Mott insulators with boundary zeros

The topological classification of electronic band structures is based on symmetry properties of Bloch eigenstates of single-particle Hamiltonians. In parallel, topological field theory has opened the doors to the formulation and characterization of non-trivial phases of matter driven by strong electron-electron interaction. Even though important examples of topological Mott insulators have been constructed, the relevance of the underlying non-interacting band topology to the physics of the Mott phase has remained unexplored. Here, we show that the momentum structure of the Green's function zeros defining the "Luttinger surface" provides a topological characterization of the Mott phase related, in the simplest description, to the one of the single-particle electronic dispersion. Considerations on the zeros lead to the prediction of new phenomena: a topological Mott insulator with an inverted gap for the bulk zeros must possess gapless zeros at the boundary, which behave as a form of "topological antimatter" annihilating conventional edge states. Placing band and Mott topological insulators in contact produces distinctive observable signatures at the interface, revealing the otherwise spectroscopically elusive Green's function zeros.

Long-term impacts of an early childhood shock on human capital: Evidence from the 1999 economic crisis in Ecuador

This paper provides evidence on the lasting effects of the 1999 economic crisis in Ecuador on human capital formation. We show for children born during the crisis that the negative repercussions are still observable more than 10 years after macroeconomic recovery. Taking advantage of micro-level data collected in 2012 and 2014, we assess long-term impacts on health and education. After controlling for age-in-months and survey effects as well as a linear birth year-cohort trend that varies by region, we find that after 12-16 years, the cohorts born during the recession report height-for-age Z-scores that are 0.003 standard deviations (SDs) lower for each month of exposure and have 0.002 fewer years of schooling per month exposed compared to the cohorts born outside the recession years. Children exposed to the entire crisis are 0.063 SDs smaller and have 0.042 years less of schooling. Girls have lower health outcomes than boys. Concomitantly, we show that selective childbearing or excess infant mortality are unlikely to drive our results. The persistence of the negative effects points to the existence of a poverty trap suggesting that policy interventions in response to (economic) crizes should be extended beyond macroeconomic recovery to counteract long-term, micro-level consequences.

Determinants of Intended Return Migration among Refugees: A Comparison of Syrian Refugees in Germany and Turkey

Little is known about whether Syrian refugees intend to return to their origin-country and what affects their return migration intentions. We introduce a theoretical framework for voluntary return, identify the refugees’ decision-making context, and empirically assess the model with a sample of 577 Syrian refugees living in Germany and Turkey in 2018. Three return scenarios were presented in the survey: (i) returning to Syria within two years, (ii) returning when Syria is as safe as before the civil war, and (iii) ever returning. The three scenarios were conceived very differently by the refugees, highlighting the dynamic nature and context dependency of the concept of voluntary return. Syrian refugees in Turkey were more likely to regard their stay as temporary (76 percent), compared to those in Germany (55 percent, p-value of difference = .000). Similarly, structural factors of the origin- and host-countries, that is, the origin-governorate and the current location, were considerably influencing return intentions. Concerning individual factors, female and highly educated refugees had a lower willingness to return. Those who were married were less inclined to return in the short run, yet refugees who self-identified as poor indicated their desired return in the long run. We also analyzed whether random exposure to information regarding return impacted refugees’ intentions. We found a negative, albeit insignificant, impact of information, suggesting that host governments cannot expect (rapid) information dissemination to impact refugees’ decision-making about voluntary return. Our findings underscore that neither proximate nor distant host-countries should bank on the speedy return of the Syrian refugees.

Genomic evidence for contrasting patterns of host-associated genetic differentiation across shared host-plant species in leaf- and bud-galling sawflies

Resource specialization and ecological speciation arising through host-associated genetic differentiation (HAD) are frequently invoked as an explanation for the high diversity of plant-feeding insects and other organisms with a parasitic lifestyle. While genetic studies have demonstrated numerous examples of HAD in insect herbivores, the rarity of comparative studies means that we still lack an understanding of how deterministic HAD is, and whether patterns of host shifts can be predicted over evolutionary timescales. We applied genome-wide single nucleotide polymorphism and mitochondrial DNA sequence data obtained through genome resequencing to define species limits and to compare host-plant use in population samples of leaf- and bud-galling sawflies (Hymenoptera: Tenthredinidae: Nematinae) collected from seven shared willow (Salicaceae: Salix) host species. To infer the repeatability of long-term cophylogenetic patterns, we also contrasted the phylogenies of the two galler groups with each other as well as with the phylogeny of their Salix hosts estimated based on RADseq data. We found clear evidence for host specialization and HAD in both of the focal galler groups, but also that leaf gallers are more specialized to single host species compared with most bud gallers. In contrast to bud gallers, leaf gallers also exhibited statistically significant cophylogenetic signal with their Salix hosts. The observed discordant patterns of resource specialization and host shifts in two related galler groups that have radiated in parallel across a shared resource base indicate a lack of evolutionary repeatability in the focal system, and suggest that short- and long-term host use and ecological diversification in plant-feeding insects are dominated by stochasticity and/or lineage-specific effects.

Untying Gordian knots: unraveling reticulate polyploid plant evolution by genomic data using the large Ranunculus auricomus species complex

Speciation via hybridization and polyploidization is a major evolutionary force in plant evolution but is still poorly understood for neopolyploid groups. Challenges are attributed to high heterozygosity, low genetic divergence, and missing information on progenitors, ploidy, and reproduction. We study the large Eurasian Ranunculus auricomus species complex and use a comprehensive workflow integrating reduced-representation sequencing (RRS) genomic data to unravel reticulate evolution, genome diversity and composition of polyploids. We rely on 97 312 restriction site-associated DNA sequencing (RAD-Seq) loci, 576 targeted nuclear genes (48 phased), and 71 plastid regions derived from 78 polyploid apomictic taxa and four diploid and one tetraploid putative sexual progenitor species. We applied (phylo)genomic structure, network, and single nucleotide polymorphism (SNP)-origin analyses. Results consistently showed only 3-5 supported and geographically structured polyploid genetic groups, each containing extant sexual and one unknown progenitor species. Combined analyses demonstrated predominantly allopolyploid origins, each involving 2-3 different diploid sexual progenitor species. Young allotetraploids were characterized by subgenome dominance and nonhybrid SNPs, suggesting substantial post-origin but little lineage-specific evolution. The biodiversity of neopolyploid complexes can result from multiple hybrid origins involving different progenitors and substantial post-origin evolution (e.g. homoeologous exchanges, hybrid segregation, gene flow). Reduced-representation sequencing genomic data including multi-approach information is efficient to delimit shallow reticulate relationships.

The feasibility and effectiveness of a novel online mental health literacy course in supporting university student mental health: a pilot study

BACKGROUND

There is a need for effective universal approaches to promote and support university student mental health that are scalable and sustainable. In this pilot study we assess the feasibility and acceptability of a fully-digitalized, comprehensive mental health literacy course co-created with and tailored to the needs of undergraduate students. We also explore preliminary associations with mental health and positive behaviour change.

METHODS

An accredited online mental health literacy course was developed using state-of-the-art pedagogical principles and a reverse mentorship approach. The course was offered as an interdisciplinary undergraduate elective. Students completed an online survey before and after the 12-week course that collected demographic information and assessed mental health knowledge, emotional self-awareness, mental health, stigma, and health-related behaviors using validated measures. Dependent group t-tests were used to compare pre- and post-course levels of knowledge, mental health, sleep quality and substance use. Mental health outcomes of students who completed the course were compared to an age and sex-matched sample of students not enrolled in the course and who completed the same survey measures over the same academic year. Multivariable linear regression was used to examine the effect of course participation on outcomes at follow-up.

RESULTS

The course had good uptake and was positively reviewed by participants. Specifically, students found the course engaging, relevant, and applicable, and agreed they would recommend it to their peers. Among course participants there was improvement in mental health knowledge (p < 0.001) and emotional self-awareness (p = 0.02) at course completion. Compared to the matched comparison group, taking the course was associated with reduced alcohol (β = - 0.41, p = 0.01) and cannabis use (β = - 0.35, p = 0.03), and improved sleep quality (β = 1.56, p = 0.09) at the end of the term.

CONCLUSIONS

Findings suggest that delivering mental health literacy as an online accredited course may be an acceptable and effective way of promoting university student mental health through improved knowledge, emotional self-awareness, and healthy lifestyle choices. As the course is expanded to larger and more diverse student cohorts we will be able to further examine the short and long-term effectiveness of the course in supporting student mental health and the underlying mechanisms.

Using localized Twitter activity to assess harmful algal bloom impacts of Karenia brevis in Florida, USA

Red tide blooms of the dinoflagellate Karenia brevis (K. brevis) produce toxic coastal conditions that can impact marine organisms and human health, while also affecting local economies. During the extreme Florida red tide event of 2017-2019, residents and visitors turned to social media platforms to both receive disaster-related information and communicate their own sentiments and experiences. This was the first major red tide event since the ubiquitous use of social media, thus providing unique crowd-sourced reporting of red tide impacts. We evaluated the spatial and temporal accuracy of red tide topic activity on Twitter, taking tweet sentiments and user types (e.g. media, citizens) into consideration, and compared tweet activity with reported red tide conditions, such as K. brevis cell counts, levels of dead fish and respiratory irritation on local beaches. The analysis was done on multiple levels with respect to both locality (e.g., entire Gulf coast, county-level, city-level, zip code tabulation areas) and temporal frequencies (e.g. daily, every three days, weekly), resulting in strong correlations between local per-capita Twitter activity and the actual red tide conditions observed in the area. Moreover, an association was observed between proximity to the affected coastal areas and per-capita counts for relevant tweets. Results show that Twitter presents a trustworthy reflection of the red tide's local impacts and development over time, and can potentially augment the already existing tools for efficient assessment and a more coordinated response to the disaster.

Epidemiology, comorbidities, and healthcare utilization of patients with chronic urticaria in Germany

BACKGROUND

Comprehensive data on the epidemiology and comorbidities of chronic urticaria (CU) in Germany are either limited, or not contemporary.

OBJECTIVES

To investigate the epidemiology of CU, overall comorbidities and healthcare resource utilized by patients with CU in Germany, using an anonymized statutory health insurance (SHI) database.

METHODS

Anonymized SHI claims research database of the Institute for Applied Health Research, Berlin [InGef] (01 January 2015-30 September 2018) was used to analyse insured individuals with a confirmed diagnosis of CU (ICD-10-GM codes). Twelve-month diagnosed prevalence and incidence, comorbidities (vs. atopic dermatitis and psoriasis), and healthcare utilization by patients with CU were investigated.

RESULTS

Of 4 693 772 individuals of all ages listed in the database, 3 538 540 were observable during 2017. Overall, 17 524 patients (˜0.5%) were diagnosed with CU; chronic spontaneous urticaria (CSU: 71.2%), chronic inducible urticaria (CIndU: 19.7%), CSU+CIndU (9.1%). Females, vs. males, had higher diagnosed prevalence (0.62% vs. 0.37%) and diagnosed incidence (0.18% vs. 0.11%) of CU among all patients. Patients most frequently visited general practitioners (41.3% of total visits). Hypertensive diseases (43.5%), lipoprotein metabolism disorders (32.1%) and affective disorders (26.0%) were the most frequently reported comorbidities of special interest. Rates of most comorbidities of special interests were similar to atopic dermatitis and psoriasis patients, and all higher vs. overall population. More than half (54.1%) of all CU patients were not prescribed any treatment. Second-generation H₁ -antihistamines were the most commonly prescribed medication for adult (17.9%) and paediatric (27.9%) patients. Patients with CIndU (paediatric, 15.5%; adult, 7.8%) were more often hospitalized versus patients with CSU (paediatric, 9.9%; adult, 4.6%).

CONCLUSIONS

In Germany, prevalence of CU along with multiple comorbidities may pose increased burden on the healthcare system. Awareness of adhering to treatment guidelines, and aiming for complete control of urticaria, needs to be driven and may improve outcomes.

Patch test informed consent form: position statement by European Academy of Dermatology and Venereology Task Force on Contact Dermatitis

BACKGROUND

To our knowledge, an international consensus is lacking regarding the development of an adequate informed consent form for a patch test (PT) and the information that should be included in such document.

OBJECTIVES

The aim of the study was to reach a consensus on the specific points that need to be addressed in a PT consent form.

METHODS

A Delphi survey, comprising 2 rounds and 1 final discussion, was used to gather and analyse data, which was conducted over the Internet. Each statement that reached a consensus with the respondents (9 expert dermatologists from Europe) was defined as a median consensus score (MED) of ≥7 and agreement among panelists as an interquartile range (IQR) of ≤3. All study participants were members of the EADV task force on contact dermatitis.

RESULTS

The expert panel addressed several topics that should be included in an informed consent form for a PT: introduction, preparation for PT, testing procedure, allowed activities, adverse events and additional authorizations.

CONCLUSIONS

Our results assess recommendations regarding points to be contained in an informed consent form for a PR. Future actions towards standardization and harmonization of this specific consent form are needed.

Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry

BACKGROUND

Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents.

METHODS

Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre.

RESULTS

3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004).

CONCLUSIONS

The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.

"When I receive the message, it is a sign of love": symbolic connotations of SMS messages for people living with HIV in Burkina Faso

Mobile health (mHealth) has gained considerable interest recently due to its potential to improve health outcomes in developing countries with high outreach yet low costs. Several studies have explored the use of short message service (SMS) reminders to improve antiretroviral (ARV) retention and adherence, with mixed results. The majority of these studies has a quantitative nature and employs randomized designs, which do not provide further qualitative insights about other possible impacts of the messages. Based on the qualitative assessment of an SMS intervention in Burkina Faso, which complemented a (quantitative) Randomized Controlled Trial (RCT), we show that beyond the functional role of improving ARV retention and adherence, SMS messages can also play important symbolic roles in offering psychosocial support to people living with HIV (PLHIV) and improving their perception of life. Concomitantly, we show that sufficient (ICT) literacy skills cannot be taken for granted in resource-poor settings. Yet, regardless of (ICT) literacy skills, the symbolism of care was perceived. Furthermore, we highlight the importance of complementing quantitative evidence of mHealth interventions with qualitative assessments.

A Systematic Review of Mobile Phone Interventions (SMS/IVR/Calls) to Improve Adherence and Retention to Antiretroviral Treatment in Low-and Middle-Income Countries

The use of mobile health technologies (mHealth) to ameliorate HIV care has considerably risen in low- and middle-income countries (LMICs) since 2010. Yet, the discrepancies in the results of accompanying studies warrant an updated and systematic consolidation of all available evidence. We report a systematic review of studies testing whether text/image messages, interactive voice response reminders, or calls promote adherence and retention to antiretroviral therapy (ART) in LMICs. We systematically compiled studies published in English until June 2018 from PubMed/Medline, Web of Science, WHO database, ProQuest Dissertations and Theses, and manual search. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 and used frequency analysis to assess reported findings. In total, we compiled 35 published articles: 27 completed studies and 8 protocols. Among the main 27 studies, 17 examine adherence, 5 retention, and 5 both measures. Results indicate that 56% report positive and statistically significantly impacts of mHealth on primary outcomes, the remaining 44% report insignificant results. While 41% of studies found a positive and significant effect for adherence, only 12% improved retention. The evidence shows ambiguous results (with high variability) about the effectiveness of mobile phone-assisted mHealth interventions to boost adherence and retention to ART. The literature also points to short follow-up periods, small samples, and limited geographical coverage. Hence, future research should focus on evaluating longer interventions with more patients spread across wider areas to address whether mHealth can be effectively used in LMICs.

Adaptation and biomedical transition of people living with HIV to antiretroviral treatment in Burkina Faso

This article examines the adaptation and biomedical transition of people living with HIV (PLHIV) to antiretroviral treatment (ART) in Burkina Faso. The study employs a representative sample of 3625 randomly selected patients. Subjective and objective measures of health and their predictors are compared for short-term (≤24 months) versus longer-term ART adherents (>24 months) in a cohort study. Subjective health is measured as Likert scale self-rating and objective health as CD4 count. The results show that subjective and objective health capture different aspects of adaptation to ART: 90% of the short-term and 94% of the longer-term patients give a subjective health rating of at least good, while the objective measure of good health is higher among longer-term (42%) compared to short-term patients (27%). For subjective health, short-lived pleasures are predictors among short-term adherents while economic characteristics are determinants among longer-term patients. Meanwhile, objective health is associated with factors that determine ART adherence (i.e. participating in self-help groups). To achieve a wholistic resilience management that caters to the needs of PLHIV, we need to acknowledge adaptation to the disease and to ART and design health programs, in particular in developing countries, away from one-size-fits-all solutions to stage-of-disease specific support.

[Increasing overhead ressources of the trauma room]

BACKGROUND

Every year up to 35,000 people in Germany are severely injured in accidents in traffic, during work or leisure activities. The 24-h availability of the trauma room as well as surgical and intensive care unit capacities are essential to provide optimal acute care. This study analyzed the frequency of utilization of the resource trauma room in a level I trauma center in the past.

METHODS

Data of a level I trauma center from 2005 to 2016 including trauma room alerts deployed by the rescue coordination center and the number of patients found to be severely injured (ISS ≥ 16) during trauma room diagnostics were analyzed retrospectively. Additionally, alerts due to trauma mechanism, accompanying by the emergency physician, ventilation and resuscitation were evaluated via a web-based interdisciplinary care capacity system (IVENA) from 2012 to 2016. Therefore, a comparison between the number of trauma room alerts and the number of severely injured patients was performed for the time after 2012.

RESULTS

For the time from 2012 to 2016, data obtained by IVENA showed a continuous increase in the number of trauma room alerts (n = 367 to n = 623). At the same time, the number of patients admitted under resuscitation (n = 15 to n = 45) as well as ventilated patients (n = 78 to n = 139) increased significantly; however, there was also an increase in the number of trauma alerts due to trauma mechanisms (n = 84 to n = 194) as well as the number of patients admitted to the trauma room not accompanied by an emergency physician (n = 38 to n = 132). The ratio between the number of trauma room alerts and severely injured patients (ISS ≥ 16) increased from 3.1 in 2012 to 5.4 in 2015 and 4.6 in 2016.

CONCLUSION

The data at hand showed a constant number of severely injured trauma patients admitted to a level I trauma center over the past few years. At the same time, there was a significant increase in utilization of the trauma room; however, in a considerable number of patients admitted to the trauma room the diagnostic process resulted in non-traumatic diagnostic findings. In the analyzed cohort, especially patients admitted to the trauma room due to trauma mechanism or without an accompanying emergency physician contributed to this development, necessitating an increased operational readiness of the trauma room team.

The impact of the Ethiopian health extension program and health development army on maternal mortality: A synthetic control approach

The Ethiopian government has implemented nationwide strategies to improve access to basic health services and enhance health outcomes. The Health Extension Program (HEP) launched in 2003, expanded basic health infrastructure and local human resources. In 2011, the government introduced the Health Development Army (HDA). HDA is a women-centered community movement inspired by military structures and discipline. Its special objective is to improve maternal health outcomes. This paper uses a synthetic control approach to assess the effects of HEP and HDA on maternal mortality ratios (MMR). The MMR data are from the Global Burden of Diseases (GBD) database. A pool of 42 Sub-Saharan African countries, covering the period 1990 to 2016, is used to construct a synthetic comparator which displays a mortality trajectory similar to Ethiopia prior to the interventions. On average, since 2004, maternal mortality in the control countries exhibits a moderate downward trend. In Ethiopia, the downward trend is considerably steeper as compared to its synthetic control. By 2016, maternal mortality in Ethiopia was lower by 171 (p-value 0.048) maternal deaths per 100,000 live births as compared to its synthetic control. Between 2003 and 2016, Ethiopia's maternal mortality ratio declined from 728 to 357. These estimates suggest that a substantial proportion of this decline may be attributed to HEP/HDA. The Ethiopian experience of enhancing nation-wide access to and use of maternal health services in a short time-span is remarkable. Whether such a model may be transplanted is an open question.

The differential impact of adverse childhood experiences in the development of pre-diabetes in a longitudinal cohort of US adults

BACKGROUND

ACEs have a dose-response relationship with diabetes. The relationship between ACEs and pre-diabetes is not well known and may represent an effective area for prevention efforts.

METHODS

Data from 1054 participants from two waves of the longitudinal MIDUS study were used. Multivariate general linear regression models assessed the relationship between ACEs and biomarker outcomes. Correlation tests and mediation models investigated the relationship between ACE and pre-diabetes.

RESULTS

Individuals reporting ACEs were statistically significantly more likely to have higher BMI (1.13 (0.34-1.92)), higher waist circumference (2.74 (0.72-4.76)), elevated blood fasting insulin levels (2.36 (0.71-4.02)) and higher insulin resistance (HOMA-IR (0.57 (0.08-1.06)). BMI/waist circumference and insulin resistance did not maintain independent relationships with ACEs once HOMA-IR was included in the dichotomized ACE model (p = 0.05 and p = 0.06, respectively), suggesting the relationship between BMI and ACEs may be mediated by insulin resistance.

CONCLUSIONS

These results represent one of the first studies to examine the differential impact of ACEs on a diverse set of clinical pre-diabetes measures. Findings suggest sexual and physical abuse, and financial strain during childhood are important factors associated with higher risk for pre-diabetes, and should be considered during intervention development.

High volume of polysorbate-containing (Tween® 80) solutions induces false-positive results in intradermal test

BACKGROUND

Intradermal test is used to detect causative allergens in IgE-mediated hypersensitivity. The surfactant polysorbate 80 can be added to intradermal test solutions to more reliably dissolve the allergen and ensure a constant bioavailability of the injected allergen. Polysorbate 80 has, however, some histamine-releasing properties which could blur the difference to the histamine-induced wheal. Routinely serving as a control.

OBJECTIVE

Allergen-free polysorbate 80 containing (0.005%) test solutions were therefore systematically tested at different injection volumes to see whether polysorbate can falsify skin reactions and if yes whether conditions can be identified to avoid this.

METHODS

In a partly blinded study, 30 patients were tested intracutaneously at the back: each received at three separate sites 0.05 mL of polysorbate-containing solvent, 0.02 mL polysorbate-containing solvent as well as 0.02 mL polysorbate-free solvent. After 15 min, wheal and erythema were documented and planimetrically quantified.

RESULTS

Unexpectedly 23 of 30 (77%) patients showed false-positive test reactions to the volume of 0.05 mL of the polysorbate-containing solvent whereas the polysorbate-containing solvent with 0.02 mL and the polysorbate-free solvent with 0.02 mL injection volume had no reinforcing effect on skin test reaction.

CONCLUSIONS

Different volumes of polysorbate-containing solutions, all recommended by manufacturers for intradermal tests, may significantly influence test results. The study shows that a polysorbate 80 used at 0.005% in solvents for intradermal test to provide a better bioavailability of allergens produces false-positive reactivity in a surprising and a hitherto unknown 77% if the 0.05 mL volume is injected. It is, therefore, mandatory to strictly adhere to an intradermal test volume of 0.02 mL as only then falsifying effects of the polysorbate additive are avoided, and comparable test results are ensured.

Does health insurance coverage or improved quality protect better against out-of-pocket payments? Experimental evidence from the Philippines

This paper explores whether health insurance coverage or improved quality at the hospital level protect better against out-of-pocket payments. Using data from a randomized policy experiment in the Philippines, we found that interventions to expand insurance coverage and improve provider quality both had an impact on out-of-pocket payments. The sample consists of 3121 child-patient patient observations across 30 hospitals either at baseline in 2003/04 or at the follow-up in 2007/08. Compared to controls, interventions that expanded insurance and provided performance-based provider payments to improve quality both resulted in a decline in out-of-pocket spending (21% decline, p-value = 0.061; and 24% decline, p-value = 0.017, respectively). With lower out-of-pocket payments for hospital care, monthly household spending on personal hygiene rose by 0.9 (p-value = 0.026) and 0.6 US$ (p-value = 0.098) under the expanded insurance and provider payment interventions, respectively, amounting to roughly a 40-60% increase relative to the controls. With the current surge for health insurance expansion in developing countries, our study suggests paying increased and possibly, equal attention to supply-side interventions will have similar impacts with operational simplicity and greater provider accountability.