Canine Carpal Injuries: From Fractures to Hyperextension Injuries.

The canine and feline carpus is a complex arrangement of bones, ligaments, and joint spaces that functions as a ginglymus joint to provide carpal flexion and extension. Given the demanding biomechanical demands on the carpus during weight bearing, a variety of region-specific pathology, often secondary to trauma, are reported. This review details carpal anatomy, biomechanical understandings, and current evidence surrounding carpal pathology and its management. Partial carpal arthrodesis and pancarpal arthrodesis outcomes are reviewed in detail.

How and to what extent can pensions facilitate increased use of health services by older people: evidence from social pension expansion in rural China.

BACKGROUND: The proportion of people aged 60 years or over is growing faster than other age groups. Traditionally, retirement has been considered as both a loss to the labour market and an additional economic burden on the nation. More recently, it is widely accepted that retired people can still contribute to society in many ways, though the extent of their contributions will depend heavily on their state of health. In this context, a significant practical issue is how to encourage older people to use the health services they need. This study aims to evaluate the effects of pensions on older adults' health service utilization, and estimate the level of pension required to influence such utilization. METHODS: Using data from a nationally representative sample survey, the China Health and Retirement Longitudinal Study, we adopted a fuzzy regression discontinuity design and undertook segmented regression analysis. RESULTS: It was found that a pension did encourage low-income people to use both outpatient (OR = 1.219, 95% 1.018-1.460) and inpatient services (OR = 1.269, 95% 1.020-1.579); but also encouraged both low- and high-income people to choose self-treatment, specifically over-the-counter (OR = 1.208, 95% 1.037-1.407; OR = 1.206, 95% 1.024-1.419; respectively) and traditional Chinese medicines (OR = 1.452, 95% 1.094-1.932; OR = 1.456, 95% 1.079-1.955; respectively). However, receiving a pension had no effect on the frequency of outpatient and inpatient service use. Breakpoints for a pension to promote health service utilization were mainly located in the range 55-95 CNY (7.1-12.3 EUR or 8.0-13.8 USD). CONCLUSIONS: A pension was found to have mixed effects on health service utilization for different income groups. Our study enriches existing evidence on the impact of pensions on healthcare-seeking behaviour and can be helpful in policy design and the formulation of improved models relating to pensions and healthcare utilisation.

A New Financing Model for Tuberculosis (TB) Care in China: Challenges of Policy Development and Lessons Learned from the Implementation.

Background: With support from the Gates Foundation, the Chinese Center for Disease Control and Prevention (China CDC) introduced a new financing model for tuberculosis (TB) care. This paper reviews the development of the associated financing policies and payment methods in three project sites and analyzes the factors impacting on policy implementation and outcomes. Methods: We reviewed policy papers and other relevant documents issued in the project sites. Semi-structured qualitative interviews were conducted with key stakeholders at provincial, city and county levels. Thematic analysis was applied to identify themes and develop interpretations. Results: The China CDC guideline proposed the introduction of a case-based payment based on TB treatment clinical pathways, increased reimbursement rates and financial assistance for the poorest TB patients. Contrary to expectations, TB patients with complications and/or comorbidities were often excluded from the program by hospitals that were concerned the cost of care would exceed the case-based payment ceiling. In addition, doctors frequently prescribed services and/or drugs beyond the coverage of the benefit package for those in the program. Consequently, actual reimbursement rates were low and poor patients still faced a heavy financial burden, though the utilization of services increased, especially by poorer patients. Qualitative interviews revealed three main factors affecting payment policy implementation. They were: hospital managers' concern on the potential for reduced revenue generation; their fear that patients would regard the service provided as sub-standard if they were not prescribed the full range of available treatments; and a lack of mechanisms to effectively monitor and support the implementation process. Conclusions: While the intervention had some success in improving access to TB care, the challenges of implementing the policy in what proved to be an unreceptive and often antagonistic context resulted in divergences from the original design that frustrated its aim of reducing the financial burden on patients.

The impact of increased reimbursement rates under the new cooperative medical scheme on the financial burden of tuberculosis patients.

BACKGROUND: Tuberculosis (TB) is still a major public health problem in China. To scale up TB control, an innovative programme entitled the 'China-Gates Foundation Collaboration on TB Control in China was initiated in 2009. During the second phase of the project, a policy of increased reimbursement rates under the New Cooperative Medical Scheme (NCMS) was implemented. In this paper, we aim to explore how this reform affects the financial burden on TB patients through comparison with baseline data. METHODS: In two cross-sectional surveys, quantitative data were collected before (January 2010 to December 2012) and after (April 2014 to June 2015) the intervention in the existing NCMS routine data system. Information on all 313 TB inpatients, among which 117 inpatients in the project was collected. Qualitative data collection included 11 focus group discussions. Three main indicators, non-reimbursable expenses rate (NER), effective reimbursement rate (ERR), and out-of-pocket payment (OOP) as a percentage of per capita household income, were used to measure the impact of intervention by comprising post-intervention data with baseline data. The quantitative data were analysed by descriptive analysis and non-parametric tests (Mann-Whitney U test) using SPSS 22.0, and qualitative data were subjected to thematic framework analysis using Nvivo10. RESULTS: The nominal reimbursement rates for inpatient care were no less than 80% for services within the package. Total inpatient expenses greatly increased, with an average growth rate of 11.3%. For all TB inpatients, the ERR for inpatient care increased from 52 to 66%. Compared with inpatients outside the project, for inpatients covered by the new policy, the ERR was higher (78%), and OOP showed a sharper decline. In addition, their financial burden decreased significantly. CONCLUSIONS: Although the nominal reimbursement rates for inpatient care of TB patients greatly increased under the new reimbursement policy, inpatient OOP expenditure was still a major financial problem for patients. Limited diagnosis and treatment options in county general hospitals and inadequate implementation of the new policy resulted in higher inpatient expenditures and limited reimbursement. Comprehensive control models are needed to effectively decrease the financial burden on all TB patients.

The Effect of an Innovative Financing and Payment Model for Tuberculosis Patients on Health Service Utilization in China: Evidence from Hubei Province of China.

Background: Tuberculosis (TB) remains a major social and public health problem in China. The "China-Gates TB Project" started in 2012, and one of its objectives was to reduce the financial burden on TB patients and to improve access to quality TB care. The aims of this study were to determine if the project had positive impacts on improving health service utilization. Methods: The 'China-Gates TB Project' was launched in Yichang City (YC), Hubei Province in April 2014 and ended in March 2015, lasting for one year. A series of questionnaire surveys of 540 patients were conducted in three counties of YC at baseline and final evaluations. Inpatient and outpatient service utilization were assessed before and after the program, with descriptive statistics. Propensity score matching was used to evaluate the impact of the China-Gates TB Project on health service utilization by minimizing the differences in the other characteristics of baseline and final stage groups. Focus group discussions (FGDs) were held to further enrich the results. Results: A total of 530 patients were included in this study. Inpatient rates significantly increased from 33.5% to 75.9% overall (p < 0.001), with the largest increase occurring for low income patients. Outpatient visits increased from 4.6 to 5.6 (p < 0.001), and this increase was also greatest for the poorest patients. Compared with those who lived in developed counties, the overall increase in outpatient visits for illness in the remote Wufeng county was higher. Conclusions: The China-Gates TB Project has effectively improved health service utilization in YC, and poor patients benefited more from it. TB patients in remote underdeveloped counties are more likely to increase the use of outpatient services rather than inpatient services. There is a need to tilt policy towards the poor, and various measures need to be in place in order to ensure health services utilization in undeveloped areas.

Over- and under-treatment of TB patients in Eastern China: an analysis based on health insurance claims data.

OBJECTIVE: Poor compliance with existing guidelines for tuberculosis (TB) care and treatment is an issue of concern in China. We assessed health service use by TB patients over the entire treatment process and compared it to the recommended guidelines. METHODS: We collected insurance claims data in three counties of one province of Eastern China. Patient records with a diagnosis of 'pulmonary TB' in 2015 and 2016 were extracted. Treatment duration, number of outpatient (OP) visits and hospital admissions, as well as total cost, out-of-pocket (OOP) payments and effective reimbursement rates were analysed. RESULTS: A total of 1394 patients were included in the analysis. More than 48% received over the 8 months of treatment that TB guidelines recommend, and over 28% received less. 49% of Urban and Rural Resident Basic Medical Insurance (URRBMI) TB patients were hospitalised while 30% of those with Urban Employee Basic Medical Insurance (UEBMI) had at least one admission. Median total cost for patients with hospital admission was almost 10 times that of patients without. By comparison, the average OOP was 5 times higher. UEBMI patients had a shorter treatment period, more outpatient visits but considerably fewer hospital admissions than URRBMI patients. CONCLUSIONS: We found an alarming extent of TB over- and under-treatment in our study population. There is an urgent need to improve compliance with treatment guidelines in China and to better understand the drivers of divergence. Extending the coverage of health insurance schemes and increasing reimbursement rates for TB outpatient services would seem to be key factors in reducing both the overall cost and financial burden on patients.

OBJECTIF: Le mauvais respect des directives existantes en matière de soins et de traitement de la tuberculose (TB) est un sujet préoccupant en Chine. Nous avons évalué l'utilisation des services de santé par les patients TB tout au long du processus de traitement et l'avons comparée aux directives recommandées. MÉTHODES: Nous avons collecté des données sur les réclamations d'assurance dans trois comtés d'une province de l'est de la Chine. Les dossiers de patients avec un diagnostic de «TB pulmonaire¼ en 2015 et 2016 ont été extraits. La durée du traitement, le nombre de visites ambulatoires et d'hospitalisations, ainsi que le coût total, les paiements directs et les taux de remboursement effectifs ont été analysés. RÉSULTATS: 1.394 patients ont été inclus dans l'analyse. Plus de 48% ont reçu plus de 8 mois du traitement recommandé par les directives TB et plus de 28% en ont reçu moins. 49% des patients TB résidents urbains et ruraux de l'assurance médicale de base (URRBMI) ont été hospitalisés, tandis que 30% de ceux avec une assurance médicale de base des employés urbains (UEBMI) ont eu au moins une admission. Le coût total moyen pour les patients hospitalisés était près de 10 fois plus élevé que celui des patients non hospitalisés. En comparaison, le payement direct moyen était 5 fois plus élevé. Les patients UEBMI ont eu une période de traitement plus courte, plus de visites ambulatoires mais beaucoup moins d'hospitalisations que les patients URRBMI. CONCLUSIONS: Nous avons trouvé une étendue alarmante de sur- et sous-traitement de la TB dans notre population d'étude. Il est urgent d'améliorer le respect des directives de traitement en Chine et de mieux comprendre les facteurs de divergence. L'extension de la couverture des schémas d'assurance santé et l'augmentation des taux de remboursement des services ambulatoires pour la TB sembleraient être des facteurs essentiels pour réduire à la fois le coût global et la charge financière pour les patients.

Impact of an innovative tuberculosis financing and payment model on health service utilization by tuberculosis patients in China: do the poor fare better than the rich?

BACKGROUND: Tuberculosis (TB) prevalence is closely associated with poverty in China, and poor patients face more barriers to treatment. Using an insurance-based approach, the China-Gates TB program Phase II was implemented between 2012 and 2014 in three cities in China to improve access to TB care and reduce the financial burden on patients, particularly among the poor. This study aims to assess the program effects on service use, and its equity impact across different income groups. METHODS: Data from 788 and 775 patients at baseline and final evaluation were available for analysis respectively. Inpatient and outpatient service utilization, treatment adherence, and patient satisfaction were assessed before and after the program, across different income groups (extreme poverty, moderate poverty and non-poverty), and in various program cities, using descriptive statistics and multi-variate regression models. Key stakeholder interviews were conducted to qualitatively evaluate program implementation and impacts. RESULTS: After program implementation, the hospital admission rate increased more for the extreme poverty group (48.5 to 70.7%) and moderate poverty group (45.0 to 68.1%), compared to the non-poverty group (52.9 to 64.3%). The largest increase in the number of outpatient visits was also for the extreme poverty group (4.6 to 5.7). The proportion of patients with good medication adherence increased by 15 percentage points in the extreme poverty group and by ten percentage points in the other groups. Satisfaction rates were high in all groups. Qualitative feedback from stakeholders also suggested that increased reimbursement rates, easier reimbursement procedures, and allowance improved patients' service utilization. Implementation of case-based payment made service provision more compliant to clinical pathways. CONCLUSION: Patients in extreme or moderate poverty benefited more from the program compared to a non-poverty group, indicating improved equity in TB service access. The pro-poor design of the program provides important lessons to other TB programs in China and other countries to better address TB care for the poor.

Impact of an innovative financing and payment model on tuberculosis patients' financial burden: is tuberculosis care more affordable for the poor?

BACKGROUND: In response to the high financial burden of health services facing tuberculosis (TB) patients in China, the China-Gates TB project, Phase II, has implemented a new financing and payment model as an important component of the overall project in three cities in eastern, central and western China. The model focuses on increasing the reimbursement rate for TB patients and reforming provider payment methods by replacing fee-for-service with a case-based payment approach. This study investigated changes in out-of-pocket (OOP) health expenditure and the financial burden on TB patients before and after the interventions, with a focus on potential differential impacts on patients from different income groups. METHODS: Three sample counties in each of the three prefectures: Zhenjiang, Yichang and Hanzhong were chosen as study sites. TB patients who started and completed treatment before, and during the intervention period, were randomly sampled and surveyed at the baseline in 2013 and final evaluation in 2015 respectively. OOP health expenditure and percentage of patients incurring catastrophic health expenditure (CHE) were calculated for different income groups. OLS regression and logit regression were conducted to explore the intervention's impacts on patient OOP health expenditure and financial burden after adjusting for other covariates. Key-informant interviews and focus group discussions were conducted to understand the reasons for any observed changes. RESULTS: Data from 738 (baseline) and 735 (evaluation) patients were available for analysis. Patient mean OOP health expenditure increased from RMB 3576 to RMB 5791, and the percentage of patients incurring CHE also increased after intervention. The percentage increase in OOP health expenditure and the likelihood of incurring CHE were significantly lower for patients from the highest income group as compared to the lowest. Qualitative findings indicated that increased use of health services not covered by the standard package of the model was likely to have caused the increase in financial burden. CONCLUSIONS: The implementation of the new financing and payment model did not protect patients, especially those from the lowest income group, from financial difficulty, due partly to their increased use of health service. More financial resources should be mobilized to increase financial protection, particularly for poor patients, while cost containment strategies need to be developed and effectively implemented to improve the effective coverage of essential healthcare in China.

Doctoral level research and training capacity in the social determinants of health at universities and higher education institutions in India, China, Oman and Vietnam: a survey of needs.

BACKGROUND: Research capacity is scarce in low- and middle-income country (LMIC) settings. Social determinants of health research (SDH) is an area in which research capacity is lacking, particularly in Asian countries. SDH research can support health decision-makers, inform policy and thereby improve the overall health and wellbeing of the population. In order to continue building this capacity, we need to know to what extent training exists and how challenges could be addressed from the perspective of students and staff. This paper aims to describe the challenges involved in training scholars to undertake research on the SDH in four Asian countries - China, India, Oman and Vietnam. METHODS: In-depth interviews were conducted with research scholars, research supervisors and principal investigators (n = 13) at ARCADE partner institutions, which included eight universities and research institutes. In addition, structured questionnaires (n = 70) were used to collect quantitative data relating to the courses available, teaching and supervisory capacity, and related issues for students being trained in research on SDH. Simple descriptive statistics were calculated from the quantitative data and thematic analysis applied to the qualitative data. RESULTS: We identified a general lack of training courses focusing on SDH. Added to this, PhD students studying related areas reported inadequate supervision, with limited time allocated to meetings and poor interpersonal communication. Supervisors cited interpersonal communication problems and student lack of skills to perform high quality research as challenges to research training. Further challenges reported included a lack of research funding to include SDH-related topics. Finally, it was suggested that there was a need for institutions to define clear and appropriate standards regarding admission and supervision of students to higher education programs awarding doctoral degrees. CONCLUSIONS: There are gaps in training for research on the SDH at the surveyed universities and research institutes, which are likely to also be present in other Asian countries and their higher education institutions. Some of the barriers to high quality research and research training can be addressed by improved training for supervisors, clearly defined standards of supervision, finances for student stipends, and increased use of information and communication technology to increase access to teaching materials. Increased opportunities for online learning could be provided.

Beyond pilotitis: taking digital health interventions to the national level in China and Uganda.

BACKGROUND: Innovation theory has focused on the adoption of new products or services by individuals and their market-driven diffusion to the population at large. However, major health sector innovations typically emerge from negotiations between diverse stakeholders who compete to impose or at least prioritise their preferred version of that innovation. Thus, while many digital health interventions have succeeded in terms of adoption by a substantial number of providers and patients, they have generally failed to gain the level of acceptance required for their integration into national health systems that would promote sustainability and population-wide application. The area of innovation considered here relates to a growing number of success stories that have created considerable enthusiasm among donors, international agencies, and governments for the potential role of ICTs in transforming weak national health information systems in middle and low income countries. This article uses a case study approach to consider the assumptions, institutional as well as technical, underlying this enthusiasm and explores possible ways in which outcomes might be improved. METHODS: Literature review and case study analysis. RESULTS: The two systems considered have had considerable success in terms of gaining and maintaining government support and addressing the concerns of providers without compromising their core elements. In Uganda, the system has flourished in spite of severe resource constraints, using a participatory approach that has encouraged a high level of community engagement. In China, concern with past failures generated the political will to build a high quality surveillance system, using the latest technology and drawing on a highly skilled human resource base. CONCLUSIONS: Both example stress the importance of recognising the political, social and historical context within which information systems have to function. Implementers need to focus as much on the perceptions, attitudes and needs of stakeholders as on the technology. Implementers should distinguish between factors which may influence engagement at an institutional level and those aimed at supporting and supervising individuals within those institutions. Finally, we would suggest that designing interoperability into systems at the outset, rather than assuming that this can be achieved at some point in the future, may prove far easier in the longer term.

The effect of NCMS on catastrophic health expenditure and impoverishment from tuberculosis care in China.

BACKGROUND: Health expenditure for tuberculosis (TB) care often pushes households into catastrophe and poverty. New Cooperative Medical Scheme (NCMS) aims to protect households from catastrophic health expenditure (CHE) and impoverishment in rural China. This article assesses the effect of NCMS on relieving CHE and impoverishment from TB care in rural China. METHODS: Three hundred fourty-seven TB cases are included in the analysis. We analyze the incidence and intensity of CHE and poverty, and assess the protective effect of NCMS by comparing the CHE and impoverishment before and after reimbursement. RESULTS: After out-of-pocket (OOP) payment for TB care, 16.1 % of non-poor fall below poverty line. The NCMS reduces the incidence of CHE and impoverishment by 11.5 % and 7.3 %. After reimbursement, 46.7 % of the households still experience CHE and 35.4 % are below the poverty line. The NCMS relieves the mean gap, mean positive gap, poverty gap and normalized positive gap by 44.5 %, 51.0 %, US$115.8 and 31.6 % respectively. CONCLUSIONS: The NCMS has partial effect on protecting households from CHE and impoverishment from TB care. The limited protection could be enhanced by redesigning benefit coverage to improve the "height" of the NCMS and representing fee-for-service with alternative payment mechanisms.

Non-medical financial burden in tuberculosis care: a cross-sectional survey in rural China.

BACKGROUND: Treatment of tuberculosis (TB) in China is partially covered by national programs and health insurance schemes, though TB patients often face considerable medical expenditures. For some, especially those from poorer households, non-medical costs, such as transport, accommodation, and nutritional supplementation may be a substantial additional burden. In this article we aim to evaluate these non-medical costs induced by seeking TB care using data from a large scale cross-sectional survey. METHODS: A total of 797 TB cases from three cities were randomly selected using a stratified cluster sampling design. Inpatient medical costs, outpatient medical costs, and direct non-medical costs related to TB treatment were collected using in-person interviews by trained interviewers. Mean and median non-medical costs for different sub-groups were calculated and compared using Kruskal-Wallis and Mann-Whitney U tests. Regression analysis was conducted to assess the influence of different patient characteristics on total non-medical cost. RESULTS: The median non-medical cost was RMB 1429, with interquartile range RMB 424-2793. The median non-medical costs relating to inpatient treatment, outpatient treatment, and additional nutrition supplementation were RMB 540, 91, and 900, respectively. Of the 797 cases, 20 % reported catastrophic expenditure on non-medical costs. Statistically significant differences were detected between different cities, age groups, geographical locations, inpatient/outpatient care, education levels and family income groups. CONCLUSIONS: Non-medical costs relating to TB treatment are a serious financial burden for many TB patients. Financial assistance that can limit this burden is urgently needed during the treatment period, especially for the poor.

Drug-resistant tuberculosis control in China: progress and challenges.

BACKGROUND: China has the second highest caseload of multidrug-resistant tuberculosis (MDR-TB) in the world. In 2009, the Chinese government agreed to draw up a plan for MDR-TB prevention and control in the context of a comprehensive health system reform launched in the same year. DISCUSSION: China is facing high prevalence rates of drug-resistant TB and MDR-TB. MDR-TB disproportionally affects the poor rural population and the highest rates are in less developed regions largely due to interrupted and/or inappropriate TB treatment. Most households with an affected member suffer a heavy financial burden because of a combination of treatment and other related costs. The influential Global Fund programme for MDR-TB control in China provides technical and financial support for MDR-TB diagnosis and treatment. However, this programme has a fixed timeline and cannot provide a long term solution. In 2009, the Bill and Melinda Gates Foundation, in cooperation with the National Health and Family Planning Commission of China, started to develop innovative approaches to TB/MDR-TB management and case-based payment mechanisms for treatment, alongside increased health insurance benefits for patients, in order to contain medical costs and reduce financial barriers to treatment. Although these efforts appear to be in the right direction, they may not be sufficient unless (a) domestic sources are mobilized to raise funding for TB/MDR-TB prevention and control and (b) appropriate incentives are given to both health facilities and their care providers. Along with the on-going Chinese health system reform, sustained government financing and social health protection schemes will be critical to ensure universal access to appropriate TB treatment in order to reduce risk of developing MDR-TB and systematic MDR-TB treatment and management.

Disparity in reimbursement for tuberculosis care among different health insurance schemes: evidence from three counties in central China.

BACKGROUND: Health inequity is an important issue all around the world. The Chinese basic medical security system comprises three major insurance schemes, namely the Urban Employee Basic Medical Insurance (UEBMI), the Urban Resident Basic Medical Insurance (URBMI), and the New Cooperative Medical Scheme (NCMS). Little research has been conducted to look into the disparity in payments among the health insurance schemes in China. In this study, we aimed to evaluate the disparity in reimbursements for tuberculosis (TB) care among the abovementioned health insurance schemes. METHODS: This study uses a World Health Organization (WHO) framework to analyze the disparities and equity relating to the three dimensions of health insurance: population coverage, the range of services covered, and the extent to which costs are covered. Each of the health insurance scheme's policies were categorized and analyzed. An analysis of the claims database of all hospitalizations reimbursed from 2010 to 2012 in three counties of Yichang city (YC), which included 1506 discharges, was conducted to identify the differences in reimbursement rates and out-of-pocket (OOP) expenses among the health insurance schemes. RESULTS: Tuberculosis patients had various inpatient expenses depending on which scheme they were covered by (TB patients covered by the NCMS have less inpatient expenses than those who were covered by the URBMI, who have less inpatient expenses than those covered by the UEBMI). We found a significant horizontal inequity of healthcare utilization among the lower socioeconomic groups. In terms of financial inequity, TB patients who earned less paid more. The NCMS provides modest financial protection, based on income. Overall, TB patients from lower socioeconomic groups were the most vulnerable. CONCLUSION: There are large disparities in reimbursement for TB care among the three health insurance schemes and this, in turn, hampers TB control. Reducing the gap in health outcomes between the three health insurance schemes in China should be a focus of TB care and control. Achieving equity through integrated policies that avoid discrimination is likely to be effective.

Factors that determine catastrophic expenditure for tuberculosis care: a patient survey in China.

BACKGROUND: Tuberculosis (TB) often causes catastrophic economic effects on both the individual suffering the disease and their households. A number of studies have analyzed patient and household expenditure on TB care, but there does not appear to be any that have assessed the incidence, intensity and determinants of catastrophic health expenditure (CHE) relating to TB care in China. That will be the objective of this paper. METHODS: The data used for this study were derived from the baseline survey of the China Government - Gates Foundation TB Phase II program. Our analysis included 747 TB cases. Catastrophic health expenditure for TB care was estimated using two approaches, with households defined as experiencing CHE if their annual expenditure on TB care: (a) exceeded 10 % of total household income; and (b) exceeded 40 % of their non-food expenditure (capacity to pay). Chi-square tests were used to identify associated factors and logistic regression analysis to identify the determinants of CHE. RESULTS: The incidence of CHE was 66.8 % using the household income measure and 54.7 % using non-food expenditure (capacity to pay). An inverse association was observed between CHE rates and household income level. Significant determinants of CHE were: age, household size, employment status, health insurance status, patient income as a percentage of total household income, hospitalization and status as a minimum living security household. Factors including gender, marital status and type of TB case had no significant associations with CHE. CONCLUSIONS: Catastrophic health expenditure incidence from TB care is high in China. An integrated policy expanding the free treatment package and ensuring universal coverage, especially the height of UHC for TB patients, is needed. Financial and social protection interventions are essential for identified at-risk groups.

Are free anti-tuberculosis drugs enough? An empirical study from three cities in China.

BACKGROUND: Tuberculosis (TB) patients in China still face a number of barriers in seeking diagnosis and treatment. There is evidence that the economic burden on TB patients and their households discourages treatment compliance. METHODS: A cross-sectional study was conducted in three cities of China. Patients were selected using probability proportional to size (PPS) cluster sampling of rural townships or urban streets, followed by list sampling from a patient register. Data were collected using a questionnaire survey, key informant interviews and focus group discussions with TB patients to gain an understanding of the economic burden of TB and implications of this burden for treatment compliance. RESULTS: A total of 797 TB patients were surveyed, of which 60 were interviewed in-depth following the survey. More than half had catastrophic health expenditure. TB patients with higher household incomes were less likely to report non-compliance (OR 0.355, 95 % CI 0.140-0.830) and patients who felt that the economic burden relating to TB treatment was high more likely to report non-compliance (OR 3.650, 95 % CI 1.278-12.346). Those who had high costs for transportation, lodging and food were also more likely to report non-compliance (OR 4.150, 95 % CI 1.804-21.999). The findings from the qualitative studies supported those from the survey. CONCLUSION: The economic burden associated with seeking diagnosis and treatment remains a barrier for TB patients in China. Reducing the cost of treatment and giving patients subsidies for transportation, lodging and food is likely to improve treatment compliance. Improving doctors' salary system to cut off the revenue-oriented incentive, and expanding current insurance's coverage can be helpful to reduce patients' actual burden or anticipated burden. Future research on this issue is needed.

New technology and illness self-management: Potential relevance for resource-poor populations in Asia.

Advances in technology have made it possible for many standard diagnostic and health monitoring procedures, traditionally carried out by qualified personnel within medical facilities, to be reliably undertaken by patients or carers in their own homes with a minimum of basic training. There has also been a dramatic increase in the number and diversity of both sources of information on health issues and the possibilities for sharing information and experiences over ICT-based social networks. It has been suggested that these developments have the potential to 'empower' patients, reducing their dependence on providers and possibly improving their quality of care by increasing the volume and timeliness of diagnostic data and encouraging active self-management of their condition, for example through lifestyle changes. Perhaps more significantly, it is also seen by many economies with ageing populations as a way to contain high and ever rising healthcare costs. It has also been suggested that a move to greater self-management supported by expert networks and smart phone technology could improve the treatment of many millions of patients with chronic diseases in low and middle income economies that are also confronting the potential cost implications of epidemiological and demographic transitions, combined with the higher expectations of a more educated and knowledgeable population. There is now limited evidence that some fairly basic e- and mHealth interventions, for example in the areas of MNCH, malaria and HIV/AIDS can have a positive impact, even in resource-poor contexts. The aim here is to explore the extent to which further investment in technology could play a role in the development of an effective and affordable health sector strategy for at least some developing economies. It is suggested that the effectiveness of the approach may be highly dependent on the specific health conditions addressed, the nature of existing health systems and the overall socio-economic and cultural context.

Accelerating learning for pro-poor health markets.

BACKGROUND: Given the rapid evolution of health markets, learning is key to promoting the identification and uptake of health market policies and practices that better serve the needs of the poor. However there are significant challenges to learning about health markets. We discuss the different forms that learning takes, from the development of codified scientific knowledge, through to experience-based learning, all in relationship to health markets. DISCUSSION: Notable challenges to learning in health markets include the difficulty of acquiring data from private health care providers, designing evaluations that capture the complex dynamics present within health markets and developing communities of practice that encompass the diverse actors present within health markets, and building trust and mutual understanding across these groups. The paper proposes experimentation with country-specific market data platforms that can integrate relevant evidence from different data sources, and simultaneously exploring strategies to secure better information on private providers and health markets. Possible approaches to adapting evaluation designs so that they are better able to take account of different and changing contexts as well as producing real time findings are discussed. Finally capturing informal knowledge about health markets is key. Communities of practice that bridge different health market actors can help to share such experience-based knowledge and in so doing, may help to formalize it. More geographically-focused communities of practice are needed, and such communities may be supported by innovation brokers and/or be built around member-based organizations. SUMMARY: Strategic investments in and support to learning about health markets can address some of the challenges experienced to-date, and accelerate learning that supports health markets that serve the poor.

eHealth and mHealth initiatives in Bangladesh: a scoping study.

BACKGROUND: The health system of Bangladesh is haunted by challenges of accessibility and affordability. Despite impressive gains in many health indicators, recent evidence has raised concerns regarding the utilization, quality and equity of healthcare. In the context of new and unfamiliar public health challenges including high population density and rapid urbanization, eHealth and mHealth are being promoted as a route to cost-effective, equitable and quality healthcare in Bangladesh. The aim of this paper is to highlight such initiatives and understand their true potential. METHODS: This scoping study applies a combination of research tools to explore 26 eHealth and mHealth initiatives in Bangladesh. A screening matrix was developed by modifying the framework of Arksey & O'Malley, further complemented by case study and SWOT analysis to identify common traits among the selected interventions. The WHO health system building blocks approach was then used for thematic analysis of these traits. RESULTS: Findings suggest that most eHealth and mHealth initiatives have proliferated within the private sector, using mobile phones. The most common initiatives include tele-consultation, prescription and referral. While a minority of projects have a monitoring and evaluation framework, less than a quarter have undertaken evaluation. Most of the initiatives use a health management information system (HMIS) to monitor implementation. However, these do not provide for effective sharing of information and interconnectedness among the various actors. There are extremely few individuals with eHealth training in Bangladesh and there is a strong demand for capacity building and experience sharing, especially for implementation and policy making. There is also a lack of research evidence on how to design interventions to meet the needs of the population and on potential benefits. CONCLUSION: This study concludes that Bangladesh needs considerable preparation and planning to sustain eHealth and mHealth initiatives successfully. Additional formative and operational research is essential to explore the true potential of the technology. Frameworks for regulation in regards to eHealth governance should be the aim of future research on the integration of eHealth and mHealth into the Bangladesh health system.