Financial protection in health revisited: Is catastrophic health spending underestimated for service- or disease-specific analysis?

Economists originally developed methods to assess financial catastrophe using total or aggregate out-of-pocket health spending. Aggregate out-of-pocket health spending is financially catastrophic when it exceeds a fixed proportion (i.e., threshold) of a household's total income or expenditure in a given period. However, these methods are now applied to assess financial catastrophe in disease- or service-specific rather than aggregate out-of-pocket health spending without using disease- or service-specific thresholds. This paper argues that not using disease- or service-specific thresholds for such assessments is misleading and underestimates the burden of financial catastrophe, especially among households from poorer backgrounds. It then proposed disease- or service-specific catastrophic payment thresholds, applied them to Nigeria and found that financial catastrophe was underestimated for the five service groups considered. The paper stresses the importance of using disease- or service-specific thresholds and avoiding unadjusted thresholds, which may leave poorer households behind as financially protected.

A qualitative evaluation of stakeholder perspectives on sustainable financing strategies for 'priority' adolescent sexual and reproductive health interventions in Ghana.

BACKGROUND: Adolescent sexual and reproductive health (ASRH) interventions are underfunded in Ghana. We explored stakeholder perspectives on innovative and sustainable financing strategies for priority ASRH interventions in Ghana. METHODS: Using qualitative design, we interviewed 36 key informants to evaluate sustainable financing sources for ASRH interventions in Ghana. Thematic content analysis of primary data was performed. Study reporting followed the consolidated criteria for reporting qualitative research. RESULTS: Proposed conventional financing strategies included tax-based, need-based, policy-based, and implementation-based approaches. Unconventional financing strategies recommended involved getting religious groups to support ASRH interventions as done to mobilize resources for the Ghana COVID-19 Trust Fund during the global pandemic. Other recommendations included leveraging existing opportunities like fundraising through annual adolescent and youth sporting activities to support ASRH interventions. Nonetheless, some participants believed financial, material, and non-material resources must complement each other to sustain funding for priority ASRH interventions. CONCLUSION: There are various sustainable financing strategies to close the funding gap for ASRH interventions in Ghana, but judicious management of financial, material, and non-material resources is needed to sustain priority ASRH interventions in Ghana.

A short note revisiting the concentration index: Does the normalization of the concentration index matter?

The concentration index, including its normalization, is prominently used to assess socioeconomic inequalities in health and health care. Wagstaff's and Erreygers' normalizations or corrections of the standard concentration index are the most suggested approaches when analyzing binary health variables encountered in many health economics and health services research. In empirical applications of the corrected or normalized concentration indices, researchers interpret them similarly to the standard concentration index, which may be problematic as this ignores their underlying behaviors. This paper shows that the empirical bounds of the standard concentration index, including the corrected indices, depend not only on the sample size directly but also on the sampling weight. Notably, the paper highlights critical challenges for assessing and interpreting the popular Wagstaff's and Erreygers' corrected concentration indices with binary health variables. Specifically, it shows that it might be misleading, for example, to assess socioeconomic health inequalities using the magnitude of the "symmetric" Erreygers' corrected concentration index in the face of progressive improvements in the binary health variable. Also, Wagstaff's normalized concentration index may give a spurious "concentration" of the binary health variable among the rich or the poor in certain rare instances.

Hospital delivery and neonatal mortality in 37 countries in sub-Saharan Africa and South Asia: An ecological study.

BACKGROUND: Widespread increases in facility delivery have not substantially reduced neonatal mortality in sub-Saharan Africa and South Asia over the past 2 decades. This may be due to poor quality care available in widely used primary care clinics. In this study, we examine the association between hospital delivery and neonatal mortality. METHODS AND FINDINGS: We used an ecological study design to assess cross-sectional associations between the share of hospital delivery and neonatal mortality across country regions. Data were from the Demographic and Health Surveys from 2009 to 2018, covering 682,239 births across all regions. We assess the association between the share of facility births in a region that occurred in hospitals (versus lower-level clinics) and early (0 to 7 days) neonatal mortality per 1,000 births, controlling for potential confounders including the share of facility births, small at birth, maternal age, maternal education, urbanicity, antenatal care visits, income, region, and survey year. We examined changes in this association in different contexts of country income, global region, and urbanicity using interaction models. Across the 1,143 regions from 37 countries in sub-Saharan Africa and South Asia, 42%, 29%, and 28% of births took place in a hospital, clinic, and at home, respectively. A 10-percentage point higher share of facility deliveries occurring in hospitals was associated with 1.2 per 1,000 fewer deaths (p-value < 0.01; 95% CI: 0.82 to 1.60), relative to mean mortality of 22. Associations were strongest in South Asian countries, middle-income countries, and urban regions. The study's limitations include the inability to control for all confounding factors given the ecological and cross-sectional design and potential misclassification of facility levels in our data. CONCLUSIONS: Regions with more hospital deliveries than clinic deliveries have reduced neonatal mortality. Increasing delivery in hospitals while improving quality across the health system may help to reduce high neonatal mortality.

Assessing financial protection in health: Does the choice of poverty line matter?

Financial protection in health is an essential aspect of the universal health coverage discourse. It is about ensuring that paying for health services does not affect the ability of households and individuals to afford necessities. A well-known way to assess financial protection is whether or not people are pushed into-or further into-poverty by paying out-of-pocket for health services. Although impoverishment from out-of-pocket health spending is not an explicit indicator of the sustainable development goals, it has gained prominence among researchers and policymakers because of its intuitive appeal and link to overall poverty reduction. Using data from Nigeria, this paper demonstrates that the choice of poverty line matters for assessing the impoverishing effect of paying out-of-pocket for health services. Among other things, the inconsistencies (or lack of dominance) could occur in ranking impoverishment levels by mutually exclusive groups within a country or in ranking different countries or a country over time. The implication is that the choice of poverty line could lead to manipulation of results for policy and for supporting an agenda that demonstrates an improvement in financial protection when this may not necessarily be the case.

Correction to: What has been the progress in addressing financial risk in Uganda? Analysis of catastrophe and impoverishment due to health payments.

An amendment to this paper has been published and can be accessed via the original article.

What has been the progress in addressing financial risk in Uganda? Analysis of catastrophe and impoverishment due to health payments.

BACKGROUND: Monitoring progress towards Universal Health Coverage (UHC) requires an assessment of progress in coverage of health services and protection of households from the impact of direct out-of-pocket payments (i.e. financial risk protection). Although Uganda has expressed aspirations for attaining UHC, out-of-pocket payments remain a major contributor to total health expenditure. The aim of this study is to monitor progress in financial risk protection in Uganda. METHODS: This study uses data from the Uganda National Household Surveys for 2005/06, 2009/10, 2012/13 and 2016/17. We measure financial risk protection using catastrophic health care payments and impoverishment indicators. Health care payments are catastrophic if they exceed a set threshold (i.e. 10 and 25%) of the total household consumption expenditure. Health payments are impoverishing if they push the household below the poverty line (the US$1.90/day and Uganda's national poverty lines). A logistic regression model is used to assess the factors associated with household financial risk. RESULTS: The results show that while progress has been made in reducing financial risk, this progress remains minimal, and there is still a risk of a reversal of this trend. We find that although catastrophic health payments at the 10% threshold decreased from 22.4% in 2005/06 to 13.8% in 2012/13, it increased to 14.2% in 2016/17. The percentage of Ugandans pushed below the national poverty line (US$1.90/day) has decreased from 5.2% in 2005/06 to 2.7% in 2016/17. The distribution of both catastrophic health payments and impoverishment varies across socio-economic status, location and residence. In addition, certain household characteristics (poverty, having a child below 5 years and an adult above 60 years) are more associated with the lack of financial risk protection. CONCLUSION: There is need for targeted interventions to reduce OOP, especially among those affected so as to increase financial risk protection. In the short-term, it is important to ensure that public health services are funded adequately to enable effective coverage with quality health care. In the medium-term, increased reliance on mandatory prepayment will reduce the burden of OOP health spending further.

Assessing medical impoverishment and associated factors in health care in Ethiopia.

BACKGROUND: About 5% of the global population, predominantly in low- and middle-income countries, is forced into poverty because of out-of-pocket (OOP) health spending. In most countries in sub-Saharan Africa, the share of OOP health spending in current health expenditure exceeds 35%, increasing the likelihood of impoverishment. In Ethiopia, OOP payments remained high at 37% of current health expenditure in 2016. This study assesses the impoverishment resulting from OOP health spending in Ethiopia and the associated factors. METHODS: This paper uses data from the Ethiopian Household Consumption Expenditure Survey (HCES) 2010/11. The HCES covered 10,368 rural and 17,664 urban households. OOP health spending includes spending on various outpatient and inpatient services. Impoverishing impact of OOP health spending was estimated by comparing poverty estimates before and after OOP health spending. A probit model was used to assess factors that are associated with impoverishment. RESULTS: Using the Ethiopian national poverty line of Birr 3781 per person per year (equivalent to US$2.10 per day), OOP health spending pushed about 1.19% of the population (i.e. over 957,169 individuals) into poverty. At the regional level, impoverishment ranged between 2.35% in Harari and 0.35% in Addis Ababa. Living in rural areas (highland, moderate, or lowland) increased the likelihood of impoverishment compared to residing in an urban area. Households headed by males and adults with formal education are less likely to be impoverished by OOP health spending, compared to their counterparts. CONCLUSION: In Ethiopia, OOP health spending impoverishes a significant number of the population. Although the country had piloted and initiated many reforms, e.g. the fee waiver system and community-based health insurance, a significant proportion of the population still lacks financial protection. The estimates of impoverishment from out-of-pocket payments reported in this paper do not consider individuals that are already poor before paying out-of-pocket for health services. It is important to note that this population may either face deepening poverty or forgo healthcare services if a need arises. More is therefore required to provide financial protection to achieve universal health coverage in Ethiopia, where the informal sector is relatively large.

Equity in household spending on alcoholic beverages in South Africa: assessing changes between 1995 and 2011.

BACKGROUND: Globally, alcohol consumption accounts for a substantial burden of disease, which translates into high social and economic costs. To address this burden, several policies (e.g. age and trading hour restrictions, increasing alcohol taxation) were implemented. Despite the existence of these policies evidence shows that alcohol misuse and alcohol-related harms have increased in South Africa over recent years. The objective of this paper is to assess progressivity and the changes in progressivity of alcohol expenditure at the household level in South Africa using datasets that span 15 years. METHODS: Data come from the 1995, 2000, 2005/06 and 2010/11 South Africa Income Expenditure Survey. Distribution of spending on alcoholic beverages were analyzed using standard methodologies. Changes in progressivity between 1995 and 2000, and between 2005/06 and 2010/11 were also assessed using the Kakwani index. RESULTS: Alcohol spending was regressive between 1995 and 2011 as the fraction of poorer households' expenditure spent on alcohol beverage exceeds that for the richest households. Also, the difference in Kakwani indexes of progressivity indicates that spending on alcoholic beverages has become less regressive between the same time periods. CONCLUSION: The results show no evidence that alcohol policy including taxation increased regressivity. Thus, there is an opportunity to further reduce the regressivity using coherent alcohol policies. This paper concludes that there is a need for further research to unpack why alcohol spending became less regressive over the years that goes beyond just looking at changes in the distribution of alcohol expenditure.

Socio-economic inequality in health service utilisation: Does accounting for seasonality in health-seeking behaviour matter?

Seasonal variation exists in disease incidence. The variation could occur across the different regions in a country. This paper argues that using national household data that are not adjusted for seasonal and regional variations in disease incidence may not be directly suitable for assessing socio-economic inequality in annual outpatient service utilisation, including for cross-country comparison. In fact, annual health service utilisation may be understated or overstated depending on the period of data collection. This may lead to miss-estimation of socio-economic inequality in health service utilisation depending, among other things, on how health service utilisation, across geographical areas, varies by socio-economic status. Using a nationally representative dataset from South Africa, the paper applies a seasonality index that is constructed from the District Health Information System, an administrative dataset, to annualise public outpatient health service visits. Using the concentration index, socio-economic inequality in health service visits, after accounting for seasonal variations, was compared with that when seasonal variations are ignored. It was found that, in some cases, socio-economic inequality in outpatient health service visits depends on the socio-economic distribution of the seasonality index. This may justify the need to account for seasonal and geographical variations.

Socioeconomic inequalities in maternal health service utilisation: a case of antenatal care in Nigeria using a decomposition approach.

BACKGROUND: Antenatal care (ANC) services are critical for maternal health but Nigeria performs poorly in ANC utilisation compared to other countries in sub-Saharan Africa. This study aimed to assess socioeconomic inequalities in ANC utilisation and the determinants of these inequalities in Nigeria. METHODS: The 2013 Nigeria Demographic and Health Survey data with 18,559 women was used for analysis. The paper used concentration curves and indices for different measures of ANC utilisation (no ANC visit, 1-3 ANC visits, at least four ANC visits, and the number of ANC visits). A positive (or negative) concentration index means that the measure of ANC utilisation was concentrated on the richer (poorer) population compared to their poorer (richer) counterparts. The concentration indices were also decomposed using standard methodologies to examine the significant determinants of the socioeconomic inequalities in no ANC visit, at least four ANC visits, and the number of ANC visits. RESULTS: No ANC visit was disproportionately concentrated among the poor (concentration index (CI) = - 0.573), whereas at least four ANC visits (CI = 0.582) and a higher number of ANC visits (CI = 0.357) were disproportionately concentrated among the rich. While these results were consistent across all the geopolitical zones and rural and urban areas, the inequalities were more prevalent in the northern zones (which also have the highest incidence of poverty in the country) and the rural areas. The significant contributors to inequalities in ANC utilisation were the zone of residence, wealth, women's education (especially secondary) and employment, urban-rural residence, ethnicity, spousal education, and problems with obtaining permission to seek health care and distance to the clinic. CONCLUSIONS: Addressing wealth inequalities, enhancing literacy, employment and mitigating spatial impediments to health care use will reduce socioeconomic inequalities in ANC utilisation in Nigeria. These factors are the social determinants of health inequalities. Thus, a social determinants of health approach is needed to address socioeconomic inequalities in ANC coverage in Nigeria.

Inequalities in health and health risk factors in the Southern African Development Community: evidence from World Health Surveys.

BACKGROUND: Socioeconomic inequalities in health have been documented in many countries including those in the Southern African Development Community (SADC). However, a comprehensive assessment of health inequalities and inequalities in the distribution of health risk factors is scarce. This study specifically investigates inequalities both in poor self-assessed health (SAH) and in the distribution of selected risk factors of ill-health among the adult populations in six SADC countries. METHODS: Data come from the 2002/04 World Health Survey (WHS) using six SADC countries (Malawi, Mauritius, South Africa, Swaziland, Zambia and Zimbabwe) where the WHS was conducted. Poor SAH is reporting bad or very bad health status. Risk factors such as smoking, heavy drinking, low fruit and vegetable consumption and physical inactivity were considered. Other environmental factors were also considered. Socioeconomic status was assessed using household expenditures. Standardised and normalised concentration indices (CIs) were used to assess socioeconomic inequalities. A positive (negative) concentration index means a pro-rich (pro-poor) distribution where the variable is reported more among the rich (poor). RESULTS: Generally, a pro-poor socioeconomic inequality exists in poor SAH in the six countries. However, this is only significant for South Africa (CI = - 0.0573; p < 0.05), and marginally significant for Zambia (CI = - 0.0341; P < 0.1) and Zimbabwe (CI = - 0.0357; p < 0.1). Smoking and inadequate fruit and vegetable consumption were significantly concentrated among the poor. Similarly, the use of biomass energy, unimproved water and sanitation were significantly concentrated among the poor. However, inequalities in heavy drinking and physical inactivity are mixed. Overall, a positive relationship exists between inequalities in ill-health and inequalities in risk factors of ill-health. CONCLUSION: There is a need for concerted efforts to tackle the significant socioeconomic inequalities in ill-health and health risk factors in the region. Because some of the determinants of ill-health lie outside the health sector, inter-sectoral action is required.

Poor recovery of households from out-of-pocket payment for assisted reproductive technology.

STUDY QUESTION: How do households recover financially from direct out-of-pocket payment for government subsidized ART? SUMMARY ANSWER: After a mean of 3.8 years, there was poor recovery from initiated financial coping strategies with the poorest households being disproportionatley affected. WHAT IS KNOWN ALREADY: Out-of-pocket payment for health services can create financial burdens for households and inequities in access to care. A previous study conducted at a public-academic institution in South Africa documented that patient co-payment for one cycle of ART resulted in catastrophic expenditure for one in five households, and more frequently among the poorest, requiring diverse financial coping strategies to offset costs. STUDY DESIGN, SIZE, DURATION: An observational follow-up study was conducted ~4 years later to assess financial recovery among the 135 couples who had participated in this previous study. Data were collected over 12 months from 73 informants. PARTICIPANTS/MATERIALS, SETTING, METHOD: The study was conducted at a level three referral hospital in the public-academic health sector of South Africa. At this institution ART is subsidized but requires patient co-payments. A purpose-built questionnaire capturing socio-economic information and recovery from financial coping strategies which had been activated was administered to all informants. Financial recovery was defined as the resolution of strategies initiated for the specific purpose of covering the original ART cycle. Results were analysed by strategy and household with the latter including analysis by tertiles based on socio-economic status at the time of the original expenditure. In addition to descriptive statistics, the Pearson Chi squared test was used to determine differences between socioeconomic tertiles and associations between recovery and other variables. MAIN RESULTS AND THE ROLE OF CHANCE: The participation rate in this follow-up study was 54.1% with equal representation from the three socio-economic tertiles. The average duration of follow-up was 46.1 months (±9.78 SD) and respondents' mean age was 42 years (range 31-52). The recovery rate was below 50% for four of five strategies evaluated: 23.1% of households had re-purchased a sold asset; 23.5% had normalized a previous reduction in household spending, 33.8% had regained their savings, and 48.7% were no longer bolstering income through additional work. Two-thirds of households (60.0%) had repaid all loans and debts. The poorest households showed lower rates of recovery when compared to households in the richest tertile. Complete recovery from all strategies initiated was reported by only 10 households (13.7%): 1 of 19 in the lowest tertile, 3 of 30 in the middle and by 6 of 24 households in the richest tertile (P > 0.05). No association was found between the degree of financial recovery and additional cost burdens incurred, including related to babies born; or between the degree of recovery and ongoing pursuit of ART. LIMITATIONS, REASONS FOR CAUTION: The sample size was limited. The participation rate was just over 50%. Results were dependent on participants' narrative and recall. WIDER IMPLICATIONS OF THE FINDINGS: The willingness of patients to pay for ART does not necessarily imply the ability to pay. As a result, the lack of comprehensive third-party funding for ART can create immediate and long-term financial hardship which is more pronounced among poorer households. While more data on the impact of out-of-pocket payment for ART are needed to illustrate the problem in other low resource settings, the results from South Africa provide useful information for similar developing countries. The current absence of more extensive data should therefore not be a barrier to the promotion of financial risk protection for infertile couples, especially the poorest, in need of ART. STUDY FUNDING/COMPETING INTEREST(S): The study was supported by a Masters Student Grant from the Faculty of Health Sciences, University of Cape Town. The authors had no competing interests. TRIAL REGISTRATION NUMBER: Not applicable.

Investigating the relationship between self-rated health and social capital in South Africa: a multilevel panel data analysis.

BACKGROUND: The relationship between social capital and self-rated health has been documented in many developed compared to developing countries. Because social capital and health play important roles in development, it may be valuable to study their relationship in the context of a developing country with poorer health status. Further, the role of social capital research for health policy has not received much attention. This paper therefore examines the relationship between social capital and health in South Africa, a country with the history of colonialism and apartheid that has contributed to the social disintegration and destruction of social capital. METHODS: This study uses data from the National Income Dynamics Study (NIDS), the first nationally representative panel study in South Africa. Two waves of the NIDS were used in this paper--Wave 1 (2008) and Wave 2 (2010). Self-rated health, social capital (individual- and contextual-level), and other covariates related to the social determinants of health (SDH) were obtained from the NIDS. Individual-level social capital included group participation, personalised trust and generalised trust while contextual-level or neighbourhood-level social capital was obtained by aggregating from the individual-level and household-level social capital variables to the neighbourhood. Mixed effects models were fitted to predict self-rated health in Wave 2, using lagged covariates (from Wave 1). RESULTS: Individual personalised trust, individual community service group membership and neighbourhood personalised trust were beneficial to self-rated health. Reciprocity, associational activity and other types of group memberships were not found to be significantly associated with self-rated health in South Africa. Results indicate that both individual- and contextual-level social capital are associated with self-rated health. CONCLUSION: Policy makers may want to consider policies that impact socioeconomic conditions as well as social capital. Some of these policies are linked to the SDH. We contend that the significant social capital including community service membership can be encouraged through policy in a way that is in line with the values of the people. This is likely to impact on health and quality of life generally and lead to a reduction in the burden of disease in South Africa considering the historic context of the country.

Assessing catastrophic and impoverishing effects of health care payments in Uganda.

BACKGROUND: Direct out-of-pocket payments for health care are recognised as limiting access to health care services and also endangering the welfare of households. In Uganda, such payments comprise a large portion of total health financing. This study assesses the catastrophic and impoverishing impact of paying for health care out-of-pocket in Uganda. METHODS: Using data from the Uganda National Household Surveys 2009/10, the catastrophic impact of out-of-pocket health care payments is defined using thresholds that vary with household income. The impoverishing effect of out-of-pocket health care payments is assessed using the Ugandan national poverty line and the World Bank poverty line ($1.25/day). RESULTS: A high level and intensity of both financial catastrophe and impoverishment due to out-of-pocket payments are recorded. Using an initial threshold of 10% of household income, about 23% of Ugandan households face financial ruin. Based on both the $1.25/day and the Ugandan poverty lines, about 4% of the population are further impoverished by such payments. This represents a relative increase in poverty head count of 17.1% and 18.1% respectively. CONCLUSION: The absence of financial protection in Uganda's health system calls for concerted action. Currently, out-of-pocket payments account for a large share of total health financing and there is no pooled prepayment system available. There is therefore a need to move towards mandatory prepayment. In this way, people could access the needed health services without any associated financial consequence.

Who pays for and who benefits from health care services in Uganda?

BACKGROUND: Equity in health care entails payment for health services according to the capacity to pay and the receipt of benefits according to need. In Uganda, as in many African countries, although equity is extolled in government policy documents, not much is known about who pays for, and who benefits from, health services. This paper assesses both equity in the financing and distribution of health care benefits in Uganda. METHODS: Data are drawn from the most recent nationally representative Uganda National Household Survey 2009/10. Equity in health financing is assessed considering the main domestic health financing sources (i.e., taxes and direct out-of-pocket payments). This is achieved using bar charts and standard concentration and Kakwani indices. Benefit incidence analysis is used to assess the distribution of health services for both public and non-public providers across socio-economic groups and the need for care. Need is assessed using limitations in functional ability while socioeconomic groups are created using per adult equivalent consumption expenditure. RESULTS: Overall, health financing in Uganda is marginally progressive; the rich pay more as a proportion of their income than the poor. The various taxes are more progressive than out-of-pocket payments (e.g., the Kakwani index of personal income tax is 0.195 compared with 0.064 for out-of-pocket payments). However, taxes are a much smaller proportion of total health sector financing compared with out-of-pocket payments. The distribution of total health sector services benefitsis pro-rich. The richest quintile receives 19.2% of total benefits compared to the 17.9% received by the poorest quintile. The rich also receive a much higher share of benefits relative to their need. Benefits from public health units are pro-poor while hospital based care, in both public and non-public sectors are pro-rich. CONCLUSION: There is a renewed interest in ensuring equity in the financing and use of health services. Based on the results in this paper, it would seem that in order to safeguard such equity, there is a need for policy that focuses on addressing the health needs of the poor while continuing to ensure that the burden of financing health services does not rest disproportionately on the poor.

A systematic review of factors that affect uptake of community-based health insurance in low-income and middle-income countries.

BACKGROUND: Low-income and middle-income countries (LMICs) have difficulties achieving universal financial protection, which is primordial for universal health coverage. A promising avenue to provide universal financial protection for the informal sector and the rural populace is community-based health insurance (CBHI). We systematically assessed and synthesised factors associated with CBHI enrolment in LMICs. METHODS: We searched PubMed, Scopus, ERIC, PsychInfo, Africa-Wide Information, Academic Search Premier, Business Source Premier, WHOLIS, CINAHL, Cochrane Library, conference proceedings, and reference lists for eligible studies available by 31 October 2013; regardless of publication status. We included both quantitative and qualitative studies in the review. RESULTS: Both quantitative and qualitative studies demonstrated low levels of income and lack of financial resources as major factors affecting enrolment. Also, poor healthcare quality (including stock-outs of drugs and medical supplies, poor healthcare worker attitudes, and long waiting times) was found to be associated with low CBHI coverage. Trust in both the CBHI scheme and healthcare providers were also found to affect enrolment. Educational attainment (less educated are willing to pay less than highly educated), sex (men are willing to pay more than women), age (younger are willing to pay more than older individuals), and household size (larger households are willing to pay more than households with fewer members) also influenced CBHI enrolment. CONCLUSION: In LMICs, while CBHI schemes may be helpful in the short term to address the issue of improving the rural population and informal workers' access to health services, they still face challenges. Lack of funds, poor quality of care, and lack of trust are major reasons for low CBHI coverage in LMICs. If CBHI schemes are to serve as a means to providing access to health services, at least in the short term, then attention should be paid to the issues that militate against their success.

Inequalities in public health care delivery in Zambia.

BACKGROUND: Access to adequate health services that is of acceptable quality is important in the move towards universal health coverage. However, previous studies have revealed inequities in health care utilisation in the favour of the rich. Further, those with the greatest need for health services are not getting a fair share. In Zambia, though equity in access is extolled in government documents, there is evidence suggesting that those needing health services are not receiving their fair share. This study seeks therefore, to assess if socioeconomic related inequalities/inequities in public health service utilisation in Zambia still persist. METHODS: The 2010 nationally representative Zambia Living Conditions and Monitoring Survey data are used. Inequality is assessed using concentration curves and concentrations indices while inequity is assessed using a horizontal equity index: an index of inequity across socioeconomic status groups, based on standardizing health service utilisation for health care need. Public health services considered include public health post visits, public clinic visits, public hospital visits and total public facility visits. RESULTS: There is evidence of pro-poor inequality in public primary health care utilisation but a pro-rich inequality in hospital visits. The concentration indices for public health post visits and public clinic visits are -0.28 and -0.09 respectively while that of public hospitals is 0.06. After controlling for need, the pro-poor distribution is maintained at primary facilities and with a pro-rich distribution at hospitals. The horizontal equity indices for health post and clinic are estimated at -0.23 and -0.04 respectively while that of public hospitals is estimated at 0.11. A pro-rich inequity is observed when all the public facilities are combined (horizontal equity index = 0.01) though statistically insignificant. CONCLUSION: The results of the paper point to areas of focus in ensuring equitable access to health services especially for the poor and needy. This includes strengthening primary facilities that serve the poor and reducing access barriers to ensure that health care utilisation at higher-level facilities is distributed in accordance with need for it. These initiatives may well reduce the observed inequities and accelerate the move towards universal health coverage in Zambia.

Restricting or banning alcohol advertising to reduce alcohol consumption in adults and adolescents.

BACKGROUND: Alcohol is estimated to be the fifth leading risk factor for global disability-adjusted life years. Restricting or banning alcohol advertising may reduce exposure to the risk posed by alcohol at the individual and general population level. To date, no systematic review has evaluated the effectiveness, possible harms and cost-effectiveness of this intervention. OBJECTIVES: To evaluate the benefits, harms and costs of restricting or banning the advertising of alcohol, via any format, compared with no restrictions or counter-advertising, on alcohol consumption in adults and adolescents. SEARCH METHODS: We searched the Cochrane Drugs and Alcohol Group Specialised Register (May 2014); CENTRAL (Issue 5, 2014); MEDLINE (1966 to 28 May 2014); EMBASE (1974 to 28 May 2014); PsychINFO (June 2013); and five alcohol and marketing databases in October 2013. We also searched seven conference databases and www.clinicaltrials.gov and http://apps.who.int/trialsearch/ in October 2013. We checked the reference lists of all studies identified and those of relevant systematic reviews or guidelines, and contacted researchers, policymakers and other experts in the field for published or unpublished data, regardless of language. SELECTION CRITERIA: We included randomised controlled trials (RCTs), controlled clinical trials, prospective and retrospective cohort studies, controlled before-and-after studies and interrupted time series (ITS) studies that evaluated the restriction or banning of alcohol advertising via any format including advertising in the press, on the television, radio, or internet, via billboards, social media or product placement in films. The data could be at the individual (adults or adolescent) or population level. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: We included one small RCT (80 male student participants conducted in the Netherlands and published in 2009) and three ITS studies (general population studies in Canadian provinces conducted in the 1970s and 80s).The RCT found that young men exposed to movies with a low-alcohol content drank less than men exposed to movies with a high-alcohol content (mean difference (MD) -0.65 drinks; 95% CI -1.2, -0.07; p value = 0.03, very-low-quality evidence). Young men exposed to commercials with a neutral content compared with those exposed to commercials for alcohol drank less (MD -0.73 drinks; 95% CI -1.30, -0.16; p value = 0.01, very-low-quality evidence). Outcomes were assessed immediately after the end of the intervention (lasting 1.5 hours), so no follow-up data were available. Using the Grading of Recommendations Assessment, Development and Evaluation approach, the quality of the evidence was rated as very low due to a serious risk of bias, serious indirectness of the included population and serious level of imprecision.Two of the ITS studies evaluated the implementation of an advertising ban and one study evaluated the lifting of such a ban. Each of the three ITS studies evaluated a different type of ban (partial or full) compared with different degrees of restrictions or no restrictions during the control period. The results from the three ITS studies were inconsistent. A meta-analysis of the two studies that evaluated the implementation of a ban showed an overall mean non-significant increase in beer consumption in the general population of 1.10% following the ban (95% CI -5.26, 7.47; p value = 0.43; I(2) = 83%, very-low-quality evidence). This finding is consistent with an increase, no difference, or a decrease in alcohol consumption. In the study evaluating the lifting of a total ban on all forms of alcohol advertising to a partial ban on spirits advertising only, which utilised an Abrupt Auto-regressive Integrated Moving Average model, the volume of all forms of alcohol sales decreased by 11.11 kilolitres (95% CI -27.56, 5.34; p value = 0.19) per month after the ban was lifted. In this model, beer and wine sales increased per month by 14.89 kilolitres (95% CI 0.39, 29.39; p value = 0.04) and 1.15 kilolitres (95% CI -0.91, 3.21; p value = 0.27), respectively, and spirits sales decreased statistically significantly by 22.49 kilolitres (95% CI -36.83, -8.15; p value = 0.002). Using the GRADE approach, the evidence from the ITS studies was rated as very low due to a high risk of bias arising from a lack of randomisation and imprecision in the results.No other prespecified outcomes (including economic loss or hardship due to decreased alcohol sales) were addressed in the included studies and no adverse effects were reported in any of the studies. None of the studies were funded by the alcohol or advertising industries. AUTHORS' CONCLUSIONS: There is a lack of robust evidence for or against recommending the implementation of alcohol advertising restrictions. Advertising restrictions should be implemented within a high-quality, well-monitored research programme to ensure the evaluation over time of all relevant outcomes in order to build the evidence base.