Increasing Health Insurance Enrollment in Low- and Middle-Income Countries: What Works, What Does Not, and Research Gaps: A Scoping Review.

Health insurance programs have the potential to shield individuals in low- and middle-income countries from catastrophic health expenses and reduce their vulnerability to poverty. However, the uptake of insurance programs remains low in these countries. We reviewed existing evidence from experimental studies on approaches that researchers have tested in order to raise the uptake. In the 12 studies we synthesized, educational programs and subsidies were the dominant interventions. Consistent with findings from previous studies on other health products, subsidies were effective in raising the uptake of insurance programs in many contexts. Conversely, education interventions-in their current forms-were largely ineffective, although they bolstered the effect of subsidies. Other strategies, such as the use of microfinance institutions and social networks for outreach and enrollment, showed mixed results. Additional research is needed on effective approaches to raise the uptake of insurance programs, including tools from behavioral economics that have shown promise in other areas of health behavior.

Determinants of support for government involvement in obesity control among American adults.

Obesity takes a substantial toll on society as a whole. Obesity and its health-related complications contribute significantly to healthcare costs and negatively affects almost every aspect of human life. It is therefore reasonable for the government to be involved in finding solutions to control the epidemic. This article examined factors that influence support for government intervention in the obesity epidemic in the United States. We used data from Obesity in the United States: Public Perceptions, a survey of a nationally representative sample of American adults. We conducted OLS regression analysis, to understand how three main covariates that described beliefs about causes of obesity and a series of controls impact support for government intervention in obesity control. There was a significant negative relationship between support for government intervention and beliefs about causes of obesity. Also, political ideology and party affiliation significantly influenced support for government intervention. For instance, while Democrats were more supportive of government interventions to control obesity, Republicans were not supportive of such intervention. Additionally, race and environmental characteristics of place of residence significantly influenced support for government intervention. Further, there were significant joint effects of political affiliation, race, and weight status on support for government intervention. Unlike previous studies, we find that one of the important factors that drive people to either support or abhor government intervention is the perception of what causes obesity. It is important that public health officials and other stakeholders understand the intricacies of public support for obesity control.

Role of laser refractive surgery in cross-subsidization of nonprofit humanitarian eyecare and the burden of uncorrected refractive error in Nepal: Pilot project.

PURPOSE: To establish a refractive surgery unit at Tilganga Institute of Ophthalmology through support from international donations and provide knowledge transfer for doctors and management to make the unit self-sustaining, nonprofit laser refractive surgery, and financial support for other eyecare projects at Tilganga. SETTING: Tilganga Institute of Ophthalmology, Kathmandu, Nepal. DESIGN: Retrospective study. METHODS: A foundation was created to establish a refractive surgery unit using a cost-recovery model; that is, patients are charged according to their financial status to cover running costs, patients without funds to pay for surgery, and other eyecare projects for the underprivileged population of Kathmandu, Nepal. Donations were obtained to fund refurbishment within Tilganga Hospital and purchase equipment and technology. A Nepalese surgeon was selected from Tilganga and completed an 8-month fellowship and proctorship of the first series of surgeries. The refractive surgery unit was opened in January 2012, and the cost-recovery model was evaluated up to December 2016. RESULTS: During the period evaluated, 74.8% of patients were treated at full cost, 17.2% at subsidized cost, and 8.6% free of charge. The refractive surgery unit generated a profit representing 28% of the running cost in this period, which was used to reduce the deficit of the main hospital. Surgical outcomes achieved were comparable to those reported by groups in the developed world. CONCLUSION: A self-sustaining nonprofit laser refractive surgery clinic, operating with high quality, was successfully implemented supported by international donations for initial setup costs and a cost-recovery model thereafter.

The Effect of Cost Sharing on an Employee Weight Loss Program: A Randomized Trial.

PURPOSE: To test the effects of employer subsidies on employee enrollment, attendance, and weight loss in a nationally available weight management program. DESIGN: A randomized trial tested the impact of employer subsidy: 100%; 80%, 50%, and a hybrid 50% subsidy that could become a 100% subsidy by attaining attendance targets. TRIAL REGISTRATION: NCT01756066. SETTING AND PARTICIPANTS: Twenty three thousand twenty-three employees of 2 US companies. MEASURES: The primary outcome was the percentage of employees who enrolled in the weight management program. We also tested whether the subsidies were associated with differential attendance and weight loss over 12 months, as might be predicted by the expectation that they attract employees with differing degrees of motivation. Analysis and Results: Enrollment differed significantly by subsidy level ( P < .0001). The 100% subsidy produced the highest enrollment (7.7%), significantly higher than each of the lower subsidies (vs 80% subsidy: 6.2%, P = .002; vs 50% subsidy: 3.9%, P < .0001; vs hybrid: 3.7%, P < .0001). Enrollment in the 80% subsidy group was significantly higher than both lower subsidy groups (vs 50% subsidy: 3.9%, P < .0001; vs hybrid: 3.7%, P < .0001). Among enrollees, there were no differences among the 4 groups in attendance or weight loss. CONCLUSION: This pragmatic trial, conducted in a real-world workplace setting, suggests that higher rates of employer subsidization help individuals to enroll in weight loss programs, without a decrement in program effectiveness. Future research could explore the cost-effectiveness of such subsidies or alternative designs.

Resource Allocation Strategies to Increase the Efficiency and Sustainability of Gavi's Health System Strengthening Grants.

BACKGROUND: Despite the increase in Health System Strengthening (HSS) grants, there is no consensus among global health actors about how to maximize the efficiency and sustainability of HSS programs and their resulting gains. To formally analyze and compare the efficiency and sustainability of Gavi's HSS grants, we investigated the factors, events and root causes that increased the time and effort needed to implement HSS grants, decreased expected outcomes and threatened the continuity of activities and the sustainability of the results gained through these grants in Cameron and Chad. METHODS: We conducted 2 retrospective independent evaluations of Gavi's HSS support in Cameroon and Chad using a mixed methodology. We investigated the chain of events and situations that increased the effort and time required to implement the HSS programs, decreased the value of the funds spent and hindered the sustainability of the implemented activities and gains achieved. RESULTS: Root causes affecting the efficiency and sustainability of HSS grants were common to Cameroon and Chad. Weaknesses in health workforce and leadership/governance of the health system in both countries led to interrupting the HSS grants, reprogramming them, almost doubling their implementation period, shifting their focus during implementation toward procurements and service provision, leaving both countries without solid exit plans to maintain the results gained. CONCLUSIONS: To increase the efficiency and sustainability of Gavi's HSS grants, recipient countries need to consider health workforce and leadership/governance prior, or in parallel to strengthening other building blocks of their health systems.

The effects of policy actions to improve population dietary patterns and prevent diet-related non-communicable diseases: scoping review.

Poor diet generates a bigger non-communicable disease (NCD) burden than tobacco, alcohol and physical inactivity combined. We reviewed the potential effectiveness of policy actions to improve healthy food consumption and thus prevent NCDs. This scoping review focused on systematic and non-systematic reviews and categorised data using a seven-part framework: price, promotion, provision, composition, labelling, supply chain, trade/investment and multi-component interventions. We screened 1805 candidate publications and included 58 systematic and non-systematic reviews. Multi-component and price interventions appeared consistently powerful in improving healthy eating. Reformulation to reduce industrial trans fat intake also seemed very effective. Evidence on food supply chain, trade and investment studies was limited and merits further research. Food labelling and restrictions on provision or marketing of unhealthy foods were generally less effective with uncertain sustainability. Increasingly strong evidence is highlighting potentially powerful policies to improve diet and thus prevent NCDs, notably multi-component interventions, taxes, subsidies, elimination and perhaps trade agreements. The implications for policy makers are becoming clearer.

Challenges in promoting joint use agreements: experiences from Community Transformation Grant awardees in North Carolina, Illinois, and Wisconsin, 2011-2014.

Community Transformation Grant awardees in North Carolina, Illinois, and Wisconsin promoted joint use agreements (formal agreements between 2 parties for the shared use of land or facilities) as a strategy to increase access to physical activity in their states. However, awardees experienced significant barriers to establishing joint use agreements, including 1) confusion about terminology and an aversion to complex legal contracts, 2) lack of applicability to single organizations with open use policies, and 3) questionable value in nonurban areas where open lands for physical activity are often available and where the need is instead for physical activity programs and infrastructure. Furthermore, promotion of formal agreements may unintentionally reduce access by raising concerns regarding legal risks and costs associated with existing shared use of land. Thus, joint use agreements have practical limitations that should be considered when selecting among strategies to promote physical activity participation.

Food price policies improve diet quality while increasing socioeconomic inequalities in nutrition.

BACKGROUND: Prices are an important determinant of food choices. Consequently, food price policies (subsidies and/or taxes) are proposed to improve the nutritional quality of diets. The aim of the present study was to explore the impact of food price policies on the expenditures and nutritional quality of the food baskets chosen by low- and medium-income households. METHODS: Experimental economics was used to examine two price manipulations: i) a fruit and vegetable price subsidy named "fruit and vegetables condition"; ii) a healthy-product subsidy coupled with an unhealthy-product tax named "nutrient profile condition". The nutrient profiling system called SAIN,LIM was used. This system classifies each individual food according to its overall nutritional quality which then allows for a food item to be taxed or subsidized. Women from low- (n = 95) and medium-incomes (n = 33) selected a daily food basket, first, at current prices and then at manipulated prices. The redistributive effects of experimental conditions were assessed by comparing the extent of savings induced by subsidies and of costs generated by the tax on the two income groups. Energy density (kcal/100 g), free sugars (% energy) and the mean adequacy ratio (MAR) were used as nutritional quality indicators. RESULTS: At baseline (before price manipulations), low-income women selected less expensive and less healthy baskets than medium-income ones. After price manipulations expenditures for both income group decreased significantly, whereas, the nutritional quality improved (energy density decreased, the MAR increased). Additionally, the redistributive effects were less favourable for low-income women and their nutritional quality improvements from baseline were significantly lower. CONCLUSION: Low-income women derived fewer financial and nutritional benefits from implemented food subsidies and taxes than medium-income women. This outcome suggests that food price policies may improve diet quality while increasing socio-economic inequalities in nutrition.

Childhood pneumonia as a global health priority and the strategic interest of the Bill & Melinda Gates Foundation.

Pneumonia kills more children than any other disease--more than HIV/AIDS, malaria, and measles combined. Introduction of vaccines against pneumococcus and Haemophilus influenzae type b (the most important causes of severe pneumonia in young children), increasing resistance to antibiotics, and changes in HIV prevalence will likely change patterns of pneumonia etiology in developing countries. Studies such as Pneumonia Etiology Research for Child Health (PERCH) that take advantage of new diagnostic technologies are needed to provide an updated and more precise description of the microbial causes of pneumonia and to inform decisions around treatment algorithms and vaccine development and introduction. In recognition of its importance for global health and especially its significance as an ongoing cause of gross inequity in risks, The Bill & Melinda Gates Foundation has made pneumonia an important part of its global health strategy and PERCH a centerpiece of its Pneumonia Program.

A randomized pilot trial of a full subsidy vs. a partial subsidy for obesity treatment.

Intensive obesity treatment is mandated by federal health care reform but is costly. A partial subsidy for obesity treatment could lower the cost of treatment, without reducing its efficacy. This study sought to test whether a partial subsidy for obesity treatment would be feasible, as compared to a fully subsidized intervention. The study was a pilot randomized trial. Participants (n = 50) were primary care patients with obesity and at least one comorbid condition (diabetes, hypertension, dyslipidemia, or obstructive sleep apnea). Each participant received eight weight loss counseling visits as well as portion-controlled foods for weight loss. Participants were randomized to full subsidy or partial subsidy (2 vs. 1 meal per day provided). The primary outcome was weight change after 4 months. Secondary outcomes included changes in blood pressure, waist circumference, and health-related quality of life. Participants in the full and partial subsidy groups lost 5.9 and 5.3 kg, equivalent to 5.3% and 5.1% of initial weight, respectively (P = 0.71). Changes in secondary outcomes were similar in the two groups. A partial subsidy was feasible and induced a clinically similar amount of weight loss, compared to a full subsidy. Large-scale testing of economic incentives for weight control is merited given the federal mandate to offer weight loss counseling to obese patients.

Changes in drug utilization during a gap in insurance coverage: an examination of the medicare Part D coverage gap.

BACKGROUND: Nations are struggling to expand access to essential medications while curbing rising health and drug spending. While the US government's Medicare Part D drug insurance benefit expanded elderly citizens' access to drugs, it also includes a controversial period called the "coverage gap" during which beneficiaries are fully responsible for drug costs. We examined the impact of entering the coverage gap on drug discontinuation, switching to another drug for the same indication, and drug adherence. While increased discontinuation of and adherence to essential medications is a regrettable response, increased switching to less expensive but therapeutically interchangeable medications is a positive response to minimize costs. METHODS AND FINDINGS: We followed 663,850 Medicare beneficiaries enrolled in Part D or retiree drug plans with prescription and health claims in 2006 and/or 2007 to determine who reached the gap spending threshold, n = 217,131 (33%). In multivariate Cox proportional hazards models, we compared drug discontinuation and switching rates in selected drug classes after reaching the threshold between all 1,993 who had no financial assistance during the coverage gap (exposed) versus 9,965 multivariate propensity score-matched comparators with financial assistance (unexposed). Multivariate logistic regressions compared drug adherence (≤ 80% versus >80% of days covered). Beneficiaries reached the gap spending threshold on average 222 d ±79. At the drug level, exposed beneficiaries were twice as likely to discontinue (hazard ratio [HR]  = 2.00, 95% confidence interval [CI] 1.64-2.43) but less likely to switch a drug (HR  = 0.60, 0.46-0.78) after reaching the threshold. Gap-exposed beneficiaries were slightly more likely to have reduced adherence (OR  = 1.07, 0.98-1.18). CONCLUSIONS: A lack of financial assistance after reaching the gap spending threshold was associated with a doubling in discontinuing essential medications but not switching drugs in 2006 and 2007. Blunt cost-containment features such as the coverage gap have an adverse impact on drug utilization that may conceivably affect health outcomes.

A global subsidy for antimalarial drugs.

In 2004, the Institute of Medicine concluded that a global high-level subsidy was the best way to make effective antimalarial drugs--currently, artemisinin-combination therapies (ACTs)--widely available at affordable prices and at the same time substantially delay the emergence and spread of artemisinin-resistant strains of falciparum malaria. The subsidy would be available to manufacturers of all ACTs meeting pre-specified efficacy, safety, and quality criteria. Buyers would pay very low prices, allowing drugs to flow through existing channels, with the aim of reaching consumers at a similar price to chloroquine, the most frequently used (although no longer effective) malaria drug. Unsubsidized artemisinin monotherapies would be more expensive than subsidized ACTs (co-formulations), thereby largely eliminating their use through market forces. Conditions favoring the emergence of artemisinin-resistant malaria would be greatly reduced. The global high-level subsidy is a powerful idea that is moving from economic concept to pragmatic reality.

What drives donor funding in population assistance programs? Evidence from OECD countries.

The 1994 International Conference on Population and Development (ICPD) established goals for the expansion of population assistance. To date, the financial promises made by donor countries in 1994 have not been met. To unravel the gap between ambitions and contributions, we use panel estimation methods to see what lies behind the level of donor contributions and the sharing of burdens across the various categories of population and HIV/AIDS assistance in 21 donor countries for the years 1996-2002. Contributions by donors depend heavily on the economic wealth and subjective preferences of donor countries. The sharing of the ICPD burden within the group of OECD/DAC countries is in line with the countries' ability to pay, although within the aggregate we observe a specialization in channels for aid: small countries predominantly use multilateral aid agencies, whereas large countries rely more on bilateral aid channels. Catholic countries are averse to donating unrestricted funds (flowing primarily to multilateral agencies) or restricted funds targeted at family planning programs.