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.

Trends in mental health before and after the onset of the COVID-19 pandemic: a longitudinal survey of a conflict-affected population in Colombia.

BACKGROUND: Focusing on the Meta region in Colombia, we investigated the relationship between mental health, the COVID-19 pandemic, and social determinants of health influenced by over five decades of civil conflict. We studied the post-2016 peace agreement trends in mental health for the population of Meta, before and after the local onset of the pandemic. METHOD: We conducted three rounds of a longitudinal health survey in years 2018 with N = 1309 (Women = 709; Men = 600); 2019 with N = 1106 (Women = 597; Men = 509); and 2020 with N = 905 (Women = 499; Men = 406). We measured mental health through the Self-Report Questionnaire (SRQ-20), investigating population trends in the average SRQ score and SRQ-positive frequency (SRQ + , indicating positive tendency towards experiencing mental health disorders). RESULTS: Between 2018 and 2020, there were reductions in the mean SRQ-20 score by 1.74 points (95% CI -2.30 to -1.18) and in SRQ + frequency by 15 percentage points (95% CI -21.0 to -9.0) for the Meta population. Yet specific subgroups have become more vulnerable to mental illness during the pandemic, for example older age groups (e.g., increase in mean SRQ score among over 60 s by 2.49 points, 95% CI 0.51 to 4.46) and people living with children younger than five years-old (e.g., increase in mean SRQ score by 0.64 points, 95% CI 0.07 to 1.20). Increased mental health vulnerability among specific subgroups may be related to differences in the likelihood of knowing people who tested positive for COVID-19 or died from itf having been in quarantine. CONCLUSION: Our findings support the importance of public policies in Colombia (and other low- and middle-income countries) that address the social determinants of mental illness whose influence was likely exacerbated by the pandemic, including persistent job insecurity leading to work and financial pressures, and inadequate support networks for isolated individuals and vulnerable caregivers.

Central America and the Dominican Republic at Crossroads: The Importance of Regional Cooperation and Health Economic Research to Address Current Health Challenges.

OBJECTIVES: We discuss key health challenges currently faced by countries in the Central America and Dominican Republic region after the COVID-19 pandemic. We highlight the influence of socioeconomic determinants for the challenging public health dynamics observed and the crucial roles that regional cooperation and health economic research can have for tackling such challenges. METHODS: We present a descriptive overview of the current situation of public finances and its effect on government capacity to improve social expenditure. We also discuss the impact of the COVID-19 pandemic crisis on social dynamics and living conditions in the region. RESULTS: Our analysis suggests that the interplay between all these factors is likely to have important consequences for health systems and population health in the post-pandemic period. Previous examples of successful cross-country cooperation in the region indicate the great potential that these initiatives have for supporting health system resilience against current challenges. Technical cooperation must be informed by (currently unavailable) research evidence that can guide decision making, especially health economic research to support national health resource allocation policies. Areas identified as priorities for applied health economic research include both macro and microeconomic analyses. CONCLUSIONS: Central America and the Dominican Republic face significant health challenges post-pandemic. Our article emphasizes the great potential that regional technical cooperation, informed by further health economic research, has to improve public policies and health governance in the region.

The Brazilian Family Health Strategy and adult health: Evidence from individual and local data for metropolitan areas.

Previous studies have found that the expansion of primary health care in Brazil following the country-wide family health strategy (ESF), one of the largest primary care programs in the world, has improved health outcomes. However, these studies have relied either on aggregate data or on limited individual data, with no fine-grained information available concerning household participation in the ESF or local supply of ESF services, which represent crucial aspects for analytical and policy purposes. This study analyzes the relationship between the ESF and health outcomes for the adult population in metropolitan areas in Brazil. We investigate this relationship through two linked dimensions of the ESF: the program's local supply of health teams and ESF household registration. In contrast with previous studies focusing on comparisons between certain definitions of "treated" versus "nontreated" populations, our results indicate that the local density of health teams is important to the observed effects of the ESF on adult health. We also find evidence consistent with the presence of positive primary health care spillovers to people not registered with the ESF. However, current ESF coverage levels in metropolitan areas have limited ability to address prevailing health inequalities. Our analysis suggests that the local intensity of ESF coverage should be a key consideration for evaluations and policy efforts related to future ESF expansion.

Assessment of the association between the Brazilian family health strategy and adult mortality.

This study aimed to analyse a wide range of related health problems that respond favourably to efficient primary care treatment among adults. We evaluate the direct impact of the Family Health Strategy (ESF) in Brazil on mortality of adults aged 25-64 years related to conditions for which access to effective primary care can reduce the likelihood of more severe outcomes. Additionally, we discuss heterogeneous effects associated with different intensities of the programme. To address these issues, we estimated a model with variation at the municipal level of the ESF expansion, including municipal-fixed effects, municipal specific trends and year-fixed effects. Our results show that a higher intensity of ESF is associated with reduced mortality by all conditions sensitive to primary care and for some diseases, especially after some years: avoidable conditions, asthma, heart failure, cerebrovascular diseases and gastrointestinal ulcer, infectious gastroenteritis and complications, diseases of the lower airways, hypertension and diabetes. As a public policy view, these results help understand how a nationwide primary care strategy can help mitigate mortality and emphasize the role of having sufficient health teams to attend to the population.

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.

Inequalities in catastrophic health expenditures in conflict-affected areas and the Colombian peace agreement: an oaxaca-blinder change decomposition analysis.

BACKGROUND: The present study analyzes inequalities in catastrophic health expenditures in conflict-affected regions of Meta, Colombia and socioeconomic factors contributing to the existence and changes in catastrophic expenditures before and after the sign of Colombian Peace Agreement with FARC-EP guerilla group in 2016. METHODS: The study uses the results of the survey Conflicto, Paz y Salud (CONPAS) conducted in 1309 households of Meta, Colombia, a territory historically impacted by armed conflict, for the years 2014 and 2018. We define catastrophic expenditures as health expenditures above 20% of the capacity to pay of a household. We disaggregate the changes in inequalities in catastrophic expenditures through the Oaxaca-Blinder change decomposition method. RESULTS: The incidence of catastrophic expenditures slightly increased between 2014 to 2018, from 29.3 to 30.7%. Inequalities in catastrophic expenditures, measured through concentration indexes (CI), also increased from 2014 (CI: -0.152) to 2018 (CI: -0.232). Results show that differences in catastrophic expenditures between socioeconomic groups are mostly attributed to an increased influence of specific sociodemographic variables such as living in rural zones, being a middle-aged person, living in conflict-affected territories, or presenting any type of mental and physical disability. CONCLUSIONS: Conflict-deescalation and the peace agreement may have facilitated lower-income groups to have access to health services, especially in territories highly impacted by conflict. This, consequently, may have led to higher levels of out-of-pocket expenditures and, therefore, to higher chances of experiencing catastrophic expenditures for lower-income groups in comparison to higher-income groups. Therefore, results indicate the importance of designing policies that guarantee access to health services for people in conflict -affected regions but also, that minimize health care inequalities in out-of-pocket payments that may arouse between people at different socioeconomic groups.

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.

Potential determinants of health system efficiency: Evidence from Latin America and the Caribbean.

This paper examines the levels of health system efficiency and their possible determinants across Latin American and Caribbean (LAC) countries using national-level data for those countries, as well as for other emerging and developed countries. The data are analyzed using data envelopment analyses and econometric advances that yield reliable estimations of the relationship between system efficiency and its potential determinants. We find that there is substantial room for efficiency improvements in the health system of most LAC countries. For example, LAC countries could improve life expectancy at birth by about five years on average at current public spending levels if they followed best practices. Furthermore, the paper assesses what factors amenable to policy act as the main possible levers for some countries to be able to translate a given level of health financing into better performance on access to care and health outcomes. Our econometric analyses suggest that efforts to increase health system efficiency could be focused in a few key policy areas associated with broader access to health services and better outcomes. These areas include general governance aspects, in addition to improvements in specific dimensions of the quality of health system institutions, notably stronger reliance on results-based management in the production of healthcare goods and services.

The impact of user charges on health outcomes in low-income and middle-income countries: a systematic review.

BACKGROUND: User charges are widely used health financing mechanisms in many health systems in low-income and middle-income countries (LMICs) due to insufficient public health spending on health. This study systematically reviews the evidence on the relationship between user charges and health outcomes in LMICs, and explores underlying mechanisms of this relationship. METHODS: Published studies were identified via electronic medical, public health, health services and economics databases from 1990 to September 2017. We included studies that evaluated the impact of user charges on health in LMICs using randomised control trial (RCT) or quasi-experimental (QE) study designs. Study quality was assessed using Cochrane Risk of Bias and Risk of Bias in Non-Randomized Studies-of Intervention for RCT and QE studies, respectively. RESULTS: We identified 17 studies from 12 countries (five upper-middle income countries, five lower-middle income countries and two low-income countries) that met our selection criteria. The findings suggested a modest relationship between reduction in user charges and improvements in health outcomes, but this depended on health outcomes measured, the populations studied, study quality and policy settings. The relationship between reduced user charges and improved health outcomes was more evident in studies focusing on children and lower-income populations. Studies examining infectious disease-related outcomes, chronic disease management and nutritional outcomes were too few to draw meaningful conclusions. Improved access to healthcare as a result of reduction in out-of-pocket expenditure was identified as the possible causal pathway for improved health. CONCLUSIONS: Reduced user charges were associated with improved health outcomes, particularly for lower-income groups and children in LMICs. Accelerating progress towards universal health coverage through prepayment mechanisms such as taxation and insurance can lead to improved health outcomes and reduced health inequalities in LMICs. TRIAL REGISTRATION NUMBER: CRD 42017054737.

The Role of Policy and Institutions on Health Spending.

This paper investigates the impact of policies and institutions on health expenditures for a large panel of Organisation for Economic Co-operation and Development countries for the period of 2000-2010. A set of 20 policy and institutional indicators developed by the Organisation for Economic Co-operation and Development are integrated into a theoretically motivated econometric framework, alongside control variables related to demographic (dependency ratio) and non-demographic (income, prices and technology) drivers of health expenditures per capita. Although a large share of cross-country differences in public health expenditures can be explained by demographic and economic factors (around 71%), cross-country variations in policies and institutions also have a significant influence, explaining most of the remaining difference in public health spending (23%). Copyright © 2016 John Wiley & Sons, Ltd.

Does progress towards universal health coverage improve population health?

Many commentators, including WHO, have advocated progress towards universal health coverage on the grounds that it leads to improvements in population health. In this report we review the most robust cross-country empirical evidence on the links between expansions in coverage and population health outcomes, with a focus on the health effects of extended risk pooling and prepayment as key indicators of progress towards universal coverage across health systems. The evidence suggests that broader health coverage generally leads to better access to necessary care and improved population health, particularly for poor people. However, the available evidence base is limited by data and methodological constraints, and further research is needed to understand better the ways in which the effectiveness of extended health coverage can be maximised, including the effects of factors such as the quality of institutions and governance.

Can competition improve outcomes in UK health care? Lessons from the past two decades.

UK governments of all political colours have sought to improve productivity in health care by introducing pro-competitive reforms in the National Health Service (NHS) during the last two decades. The first wave of reform operated from 1991 to 1997. The second wave was introduced in England only in the mid 2000s. In 2010, further reform in England, intended to increase the extent of competition, was proposed by the Coalition administration. But the effect of competition on productivity in health care and in particular on the quality of health care remains a contested issue. This paper reviews the evidence, focusing on robust and recent evidence, on the use of competition as a mechanism for improving quality. The consensus is that competition will increase quality in health care, but that institutional details matter. Given this, we end by discussing whether the current plans to make the buyers of care family doctors and other professionals and to allow some local price variation are likely to be beneficial in the UK context of full public funding for health care.

System-wide impacts of hospital payment reforms: evidence from Central and Eastern Europe and Central Asia.

While there is broad agreement that the way that health care providers are paid affects their performance, the empirical literature on the impacts of provider payment reforms is surprisingly thin. During the 1990s and early 2000s, many European and Central Asian (ECA) countries shifted from paying hospitals through historical budgets to fee-for-service (FFS) or patient-based payment (PBP) methods (mostly variants of diagnosis-related groups, or DRGs). Using panel data on 28 countries over the period 1990-2004, we exploit the phased shift from historical budgets to explore aggregate impacts on hospital throughput, national health spending, and mortality from causes amenable to medical care. We use a regression version of difference-in-differences (DID) and two variants that relax the DID parallel trends assumption. We find that FFS and PBP both increased national health spending, including private (i.e. out-of-pocket) spending. However, they had different effects on inpatient admissions (FFS increased them; PBP had no effect), and average length of stay (FFS had no effect; PBP reduced it). Of the two methods, only PBP appears to have had any beneficial effect on "amenable mortality", but we found significant impacts for only a couple of causes of death, and not in all model specifications.

Social health insurance and labor market outcomes: evidence from central and eastern Europe, and central Asia.

OBJECTIVE: The implications of social health insurance (SHI) for labor markets have featured prominently in recent debates over the merits of SHI and general revenue financing. It has been argued that by raising the nonwage component of labor costs, SHI reduces firms' demand for labor, lowers employment levels and net wages, and encourages self-employment and informal working arrangements. At the national level, SHI has been claimed to reduce a country's competitiveness in international markets and to discourage foreign direct investment (FDI). The transition from general revenue finance to SHI that occurred during the 1990s in many of the central and eastern European and central Asian countries provides a unique opportunity to investigate empirically these claims. METHODOLOGY/APPROACH: We employ regression-based generalizations of difference-in-differences (DID) and instrumental variables (IV) on country-level panel data from 28 countries for the period 1990-2004. FINDINGS: We find that, controlling for gross domestic product (GDP) per capita, SHI increases (gross) wages by 20%, reduces employment (as a share of the population) by 10%, and increases self-employment by 17%. However, we find no significant effects of SHI on unemployment (registered or self-reported), agricultural employment, a widely used measure of the size of the informal economy, or FDI. IMPLICATIONS FOR POLICY: We do not claim that our results imply that SHI adoption everywhere must necessarily reduce employment and increase self-employment. Nonetheless, our results ought to serve as a warning to those contemplating shifting the financing of health care from general revenues to a SHI system.

Europe and central Asia's great post-communist social health insurance experiment: Aggregate impacts on health sector outcomes.

The post-Communist transition to social health insurance in many of the Central and Eastern European and Central Asian countries provides a unique opportunity to try to answer some of the unresolved issues in the debate over the relative merits of social health insurance and tax-financed health systems. This paper employs regression-based generalizations of the difference-in-differences method on panel data from 28 countries for the period 1990-2004. We find that, controlling for any concurrent provider payment reforms, adoption of social health insurance increased national health spending and hospital activity rates, but did not lead to better health outcomes.