American clusters: using machine learning to understand health and health care disparities in the United States.

Health and health care access in the United States are plagued by high inequality. While machine learning (ML) is increasingly used in clinical settings to inform health care delivery decisions and predict health care utilization, using ML as a research tool to understand health care disparities in the United States and how these are connected to health outcomes, access to health care, and health system organization is less common. We utilized over 650 variables from 24 different databases aggregated by the Agency for Healthcare Research and Quality in their Social Determinants of Health (SDOH) database. We used k-means-a non-hierarchical ML clustering method-to cluster county-level data. Principal factor analysis created county-level index values for each SDOH domain and 2 health care domains: health care infrastructure and health care access. Logistic regression classification was used to identify the primary drivers of cluster classification. The most efficient cluster classification consists of 3 distinct clusters in the United States; the cluster having the highest life expectancy comprised only 10% of counties. The most efficient ML clusters do not identify the clusters with the widest health care disparities. ML clustering, using county-level data, shows that health care infrastructure and access are the primary drivers of cluster composition.

Return on investments in the Health Extension Program in Ethiopia.

BACKGROUND: Since 2003, the government of Ethiopia has trained and deployed more than 42,000 Health Extension Workers across the country to provide primary healthcare services. However, no research has assessed the return on investments into human resources for health in this setting. This study aims to fill this gap by analyzing the return on investment within the context of the Ethiopian Health Extension Program. METHODS: We collected data on associated costs and benefits attributed to the Health Extension Program from primary and secondary sources. Primary sources included patient exit interviews, surveys with Health Extension Workers and other health professionals, key informant interviews, and focus groups conducted in the following regions: Amhara, Oromia, Tigray, and the Southern Nations Nationalities and Peoples' Region. Secondary sources consisted of financial and administrative reports gathered from the Ministry of Health and its subsidiaries, as well as data accessed through the Lives Saved Tool. A long-run return on investment analysis was conducted considering program costs (personnel, recurrent, and capital investments) in comparison to benefits gained through improved productivity, equity, empowerment, and employment. FINDINGS: Between 2008-2017, Health Extension Workers saved 50,700 maternal and child lives. Much of the benefits were accrued by low income, less educated, and rural women who had limited access to services at higher level health centers and hospitals. Regional return ranged from $1.27 to $6.64, with an overall return on investment in the range of $1.59 to $3.71. CONCLUSION: While evidence of return on investments are limited, results from the Health Extension Program in Ethiopia show promise for similar large, sustainable system redesigns. However, this evidence needs to be contextualized and adapted in different settings to inform policy and practice. The Ethiopian Health Extension Program can serve as a model for other nations of a large-scale human resources for health program containing strong economic benefits and long-term sustainability through successful government integration.

Impact of COVID-19 on healthcare utilization, cases, and deaths of citizens and displaced Venezuelans in Colombia: Complementary comprehensive and safety-net systems under Colombia's constitutional commitment.

OBJECTIVE: Colombia hosts 1.8 million displaced Venezuelans, the second highest number of displaced persons globally. Colombia's constitution entitles all residents, including migrants, to life-saving health care, but actual performance data are rare. This study assessed Colombia's COVID-era achievements. METHODS: We compared utilization of comprehensive (primarily consultations) and safety-net (primarily hospitalization) services, COVID-19 case rates, and mortality between Colombian citizens and Venezuelans in Colombia across 60 municipalities (local governments). We employed ratios, log transformations, correlations, and regressions using national databases for population, health services, disease surveillance, and deaths. We analyzed March through November 2020 (during COVID-19) and the corresponding months in 2019 (pre-COVID-19). RESULTS: Compared to Venezuelans, Colombians used vastly more comprehensive services than Venezuelans (608% more consultations), in part due to their 25-fold higher enrollment rates in contributory insurance. For safety-net services, however, the gap in utilization was smaller and narrowed. From 2019 to 2020, Colombians' hospitalization rate per person declined by 37% compared to Venezuelans' 24%. In 2020, Colombians had only moderately (55%) more hospitalizations per person than Venezuelans. In 2020, rates by municipality between Colombians and Venezuelans were positively correlated for consultations (r = 0.28, p = 0.04) but uncorrelated for hospitalizations (r = 0.10, p = 0.46). From 2019 to 2020, Colombians' age-adjusted mortality rate rose by 26% while Venezuelans' rate fell by 11%, strengthening Venezuelans' mortality advantage to 14.5-fold. CONCLUSIONS: The contrasting patterns between comprehensive and safety net services suggest that the complementary systems behaved independently. Venezuelans' lower 2019 mortality rate likely reflects the healthy migrant effect (selective migration) and Colombia's safety net healthcare system providing Venezuelans with reasonable access to life-saving treatment. However, in 2020, Venezuelans still faced large gaps in utilization of comprehensive services. Colombia's 2021 authorization of 10-year residence to most Venezuelans is encouraging, but additional policy changes are recommended to further integrate Venezuelans into the Colombian health care system.

Economic Evaluation Design within the HEAL Prevention Cooperative.

The rapid rise in opioid misuse, disorder, and opioid-involved deaths among older adolescents and young adults is an urgent public health problem. Prevention is a vital part of the nation's response to the opioid crisis, yet preventive interventions for those at risk for opioid misuse and opioid use disorder are scarce. In 2019, the National Institutes of Health (NIH) launched the Preventing Opioid Use Disorder in Older Adolescents and Young Adults cooperative as part of its broader Helping to End Addiction Long-term (HEAL) Initiative ( https://heal.nih.gov/ ). The HEAL Prevention Cooperative (HPC) includes ten research projects funded with the goal of developing effective prevention interventions across various settings (e.g., community, health care, juvenile justice, school) for older adolescent and young adults at risk for opioid misuse and opioid use disorder (OUD). An important component of the HPC is the inclusion of an economic evaluation by nine of these research projects that will provide information on the costs, cost-effectiveness, and sustainability of these interventions. The HPC economic evaluation is integrated into each research project's overall design with start-up costs and ongoing delivery costs collected prospectively using an activity-based costing approach. The primary objectives of the economic evaluation are to estimate the intervention implementation costs to providers, estimate the cost-effectiveness of each intervention for reducing opioid misuse initiation and escalation among youth, and use simulation modeling to estimate the budget impact of broader implementation of the interventions within the various settings over multiple years. The HPC offers an extraordinary opportunity to generate economic evidence for substance use prevention programming, providing policy makers and providers with critical information on the investments needed to start-up prevention interventions, as well as the cost-effectiveness of these interventions relative to alternatives. These data will help demonstrate the valuable role that prevention can play in combating the opioid crisis.

Impact of weekday and weekend mobility and public policies on COVID-19 incidence and deaths across 76 large municipalities in Colombia: statistical analysis and simulation.

BACKGROUND: Despite widespread restrictions on residents' mobility to limit the COVID-19 pandemic, controlled impact evaluations on such restrictions are rare. While Colombia imposed a National Lockdown, exceptions and additions created variations across municipalities and over time.  METHODS: We analyzed how weekend and weekday mobility affected COVID-19 cases and deaths. Using GRANDATA from the United Nations Development Program (UNDP) we examined movement in 76 Colombian municipalities, representing 60% of Colombia's population, from March 2, 2020 through October 31, 2020. We combined the mobility data with Colombia's National Epidemiological Surveillance System (SIVIGILA) and other databases and simulated impacts on COVID-19 burden.  RESULTS: During the study period, Colombians stayed at home more on weekends compared to weekdays. In highly dense municipalities, people moved less than in less dense municipalities. Overall, decreased movement was associated with significant reductions in COVID-19 cases and deaths two weeks later. If mobility had been reduced from the median to the threshold of the best quartile, we estimate that Colombia would have averted 17,145 cases and 1,209 deaths over 34.9 weeks, reductions of 1.63% and 3.91%, respectively. The effects of weekend mobility reductions (with 95% confidence intervals) were 6.40 (1.99-9.97) and 4.94 (1.33-19.72) times those of overall reductions for cases and deaths, respectively. CONCLUSIONS: We believe this is the first evaluation of day-of-the week mobility on COVID-19. Weekend behavior was likely riskier than weekday behavior due to larger gatherings and less social distancing or protective measures. Reducing or shifting such activities outdoors would reduce COVID-19 cases and deaths.

Impact of Respiratory Syncytial Virus on Child, Caregiver, and Family Quality of Life in the United States: Systematic Literature Review and Analysis.

BACKGROUND: Respiratory syncytial virus (RSV), a leading cause of lower respiratory tract infection in US children, reduces quality of life (QOL) of children, their caregivers, and families. METHODS: We conducted a systematic literature review in PubMed, EconLit, and other databases in the United States of articles published since 2000, derived utility lost per RSV episode from cohort studies, and performed a systematic analysis. RESULTS: From 2262 unique citations, 35 received full-text review and 7 met the inclusion criteria (2 cohort studies, 4 modeling studies, and 1 synthesis). Pooled data from the 2 cohort studies (both containing only hospitalized premature infants) gave quality-adjusted life-year (QALY) losses per episode of 0.0173 at day 38. From the cohort study that also assessed caregivers' QOL, we calculated net QALYs lost directly attributable to RSV per nonfatal episode from onset to 60 days after onset for the child, caregiver, child-and-caregiver dyad of 0.0169 (167% over prematurity alone), 0.0031, and 0.0200, respectively. CONCLUSION: Published data on QOL of children in the United States with RSV are scarce and consider only premature hospitalized infants, whereas most RSV episodes occur in children who were born at term and were otherwise healthy. QOL studies are needed beyond hospitalized premature infants.

Cost of Respiratory Syncytial Virus Infections in US Infants: Systematic Literature Review and Analysis.

BACKGROUND: Limited data are available on the economic costs of respiratory syncytial virus (RSV) infections among infants and young children in the United States. METHODS: We performed a systematic literature review of 10 key databases to identify studies published between 1 January 2014 and 2 August 2021 that reported RSV-related costs in US children aged 0-59 months. Costs were extracted and a systematic analysis was performed. RESULTS: Seventeen studies were included. Although an RSV hospitalization (RSVH) of an extremely premature infant costs 5.6 times that of a full-term infant ($10 214), full-term infants accounted for 82% of RSVHs and 70% of RSVH costs. Medicaid-insured infants were 91% more likely than commercially insured infants to be hospitalized for RSV treatment in their first year of life. Medicaid financed 61% of infant RSVHs. Paying 32% less per hospitalization than commercial insurance, Medicaid paid 51% of infant RSVH costs. Infants' RSV treatment costs $709.6 million annually, representing $187 per overall birth and $227 per publicly funded birth. CONCLUSIONS: Public sources pay for more than half of infants' RSV medical costs, constituting the highest rate of RSVHs and the highest expenditure per birth. Full-term infants are the predominant source of infant RSVHs and costs.

Integrating Venezuelan Migrants into the Colombian Health System during COVID-19.

Colombia provides a unique setting to understand the complicated interaction between health systems, health insurance, migrant populations, and COVID-19 due to its system of Universal Health Coverage and its hosting of the second-largest population of displaced persons globally, including approximately 1.8 million Venezuelan migrants. We surveyed 8,130 Venezuelan migrants and Colombian nationals across 60 municipalities using a telephone survey during the first wave of the pandemic (September through November 2020). Using self-reported enrollment in one of the several Colombian health insurance schemes, we analyzed the access to and disparities in the use of health-care services for both Colombians and Venezuelan migrants by insurance status, including access to formal health services, virtual visits, and COVID-19 testing for both groups. We found that compared with 3.6% of Colombians, 73.6% of Venezuelan telephone survey respondents remain uninsured, despite existing policies that allow legally present migrants to enroll in national health insurance schemes. Enrolling migrants in either the subsidized or contributory regime increases their access to health-care services, and equality between Colombians and Venezuelans within the same insurance schemes can be achieved for some services. Colombia's experience integrating Venezuelan migrants into their current health system through various insurance schemes during the first wave of their COVID-19 pandemic shows that access and equality can be achieved, although there continue to be challenges.

Health system strengthening for vision care in The Gambia.

INTRODUCTION: According to global estimates, 39 million people are blind and 285 million are at risk of severe vision loss, with a significant portion of this burden in Sub-Saharan Africa. Some African nations like The Gambia are beginning to tackle vision impairment by addressing the problem through a health system lens. METHODS: A health system framework, focusing on system areas of leadership and governance, resources for vision care, and vision care access, was used to understand and analyze how The Gambia has increased access to vision care using a public-private pilot partnership. A desk review of relevant literature, key informant interviews with stakeholders, and a cross-sectional analysis of several databases were used to understand the following aspects of the pilot vision care model in The Gambia: leadership and governance, financial and human resources, and vision care access. RESULTS: The results show that a coordinated public-private pilot partnership between the government of The Gambia and the non-profit organization OneSight has led to improved leadership and governance for vision care, increased workforce and training, and sustainable financing for vision centers producing net revenue resulting in an increase in both the supply and demand for eyeglasses. The results also show that there is considerable variation in the prevalence of refractive errors and access to eyecare services across The Gambia, which can be influenced by accessibility, awareness, and affordability. CONCLUSION: Using a health system framework enables a systematic examination of vision care services. Results from The Gambia provide an example of a public-private pilot partnership that can improve vision care for all.

Cost analysis in implementation studies of evidence-based practices for mental health and substance use disorders: a systematic review.

BACKGROUND: This study is a systematic literature review of cost analyses conducted within implementation studies on behavioral health services. Cost analysis of implementing evidence-based practices (EBP) has become important within implementation science and is critical for bridging the research to practice gap to improve access to quality healthcare services. Costing studies in this area are rare but necessary since cost can be a barrier to implementation and sustainment of EBP. METHODS: We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and applied the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Key search terms included: (1) economics, (2) implementation, (3) EBP, and (4) behavioral health. Terms were searched within article title and abstracts in: EconLit, SocINDEX, Medline, and PsychINFO. A total of 464 abstracts were screened independently by two authors and reduced to 37 articles using inclusion and exclusion criteria. After a full-text review, 18 articles were included. RESULTS: Findings were used to classify costs into direct implementation, direct services, and indirect implementation. While all studies included phases of implementation as part of their design, only five studies examined resources across multiple phases of an implementation framework. Most studies reported direct service costs associated with adopting a new practice, usually summarized as total EBP cost, cost per client, cost per clinician, and/or cost per agency. For studies with detailed analysis, there were eleven direct cost categories represented. For five studies that reported costs per child served, direct implementation costs varied from $886 to $9470 per child, while indirect implementation costs ranged from $897 to $3805 per child. CONCLUSIONS: This is the first systematic literature review to examine costs of implementing EBP in behavioral healthcare settings. Since 2000, 18 studies were identified that included a cost analysis. Given a wide variation in the study designs and economic methods, comparison across studies was challenging, which is a major limitation in the field, as it becomes difficult to replicate studies or to estimate future costs to inform policy decisions related to budgeting. We recommend future economic implementation studies to consider standard economic costing methods capturing costs across implementation framework phases to support comparisons and replicability.

Activity-based costing for HIV, primary care and nutrition services in low- and middle-income countries: A systematic literature review and synthesis.

Background: This study is a systematic literature review of HIV, nutrition, and primary care activity-based costing (ABC) studies conducted in low- and middle-income countries. ABC studies are critical for understanding the quantities and unit costs of the activities and resources for specific cost functions. The results of ABC studies enable governments, funders, and policymakers to utilize costing results to make efficient, cost-effective decisions on how to allocate scarce resources. Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology for systematic literature reviews. Key search terms included: (1) activity-based costing and time-driven activity-based costing, (2) cost of services, (3) HIV interventions OR (4) primary health care. Terms were searched within article titles and abstracts in PubMed, EconLit, and Scopus. Results: 1,884 abstracts were screened and reduced to 57 articles using exclusion criteria. After a full text review, 16 articles were included in the final data synthesis. Findings were used to classify costs into relevant and common inputs for activity-based costing. All costs were converted to unit cost (cost per patient) and inflated to January 2020 USD. The largest unit cost across nutrition services was training (US$194.16 per patient, 34.6% of total unit cost). The largest unit cost for HIV was antiretroviral therapy (ART) (US$125.41, 71.0%). The largest unit cost for primary care services was human resources (US$84.78, 62.5%). Overall costs per patient for HIV services were US$176.71, US$135.67 for primary care services, and US$561.68 for nutrition services. The costing results presented suggest that spending on HIV exceeds the actual cost of HIV services. Conclusions: This is the first systematic literature review to summarize the costs of HIV, primary care, and nutrition services across activity-based costing studies. While there was a wide variation in the study designs and economic methods, many of the input cost categories were similar. With the increasing number of costing studies in countries around the world, understanding trends in costs by function and service can lead to greater efficiency in the implementation of HIV, primary care, and nutrition programs.

Opioid prescribing for surgical dental procedures in dental clinics of military treatment facilities.

BACKGROUND: Variation in opioid prescribing rates among geographic regions is well known and, to the authors' knowledge, there have been no studies of variation from 1 dental clinic to another, and such variation might suggest an excess of opioid prescriptions. METHODS: The authors used a retrospective cohort design study of all dental encounter records for 819,453 soldiers in the dental clinics (n = 250) of the US Military Health System during the period from 2008 through 2017. RESULTS: There were 743,459 dental surgical encounters. Opioid prescriptions were filled for 36.7% of these encounters. Multinomial multilevel regression found statistically significant between-facility variance in opioid prescribing, which was partially explained via facility-level characteristics (region, type, and percentage of surgeries for young patients), and practice variables (mean percentage extractions, percentage periodontic surgery, and percentage specialists). CONCLUSIONS: The authors found a substantial variation in opioid prescribing among dental clinics in the US Military Health System. Dentists at 11 of the 30 largest military treatment facilities prescribed at a rate 4 percentage points higher than expected, and dentists at 9 of these military treatment facilities had a rate of 4 percentage points lower than expected. Additional study of the factors allowing the low-prescribing facilities to achieve these rates might lead to an overall decrease in opioid prescribing. PRACTICAL IMPLICATIONS: The authors' findings of dental opioid prescribing in the military can lead to appreciation of the guidelines from the American Dental Association and the American Association of Oral and Maxillofacial Surgeons, which suggest alternatives to opioid prescribing for surgical procedures, particularly for tooth extractions.

Global Fund financing and human resources for health investments in the Eastern Mediterranean Region.

BACKGROUND: Despite the large investments in donor-related health activities in areas of the globe prone to tension and conflict, few studies have examined in detail the role of these donor investments in human resources for health (HRH). METHODS: We used a mixed-methods research methodology comprising both quantitative and qualitative analyses to analyze the Enhanced Financial Reporting System of the Global Fund to Fight AIDS, Tuberculosis and Malaria budget and expenditure data from 2003 to 2017 for 13 countries in the Eastern Mediterranean Region (EMR). We analyzed additional detailed budgetary data over the period 2015-2017 for a sub-set of these countries. Two country-case studies were conducted in Afghanistan and Sudan for a more in-depth understanding of the HRH-related activities that occurred as a result of Global Fund grants. RESULTS: The results show that US$2.2 billion Global Fund dollars had been budgeted and US$1.6 billion were expended over the period 2003-2017 in 13 Eastern Mediterranean countries. The average expenditures for human resources for health (training and human resources) as a percentage of total expenditure are 28%. Additional detailed budgetary data analysis shows a more conservative investment in HRH with 13% of total budgets allocated to "direct" HRH activities such as salaries, training costs, and technical assistance. HRH-related activities supported by the Global Fund in Afghanistan and Sudan were similar, including pre-service and in-services training, hiring of program coordinators and staff, and top-ups for clinical staff. CONCLUSIONS: HRH remains a key issue in strengthening the health systems of low- and middle-income countries. While this study suggests that Global Fund's HRH investments in the EMR are not lagging behind the global average, there appears to be a need to further scale up these investments considering this region's unique HRH challenges.

The Challenge of Additionality: The Impact of Central Grants for Primary Healthcare on State-Level Spending on Primary Healthcare in India.

BACKGROUND: In planning for universal health coverage, many countries have been examining their fiscal decentralization policies with the goal of increasing efficiency and equity via "additionalities." The concept of "additionality," when the government of a lower administrative level increases the funding allocated to a particular issue when extra funds are present, is often used in these contexts. Although the definition of "additionality" can be used more broadly, for the purposes of this paper we focus narrowly on the additional allocation of primary healthcare expenditures. This paper explores this idea by examining the impact of central level primary healthcare expenditure, on individual state level contributions to primary healthcare expenditure within 16 Indian states between 2005 and 2013. METHODS: In examining 5 main variables, we compared differences between government expenditures, contributions, and revenues for Empowered Action Group (EAG) states, and non-EAG states. EAG states are normally larger states that have weaker public health infrastructure and hence qualify for additional funding. Finally, using a model that captured the quantity of central level primary healthcare expenditure distributions to these states, we measured its impact on each state's own contributions to primary healthcare spending. RESULTS: Our results show that, at the state level, growth in per capita central level primary healthcare expenditure has increased by 110% from 2005-2013, while state's own contributions to primary healthcare expenditure per capita increased by 32%. Further analyses show that a 1% change disbursement from the central level leads to a -0.132%, although not significant, change by states in their own expenditure. The effect for wealthier states is -0.151% and significant and for poorer states the effect is smaller at -0.096% and not significant. CONCLUSION: This analysis suggests that increases in central level primary healthcare expenditure to states have an inverse relationship with primary healthcare expenditures by the state level. Furthermore, this effect is more pronounced in wealthier Indian states. This finding has policy implications on India's decision to increase block grants to states in place of targeted program expenditures.

An Overlapping Systems Conceptual Framework to Evaluate Implementation of a Behavioral Health Intervention for Justice-Involved Youth.

BACKGROUND: Nearly 65% of justice-involved youth have a substance use and/or mental health disorder. Although evidence-based practices have been established for adolescents with co-occurring mental health and substance use disorders, these practices are not widely used in juvenile justice agencies due to environmental and organizational complexities. METHODS: Our study builds on Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS), a multi-site cooperative research initiative of juvenile justice and partnering behavioral health agencies. We also integrate state and county-level data to support broader assessment of key drivers of implementation success. RESULTS: We present an economics/systems conceptual model describing how the environmental context, systems organization, and economic costs of implementation can affect implementation outcomes. Comparison of intervention condition (Core vs Enhanced) and pre-implementation costs (High vs Low) found differences in insurance reimbursements and types, as well as agency staffing characteristics. DISCUSSION: Implementing new procedures or policies at a systems level must consider implementation outcomes in a broad context. Factors such as population demographics, primary care and behavioral health treatment capacity, unemployment rates, and public funding for treatment and other services are important in determining intervention success and sustainability.

Associations Between Practices and Behaviors at the Health Facility Level and Supply Chain Management for Antiretrovirals: Evidence from Cameroon, Namibia, and Swaziland.

BACKGROUND: While measuring, monitoring, and improving supply chain management (SCM) for antiretrovirals (ARVs) is understood at many levels of health systems, a gap remains in the identification and measurement of facility-level practices and behaviors that affect SCM. This study identifies practices and behaviors that are associated with SCM of ARVs at the hospital level and proposes new indicators for measurement. METHODS: We performed an in-depth literature review to identify facility-level practices and behaviors and existing indicators that are associated with SCM. We used the United States Agency for International Development's 2013 National Supply Chain Assessment Toolkit to define 7 supply chain function areas to frame the study. Qualitative, semistructured key informant and focus group interviews were conducted in hospitals with health professionals from Cameroon, Namibia, and Swaziland to understand facility-level practices and behaviors. RESULTS: Using the results from 54 key informant and focus group interviews from 12 hospitals, we identified 30 practices and behaviors that may affect ARV SCM at the facility level. The following practice areas were particularly associated with SCM: order verification, actions taken when ARV stock is received, changes in prescription and dispensing due to ARV stock-out, actions to ensure patient adherence, and communication with other affiliated facilities and higher-level SCM. We subsequently developed measurable indicators for future research. CONCLUSION: This study characterizes facility-level practices and behaviors that can affect ARV SCM. It also identifies gaps in their measurement. While this study uses ARVs as a tracer medicine to understand gaps in practices at the facility level, many of the findings are more broadly applicable to other medicines in an integrated setting. This study provides real-world evidence and the groundwork for further research to characterize the link between 30 facility-level practices and behaviors and ARV SCM at the facility and central levels.

Correction to: benefit incidence analysis in public health facilities in India: utilization and benefits at the national and state levels.

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Low effective coverage of family planning and antenatal care services in Ethiopia.

OBJECTIVE: To assess the quality and effective coverage (EC) of family planning (FP) and antenatal care (ANC) services in Ethiopia. DESIGN: Secondary analyses of the 2014 Ethiopia Service Provision Assessment Plus Survey and 2016 Ethiopia Demographic and Health Survey data. SETTING AND PARTICIPANTS: Women using FP and ANC. MAIN OUTCOME MEASURES: Quality indices are created as a proportion of recommended clinical actions done in observations of ANC and FP visits. We adjust the crude coverage of ANC and of FP by the quality to estimate EC for both services. RESULTS: The crude coverage of FP was 61% and 62% for ANC in Ethiopia in 2016. On average, quality was 35.8% during FP visits and 86% of women received <50% of the recommended clinical actions. When adjusting the crude coverage to account for the quality of service, Ethiopia's FP services EC was 22%. On average, ANC quality was 34% and 81% received <50% of the recommended ANC clinical actions. When adjusting the crude coverage by the service quality, the mean EC of ANC services was 22% in Ethiopia. CONCLUSIONS: The quality of both FP and ANC services is low in Ethiopia, with women obtaining only a fraction of the standard clinical actions during their visits. In addition, there is considerable variation in EC across Ethiopia's regions, with variation driven largely by variations in crude coverage. To improve EC, actions are needed to improve the quality of ANC and FP care.

Benefit incidence analysis in public health facilities in India: utilization and benefits at the national and state levels.

BACKGROUND: Benefit Incidence Analysis (BIA) is used to understand the distribution of health care utilization and spending in comparison to income distribution. The results can illustrate how effectively governments allocate limited resources towards meeting the needs of the poor. In analyzing the distribution of public spending on inpatient, outpatient, and deliveries, this paper represents the most recent BIA completed in India. METHODS: In order to conduct the BIA statistical analysis for this project, 2014 utilization data from the most recently completed Indian National Sample Survey (NSS) was used. Unit costs were estimated for primary care, hospital inpatient, hospital outpatient, and deliveries. Concentration curves and concentration indices were estimated both at the national and state levels. Analyses were reported for overall utilization, as well as for the gross and net benefits for inpatient, outpatient, and deliveries. RESULTS: According to the results, utilization of government inpatient and delivery services is pro-poor. When gross and net benefits are included in the analysis, services become more equal and less pro-poor. Gross benefits, which are measured with state-level unit costs, are virtually equal for all services. Although there are some pro-poor gross benefits trends for national outpatient services, the results also show that the equality of national gross benefits trends hides a significant disparity across Indian States. While a number of Indian States have outpatient gross benefits that are pro-poor, few show pro-poor benefits for inpatient and delivery services. Net benefits, which considers both unit costs for each respective service, and out-of-pocket (OOP) expenditures, trend similarly to gross benefits. In addition, those who use public facilities spend considerable OOP to supplement government services. CONCLUSIONS: This BIA reveals that government spending on public health care has not resulted in significantly pro-poor services. While some progress has been made relative to deliveries and outpatient services, inpatient stays are not pro-poor. In addition, national results mask significant disparities across Indian states.