Equity in out-of-pocket health expenditure: Evidence from a health insurance program reform in Mexico.

Background: The fragmentation of health systems in low- and middle-income countries (LMICs) deepens health inequities and shifts the economic burden of health care to families via out-of-pocket spending (OOPHE). This problem has been addressed by introducing public health insurance programs for poor people; however, there is a lack of knowledge about how equitable these programs are. We aimed to analyse the long-term effects of the Seguro Popular (SP) voluntary health insurance program, recently phased out and replaced by the Health Institute for Welfare (Instituto de Salud para el Bienestar (INSABI)), on OOPHE equity in the poor Mexican population. Methods: We conducted a pooled cross-sectional analysis using eleven waves of the National Household Income and Expenditure Survey (2002-2020). We identified the effect of SP by selecting households without social security (with SP or without health insurance (n = 169 766)) and matched them by propensity score to reduce bias in the decision to enrol in SP. We estimated horizontal and vertical equity metrics and assessed their evolution across subpopulations. Results: The program's entry years (2003-2010) show a positive redistributive effect associated with a focalised stage of the program, while oversaturation could have diluted these effects during 2010-2014, with adverse results in terms of vertical equity and re-ranking among insured families. SP is more horizontally inequitable than for those uninsured. Within SP, the redistributive effect could improve up to 13% if all families with similar expenditures were spending equal OOPHE and horizontal equity was eliminated. Regarding vertical equity, SP outperforms the insured population with middle-range coverage some years after the implementation, but this progress disappears. Conclusions: To achieve universal health coverage, health authorities need to create and execute financial protection mechanisms that effectively address structural inequalities. This involves implementing a more comprehensive risk-pooling mechanism that makes social insurance sustainable in the long-run by increasing the social-economic influx of resources. It is essential to monitor oversaturation and financial sustainability to achieve optimal results. The replacement of the SP with INSABI highlights the complexity of maintaining a social insurance program where the ideology of different governments can influence the program structure, regulation, financing, and even its existence.

Intergenerational Replication of Teenage Pregnancy and Educational Attainment in Mexico.

Mexico ranks among the OECD countries with the highest prevalence of teenage pregnancies, exhibiting a fertility rate of 70.6 births for every 1000 adolescents. Mexican adolescents with a history of pregnancy are twice as likely to lag behind in their studies as those who have not been pregnant. Research on adolescent maternity and its explanatory mechanisms is required as a basis for implementing policies and programs that effectively curb teenage pregnancy-related behaviors, prevent educational gaps, and reduce the intergenerational transmission of poverty. Based on quasi-experimental methodology and a non-recursive structural equation model with instrumental variables, this paper analyzed the intergenerational transmission of teenage pregnancy from mothers to daughters, as well as the relationship between teenage pregnancy and educational attainment. Using data from the 2009 National Survey of Demographic Dynamics in Mexico, our estimated model indicated a unidirectional relationship from teenage pregnancy to educational attainment. An association was observed between teenage pregnancy and an increased probability of a moderate or severe educational gap (≥ 1 year) by 21% ± 5 and a severe educational gap (≥ 2 years) by 33% ± 8. Adolescents whose mothers reported teenage pregnancy at < 15 years of age were approximately 84% more likely to experience teenage pregnancy themselves than other adolescents. Relevant explanatory mechanisms included low socioeconomic status and a low level of education in the household. Mexico needs to formulate, implement, and expand comprehensive and early prevention strategies as well as teenage pregnancy care throughout its most vulnerable regions. Efforts should be made at the individual, family, and community levels; incorporate alliances with teenage networks; actively engage parents, teachers, and health care providers; and reinforce educational initiatives on sexual and reproductive health for adolescents. It would be convenient for the Government to implement public policies that emphasize the results obtained. There is no better instrument than to show the evidence of the gradual deterioration of human capital in Mexico associated with adolescent pregnancy.

Incorporating respondent-driven sampling into web-based discrete choice experiments: preferences for COVID-19 mitigation measures.

To slow the spread of COVID-19, most countries implemented stay-at-home orders, social distancing, and other nonpharmaceutical mitigation strategies. To understand individual preferences for mitigation strategies, we piloted a web-based Respondent Driven Sampling (RDS) approach to recruit participants from four universities in three countries to complete a computer-based Discrete Choice Experiment (DCE). Use of these methods, in combination, can serve to increase the external validity of a study by enabling recruitment of populations underrepresented in sampling frames, thus allowing preference results to be more generalizable to targeted subpopulations. A total of 99 students or staff members were invited to complete the survey, of which 72% started the survey (n = 71). Sixty-three participants (89% of starters) completed all tasks in the DCE. A rank-ordered mixed logit model was used to estimate preferences for COVID-19 nonpharmaceutical mitigation strategies. The model estimates indicated that participants preferred mitigation strategies that resulted in lower COVID-19 risk (i.e. sheltering-in-place more days a week), financial compensation from the government, fewer health (mental and physical) problems, and fewer financial problems. The high response rate and survey engagement provide proof of concept that RDS and DCE can be implemented as web-based applications, with the potential for scale up to produce nationally-representative preference estimates.

Preferences for Conditional Economic Incentives to Improve Pre-exposure Prophylaxis Adherence: A Discrete Choice Experiment Among Male Sex Workers in Mexico.

Pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV but requires sustained adherence. Conditional economic incentives (CEIs) can improve medication-taking behaviors, yet preferences for programs that employ CEIs to increase PrEP use among male sex workers (MSWs) have not been investigated. We conducted a discrete choice experiment in Mexico City to elicit stated preferences for a CEI-based PrEP adherence program among MSWs. Respondents expressed their preferences for different program characteristics: incentive amount; incentive format; incentive type; and adherence-verification method. We used a random utility logit model to estimate the relative importance of each attribute and estimated willingness-to-pay. MSWs preferred a higher, fixed incentive, with PrEP adherence measured via hair sampling. MSWs were willing to forego up to 21% of their potential maximum CEI amount to ensure receipt of a fixed payment. MSWs are highly willing to accept a CEI-based intervention for PrEP adherence, if offered along with fixed payments.

RESUMEN: La profilaxis previa a la exposición (PrEP) es muy eficaz para prevenir el VIH, pero requiere una adherencia sostenida. Los incentivos económicos condicionales (IEC) pueden mejorar los comportamientos de toma de medicamentos, sin embargo, no se han investigado las preferencias por los programas que emplean IEC para aumentar el uso de PrEP entre los trabajadores sexuales masculinos (TSM). Realizamos un experimento de elección discreta con TSM en la Ciudad de México para obtener preferencias declaradas para un programa de adherencia a la PrEP basado en IEC. Los participantes expresaron sus preferencias en cuanto a diferentes características: monto del incentivo; formato del incentivo; tipo de incentivo; y método de verificación de la adherencia. Utilizamos un modelo logit de utilidad aleatoria para estimar la importancia relativa de cada atributo y la disposición a pagar estimada (DAP). Los TSM prefirieron un incentivo fijo más alto, con la adherencia a la PrEP medida a través de muestras de cabello. Los TSM estaban dispuestos a renunciar hasta el 21% de su monto máximo potencial de IEC para garantizar la recepción de un pago fijo. Los TSM están muy dispuestos a aceptar una intervención basada en IEC para la adherencia a la PrEP, si se ofrece junto con pagos fijos.

Barriers and facilitators to pre-exposure prophylaxis uptake among male sex workers in Mexico: an application of the RE-AIM framework.

BACKGROUND: The ImPrEP México demonstration project is the first to distribute free HIV pre-exposure prophylaxis (PrEP) to men who have sex with men (MSM) and transgender women living in Mexico. In Mexico City, MSM who are also male sex workers (MSWs) face a disproportionately high risk of HIV infection. PrEP is highly effective for HIV prevention, yet "real-life" implementation among MSWs is a challenge due to the unique adherence barriers faced by this population. METHODS: This study uses the RE-AIM implementation science framework to characterize the unique barriers to and facilitators of PrEP uptake among MSWs in Mexico City. We conducted 9 in-depth key informant interviews and 2 focus group discussions with MSWs across 5 clinic and community sites. Qualitative data were analyzed using inductive, open coding approaches from grounded theory. We supplemented findings from the primary qualitative analysis with quantitative indicators derived from ImPrEP program records to describe the current Reach of the ImPrEP program among MSWs in Mexico City and the potential for wider PrEP Adoption among other high-risk populations in Mexico. RESULTS: The Reach of the ImPrEP program was 10% of known HIV-negative MSWs in Mexico City. Program Reach was lowest among MSWs who were street-based sex workers, of lower socioeconomic status, migrants from other states and self-identified as heterosexual. Barriers to program Reach included limited PrEP knowledge, HIV-related stigma, and structural barriers; facilitators included in-person program recruitment, patient-centered care, and spread of information through word of mouth among MSWs. Two out of the four eligible institutions had adopted the ImPrEP protocol. Barriers to wider program Adoption included HIV- and sexual identity- related stigma, protocol limitations, and lack of a national policy for PrEP distribution; facilitators of Adoption included existing healthcare infrastructure, sensitized providers, and community support from non-governmental organizations. CONCLUSIONS: Increasing the ImPrEP program's Reach among MSWs will depend on improving PrEP education and addressing HIV-related stigma and access barriers. Future Adoption of the ImPrEP program should build on existing clinical infrastructure and community support. Creation of a national policy for PrEP distribution may improve the Reach and Adoption of PrEP among highest-risk populations in Mexico.

Diabetes mellitus as a risk factor for SARS-CoV-2 test positivity in Mexico: A propensity score matched study.

AIMS: We sought to investigate whether individuals with diabetes have a higher likelihood of testing positive for SARS-CoV-2, as a proxy for infection risk, than individuals without diabetes. METHODS: We conducted a cross-sectional study of publicly available data among a Mexican population, totaling 2,314,022 adults ≥ 18 years who underwent SARS-CoV-2 testing between March 1 and December 20, 2020. We used 1:1 nearest neighborhood propensity score matching by diabetes status to account for confounding among those with and without diabetes. RESULTS: In the overall study population, 1,057,779 (45.7%) individuals tested positive for SARS-CoV-2 and 270,486 (11.7%) self-reported diabetes. After propensity score matching, patient characteristics were well-balanced, with 150,487 patients in the diabetes group (mean [SD] age 55.9 [12.7] years; 51.3% women) and 150,487 patients in the no diabetes group (55.5 [13.3] years; 50.3% women). The strictest matching algorithm (1:1 nearest neighbor) showed that compared to individuals without diabetes, having diabetes was associated with 9.0% higher odds of having a positive SARS-CoV-2 test (OR 1.09 [95% CI: 1.08-1.10]). CONCLUSIONS: Presence of diabetes was associated with higher odds of testing positive for SARS-CoV-2, which could have important implications for risk mitigation efforts for people with diabetes at risk of SARS-CoV-2 infection.

Assessing the continuum of care for maternal health in Mexico, 1994-2018.

OBJECTIVE: To describe the temporal and geographical patterns of the continuum of maternal health care in Mexico, as well as the sociodemographic characteristics that affect the likelihood of receiving this care. METHODS: We conducted a pooled cross-sectional analysis using the 1997, 2009, 2014 and 2018 waves of the National Survey of Demographic Dynamics, collating sociodemographic and obstetric characteristics of 93 745 women aged 12-54 years at last delivery. We defined eight variables along the antenatal-postnatal continuum, both independently and conditionally. We used a pooled fixed-effects multivariable logistic model to determine the likelihood of receiving the continuum of care for various properties. We also mapped the quintiles of adjusted state-level absolute change in continuum of care coverage during 1994-2018. FINDINGS: We observed large absolute increases in the proportion of women receiving timely antenatal and postnatal care (from 48.9% to 88.2% and from 39.1% to 68.7%, respectively). In our conditional analysis, we found that the proportion of women receiving adequate antenatal care doubled over this period. We showed that having social security and a higher level of education is positively associated with receiving the continuum of care. We observed the largest relative increases in continuum of care coverage in Chiapas (181.5%) and Durango (160.6%), assigned human development index categories of low and medium, respectively. CONCLUSION: Despite significant progress in coverage of the continuum of maternal health care, disparities remain. While ensuring progress towards achievement of the health-related sustainable development goal, government intervention must also target underserved populations.

Efficiency, quality, and management practices in health facilities providing outpatient HIV services in Kenya, Nigeria, Rwanda, South Africa and Zambia.

Few studies have assessed the efficiency and quality of HIV services in low-resource settings or considered the factors that determine both performance dimensions. To provide insights on the performance of outpatient HIV prevention units, we used benchmarking methods to identify best-practices in terms of technical efficiency and process quality and uncover management practices with the potential to improve efficiency and quality. We used data collected in 338 facilities in Kenya, Nigeria, Rwanda, South Africa, and Zambia. Data envelopment analysis (DEA) was used to estimate technical efficiency. Process quality was estimated using data from medical vignettes. We mapped the relationship between efficiency and quality scores and studied the managerial determinants of best performance in terms of both efficiency and quality. We also explored the relationship between management factors and efficiency and quality independently. We found levels of both technical efficiency and process quality to be low, though there was substantial variation across countries. One third of facilities were mapped in the best-performing group with above-median efficiency and above-median quality. Several management practices were associated with best performance in terms of both efficiency and quality. When considering efficiency and quality independently, the patterns of associations between management practices and the two performance dimensions were not necessarily the same. One management characteristic was associated with best performance in terms of efficiency and quality and also positively associated with efficiency and quality independently: number of supervision visits to HIV units.

Incidence and time-varying predictors of HIV and sexually transmitted infections among male sex workers in Mexico City.

BACKGROUND: Male sex workers are at high-risk for acquisition of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). We quantified incidence rates of STIs and identified their time-varying predictors among male sex workers in Mexico City. METHODS: From January 2012 to May 2014, male sex workers recruited from the largest HIV clinic and community sites in Mexico City were tested for chlamydia, gonorrhea, syphilis, hepatitis, and HIV at baseline, 6-months, and 12-months. Incidence rates with 95% bootstrapped confidence limits were calculated. We examined potential time-varying predictors using generalized estimating equations for a population averaged model. RESULTS: Among 227 male sex workers, median age was 24 and baseline HIV prevalence was 32%. Incidence rates (per 100 person-years) were as follows: HIV [5.23; 95% confidence interval (CI): 2.15-10.31], chlamydia (5.15; 95% CI: 2.58-9.34), gonorrhea (3.93; 95% CI: 1.88-7.83), syphilis (13.04; 95% CI: 8.24-19.94), hepatitis B (2.11; 95% CI: 0.53-4.89), hepatitis C (0.95; 95% CI: 0.00-3.16), any STI except HIV (30.99; 95% CI: 21.73-40.26), and any STI including HIV (50.08; 95% CI: 37.60-62.55). In the multivariable-adjusted model, incident STI (excluding HIV) were lower among those who reported consistently using condoms during anal and vaginal intercourse (odds ratio = 0.03, 95% CI: 0.00-0.68) compared to those who reported inconsistently using condoms during anal and vaginal intercourse. CONCLUSIONS: Incidence of STIs is high among male sex workers in Mexico City. Consistent condom use is an important protective factor for STIs, and should be an important component of interventions to prevent incident infections.

Incremental Risk of Developing Severe COVID-19 Among Mexican Patients With Diabetes Attributed to Social and Health Care Access Disadvantages.

OBJECTIVE: Diabetes is an important risk factor for severe coronavirus disease 2019 (COVID-19), but little is known about the marginal effect of additional risk factors for severe COVID-19 among individuals with diabetes. We tested the hypothesis that sociodemographic, access to health care, and presentation to care characteristics among individuals with diabetes in Mexico confer an additional risk of hospitalization with COVID-19. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study using public data from the General Directorate of Epidemiology of the Mexican Ministry of Health. We included individuals with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 between 1 March and 31 July 2020. The primary outcome was the predicted probability of hospitalization, inclusive of 8.5% of patients who required intensive care unit admission. RESULTS: Among 373,963 adults with COVID-19, 16.1% (95% CI 16.0-16.3) self-reported diabetes. The predicted probability of hospitalization was 38.4% (37.6-39.2) for patients with diabetes only and 42.9% (42.2-43.7) for patients with diabetes and one or more comorbidities (obesity, hypertension, cardiovascular disease, and chronic kidney disease). High municipality-level of social deprivation and low state-level health care resources were associated with a 9.5% (6.3-12.7) and 17.5% (14.5-20.4) increased probability of hospitalization among patients with diabetes, respectively. In age-, sex-, and comorbidity-adjusted models, living in a context of high social vulnerability and low health care resources was associated with the highest predicted probability of hospitalization. CONCLUSIONS: Social vulnerability contributes considerably to the probability of hospitalization among individuals with COVID-19 and diabetes with associated comorbidities. These findings can inform mitigation strategies for populations at the highest risk of severe COVID-19.

Conditional economic incentives to improve HIV prevention and treatment in low-income and middle-income countries.

New and innovative approaches are needed to improve the prevention, diagnosis, and treatment of HIV in low-income and middle-income countries. Several trials use conditional economic incentives (CEIs) to improve HIV outcomes. Most CEI interventions use a traditional economic theory approach, although some interventions incorporate behavioural economics, which combines traditional economics with insights from psychology. Incentive interventions that are appropriately implemented can increase HIV testing rates and voluntary male circumcision, and they can improve other HIV prevention and treatment outcomes in certain settings in the short term. More research is needed to uncover theory-based mechanisms that increase the duration of incentive effects and provide strategies for susceptible individuals, which will help to address common constraints and biases that can influence health-related decisions.

The relationship between management practices and the efficiency and quality of voluntary medical male circumcision services in four African countries.

INTRODUCTION: Given constrained funding for Human Immunodeficiency Virus (HIV) programs across Sub-Saharan Africa, delivering services efficiently is paramount. Voluntary medical male circumcision (VMMC) is a key intervention that can substantially reduce heterosexual transmission-the primary mode of transmission across the continent. There is limited research, however, on what factors may contribute to the efficient and high-quality execution of such programs. METHODS: We analyzed a multi-country, multi-stage random sample of 108 health facilities providing VMMC services in sub-Saharan Africa in 2012 and 2013. The survey collected information on inputs, outputs, process quality and management practices from facilities providing VMMC services. We analyzed the relationship between management practices, quality (measured through provider vignettes) and efficiency (estimated through data envelopment analysis) using Generalized Linear Models and Mixed-effects Models. Applying multivariate regression models, we assessed the relationship between management indices and efficiency and quality of VMMC services. RESULTS: Across countries, both efficiency and quality varied widely. After adjusting for type of facility, country and scale, performance-base funding was negatively correlated with efficiency -0.156 (p < 0.05). In our analysis, we did not find any significant relationships between quality and management practices. CONCLUSIONS: No significant relationship was found between process quality and management practices across 108 VMMC facilities. This study is the first to analyze the potential relationships between management and service quality and efficiency among a sample of VMMC health facilities in sub-Saharan Africa and can potentially inform policy-relevant hypotheses to later test through prospective experimental studies.

Short-term health and economic burden of gestational diabetes mellitus in Mexico: A modeling study.

AIM: To estimate the annual burden of gestational diabetes mellitus (GDM) in Mexico. METHODS: A model was built to conduct estimates from a healthcare system perspective, namely, the incremental costs of GDM pregnancy compared with non-GDM pregnancy from the first trimester until childbirth. The model used probabilities from the literature and surveys, and costs obtained from the Ministry of Health and national healthcare institutions. Scenario analyses were performed to estimate the GDM burden at different levels of incidence. RESULTS: Although a non-GDM pregnancy cost on average USD 1880.6 (low risk was USD 1043.9 and high risk was USD 1673.5), a pregnancy with GDM cost USD 2934.9. Therefore, the total additional cost was USD 1576.2 per case. Given the considerable variability of the GDM incidence in Mexico, the total burden could range from USD 86.8 to USD 827.4 million per year. CONCLUSIONS: GDM is one of the most frequent complications of pregnancy, but research has been insufficient regarding its epidemiological and economic burden in Latin America. This paper shows that the GDM economic burden in Mexico is substantial despite only accounting for short-term medical costs. Further research to assess the GDM incidence and evaluate its long-term consequences from a broader societal perspective in Mexico is recommended.

Improving the effective maternal-child health care coverage through synergies between supply and demand-side interventions: evidence from Mexico.

BACKGROUND: Over the last two decades, the Mexican government has released several efforts to achieve universal health coverage (UHC), based on the principles of fairness and social protection, to reduce the inequities in utilization, access, and quality of care existing in the health system. Two of the most important social public policies that have targeted the population without access to social security include the 1997 conditional cash transfers (CCT) program known as Prospera (formerly Oportunidades or Progresa) and the Seguro Popular de Salud (SPS by its Spanish initials), launched in 2003. These two programs, so far, have survived changes in the federal administrations being the most longstanding social programs targeting poor (or unprotected) populations ever in the history of modern Mexico. We tested the existence of positive synergies between demand-side (or CCT-Prospera) and supply-side (or Seguro Popular de Salud, SPS) social programs in the achievement of effective coverage (EC) of maternal-child health interventions in Mexico. METHODS: We performed a retrospective-cohort analysis to 6413 women aged 12-49 years who participated in a probabilistic survey conducted in 2012. We calculated EC as the product of three indexes: need, utilization and quality of health care. Correlates of EC were identified estimating a logistic regression model. We also presented adjusted EC by specific women groups. RESULTS: EC among beneficiaries of both programs was similar to estimates in Social Security affiliates (54%). For those not affiliated to any of the programs or those who received benefits for only one of them, the EC was 47.6% and 45.5% respectively. Adjusted estimates of EC suggest that overall, having both programs (Prospera + SPS) has a positive effect on maternal and child care coverage, which makes the observed differences in EC not statistically significant between those affiliated to both programs in comparison with the observed in the population with social security. CONCLUSIONS: Results support positive synergies between Prospera and SPS in the reduction of the gaps in EC. The most vulnerable population groups need to be reached by the combination of these programs so that public health efforts translate into greater EC of maternal health services and better maternal-child outcomes.

Influence of supply-side factors on voluntary medical male circumcision costs in Kenya, Rwanda, South Africa, and Zambia.

BACKGROUND: In this study, we described facility-level voluntary medical male circumcision (VMMC) unit cost, examined unit cost variation across facilities, and investigated key facility characteristics associated with unit cost variation. METHODS: We used data from 107 facilities in Kenya, Rwanda, South Africa, and Zambia covering 2011 or 2012. We used micro-costing to estimate economic costs from the service provider's perspective. Average annual costs per client were estimated in 2013 United States dollars (US$). Econometric analysis was used to explore the relationship between VMMC total and unit cost and facility characteristics. RESULTS: Average VMMC unit cost ranged from US$66 (SD US$79) in Kenya to US$160 (SD US$144) in South Africa. Total cost function estimates were consistent with economies of scale and scope. We found a negative association between the number of VMMC clients and VMMC unit cost with a 3% decrease in unit cost for every 10% increase in number of clients and we found a negative association between the provision of other HIV services and VMMC unit cost. Also, VMMC unit cost was lower in primary health care facilities than in hospitals, and lower in facilities implementing task shifting. CONCLUSIONS: Substantial efficiency gains could be made in VMMC service delivery in all countries. Options to increase efficiency of VMMC programs in the short term include focusing service provision in high yield sites when demand is high, focusing on task shifting, and taking advantage of efficiencies created by integrating HIV services. In the longer term, reductions in VMMC unit cost are likely by increasing the volume of clients at facilities by implementing effective demand generation activities.

Efficiency of HIV services in Nigeria: Determinants of unit cost variation of HIV counseling and testing and prevention of mother-to-child transmission interventions.

BACKGROUND: Like most countries with a substantial HIV burden, Nigeria continues to face challenges in reaching coverage targets of HIV services. A fundamental problem is stagnated funding in recent years. Improving efficiency is therefore paramount to effectively scale-up HIV services. In this study, we estimated the facility-level average costs (or unit costs) of HIV Counseling and Testing (HCT) and Prevention of Mother-to-Child Transmission (PMTCT) services and characterized determinants of unit cost variation. We investigated the role of service delivery modalities and the link between facility-level management practices and unit cost variability along both services' cascades. METHODS: We conducted a cross-sectional, observational, micro-costing study in Nigeria between December 2014 and May 2015 in 141 HCT, and 137 PMTCT facilities, respectively. We retrospectively collected relevant input quantities (personnel, supplies, utilities, capital, and training), input prices, and output data for the year 2013. Staff costs were adjusted using time-motion methods. We estimated the facility-level average cost per service along the HCT and PMTCT service cascades and analyzed their composition and variability. Through linear regressions analysis, we identified aspects of service delivery and management practices associated with unit costs variations. RESULTS: The weighted average cost per HIV-positive client diagnosed through HCT services was US$130. The weighted average cost per HIV-positive woman on prophylaxis in PMTCT services was US$858. These weighted values are estimates of nationally representative unit costs in Nigeria. For HCT, the facility-level unit costs per client tested and per HIV-positive client diagnosed were US$30 and US$1,364, respectively; and the median unit costs were US$17 and US$245 respectively. For PMTCT, the facility-level unit costs per woman tested, per HIV-positive woman diagnosed, and per HIV-positive woman on prophylaxis were US$46, US$2,932, and US$3,647, respectively, and the median unit costs were US$24, US$1,013 and US$1,448, respectively. Variability in costs across facilities was principally explained by the number of patients, integration of HIV services, task shifting, and the level of care. DISCUSSION: Our findings demonstrate variability in unit costs across facilities. We found evidence consistent with economies of scale and scope, and efficiency gains in facilities implementing task-shifting. Our results could inform program design by suggesting ways to improve resource allocation and efficiently scale-up the HIV response in Nigeria. Some of our findings might also be relevant for other settings.

Welfare effects of health insurance in Mexico: The case of Seguro Popular de Salud.

This study contributes with original empirical evidence on the distributional and welfare effects of one of the most important health policies implemented by the Mexican government in the last decade, the Seguro Popular de Salud (SPS). We analyze the effect of SPS on households' welfare using a decomposable index that considers insured and uninsured households' response to out-of-pocket (OOP) payments using both social welfare weights and inequality aversion. The disaggregation of the welfare index allows us to explore the heterogeneity of the SPS impact on households' welfare. We applied propensity score matching to reduce the self-selection bias of being SPS insured. Overall results suggest non-conclusive results of the impact of SPS on households' welfare. When we disaggregated the welfare index by different sub-population groups, our results suggest that households' beneficiaries of SPS with older adults or living in larger cities are better protected against OOP health care payments than their uninsured counterparts. However, no effect was found among SPS-insured households living in rural and smaller cities, which is a result that could be attributed to limited access to health resources in these regions. Scaling up health insurance coverage is a necessary but not sufficient condition to ensure the protection of SPS coverage against financial risks among the poor.

Screening and management of gestational diabetes in Mexico: results from a survey of multilocation, multi-health care institution practitioners.

PURPOSE: To identify the most common practices implemented for the screening and treatment of gestational diabetes mellitus (GDM) and to estimate the GDM clinician-reported proportion as a proxy of the incidence in Mexico. MATERIALS AND METHODS: Three hundred fifty-seven physicians in four major cities were asked about their practices regarding GDM screening, treatment, clinical exams, and health care staff involved in case of GDM diagnosis, as well as the percentage of women with GDM they care for. Data management and statistical analyses were done with Stata 13. RESULTS: The overall GDM clinician-reported proportion was 23.7%. Regional differences were expected and consistent with the data on the epidemiology of the obesity in the country. The most common screening test was the oral glucose tolerance test 75 g one step (46.6% of total cases). Diet and exercise were sufficient to treat GDM in 40.6% of cases; the rest of the sample relied on some form of medication, especially oral hypoglycemic agents (63.0% of cases), insulin (22.0%), or a combination of these (13.0%). To educate women on how to measure glycemia and eventually take medications, an average of 2-3 hours were necessary. The three most common prenatal screening tests were the "no stress", the "Doppler ultrasound", and the "biophysical profile", respectively, taken at least once by 70%, 60%, and 45% of women. Among women who were prescribed insulin, only 37% managed to keep the initial prescribed dose during the whole pregnancy. CONCLUSION: The survey confirmed the expected incidence and gave interesting results on the treatment of GDM. The current Mexican guidelines seem to have been partially implemented in practice, and a coherent national strategy for GDM is still missing. More studies are encouraged to investigate this topic, with the aim to better understand the importance of the monetary cost of GDM, which is currently underestimated.