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.

Addiction to a bad idea, especially in low- and middle-income countries: Contributory health insurance.

Despite limited evidence of successful development and implementation of contributory health insurance and low and middle income countries, many countries are in the process implementing such schemes. This commentary summarizes all available evidence on the limitations of contributory health insurance including the lack of good theoretical underpinning and the considerable evidence of inequity and fragmentation created by such schemes. Moreover, the initiation of a contributory health insurance scheme has not been found to increase revenues to the health sector or help health countries achieve universal health coverage. Low and middle income countries can improve equity and efficiency of the health sector by replacing out-of-pocket spending with pre-paid pooling mechanisms, but that is best done through budget transfers and not by contributory insurance that links payment to sub-population entitlements.

Maternal inflammatory and omega-3 fatty acid pathways mediate the association between socioeconomic disadvantage and childhood cognition.

Poor cognitive outcomes in early childhood predict poor educational outcomes and diminished health over the life course. We sought to investigate (i) whether maternal metabolites predict child cognition, and (ii) if maternal metabolomic profile mediates the relationship between environmental exposures and child cognition. Metabolites were measured using nuclear magnetic resonance-based metabolomics in pregnant women from a population-derived birth cohort. Child cognition was measured at age 2 years. In 662 mother-child pairs, elevated inflammatory markers (ß = -2.62; 95% CI -4.10, -1.15; P = 0.0005) and lower omega-3 fatty acid-related metabolites (ß = 0.49; 95% CI 0.09, 0.88; P = 0.02) in the mother were associated with lower child cognition and partially mediated the association between lower child cognition and multiple risk factors common to socioeconomic disadvantage. Modifying maternal prenatal metabolic pathways related to inflammation and omega-3 fatty acids may offset the adverse associations between prenatal risk factors related to socioeconomic disadvantage and low child cognition.

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.

Inferring Future Landscapes: Sampling the Local Optima Level.

Connection patterns among Local Optima Networks (LONs) can inform heuristic design for optimisation. LON research has predominantly required complete enumeration of a fitness landscape, thereby restricting analysis to problems diminutive in size compared to real-life situations. LON sampling algorithms are therefore important. In this article, we study LON construction algorithms for the Quadratic Assignment Problem (QAP). Using machine learning, we use estimated LON features to predict search performance for competitive heuristics used in the QAP domain. The results show that by using random forest regression, LON construction algorithms produce fitness landscape features which can explain almost all search variance. We find that LON samples better relate to search than enumerated LONs do. The importance of fitness levels of sampled LONs in search predictions is crystallised. Features from LONs produced by different algorithms are combined in predictions for the first time, with promising results for this "super-sampling": a model to predict tabu search success explained 99% of variance. Arguments are made for the use-case of each LON algorithm and for combining the exploitative process of one with the exploratory optimisation of the other.

Assessment of doxorubicin-induced remodeling of Ca2+ signaling and associated Ca2+ regulating proteins in MDA-MB-231 breast cancer cells.

Triple-negative breast cancers (TNBC) are often associated with high relapse rates, despite treatment with chemotherapy agents such as doxorubicin. A better understanding of the signaling and molecular changes associated with doxorubicin may provide novel insights into strategies to enhance treatment efficacy. Calcium signaling is involved in many pathways influencing the efficacy of chemotherapy agents such as proliferation and cell death. However, there are a limited number of studies exploring the effect of doxorubicin on calcium signaling in TNBC. In this study, MDA-MB-231 triple-negative, basal breast cancer cells stably expressing the genetically-encoded calcium indicator GCaMP6m (GCaMP6m-MDA-MB-231) were used to define alterations in calcium signaling. The effects of doxorubicin in GCaMP6m-MDA-MB-231 cells were determined using live cell imaging and fluorescence microscopy. Changes in mRNA levels of specific calcium regulating proteins as a result of doxorubicin treatment were also assessed using real time qPCR. Doxorubicin (1 µM) produced alterations in intracellular calcium signaling, including enhancing the sensitivity of MDA-MB-231 cells to ATP stimulation and prolonging the recovery time after store-operated calcium entry. Upregulation in mRNA levels of ORAI1, TRPC1, SERCA1, IP3R2 and PMCA2 with doxorubicin 1 µM treatment was also observed. Doxorubicin treatment is associated with specific remodeling in calcium signaling in MDA-MB-231 cells, with associated changes in mRNA levels of specific calcium-regulating proteins.

В состоянии ли люди платить за услуги здравоохранения? Hовые фактические данные о финансовой защите в Европе

Выплаты из кармана населения (прямые платежи, осуществляемые населением) за услуги здравоохранения могут создавать финансовые препятствия для доступа к услугам здравоохранения, что приводит к возникновению неудовлетворенных потребностей или ведет к финансовым трудностям для лиц, использующих услуги здравоохранения. Данный отчет впервые объединяет данные о неудовлетворенных потребностях и финансовых трудностях в целях оценки того, в состоянии ли люди, живущие в Европе, платить за услуги здравоохранения. Объединяя труд национальных экспертов из 24 стран, данный отчет демонстрирует, что финансовые трудности в Европе сильно различаются и что потенциал для улучшения имеется даже в странах с высоким уровнем дохода, которые предоставляют всему населению доступ к государственным услугам здравоохранения. Катастрофические расходы на здравоохранение в значительной степени концентрируются среди самых бедных домохозяйств во всех странах, изученных в ходе исследования. Там, где финансовая защита особенно слаба, катастрофические расходы в основном связаны с выплатами из кармана за лекарственные средства для амбулаторного лечения. Системы здравоохранения с сильной финансовой защитой и низким уровнем неудовлетворенных потребностей имеют следующие общие черты: отсутствие больших пробелов и разрывов в охвате услугами здравоохранения; политика охвата (дизайн политики охвата услугами здравоохранения, а также ее реализация и управление) тщательно разработана таким образом, чтобы минимизировать барьеры в доступе и выплаты из кармана – особенно для бедных и регулярных пользователей услуг здравоохранения; государственные расходы на здравоохранение достаточно высоки для обеспечения относительно своевременного доступа к широкому спектру услуг здравоохранения без неформальных платежей. В результате этого выплаты из кармана населения невелики и составляют менее или около 15% от текущих расходов на здравоохранение. Пробелы в охвате возникают из-за недостатков в дизайне трех областей политики: права населения на получение гарантированных услуг здравоохранения, пакета гарантированных медицинских услуг (пакета государственных гарантий), и официальных платежей, осуществляемых потребителями (сооплаты). Данный отчет резюмирует действия, которые могут снизить уровень неудовлетворенных потребностей и финансовых трудностей за счет укрепления политики охвата. Он также указывает на те действия, которых стоит избегать.

Can people afford to pay for health care? New evidence on financial protection in Europe

Out-of-pocket payments for health can create a financial barrier toaccess, resulting in unmet need, or lead to financial hardship for peopleusing health services. This report brings together for the first time dataon unmet need and financial hardship to assess whether people living inEurope can afford to pay for health care. Drawing on contributions fromnational experts in 24 countries, the report shows that financial hardshipvaries widely in Europe, and that there is room for improvement even inhigh-income countries that provide the whole population with access topublicly financed health services. Catastrophic health spending is heavilyconcentrated among the poorest households in all of the countries in thestudy. Where financial protection is relatively weak, catastrophic spendingis mainly driven by out-of-pocket payments for outpatient medicines. Health systems with strong financial protection and low levels of unmetneed share the following features: there are no large gaps in healthcoverage; coverage policy – the way in which coverage is designed,implemented and governed – is carefully designed to minimize accessbarriers and out-of-pocket payments, particularly for poor people andregular users of health services; public spending on health is high enough toensure relatively timely access to a broad range of health services withoutinformal payments; and as a result, out-of-pocket payments are low, accounting for less than or close to 15% of current spending on health. Gaps in coverage arise from weaknesses in the design of three policyareas: population entitlement, the benefits package and user charges (copayments). The report summarizes actions that can reduce unmet needand financial hardship by strengthening coverage policy. It also highlightsactions that should be avoided.

Catastrophic health spending in Europe: equity and policy implications of different calculation methods.

OBJECTIVE: To investigate the equity and policy implications of different methods to calculate catastrophic health spending. METHODS: We used routinely collected data from recent household budget surveys in 14 European countries. We calculated the incidence of catastrophic health spending and its distribution across consumption quintiles using four methods. We compared the budget share method, which is used to monitor universal health coverage (UHC) in the sustainable development goals (SDGs), with three other well-established methods: actual food spending; partial normative food spending; and normative spending on food, housing and utilities. FINDINGS: Country estimates of the incidence of catastrophic health spending were generally similar using the normative spending on food, housing and utilities method and the budget share method at the 10% threshold of a household's ability to pay. The former method found that catastrophic spending was concentrated in the poorest quintile in all countries, whereas with the budget share method catastrophic spending was largely experienced by richer households. This is because the threshold for catastrophic health spending in the budget share method is the same for all households, while the other methods generated effective thresholds that varied across households. The normative spending on food, housing and utilities method was the only one that produced an effective threshold that rose smoothly with total household expenditure. CONCLUSION: The budget share method used in the SDGs overestimates financial hardship among rich households and underestimates hardship among poor households. This raises concerns about the ability of the SDG process to generate appropriate guidance for policy on UHC.

Assessment of cytosolic free calcium changes during ceramide-induced cell death in MDA-MB-231 breast cancer cells expressing the calcium sensor GCaMP6m.

Alterations in Ca2+ signaling can regulate key cancer hallmarks such as proliferation, invasiveness and resistance to cell death. Changes in the regulation of intracellular Ca2+ and specific components of Ca2+ influx are a feature of several cancers and/or cancer subtypes, including the basal-like breast cancer subtype, which has a poor prognosis. The development of genetically encoded calcium indicators, such as GCaMP6, represents an opportunity to measure changes in intracellular free Ca2+ during processes relevant to breast cancer progression that occur over long periods (e.g. hours), such as cell death. This study describes the development of a MDA-MB-231 breast cancer cell line stably expressing GCaMP6m. The cell line retained the key features of this aggressive basal-like breast cancer cell line. Using this model, we defined alterations in relative cytosolic free Ca2+ ([Ca2+]CYT) when the cells were treated with C2-ceramide. Cell death was measured simultaneously via assessment of propidium iodide permeability. Treatment with ceramide produced delayed and heterogeneous sustained increases in [Ca2+]CYT. Where cell death occurred, [Ca2+]CYT increases preceded cell death. The sustained increases in [Ca2+]CYT were not related to the rapid morphological changes induced by ceramide. Silencing of the plasma membrane Ca2+ ATPase isoform 1 (PMCA1) was associated with an augmentation in ceramide-induced increases in [Ca2+]CYT and also cell death. This work demonstrates the utility of GCaMP6 Ca2+ indicators for investigating [Ca2+]CYT changes in breast cancer cells during events relevant to tumor progression, which occur over hours rather than minutes.

Financial protection in Europe: a systematic review of the literature and mapping of data availability.

BACKGROUND: A comprehensive and context-specific approach to monitoring financial protection can provide valuable evidence on progress towards universal health coverage. OBJECTIVES: This article systematically reviews the literature on financial protection in Europe to identify trends across countries and over time. It also maps the availability of data for regular monitoring in 53 countries. METHODS: Two people independently searched for studies using a standard strategy. Results were extracted from 54 publications and studies analysed in terms of geographical focus, data sources, methods and depth of analysis. RESULTS: Financial protection varies across countries in Europe; substantial changes over time have mainly taken place in the east of the region. Although the data required for regular monitoring are widely available, the literature presents major gaps in geographical scope - most studies focus on middle-income countries; it is not up to date - the latest year of data analysed is 2011; and cross-national comparison is only possible for a handful of countries due to variation in data sources and methods. The literature is also limited in depth. Very few studies go beyond analysing how many people incur catastrophic or impoverishing out-of-pocket payments. Only a small minority analyse who is most likely to experience financial hardship and what drives lack of financial protection. CONCLUSIONS: The literature provides little actionable evidence on financial protection in Europe.

Assessment of the TRPM8 inhibitor AMTB in breast cancer cells and its identification as an inhibitor of voltage gated sodium channels.

AIMS: To assess levels of the calcium permeable transient receptor potential cation channel, subfamily melastatin, member 8 (TRPM8) in breast cancer molecular subtypes and to assess the consequences of TRPM8 pharmacological inhibition with AMTB (an inhibitor of TRPM8) on breast cancer cell lines. MATERIALS AND METHODS: Cell viability and migration of breast cancer cells was determined using MTS assays and wound healing assays, respectively. RNA-Seq analysis of breast tumours and qPCR in breast cancer cell lines were used to assess mRNA levels of ion channels. Membrane potential assays were employed to assess the effects of AMTB against specific voltage gated sodium channels (NaV). KEY FINDINGS: TRPM8 levels were significantly higher in breast cancers of the basal molecular subtype. AMTB decreased viable cell number in MDA-MB-231 and SK-BR-3 breast cancer cell lines (30 and 100 µM), and also reduced the migration of MDA-MB-231 cells (30 µM). However, these effects were independent of TRPM8, as no TRPM8 mRNA was detected in MDA-MB-231 cells. AMTB was identified as an inhibitor of NaV isoforms. NaV1.1-1.9 were expressed in a number of breast cancer cell lines, with NaV1.5 mRNA highest in MDA-MB-231 cells compared to the other breast cancer cell lines assessed. SIGNIFICANCE: TRPM8 levels may be elevated in basal breast cancers, however, TRPM8 expression appears to be lost in many breast cancer cell lines. Some of the effects of AMTB attributed to TRPM8 may be due to effects on NaV channels.

How much do cancer specialists earn? A comparison of physician fees and remuneration in oncology and radiology in high-income countries.

The main driver of higher spending on health care in the US is believed to be substantially higher fees paid to US physicians in comparison with other countries. We aim to compare physician incomes in radiology and oncology considering differences in relation to fees paid, physician capacity and volume of services provided in five countries: the United States, Canada, Australia, France and the United Kingdom. The fee for a consultation with a specialist in oncology varies threefold across countries, and more than fourfold for chemotherapy. There is also a three to fourfold variation in fees for ultrasound and CT scans. Physician earnings in the US are greater than in other countries in both oncology and radiology, more than three times higher than in the UK; Canadian oncologists and radiologists earn considerably more than their European counterparts. Although challenging, benchmarking earnings and fees for similar health care activities across countries, and understanding the factors that explain any differences, can provide valuable insights for policy makers trying to enhance efficiency and quality in service delivery, especially in the face of rising care costs.

Can people afford to pay for health care?: new evidence on financial protection in Lithuania: summary

This review is part of a series of country-based studies generating new evidence on financial protection in European health systems. Financial protection is central to universal health coverage and a core dimension of health system performance.This review assesses the extent to which people in Lithuania experience financial hardship when they use health care. The analysis draws on household budget survey data collected in 2005, 2008 and 2012 by Statistics Lithuania. It focuses on two indicators of financial protection: catastrophic out-of-pocket payments and impoverishing out-of-pocket payments. It also considers the presence of access barriers leading to unmet need for health care.

Financial protection in high-income countries: a comparison of the Czech Republic, Estonia and Latvia

This report compares financial protection across 3 countries that are similar in many ways but experience very different levels of financial hardship. The incidence of catastrophic and impoverishing out-of-pocket payments is low in Czechia, much higher in Estonia and among the highest in the WHO European Region in Latvia. Differences in financial hardship are partly explained by variations in health spending across the 3 countries. An increase in public spending on health in Estonia and Latvia would help to lower the out-of-pocket share of total spending on health. Coverage policy – the way in which health coverage is designed and implemented – is an equally important explanatory factor. The weak design of user charges (co-payments) for outpatient medicines in Estonia and Latvia shifts health-care costs onto those who can least afford to pay: poor people, people with chronic conditions and older people. In contrast, co-payment policy in Czechia is relatively strong: co-payments are used sparingly; they are set as a low fixed co-payment rather than a percentage of price; vulnerable people are exempt; and there is a cap on all co-payments for everyone. As a result, catastrophic incidence is low, outpatient medicines are accessible and pensioners do not experience undue financial hardship.

Can people afford to pay for health care? New evidence on financial protection in Lithuania

The review assesses the extent to which people in Lithuania experience financial hardship when they use health care. The analysis draws on household budget survey data collected in 2005, 2008 and 2012 by Statistics Lithuania. It focuses on two indicators of financial protection: catastrophic out-of-pocket payments and impoverishing out-of-pocket payments. It also considers the presence of access barriers leading to unmet need for health care. This review is part of a series of country-based studies generating new evidence on financial protection in European health systems.

Ar gyventojai gali susimokėti už sveikatos priežiūrą?: Nauji duomenys apie finansinę apsaugą Lietuvoje: santrauka

Ši apžvalga – tai šalies tyrimų serijosdalis, kurioje pateikiami naujausiduomenys apie finansinę Europossveikatos sistemų apsaugą. Finansinėapsauga ypač svarbi visuotineisveikatos priežiūros aprėpčiaiir tinkamam sveikatos sistemosfunkcionavimui.

Single vs multiple competing purchasing agencies: analysis of options for the health system in Cyprus

This report considers the requirements, advantages and risks associated with operating a proposed new national health system in Cyprus through a single purchasing agency versus through multiple competing purchasers. It analyses three options in the light of international experience and the context in Cyprus: (1) a single public purchasing agency; (2) competition among multiple private insurance companies; and (3) competition between the public purchasing agency and private insurance companies. Option 1 offers the significant advantage of a unified risk pool for equity, efficiency and lower transaction costs. Under the national health system a single purchasing agency will have substantial leverage over providers, giving it opportunity to influence health care quality and costs. Option 2 poses significant technical challenges in comparison to Option 1 and adds a great deal of complexity to the governance of the health system, implying high transaction costs. Few countries have succeeded in making competition among purchasing agencies work well in terms of promoting better purchasing of mandatory health benefits. The third option is the most likely of the three to result in two-tier access to health services, with lower financial protection and worse access for poorer, sicker and older people. The report concludes that there are advantages, risks and challenges under all three options, and that none of the options will improve health system performance unless there is strong government capacity to set priorities, monitor performance and hold all stakeholders to account.