A Tale of Two Social Insurance Systems in South Korea and Taiwan: A Financial Risk Protection Perspective.

Universal Health Coverage (UHC) is a widespread policy goal in the 21st century. The aim is to protect people from financial risk while promoting their access to good-quality care. This study examined the social insurance systems of South Korea and Taiwan to explore the critical challenges of achieving effective UHC. By assessing the impact of UHC on financial risk protection (measured by out-of-pocket payment share and catastrophic payment headcount), we found that when South Korea inaugurated its National Health Insurance (NHI) program with a limited benefits package and high cost sharing, it did not reduce the financial burden. Meanwhile, we observed a drop of 5 to 6 percentage points in the catastrophic payment headcount in Taiwan, which offered a universal and rather comprehensive benefits package with a modest cost-sharing design under its single-payer NHI system. The political-economic context of the UHC policy evolution was further explored through an in-depth discussion. We conclude that to provide sufficient financial risk protection against unexpected medical expenses, the design of the insurance scheme, in particular the risk-sharing mechanism, not only matters but is also the key to success.

How does domestic migration pose a challenge in achieving equitable social health insurance benefits in China? A national cross-sectional study.

OBJECTIVES: To evaluate the benefit distribution of social health insurance among domestic migrants in China. DESIGN: A national cross-sectional survey. SETTING: 348 cities from 32 provincial units in China. PARTICIPANTS: 1165 domestic migrants who used inpatient care services in the city of a new residence and had social health insurance. PRIMARY AND SECONDARY OUTCOME MEASURES: The probability of receiving reimbursements from social health insurance, the amounts and ratio of reimbursement received. RESULTS: Among migrants who used inpatient care in 2013, only 67% received reimbursements from social health insurance, and the reimbursement amount only accounted for 47% of the inpatient care expenditure. The broader the geographical scope of migration, the lower the probability of receiving reimbursement and the reimbursement ratio, but the higher the reimbursement amount. Specifically, the probability of receiving reimbursements for those who migrated across cities or provinces was significantly lower by 14.7% or 26.0%, respectively, than those who migrated within a city. However, they received significantly higher reimbursement amounts by 33.4% or 27.2%, respectively, than those who migrated within a city. And those who migrated across provinces had the lowest reimbursement ratio, although not reaching significance level. CONCLUSIONS: The unequal benefit distribution among domestic migrants may be attributed to the fragmented health insurance design that relies on localised administration, and later reimbursement approach that migrating patients pay for health services up-front and get reimbursement later from health insurance. To improve the equity in social health insurance benefits, China has been promoting the portability of social health insurance, immediate reimbursement for inpatient care used across regions, and a more integrated health insurance system. Efforts should also be made to control inflation of healthcare expenditures and prevent inverse government subsidies from out-migration regions to in-migration regions. This study has policy implications for China and other low/middle-income countries that experience rapid urbanisation and domestic migration.

The Economic Burden of Disease in France From the National Health Insurance Perspective: The Healthcare Expenditures and Conditions Mapping Used to Prepare the French Social Security Funding Act and the Public Health Act.

BACKGROUND: Identifying the most frequently treated and the costliest health conditions is essential for prioritizing actions to improve the resilience of health systems. OBJECTIVES: Healthcare Expenditures and Conditions Mapping describes the annual economic burden of 58 health conditions to prepare the French Social Security Funding Act and the Public Health Act. DESIGN: Annual cross-sectional study (2015-2019) based on the French national health database. SUBJECTS: National health insurance beneficiaries (97% of the French residents). MEASURES: All individual health care expenditures reimbursed by the national health insurance were attributed to 58 health conditions (treated diseases, chronic treatments, and episodes of care) identified by using algorithms based on available medical information (diagnosis coded during hospital stays, long-term diseases, and specific drugs). RESULTS: In 2019, €167.0 billion were reimbursed to 66.3 million people (52% women, median age: 42 y). The most prevalent treated diseases were diabetes (6.0%), chronic respiratory diseases (5.5%), and coronary diseases (3.2%). Coronary diseases accounted for 4.6% of expenditures, neurotic and mood disorders 3.7%, psychotic disorders 2.8%, and breast cancer 2.1%. Between 2015 and 2019, the expenditures increased primarily for diabetes (+€906 million) and neurotic and mood disorders (+€861 million) due to the growing number of patients. "Active lung cancer" (+€797 million) represented the highest relative increase (+54%) due to expenditures for the expensive drugs and medical devices delivered at hospital. CONCLUSIONS: These results have provided policy-makers, evaluators, and public health specialists with key insights into identifying health priorities and a better understanding of trends in health care expenditures in France.

[Integrated Care Protocols, a strategy for chronic diseases]. / Protocolos de Atención Integral, una estrategia para las enfermedades crónicas.

Noncommunicable diseases (NCD) cause more than 41 million deaths each year, equivalent to 71% of all deaths globally. The main types of NCD are: cardiovascular diseases (heart attack or cerebrovascular infarction), diabetes, cancer and chronic respiratory diseases (chronic obstructive pulmonary disease and asthma). In Mexico, NCD are responsible of more than three-quarters of deaths. This supplement describes a novel strategy by the Instituto Mexicano del Seguro Social (IMSS) to confront chronic diseases, known as Integrated Care Protocols, which aim to be a simple and easy-to-interpret reference document, but at the forefront of national and international knowledge, based on scientific evidence and normative documents. In addition, they specify the indispensable, optional actions and those that have to be avoided by the expanded health team. Therefore, this tool will guide our actions according to scientific advances and social needs.

Las enfermedades no transmisibles (ENT) son causa de más de 41 millones de fallecimientos cada año, lo que equivale al 71% de todas las muertes a nivel mundial. Los principales tipos de ENT son: las enfermedades cardiovasculares (infarto cardíaco o cerebrovascular), la diabetes, el cáncer y las enfermedades respiratorias crónicas (enfermedad pulmonar obstructiva crónica y asma). Las ENT constituyen las tres cuartas partes de las muertes ocurridas en México. En este suplemento se describe una novedosa estrategia del Instituto Mexicano del Seguro Social (IMSS) para afrontar a las enfermedades crónicas, conocida como Protocolos de Atención Integral, los cuales tienen como objetivo ser un documento de consulta sencillo y de fácil interpretación, pero a la vanguardia de los conocimientos nacionales e internacionales, con base en la evidencia científica y documentos normativos. Además, especifican las acciones indispensables, opcionales y las que se tienen que evitar por parte del equipo ampliado de salud. Por lo tanto, esta herramienta orientará nuestras acciones conforme a los avances científicos y a las necesidades sociales.

[PRIISMA Project: Transformation into a more preventive, resilient, comprehensive, innovative, sustainable, modern and accessible IMSS]. / Proyecto PRIISMA: transformación hacia un IMSS más preventivo, resiliente, integral, innovador, sostenible, moderno y accesible.

Two years after the onset of the COVID-19 pandemic, the Mexican Institute for Social Security (IMSS, according to its initials in Spanish) rethought new projects focused on the new needs of the population and social security organizations and institutions. The Institute, as a cornerstone in the search for the wellbeing of Mexicans, aligned with the National Development Plan and the Strategic Health for Wellbeing Program, sought to direct its transformation towards a preventive, resilient, comprehensive, innovative, sustainable, modern and accessible IMSS. For this reason, the Medical Services Director designed the PRIISMA Project, as the one that over the next three years could make possible to innovate and improve its medical care processes, starting with the recovery of medical services and identifying those groups of beneficiaries who experience the most vulnerable circumstances. The PRIISMA project consisted of five sub-projects: 1. Vulnerable groups; 2. Efficient and effective care; 3. Prevent IMSS plus; 4 IMSS University and 5. Recovery of medical services. The strategies of each project seek to improve medical care for all IMSS beneficiaries and users with a human rights perspective and by priority groups; the goal is reducing the gaps in access to health care, leaving no one behind and leaving no one out; and to surpass the goals for medical services provided before the pandemic. This document provides an overview of strategies and progress of the PRIISMA sub-projects achieved during 2022.

Después de dos años del inicio de la pandemia por COVID-19, el Instituto Mexicano del Seguro Social (IMSS) se replanteó nuevos proyectos enfocados a las nuevas necesidades de la población y de las organizaciones e instituciones de salud y seguridad social. El Instituto, como piedra angular de la búsqueda del bienestar de las mexicanas y mexicanos, alineado al Plan Nacional de Desarrollo y al Programa Estratégico de Salud para el Bienestar, buscó dirigir su transformación hacia un IMSS más preventivo, resiliente, integral, innovador, sostenible, moderno y accesible. Por ello la Dirección de Prestaciones Médicas diseñó el Proyecto PRIISMA, el cual durante los próximos tres años permitirá innovar y mejorar sus procesos de atención médica, comenzando con la recuperación de los servicios médicos y la identificación de aquellos grupos de derechohabientes que experimentan mayores circunstancias en situación de vulnerabilidad. El Proyecto PRIISMA está constituido por cinco subproyectos: 1) grupos en situación de vulnerabilidad; 2) atención eficiente y eficaz; 3) PrevenIMSS más; 4) Universidad IMSS, y 5) recuperación de servicios médicos. Las estrategias de cada proyecto buscan mejorar la atención médica de todos los derechohabientes y usuarios del IMSS con perspectiva de derechos humanos y por grupos prioritarios; se trata de reducir las brechas para el acceso a la salud sin dejar a nadie atrás y a nadie fuera; además, con ellas se busca superar las metas de atención de servicios médicos otorgados antes de la pandemia. El presente documento da a conocer los porqués, las estrategias y los avances de los subproyectos PRIISMA logrados durante el 2022.

Análisis de los sistemas de salud como sistemas políticos / Analysis of health systems as political systems

La literatura técnica suele presentar los Sistemas de Salud (SS) como conjuntos de recursos médicos destinados a atender enfermedades. Un análisis más amplio del tema permite caracterizar los SS como la expresión de sistemas políticos que surgen y cambian en contextos históricos diferentes, al impulso de las condiciones e intereses predominantes. Los sistemas políticos son los mismos sistemas sociales cuando los valoramos desde la perspectiva de las relaciones de poder que se establecen entre sus integrantes. Desde esta perspectiva los SS, sus agentes, discursos y dispositivos, se revelan como componentes de sistemas políticos que determinan, bajo las apariencias el tipo de gestión que se aplica a la comprensión y cuidado de la salud, y configuran "modelos de respuesta social". Este documento, describe los SS como sistemas políticos, con base en las características de la respuesta social preponderante. Se describen cinco tipologías que pueden coexistir tanto de forma sinérgica como contradictoria reflejando las condiciones e intereses predominantes en el grupo: sistemas populares, de beneficencia, de seguridad social, estatales, y privados. Al final se propone que el análisis de los aspectos formales y técnicos es por sí mismo insuficiente para explicar e intervenir la dinámica de los SS.

Technical literature usually presents Health Systems (HS) as sets of medical resources aimed at treating diseases. A broader analysis of the subject allows us to characterize HS as the expression of political systems, which arise and change in different historical contexts, driven by prevailing conditions and interests. Political systems are the same social systems when we value them from the perspective of the power relations established among their members. From this perspective, HS, their agents, discourses, and devices, are revealed as components of political systems that determine, under appearances, the type of management that people applied to understand and care for their health, and configure "models of social response." In this document, the analysis of HS is based on the characteristics of the prevailing social response. We describe five typologies that can coexist, both synergistically and contradictory, reflecting the prevailing conditions and interests in the group: popular, charity, social security, state, and private systems. In the end, it is proposed that the analysis of the formal and technical aspects is by itself insufficient to explain HS and intervene in their dynamics

Historia de la seguridad social en el Perú: 1936 - 2021 / History of social security in Peru: 1936 - 2021

En estos 200 años de Independencia del Perú, el Seguro Social de Salud ­ EsSalud celebra sus 85 años de gestión institucional, realizando una cobertura de prestaciones de salud, económicas y sociales a más de 11 millones de asegurados, asumiendo un reto difícil y delicado por la actual pandemia que nos ha llevado a replantear nuevas estrategias de gestión y coordinación con otras entidades públicas y privadas, así como fortalecer nuestras buenas prácticas institucionales que nos permitan cumplir el objetivo de servir a nuestros asegurados y a la sociedad peruana. A lo largo de nuestra historia las diferentes gestiones han identificados sus fortalezas, oportunidades, debilidades y amenazas, las cuales han exigido renovar y establecer nuevos mecanismos y políticas institucionales para mejorar y modernizar la seguridad social, como lo fue en su momento la contratación de personal administrativo y asistencial; construcción de hospitales; funcionamiento de escuelas de enfermeras, nutricionistas, laboratoristas; construcción de viviendas; otorgamiento de préstamos hipotecarios; cobertura de prestaciones pensionarias; protección con subsidios; funcionamiento de centros de adulto mayor, rehabilitación profesional y social, medicina complementaria, centros de salud especializados y otros hasta nuestras actuales funciones misionales. Es en este contexto, que nos satisface presentar este resumen de nuestra historia institucional para que la sociedad y las futuras generaciones conozcan de la importancia social que hemos desarrollado a lo largo de éstas décadas, así como para fortalecer nuestra identidad institucional en nuestros asegurados, funcionarios, servidores y personal de apoyo que día a día escriben la historia de la seguridad social en el Perú

Impacto del COVID-19 en el Sistema Nacional Integrado de Salud / Impact of COVID-19 on the National Integrated Health System

El presente artículo intenta realizar una aproximación a la situación del Sistema Nacional Integrado de Salud (en adelante SNIS) en el contexto actual de pandemia, con el objetivo de reflexionar sobre la importancia de mantener y proteger el equilibrio de un sistema que será vital para superar los efectos negativos del COVID-19 en la salud de la población.

The effects of expanded social health insurance on young mothers: Lessons from a pro-choice reform in Uruguay.

With the implementation of the National Integrated Health System in 2007, the Uruguayan government extended social health insurance (SHI) to groups of individuals previously covered by the public safety net (PSN) or that paid for private insurance out-of-pocket. The policy allowed new beneficiaries to choose care from a set of private providers. In this study, we focus on the extension of SHI to adolescent mothers previously covered by the PSN. Exploiting the gradual incorporation of children of formal workers during the 2008-2013 period, and the geographic variation in the intensity of the reform, we find suggestive evidence that the increase in choice associated to the expansion of SHI decreased adolescent fertility, improved prenatal care and birthweight, and decreased first year mortality among low birthweight infants. These effects were only observed in the medium run, suggesting initial choice frictions and input shortage. We provide evidence that families increased their choice of private providers and that market concentration decreased in certain areas of the country, supporting the hypothesis that choice, and possibly competition, were the main mechanisms behind the findings.

Historia de la medicina complementaria en el seguro social de salud del Perú / History of complementary medicine in the social health insurance of Peru

La historia de la Medicina Complementaria en el Seguro Social de Salud comenzó con el IMET, pero siguió avanzando. En 1994, en una evaluación realizada por la Gerencia de Recursos Médicos de la Gerencia Central de Prestaciones de Salud, se realizó un análisis del consumo de medicamentos, determinando que los medicamentos de mayor consumo eran los antiinflamatorios, los analgésicos, los antihipertensivos y los ansiolíticos, esto condujo a que se planteara la necesidad de buscar otras formas de ayudar al paciente a mejorar sus niveles de salud. Dicha inquietud dio lugar a la realización de una experiencia piloto en uno de los Policlínicos del Seguro Social de Salud, ubicado en el Callao ­ Lima.

Medicina Tradicional y Complementaria en el contexto colombiano: una breve mirada / Traditional and Complementary Medicine in the Colombian context: a brief look

Este capítulo presenta un breve contexto de la Medicina Complementaria (MTAC ­ Medicina y Terapias Alternativas y Complementarias como actualmente se denomina en Colombia), y la Medicina Tradicional- Ancestral (MT-A) de los grupos étnicos que habitan en el país (pueblos indígenas, pueblo ROM gitano, comunidades afrocolombianas, raizales y palenquera). El contexto incluye información referente a los antecedentes históricos, la normativa, la situación actual, y menciona elementos del marco académico e investigativo de la MT-A y la MTAC. Aunque en el Sistema General de Seguridad Social en Salud (SGSSS) colombiano prima el enfoque convencional de atención en salud (medicina alopática, facultativa u occidental), los saberes en salud propios de grupos étnicos, así como las Medicinas Complementarias, y Alternativas también se contemplan como parte del sistema. La Ley 1438 de 2011, en su capítulo III "Para la implementación de la Atención Primaria en Salud (APS) en el marco del Sistema General de Seguridad Social en Salud", menciona dentro de sus elementos la "Interculturalidad, que incluye entre otros, los elementos de prácticas tradicionales, alternativas y complementarias para la atención en salud". Sin embargo, se hace una distinción y legislación diferencial entre ellas. Mientras que, la Medicina Tradicional o Ancestral, MT-A, hace referencia a la medicina de los grupos étnicos de Colombia (Rom Gitanos, Pueblos Indígenas y comunidades Negras, Afrocolombianas, Raizales y Palenqueras), las Medicinas y Terapias Alternativas y Complementarias- MTAC son definidas como "aquellas técnicas, prácticas, procedimientos, enfoques o conocimientos que utilizan la estimulación del funcionamiento de las leyes naturales para la autorregulación del ser humano con el objeto de promover, prevenir, tratar y rehabilitar la salud de la población desde un pensamiento holístico". Cabe aclarar que las medicinas tradicionales de otros países, como la MT China y la MT Ayurveda, se incluyen dentro de las MTAC y no como MT-A, puesto que no son propias de los grupos étnicos del país. Dados estos planteamientos, en este capítulo se presentarán algunos aspectos históricos y legislativos, así como el contexto actual de manera separada para las MTAC, y para las MT-A.

Ethnic disparities in receiving benefits for disability following postpartum mental illness during first two years after delivery: an Israeli nationwide study.

BACKGROUND: Despite relatively high rates of Postpartum Depression (PPD), little is known about the granting of social security benefits to women who are disabled as a result of PPD or of other postpartum mood and anxiety disorders (PMAD). This study aims to identify populations at risk for underutilization of social security benefits due to PMAD among Israeli women, with a focus on ethnic minorities. METHODS: This retrospective cohort study is based on the National Insurance Institute (NII) database. The study population included a simple 10% random sample of 79,391 female Israeli citizens who gave birth during 2008-2016 (these women delivered a total of 143,871 infants during the study period), and who had not been eligible for NII mental health disability benefits before 2008. The dependent variable was receipt of Benefit Entitlement (BE) due to mental illness within 2 years following childbirth. Maternal age at delivery, population group, Socio-Economic Status (SES), family status, employment status of the mother and her spouse, and infant mortality were the independent variables. Left truncation COX proportional hazard model with time-dependent variables was used, and birth number served as a time discrete variable. RESULTS: Bedouin and Arab women had significantly lower likelihood of BE (2.6 times lower and twice lower) compared with other ethnic groups (HR = 0.38; 95% CI: 0.26-0.56; HR = 0.47; 95% CI: 0.37-0.60 respectively). The probability of divorced or widowed women for BE was significantly higher compared to those living with a spouse (HR = 3.64; 95% CI: 2.49-5.33). Lack of employment was associated with higher likelihood of BE (HR = 1.54; 95% CI: 1.30-1.82). Income had a dose-response relationship with BE in multivariable analysis: lower income was associated with the nearly four-fold greater probability compared to the highest income quartile (HR = 3.83; 95% CI: 2.89-5.07). CONCLUSIONS: Despite the exceptionally high prevalence of PMAD among ethnic minorities, Bedouins and Arabs had lowest likelihood of Benefit Entitlement. In addition to developing programs for early identification of postpartum emotional disorders among unprivileged ethnic groups, awareness regarding entitlement to a mental health disability allowance among ethnic minorities should be improved.

Mexico: Health System Review.

This analysis of the Mexican health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Mexican health system consists of three main components operating in parallel: 1) employment-based social insurance schemes, 2) public assistance services for the uninsured supported by a financial protection scheme, and 3) a private sector composed of service providers, insurers, and pharmaceutical and medical device manufacturers and distributors. The social insurance schemes are managed by highly centralized national institutions while coverage for the uninsured is operated by both state and federal authorities and providers. The largest social insurance institution - the Mexican Social Insurance Institute (IMSS) - is governed by a corporatist arrangement, which reflects the political realities of the 1940s rather than the needs of the 21st century. National health spending has grown in recent years but is lower than the Latin America and Caribbean average and considerably lower than the OECD average in 2015. Public spending accounts for 58% of total financing, with private contributions being mostly comprised of out-of-pocket spending. The private sector, while regulated by the government, mostly operates independently. Mexico's health system delivers a wide range of health care services; however, nearly 14% of the population lacks financial protection, while the insured are mostly enrolled in diverse public schemes which provide varying benefits packages. Private sector services are in high demand given insufficient resources among most public institutions and the lack of voice by the insured to ensure the fulfilment of entitlements. Furthermore, the system faces challenges with obesity, diabetes, violence, as well as with health inequity. Recognizing the inequities in access created by its segmented structure, both civil society and government are calling for greater integration of service delivery across public institutions, although no consensus yet exists as to how to bring this about.

La enfermedad renal crónica de causa no tradicional (ERCnT): una visión desde la protección social y la economía preventiva / Chronic kidney disease of unknown cause (CKDu): A vision from social protection and preventive economy

La presente es una ponencia presentada durante la realización del Seminario de Enfermedad Renal Crónica no Tradicional, celebrado en ciudad de Guatemala en junio de 2019. El mismo busca el enfoque de tal enfermedad desde una perspectiva económica de costos, y previsión en la seguridad social, buscando el ahorro de prestaciones pecuniarias en materia de discapacidad para los trabajadores de arduas tareas agrícolas estacionales, principalmente en la costa sur. El enfoque se efectúa desde el ámbito de la Economía Preventiva, y las experiencias en costos sociales del autor, concluyendo que tal enfermedad se encuentra en ascenso y amerita de políticas de salud curativa y preventiva, para impedir la discapacidad de trabajadores agrícolas muy jóvenes, quienes gracias a una resolución especial de la Junta Directiva del Instituto Guatemalteco de Seguridad Social (Igss), son cubiertos.

This paper is based on a lecture given at the Seminar on Chronis Kidney Disease of Unknown Cause, celebrated in Guatemala City, in June 2019. The focus is placed on the perspective of the preventive economy framework and the discipline of social and economic costs, this time associated with heat stress of labor in agricultural activities, and the measures taken by the Social Security Institute of Guatemala, aiming to protect the seasonal workers. The critic nature of the analysis allows to present some recommendations for the future of the social protection policies in Guatemala.

Breve historia de la Caja Nacional de Seguro Social - CNSS (1936-1973) / Brief history of the National Social Security Fund - CNSS (1936-1973)

El Seguro Social de Salud ­ EsSalud cumple ochenta y tres años de historia institucional de la cual formamos parte todos nosotros, gestionando los recursos e información para brindar cobertura de prestaciones económicas, sociales y salud a más de diez millones de asegurados y sus derecho-habientes a nivel nacional. En esta oportunidad presentamos un resumen de la historia de la Caja Nacional de Seguro Social. Aquella que se ha venido desarrollando, fortaleciendo y reorganizando con el fin de estar a la vanguardia en el registro y afiliación de los asegurados, recaudando las aportaciones necesarias para brindar los diversos pagos de subsidios, préstamos hipotecarios y pago de pensiones de acuerdo a ley, y contando con una adecuada infraestructura, equipamiento, medicinas y capital humano, para alcanzar los objetivos y metas en favor de nuestros asegurados

Impact of frailty status on the cost of drugs and dietary supplements prescribed to nursing home residents: the SENIOR cohort.

BACKGROUND: The financial impact associated with drug consumption has been poorly investigated among frail subjects and, specifically, in nursing home settings. AIMS: To determine the association of the average monthly cost of the drugs and dietary supplements consumed by nursing home residents with their frailty status. METHODS: This is an analysis of the first follow-up year of the SENIOR cohort. All participants were classified into "frail" or "non-frail" categories according to Fried's criteria at baseline. Monthly bills from the pharmacy were analysed to determine the association between the average monthly cost of the drugs and dietary supplements consumed and frailty status. RESULTS: A sample of 87 residents (83.8 ± 9.33 years and 75.9% women) from the SENIOR cohort was included. The prevalence of frailty was 28%. The median number of medications consumed each day was 9 (6-12) (no difference between frail and non-frail subjects; p = 0.15). The overall median monthly cost was € 109.6, of which 49% was covered by Belgian social security and the remaining balance was paid by the patient. When comparing the drug expenses of the frail subjects and the non-frail subjects, the overall average monthly cost did not differ between the 2 groups (p = 0.057). Nevertheless, the expenditure remaining to be paid by the residents, after the Belgian social security intervention, was significantly higher among the frail residents (€ 65.7) than among the non-frail residents (€ 47.6; p = 0.017). CONCLUSIONS: Frailty status has an impact on the expenditures related to the consumption of drugs.

Cardiac rehabilitation availability and delivery in Europe: How does it differ by region and compare with other high-income countries?: Endorsed by the European Association of Preventive Cardiology.

AIMS: The aims of this study were to establish cardiac rehabilitation availability and density, as well as the nature of programmes, and to compare these by European region (geoscheme) and with other high-income countries. METHODS: A survey was administered to cardiac rehabilitation programmes globally. Cardiac associations were engaged to facilitate programme identification. Density was computed using global burden of disease study ischaemic heart disease incidence estimates. Four high-income countries were selected for comparison (N = 790 programmes) to European data, and multilevel analyses were performed. RESULTS: Cardiac rehabilitation was available in 40/44 (90.9%) European countries. Data were collected in 37 (94.8% country response rate). A total of 455/1538 (29.6% response rate) programme respondents initiated the survey. Programme volumes (median 300) were greatest in western European countries, but overall were higher than in other high-income countries (P < 0.001). Across all Europe, there was on average only 1 CR spot per 7 IHD patients, with an unmet regional need of 3,449,460 spots annually. Most programmes were funded by social security (n = 25, 59.5%; with significant regional variation, P < 0.001), but in 72 (16.0%) patients paid some or all of the programme costs (or ∼18.5% of the ∼€150.0/programme) out of pocket. Guideline-indicated conditions were accepted in 70% or more of programmes (lower for stable coronary disease), with no regional variation. Programmes had a multidisciplinary team of 6.5 ± 3.0 staff (number and type varied regionally; and European programmes had more staff than other high-income countries), offering 8.5 ± 1.5/10 core components (consistent with other high-income countries) over 24.8 ± 26.0 hours (regional differences, P < 0.05). CONCLUSION: European cardiac rehabilitation capacity must be augmented. Where available, services were consistent with guidelines, but varied regionally.

[Formation of quality of counselling in nursing : Development and testing of a causal model for care counselling according to § 7a SGB XI]. / Entstehung von Beratungsqualität in der Pflege : Entwicklung und Testung eines Kausalmodells für die Pflegeberatung nach § 7a SGB XI.

At present, the question of what quality of counselling means is very open. This is particularly reflected in the lack of a widely accepted catalogue of criteria. For evaluations and further developments of corresponding advisory services, this represents an essential issue. In this article a causal-theoretical model for quality in care counselling is developed and tested based on empirical data collected by compass private pflegeberatung (care consultants). The results lead to implications for the legally formulated evaluation order according to § 7a of the Social Security Code XI (SGB XI).

Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study.

BACKGROUND: Small private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers' ability to serve poorer patient populations with quality health services? METHODS: In-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials' experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically. RESULTS: Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers' abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility. CONCLUSIONS: Our data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing.