RESUMEN
Background: Ensuring that access to health care is affordable for everyone-financial protection-is central to universal health coverage (UHC). Financial protection is commonly measured using indicators of financial barriers to access (unmet need for health care) and financial hardship caused by out-of-pocket payments for health care (impoverishing and catastrophic health spending). We aim to assess financial hardship and unmet need in Europe and identify the coverage policy choices that undermine financial protection. Methods: We carry out a cross-sectional study of financial hardship in 40 countries in Europe in 2019 (the latest available year of data before COVID-19) using microdata from national household budget surveys. We define impoverishing health spending as out-of-pocket payments that push households below or further below a relative poverty line and catastrophic health spending as out-of-pocket payments that exceed 40% of a household's capacity to pay for health care. We link these results to survey data on unmet need for health care, dental care, and prescribed medicines and information on two aspects of coverage policy at country level: the main basis for entitlement to publicly financed health care and user charges for covered services. Findings: Out-of-pocket payments for health care lead to financial hardship and unmet need in every country in the study, particularly for people with low incomes. Impoverishing health spending ranges from under 1% of households (in six countries) to 12%, with a median of 3%. Catastrophic health spending ranges from under 1% of households (in two countries) to 20%, with a median of 6%. Catastrophic health spending is consistently concentrated in the poorest fifth of the population and is largely driven by out-of-pocket payments for outpatient medicines, medical products, and dental care-all forms of treatment that should be an essential part of primary care. The median incidence of catastrophic health spending is three times lower in countries that cover over 99% of the population than in countries that cover less than 99%. In 16 out of the 17 countries that cover less than 99% of the population, the basis for entitlement is payment of contributions to a social health insurance (SHI) scheme. Countries that give greater protection from user charges to people with low incomes have lower levels of catastrophic health spending. Interpretation: It is challenging to identify with certainty the coverage policy choices that undermine financial protection due to the complexity of the policies involved and the difficulty of disentangling the effects of different choices. The conclusions we draw are therefore tentative, though plausible. Countries are more likely to move towards UHC if they reduce out-of-pocket payments in a progressive way, decreasing them for people with low incomes first. Coverage policy choices that seem likely to achieve this include de-linking entitlement from payment of SHI contributions; expanding the coverage of outpatient medicines, medical products, and dental care; limiting user charges; and strengthening protection against user charges, particularly for people with low incomes. Funding: The European Union (DG SANTE and DG NEAR) and the Government of the Autonomous Community of Catalonia, Spain.
RESUMEN
Research has shown that multidimensional approaches to Chagas disease (CD), integrating its biomedical and psycho-socio-cultural components, are successful in enhancing early access to diagnosis, treatment and sustainable follow-up.For the first time, a consulate was selected for a community-based CD detection campaign. Two different strategies were designed, implemented and compared between 2021 and 2022 at the Consulate General of Bolivia and a reference health facility in Barcelona open to all Bolivians in Catalonia.Strategy 1 consisted in CD awareness-raising activities before referring those interested to the reference facility for infectious disease screening. Strategy 2 offered additional in-situ serological CD screening. Most of the 307 participants were Bolivian women residents in Barcelona. In strategy 1, 73 people (35.8% of those who were offered the test) were screened and 19.2% of them were diagnosed with CD. Additionally, 53,4% completed their vaccination schedules and 28.8% were treated for other parasitic infections (strongyloidiasis, giardiasis, eosinophilia, syphilis). In strategy 2, 103 people were screened in-situ (100% of those who were offered the test) and 13.5% received a CD diagnosis. 21,4% completed their vaccination schedule at the reference health facility and 2,9% were referred for iron deficiency anemia, strongyloidiasis or chronic hepatitis C.The fact that the screening took place in an official workplace of representatives of their own country, together with the presence of community-based participants fueled trust and increased CD understanding. Each of the strategies assessed had different benefits. Opportunities for systematic integration for CD based on community action in consulates may enhance early access to diagnosis, care and disease prevention.
