple risk-of-bias concerns. Excluding those with data integrity issues, a significant proportion (21/27) reported consistently adverse effects of sanctions across examined outcomes, with no apparent association to assessed quality, focus on early episodes or publication period. The thematic synthesis highlights the complexity of sanctions, their multidimensionality and the possible mechanisms of impact. CONCLUSION: Future research should draw on qualitative knowledge to collect domain-relevant data, combining it with better estimation techniques and study design. However, only the adoption of a risk assessment framework based on prospective data collection and monitoring can certify claims that civilians are adequately protected.

The effect of health financing systems on health system outcomes: A cross-country panel analysis.

Several low- and middle-income countries are considering health financing system reforms to accelerate progress toward universal health coverage (UHC). However, empirical evidence of the effect of health financing systems on health system outcomes is scarce, partly because it is difficult to quantitatively capture the 'health financing system'. We assign country-year observations to one of three health financing systems (i.e., predominantly out-of-pocket, social health insurance (SHI) or government-financed), using clustering based on out-of-pocket, contributory SHI and non-contributory government expenditure, as a percentage of total health expenditures. We then estimate the effect of these different systems on health system outcomes, using fixed effects regressions. We find that transitions from OOP-dominant to government-financed systems improved most outcomes more than did transitions to SHI systems. Transitions to government financing increases life expectancy (+1.3 years, p < 0.05) and reduces under-5 mortality (-8.7%, p < 0.05) and catastrophic health expenditure incidence (-3.3 percentage points, p < 0.05). Results are robust to several sensitivity tests. It is more likely that increases in non-contributory government financing rather than SHI financing improve health system outcomes. Notable reasons include SHI's higher implementation costs and more limited coverage. These results may raise a warning for policymakers considering SHI reforms to reach UHC.

The Effects and Costs of Personalized Budgets for People with Disabilities: A Systematic Review.

This article reviews the peer-reviewed and grey literature published from January 1985 to November 2022 that has quantitatively evaluated the effects of personalized budgets for people with disabilities (PwDs), in terms of a range of benefit and cost outcomes. Benefit metrics of interest comprised measures of well-being, service satisfaction and use, quality of life, health, and unmet needs. A search was conducted using the PsycINFO, MEDLINE, CINAHL, ASSIA, and Social Care Online databases. Based on inclusion criteria and a quality assessment using the Downs and Black Checklist, a final count of 23 studies were identified for in-depth review. Given the heterogeneous nature of the studies, a narrative synthesis, rather than a formal meta-analysis, was undertaken. Taking the relatively scarce and often methodologically limited evidence base at face value, the findings suggest that-overall-personalized budget users tend to benefit in terms of well-being and service satisfaction outcomes, with the exception of mixed effects for people with mental health conditions. Only a minority of studies have investigated the cost-effectiveness or costs-only of personalized budgets, finding mixed results. Two out of the three cost-effectiveness studies find personal budgets to be more cost-effective than alternative options, meaning that the possibly higher costs of personalized budgets may be more than outweighed by additional benefits. Some evidence looking at service use and/or costs only also points to significant reductions in certain service use areas, which at least hints at the potential that personalized budgeting may-in some cases-entail reduced costs. Further research is needed to explore the generalizability of these conclusions and to better capture and understand the factors driving the observed heterogeneity in some of the results.

Estimating the Health Effects of Expansions in Health Expenditure in Indonesia: A Dynamic Panel Data Approach.

BACKGROUND: The marginal productivity of a country's healthcare system refers to the health gains produced per unit change in the level of spending. In budget-constrained settings, this metric reflects the opportunity cost, in terms of health gains forgone, of committing additional or existing resources to alternative uses within the healthcare system. It can therefore assist in evidence-based decisions on whether different interventions represent good value for money. OBJECTIVE: The aim of this paper was to estimate the marginal productivity of the Indonesian healthcare system using subnational data, and to use this to inform health opportunity costs in the country. METHODS: We define a dynamic health production function to model the stream of effects of current and prior public health spending decisions on population under-five mortality. To estimate the model, we use data from the 33 Indonesian provinces for the 2004-2012 period. The estimated elasticity is then translated into gains in terms of cost per DALY (disability-adjusted life-year) averted. We use dynamic panel data methods to address potential endogeneity issues in the model. RESULTS: Our base-case estimates suggest that a 1% expansion in the level of health spending reduces under-five mortality by 0.38% (95% CI 0.00-0.76), which translates into a cost of averting one DALY of $235 (2019 US$). CONCLUSION: With Indonesia aiming for universal health coverage, our results support these efforts by highlighting the associated benefits resulting from increases in public health expenditure and have the potential to inform the decision-making process about a suitable locally relevant cost-effectiveness threshold.

Toward the economic evaluation of participatory approaches in health promotion: lessons from four German physical activity promotion projects.

Health promotion increasingly employs participatory approaches, but the question arises whether the likely higher costs of participation also translate into greater benefits. This article takes a first step toward a full health economic evaluation by comprehensively reporting the costs of a specific participatory approach, Cooperative Planning, in a German research consortium to promote physical activity. We conducted a costing analysis of Cooperative Planning at 22 sites across six settings. Project teams used a custom template to record resource use. We calculated average costs per meeting, site and setting using the opportunity costs approach, and obtained feedback from participating researchers. A total of 144 planning meetings with an average of nine participants were conducted. Costs per meeting varied significantly across settings. Differences were mostly attributable to varying meeting duration, preparation time and numbers of participants. Across settings, human resources accounted for roughly 95% of the costs. Implementing researchers reported challenges regarding the logic and methods of the health economic analysis. A participatory approach to physical activity promotion may cause substantially varying costs in different settings despite similar cost structures. However, their value for money could turn out comparably favorable if (and only if) the expected benefits is indeed forthcoming. Despite some challenges implementing the costing exercise into the logistics of ongoing participatory projects, this analysis may pave the way toward a full health economic evaluation, and the template may be useful to future participatory health promotion projects.

Health in Conflict Zones: Analyzing Inequalities in Mental Health in Colombian Conflict-Affected Territories.

Objectives: Colombia's civil conflict and persistent socio-economic disparities have contributed to mental health inequalities in conflict-affected territories. We explore the magnitude of mental health inequalities, contributing socio-economic factors, and sociodemographic characteristics that explain these differences. Methods: The study draws on data collected in 2018, using the household survey Conflicto, Paz y Salud (CONPAS) applied to 1,309 households in Meta, Colombia. Logistic regression and decomposition analysis were used to analyze the risk of mental health disorders, measured with the Self-Reporting Questionnaire -20 (SRQ-20). Results: Individuals with lower socio-economic status are at a higher risk for mental health disorders. Forced displacement accounts for 31% of the measured mental health inequalities. Disparities in employment, education level, disability and conflict incidence between municipalities are other contributing factors. Women and people with disabilities are respectively 2.3 and 1.2 times more prone to present a mental health disorder. Conclusion: It is necessary to tackle the identified risk factors and sociodemographic circumstances that contribute to mental health inequalities in conflict-affected territories, as these hinder adequate/equitable access to mental health services.

Investigating unmet need for healthcare using the European Health Interview Survey: a cross-sectional survey study of Luxembourg.

OBJECTIVES: We investigate the prevalence of unmet need arising from wait times, distance/transportation and financial affordability using the European Health Interview Survey. We explore associations between individual characteristics and the probability of reporting unmet need. DESIGN: Cross-sectional survey conducted between February and December 2014. SETTING AND PARTICIPANTS: 4004 members of the resident population in private households registered with the health insurance fund in Luxembourg aged 15 years and over. OUTCOME MEASURES: Six binary variables that measured unmet need arising from wait time, distance/transportation and affordability of medical, dental and mental healthcare and prescribed medicines among those who reported a need for care. RESULTS: The most common barrier to access arose from wait times (32%) and the least common from distance/transportation (4%). Dental care (12%) was most often reported as unaffordable, followed by prescribed medicines (6%), medical (5%) and mental health (5%) care. Respondents who reported bad/very bad health were associated with a higher risk of unmet need compared with those with good/very good health (wait: OR 2.41, 95% CI 1.53 to 3.80, distance/transportation: OR 7.12, 95% CI 2.91 to 17.44, afford medical care: OR 5.35, 95% CI 2.39 to 11.95, afford dental care: OR 3.26, 95% CI 1.86 to 5.71, afford prescribed medicines: OR 2.22, 95% CI 1.04 to 4.71, afford mental healthcare: OR 3.58, 95% CI 1.25 to 10.30). Income between the fourth and fifth quintiles was associated with a lower risk of unmet need for dental care (OR 0.29, 95% CI 0.16 to 0.53), prescribed medicines (OR 0.38, 95% CI 0.17 to 0.82) and mental healthcare (OR 0.17, 95% CI 0.05 to 0.61) compared with income between the first and second quintiles. CONCLUSIONS: Recent and planned reforms to address waiting times and financial barriers to accessing healthcare may help to address unmet need. In addition, policy-makers should consider additional policies targeted at high-risk groups with poor health and low incomes.

How to make universal, voluntary testing for COVID-19 work? A behavioural economics perspective.

Testing is widely seen as one core element of a successful strategy to curtail the COVID-19 pandemic and many countries have increased their efforts to provide testing at large scale. As most democratic governments refrain from enacting mandatory testing, a key emerging challenge is to increase voluntary participation. Using behavioural economics insights complemented with data from a novel survey in the US and a survey experiment in Luxembourg, we examine behavioural factors associated with the individual willingness to get tested (WTT). In our analysis, individual characteristics that correlate positively with WTT include age, altruism, conformism, the tendency to abide by government-imposed rules, concern about contracting COVID-19, and patience. Risk aversion, unemployment, and conservative political orientation correlate negatively with WTT. Building on and expanding these insights may prove fruitful for policy to effectively raise people's propensity to get tested.

Mortality, morbidity and economic growth.

The question of whether and how changes to population health impact on economic growth has been actively studied in the literature, albeit with mixed results. We contribute to this debate by reassessing-and extending-[1], one of the most influential studies. We include a larger set of countries (135) and cover a more recent period (1990-2014). We also account for morbidity in addition to mortality and adopt the strategy of providing bounding sets for the effects of interest rather than point estimates. We find that reducing mortality and disability adjusted life years (DALYs), a measure which combines morbidity and mortality, promotes per capita GDP growth. The magnitude of the effect is moderate, but non negligible, and it is similar for mortality and DALYs.

Equity and economic evaluation of system-level health interventions: A case study of Brazil's Family Health Program.

Distributional economic evaluation estimates the value for money of health interventions in terms of population health and health equity impacts. When applied to interventions delivered at the population and health system-level interventions (PSIs) instead of clinical interventions, additional practical and methodological challenges arise. Using the example of the Programme Saúde da Familia (PSF) in Brazil, a community-level primary care system intervention, we seek to illustrate these challenges and provide potential solutions. We use a distributional cost-effectiveness analysis (DCEA) approach to evaluate the impact of the PSF on population health and between-state health inequalities in Brazil. Data on baseline health status, disease prevalence and PSF effectiveness are extracted from the literature and incorporated into a Markov model to estimate the long-term impacts in terms of disability-adjusted life years. The inequality and average health impacts are analysed simultaneously using health-related social welfare functions. Uncertainty is computed using Monte Carlo simulation. The DCEA encountered several challenges in the context of PSIs. Non-randomized, quasi-experimental methods may not be powered to identify treatment effect heterogeneity estimates to inform a decision model. PSIs are more likely to be funded from multiple public sector budgets, complicating the calculation of health opportunity costs. We estimate a cost-per-disability-adjusted life years of funding the PSF of $2640. Net benefits were positive across the likely range of intervention cost. Social welfare analysis indicates that, compared to gains in average health, changes in health inequalities accounted for a small proportion of the total welfare improvement, even at high levels of social inequality aversion. Evidence on the population health and health equity impacts of PSIs can be incorporated into economic evaluation methods, although with additional complexity and assumptions. The case study results indicate that the PSF is likely to be cost-effective but that the inequality impacts are small and highly uncertain.

A light of hope? Inequalities in mental health before and after the peace agreement in Colombia: a decomposition analysis.

BACKGROUND: The present study seeks to evaluate the change in mental health inequalities in the department of Meta after the signing of Colombia's Peace Agreement in 2016 with the FARC guerrilla group. Using a validated survey instrument composed of 20 questions ('SRQ-20'), we measure changes in mental health inequalities from 2014, before the signing of the agreement, to 2018, after the signing. We then decompose the changes in inequalities to establish which socioeconomic factors explain differences in mental health inequalities over time. METHODS: Our study uses information from the Conflicto, Salud y Paz (CONPAS) survey conducted in the department of Meta, Colombia, in 1309 households in 2018, with retrospective information for 2014. To measure inequalities, we calculate the concentration indices for both years. Through the Oaxaca change decomposition method, we disaggregate changes in mental health inequalities into its underlying factors. This method allows us to explain the relationship between changes in mental health inequalities and changes in inequalities in several sociodemographic factors. It also identifies the extent to which these factors help explain the changes in mental health inequalities. RESULTS: Mental health inequalities in Meta were reduced almost by half from 2014 to 2018. In 2018, the population at the lower and middle socioeconomic levels had fewer chances of experiencing mental health disorders in comparison to 2014. The reduction in mental health differences is mostly attributed to reductions in the influence of certain sociodemographic variables, such as residence in rural zones and conflict-affected territories, working in the informal sector, or experiencing internal displacement. However, even though mental health inequalities have diminished, overall mental health outcomes have worsened in these years. CONCLUSIONS: The reduction in the contribution of conflict-related variables for explaining mental health inequalities could mean that the negative consequences of conflict on mental health have started to diminish in the short run after the peace agreement. Nevertheless, conflict and the presence of other socioeconomic inequalities still contribute to persistent adverse mental health outcomes in the overall population. Thus, public policy should be oriented towards improving mental health care services in these territories, given the post-accord context.

Socioeconomic inequality in premiums for a community-based health insurance scheme in Rwanda.

Community-based health insurance (CBHI) has gained popularity in many low- and middle-income countries, partly as a policy response to calls for low-cost, pro-poor health financing solutions. In Africa, Rwanda has successfully implemented two types of CBHI systems since 2005, one of which with a flat rate premium (2005-10) and the other with a stratified premium (2011-present). Existing CBHI evaluations have, however, tended to ignore the potential distributional aspects of the household contributions made towards CBHI. In this paper, we investigate the pattern of socioeconomic inequality in CBHI household premium contributions in Rwanda within the implementation periods. We also assess gender differences in CBHI contributions. Using the 2010/11 and 2013/14 rounds of national survey data, we quantify the magnitude of inequality in CBHI payments, decompose the concentration index of inequality, calculate Kakwani indices and implement unconditional quantile regression decomposition to assess gender differences in CBHI expenditure. We find that the CBHI with stratified premiums is less regressive than CBHI with a flat rate premium system. Decomposition analysis indicates that income and CBHI stratification explain a large share of the inequality in CBHI payments. With respect to gender, female-headed households make lower contributions towards CBHI expenditure, compared with male-headed households. In terms of policy implications, the results suggest that there may be a need for increasing the premium bracket for the wealthier households, as well as for the provision of more subsidies to vulnerable households.

Evaluation of a very brief pedometer-based physical activity intervention delivered in NHS Health Checks in England: The VBI randomised controlled trial.

BACKGROUND: The majority of people do not achieve recommended levels of physical activity. There is a need for effective, scalable interventions to promote activity. Self-monitoring by pedometer is a potentially suitable strategy. We assessed the effectiveness and cost-effectiveness of a very brief (5-minute) pedometer-based intervention ('Step It Up') delivered as part of National Health Service (NHS) Health Checks in primary care. METHODS AND FINDINGS: The Very Brief Intervention (VBI) Trial was a two parallel-group, randomised controlled trial (RCT) with 3-month follow-up, conducted in 23 primary care practices in the East of England. Participants were 1,007 healthy adults aged 40 to 74 years eligible for an NHS Health Check. They were randomly allocated (1:1) using a web-based tool between October 1, 2014, and December 31, 2015, to either intervention (505) or control group (502), stratified by primary care practice. Participants were aware of study group allocation. Control participants received the NHS Health Check only. Intervention participants additionally received Step It Up: a 5-minute face-to-face discussion, written materials, pedometer, and step chart. The primary outcome was accelerometer-based physical activity volume at 3-month follow-up adjusted for sex, 5-year age group, and general practice. Secondary outcomes included time spent in different intensities of physical activity, self-reported physical activity, and economic measures. We conducted an in-depth fidelity assessment on a subsample of Health Check consultations. Participants' mean age was 56 years, two-thirds were female, they were predominantly white, and two-thirds were in paid employment. The primary outcome was available in 859 (85.3%) participants. There was no significant between-group difference in activity volume at 3 months (adjusted intervention effect 8.8 counts per minute [cpm]; 95% CI -18.7 to 36.3; p = 0.53). We found no significant between-group differences in the secondary outcomes of step counts per day, time spent in moderate or vigorous activity, time spent in vigorous activity, and time spent in moderate-intensity activity (accelerometer-derived variables); as well as in total physical activity, home-based activity, work-based activity, leisure-based activity, commuting physical activity, and screen or TV time (self-reported physical activity variables). Of the 505 intervention participants, 491 (97%) received the Step it Up intervention. Analysis of 37 intervention consultations showed that 60% of Step it Up components were delivered faithfully. The intervention cost £18.04 per participant. Incremental cost to the NHS per 1,000-step increase per day was £96 and to society was £239. Adverse events were reported by 5 intervention participants (of which 2 were serious) and 5 control participants (of which 2 were serious). The study's limitations include a participation rate of 16% and low return of audiotapes by practices for fidelity assessment. CONCLUSIONS: In this large well-conducted trial, we found no evidence of effect of a plausible very brief pedometer intervention embedded in NHS Health Checks on objectively measured activity at 3-month follow-up. TRIAL REGISTRATION: Current Controlled Trials (ISRCTN72691150).

Can economic indicators predict infectious disease spread? A cross-country panel analysis of 13 European countries.

Aims: It is unclear how economic factors impact on the epidemiology of infectious disease. We evaluated the relationship between incidence of selected infectious diseases and economic factors, including economic downturn, in 13 European countries between 1970 and 2010. Methods: Data were obtained from national communicable disease surveillance centres. Negative binomial forms of the generalised additive model (GAM) and the generalised linear model were tested to see which best reflected transmission dynamics of: diphtheria, pertussis, measles, meningococcal disease, hepatitis B, gonorrhoea, syphilis, hepatitis A and salmonella. Economic indicators were gross domestic product per capita (GDPpc), unemployment rates and (economic) downturn. Results: GAM models produced the best goodness-of-fit results. The relationship between GDPpc and disease incidence was often non-linear. Strength and directions of association between population age, tertiary education levels, GDPpc and unemployment were disease dependent. Overdispersion for almost all diseases validated the assumption of a negative binomial relationship. Downturns were not independently linked to disease incidence. Conclusions: Social and economic factors can be correlated with many infections. However, the trend is not always in the same direction, and these associations are often non-linear. Economic downturn or recessions as indicators of increased disease risk may be better replaced by GDPpc or unemployment measures.

Effects of a sugar-sweetened beverage tax on prices and affordability of soft drinks in Chile: A time series analysis.

Chile is one of several countries that recently implemented a fiscal policy to reduce soft drink (SD) intake and obesity. In 2014 the government increased the existing ad-valorem tax on high-sugar SD by 5% and decreased by 3% the tax on low-sugar SD, based on a 6.25gr/100 ml sugar threshold. This study aims to evaluate the tax modification passed-on to consumers through prices, and to calculate changes in affordability of SDs. We analysed nationally representative consumer price index data of 41 soft drinks within 6 beverage categories between 2009 and 2016. Price change post-tax implementation was estimated for different categories (carbonates, juices, concentrates, waters and energy-sport drinks), using time-series analyses. In addition, changes in affordability were evaluated by estimating the changes in prices relative to wages. The price of carbonates increased by 5.60% (CI 95% 3.18-8.03%) immediately after the tax was implemented. A sustained increase in the prices of concentrates was observed after the implementation. Unexpectedly, a smaller increase was also seen for the price of bottled water - a category that saw no tax change. There were no effects for juices and energy-sports drinks. There was a reduction in affordability for carbonates, concentrates and waters. Overall, the fiscal policy was effective in increasing prices and there are some signs of reduced affordability. Results varied substantially among categories directly affected by the tax policy. While for carbonates the price increase exceeded the tax change ('over-shifting'), in other categories subject to a tax cut, a price reduction was expected but the opposite occurred. As the effect of the tax on prices differed between categories, the effects of the tax policy on consumption patterns are likely to be mixed. Our findings underline the need to better understand and anticipate price setting behaviour of firms in response to a tax.

Correction: The impact of public health insurance on health care utilisation, financial protection and health status in low- and middle-income countries: A systematic review.

[This corrects the article DOI: 10.1371/journal.pone.0219731.].

Coping with healthcare costs for chronic illness in low-income and middle-income countries: a systematic literature review.

BACKGROUND: Experiencing illness in low-income and middle-income countries (LMICs) can incur very high out-of-pocket (OOP) payments for healthcare and, while the existing literature typically focuses on levels of expenditure, it rarely examines what happens when households do not have the necessary money. Some will adopt one or more 'coping strategies', such as borrowing money, perhaps at exorbitant interest rates, or selling assets, some necessary for their future income, with detrimental long-term effects. This is particularly relevant for chronic illnesses that require consistent, long-term OOP payments. We systematically review the literature on strategies for financing OOP costs of chronic illnesses in LMICs, their correlates and their impacts on households. METHODS: We searched MEDLINE, EconLit, EMBASE, Global Health and Scopus on 22 October 2018 for literature published on or after 1 January 2000. We included qualitative or quantitative studies describing at least one coping strategy for chronic illness OOP payments in a LMIC context. Our narrative review follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. RESULTS: Forty-seven papers were included. Studies identified coping strategies for chronic illness costs that are not traditionally addressed in financial risk protection research (eg, taking children out of school, sending them to work, reducing expenditure on food or education, quitting work to give care). Twenty studies reported socioeconomic or other correlates of coping strategies, with poorer households and those with more advanced disease more vulnerable to detrimental strategies. Only six studies (three cross-sectional and three qualitative) included evidence of impacts of coping strategies on households, including increased labour to repay debts and discontinuing treatment. CONCLUSIONS: Monitoring of financial risk protection provides an incomplete picture if it fails to capture the effect of coping strategies. This will require qualitative and longitudinal research to understand the long-term effects, especially those associated with chronic illness in LMICs.