Measuring primary healthcare expenditure in low-income and lower middle-income countries.

Primary healthcare (PHC) is considered as the pathway to Universal Health Coverage (UHC) and to achieving sustainable development goals. Measuring PHC expenditure is a critical first step to understanding why some countries improve access to health services, provide financial risk protection and achieve UHC. In this paper, we tested and examined different measurement options using the System of Health Accounts (SHA) 2011 for systematic monitoring of PHC expenditure. We used the 'first-contact' approach to PHC and applied it to the healthcare function or healthcare provider classifications of SHA 2011. Data comes from 36 recent low-income and middle-income countries health accounts 2011-2016. Country spending on PHC varies largely, across countries and across definition options. For example, PHC expenditure ranges from US$15 to US$60 per capita. The sensitivity analysis highlighted the weight of including or excluding medical goods. The correlation analysis comparing countries ranking is strong between options. The study identified the major challenges in developing standard monitoring of PHC expenditure. One, there is a lack of clear operational definition for PHC, suggesting that a global standard definition would not replace the need for country context specific definition. Two, there is insufficient data granularity both because the standard framework does not offer it and because quality data breakdown is unavailable.

Applying behavioural economics to health systems of low- and middle-income countries: what are policymakers' and practitioners' views?

Interest in behavioural economics has soared in recent years, particularly because of its application to several areas of public policy, now including international development, education, and health. Yet, little is known about how the policy and political implications of behavioural economics are perceived among stakeholders. Using an innovative vignette-based online survey, we assessed the opinions of 520 policymakers and practitioners around the world about health policy recommendations emanating from behavioural economics principles that are relevant to low- and middle-income country settings. We also determined the sources of disagreement among the respondents. The results suggest that there is strong support for health policies based on the concepts of framing choices to overcome present bias, providing periodic information to form habits, and messaging to promote social norms. There is less support for policies which use cash rewards as extrinsic motivators either to change individual behaviour related to the management of chronic conditions or to mitigate risky sexual behaviour. The sources of disagreement for these policy prescriptions derive mainly from normative concerns and perceived lack of effectiveness of such interventions. Addressing these disagreements may require developing a broader research agenda to explore the policy and political implications of these prescriptions.

Reprioritizing government spending on health: pushing an elephant up the stairs?

Countries vary widely with respect to the share of government spending on health, a metric that can serve as a proxy for the extent to which health is prioritized by governments. World Health Organization (WHO) data estimate that, in 2011, health's share of aggregate government expenditure averaged 12% in the 170 countries for which data were available. However, country differences were striking: ranging from a low of 1% in Myanmar to a high of 28% in Costa Rica. Some of the observed differences in health's share of government spending across countries are unsurprisingly related to differences in national income. However, significant variations exist in health's share of government spending even after controlling for national income. This paper provides a global overview of health's share of government spending and summarizes some of the key theoretical and empirical perspectives on allocation of public resources to health vis-à-vis other sectors from the perspective of reprioritization, one of the modalities for realizing fiscal space for health. The paper argues that theory and cross-country empirical analyses do not provide clear-cut explanations for the observed variations in government prioritization of health. Standard economic theory arguments that are often used to justify public financing for health are equally applicable to many other sectors including defence, education and infrastructure. To date, empirical work on prioritization has been sparse: available cross-country econometric analyses suggest that factors such as democratization, lower levels of corruption, ethnolinguistic homogeneity and more women in public office are correlated with higher shares of public spending on health; however, these findings are not robust and are sensitive to model specification. Evidence from case studies suggests that country-specific political economy considerations are key, and that results-focused reform efforts - in particular efforts to explicitly expand the breadth and depth of health coverage as opposed to efforts focused only on government budgetary benchmarking targets - are more likely to result in sustained and politically feasible prioritization of health from a fiscal space perspective.

Beyond income, access, and knowledge: factors explaining the education gradient in prevention among older adults with diabetes and hypertension in Latin America.

OBJECTIVE: While the education gradient in prevention of chronic conditions is well documented, contributing factors remain underexplored. The contribution of income, knowledge and management of illness, market prices, cognitive ability, ability to act, perception about the future, and psychosocial constraints to the education gradient in prevention is examined. METHODS: To solve problems of unobservable factors that influence prevention and illness severity, we estimate the role of each component of the education gradient on prevention using data on diabetes and hypertension from five Latin American countries. RESULTS: Overall, these components explain 50% to 70% of the education gradient in prevention, with income being the most important. DISCUSSION: Cognitive ability and ability to act capture an important part of the education gradient in prevention whereas knowledge about illness explains little. Medicine individualized to patients' cognitive ability and ability to act could improve adherence to prevention protocols among patients with chronic conditions.

Impact of conditional cash transfers on maternal and newborn health.

Maternal and newborn health (MNH) is a high priority for global health and is included among the Millennium Development Goals (MDGs). However, the slow decline in maternal and newborn mortality jeopardizes achievements of the targets of MDGs. According to UNICEF, 60 million women give birth outside of health facilities, and family planning needs are satisfied for only 50%. Further, skilled birth attendance and the use of antenatal care are most inequitably distributed in maternal and newborn health interventions in low- and middle-income countries. Conditional cash transfer (CCT) programmes have been shown to increase health service utilization among the poorest but little is written on the effects of such programmes on maternal and newborn health. We carried out a systematic review of studies on CCT that report maternal and newborn health outcomes, including studies from 8 countries. The CCT programmes have increased antenatal visits, skilled attendance at birth, delivery at a health facility, and tetanus toxoid vaccination for mothers and reduced the incidence of low birthweight. The programmes have not had a significant impact on fertility while the impact on maternal and newborn mortality has not been well-documented thus far. Given these positive effects, we make the case for further investment in CCT programmes for maternal and newborn health, noting gaps in knowledge and providing recommendations for better design and evaluation of such programmes. We recommend more rigorous impact evaluations that document impact pathways and take factors, such as cost-effectiveness, into account.

Lumbar spine flexion and extension extremes of motion in women of different age and racial groups: the WIN Study.

STUDY DESIGN: Observational. OBJECTIVE: To provide normative values of lumbar flexion and extension for women of different age and racial groups. SUMMARY OF BACKGROUND DATA: Spinal range of motion (ROM) is one of the AMA Guides criteria used to estimate level of impairment and subsequent compensation entitlement. Studies show that spinal ROM varies with age, gender, and possibly race/ethnicity, but adequate normative values for different age and racial/ethnic groups do not exist. METHODS: A cohort of free-living women was recruited for the Women's Injury Study at The Cooper Institute in Dallas. Originally, 917 women between the ages of 20 and 83 (M = 52 +/- 13) underwent an orthopedic examination including lumbar spine flexion and extension measurement using an electronic inclinometer. Measurements were taken in the fully extended and flexed positions, respectively. This removes the influence of initial resting posture and is termed "extreme of motion" (EOM) as opposed to ROM. Age and racial groups were compared using a 2-way multivariate analysis of variance (MANOVA) followed with post hoc tests. RESULTS: Means (+/-SD) were calculated for racial (white, N = 619, African-American, N = 147) and age groups (young, 20-39 years, n = 126; middle, 40-59 years, n = 412; older, > or = 60 years, n = 228). Lumbar extension for African-American women (60.1 degrees) was significantly greater (P < 0.05) than for white women (52.6 degrees), but flexion was not different (15.2 degrees and 17.0 degrees), respectively. Extension EOM for the young group (61.6 degrees) was greater (P < 0.05) than the middle (56.6 degrees) and older (50.8 degrees) groups. Extension difference between the middle and older groups was significant. Flexion EOM for the young group (20.1 degrees) was greater (P < 0.05) than the middle (15.2 degrees) and older (12.8 degrees) groups. The difference in flexion between the middle and older groups was not significant. CONCLUSION: Normative values of lumbar extension are different for white and African-American women. Values for lumbar flexion and extension are different between age groups. Different criteria should be used to estimate impairment level in women of different racial and age groups.

Financing global health: mission unaccomplished.

Poor countries account for 56 percent of the global disease burden but less than 2 percent of global health spending. With the global commitment to the Millennium Development Goals in 2000, poverty and the deplorable health conditions of the world's poor have finally reached center stage in the international policy arena, and aid for health has greatly increased. This paper evaluates health financing in developing countries from global- and country-level perspectives and briefly describes the types of reforms needed in the global aid architecture to make effective use of this historic opportunity to improve the plight of the world's poor.