Impact of user charges on vulnerable groups: the case of Kibwezi in rural Kenya

The Government of Kenya introduced user fees for inpatient and curative outpatient care at its hospitals and health centres in December 1989. Children under five years old and those judged by the health staff to be indigent were among the groups exempted from fees. In September 1990, outpatient registration fees were removed, but other fees were retained. This paper describes the effects of these policy changes on the use of health services in Kibwezi division, a poor rural area. It focuses particularly on the impact of the fees on access to care by children and the poor. The assessment is based on attendance data from government health facilities and on a longitudinal household survey of health care utilization, which covered the nine months during which all fees were charged and two months following the removal of the registration fees. Attendance at government fee-charging health facilities for both outpatient and inpatient care was lower during the period when full fees were charged than during the same months of the previous year. Outpatient attendances rose again when the registration fees were lifted. The study households reported lower levels of utilization of public hospitals and health centres when full fees were in force than during the period after the registration fees were lifted. The pattern of utilization by young children, who were exempted from fees, mirrored that of the rest of the population, suggesting that they were not fully protected from the adverse effects of fees. The poorest households made much less use of the fee-charging government facilities than the better-off households.(ABSTRACT TRUNCATED AT 250 WORDS)

Socioeconomic equity in Finnish hospital care in relation to need

The aim of the study was to evaluate the success of Finnish health care policy in establishing socioeconomic equity in the use of hospital inpatient care. We studied the use of short-term (< 30 days) care at Finnish general hospitals among those aged 25 or over, psychiatric and obstetric patients excluded. The data on service utilization were obtained from the 1988 Finnish Hospital Discharge Register. Patient data were linked with socioeconomic indicators from the 1970-1987 population censuses by personal identification number. The data on population at risk were obtained from the 1987 census. Hospital utilization was measured by annual risk of hospitalization, discharge rate, and inpatient days. The socioeconomic distribution of hospital utilization according to need was assessed by mortality and morbidity data. The same data were used to calculate inequity indices. Low socioeconomic groups used more hospital services than high in all age-groups and both genders. The socioeconomic differences in hospital utilization were similar to the gradients in death rate or to the prevalences of poor self-perceived health and limiting long-standing illness. In relation to need, the lower socioeconomic groups used at least as much inpatient care as the higher. The inequity index showed a neutral distribution of hospital services with respect to need. Finnish health care policy in the late 1980s seems to have been successful in providing hospital care equitably. This study compared overall hospital use with overall mortality and morbidity. It did not address possible socioeconomic differences in hospital use by causes of hospitalization or the quality of hospital services provided.

Equity of health care in Australia

This paper examines the equity characteristics of health care financing and delivery in Australia and compares its performance with recent findings on systems in Europe and the United States. Vertical equity of finance is evaluated with income and payment concentration indices derived from published survey data on taxes and expenditure by income decile. Horizontal equity of health care delivery is assessed with standardized expenditure concentration coefficients for three measures of health status and four types of health services, derived from household survey data on health care utilization, health status, income and demographics. Health cover is available to the entire population. Results show the financing system is slightly progressive despite the fact that 30% of payment comes from private sources, which are regressive. The equity index compares favorably to many European countries and is much better than the U.S. which has a regressive financing system. The Australian system fares less well in terms of equity of health care delivery. Several features favor privately insured higher income persons in use of health care and this is reflected, for some health status measures and types of service, in inequity favoring the better off. This contrasts with inequity favoring the less well off in many European countries and the U.S. This analysis provides a benchmark for monitoring the equity of the Australian system and provides information on the equity of a mixed private and public financing system that covers the entire population. This is relevant to the U.S. which is moving in this direction by extending private cover to the uninsured and to European countries that are increasing private sector involvement in health care financing.

The influence of urinary incontinence on publicly financed home care services to low-income elderly people

Urinary incontinence (UI) has been shown to be prevalent and a risk factor for permanent institutionalization; yet it is not routinely measured in research of home care utilization. A retrospective cohort design is used to directly estimate the effect of UI on the public costs of home care services to elderly individuals. Multivariate analyses controlling for other individual, household, and supply characteristics demonstrate that those with UI generate significantly greater public costs for home care services. Patterns of service use suggest palliative rather than rehabilitative service, raising questions regarding the effective use of resources.

Health care for the uninsured in Duluth

Providing health care for Minnesota's uninsured population continues to be both a clinical and political challenge. Between October 1, 1991, and September 30, 1993, 1,260 previously uninsured people received charity health care in Duluth. No one was excluded because of pre-existing conditions. Their utilization of services and associated costs can help project the health care needs and costs of care for uninsured Minnesotans. This group of uninsured people used a different mix of health care services compared with insured Minnesotans, and their total costs (including prescriptions) were about 15% greater. A large proportion of these uninsured Minnesotans had chronic health conditions and a "pent-up need" for services and medications. This experience demonstrated that it is possible to administer a limited benefits plan in coordination with existing public and private resources.

The class analysis of poverty

To understand more fully the nature of poverty it must be viewed as the result, in part, of inherent features of the social system. The author describes four general approaches to explaining poverty: poverty as a result of inherent individual attributes, as the by-product of contingent individual characteristics, as a by-product of social causes, and as a result of inherent properties of the social system. He then elaborates a class exploitation analysis of poverty by explaining how economic oppression, economic exploitation, and class generate a social system in which poverty plays a crucial functional role. The general problem of poverty must be broken down into two subproblems: poverty generated inside exploitative relations (the working poor) and poverty generated by nonexploitative oppression (the underclass). A class analysis of poverty argues that significant numbers of privileged people have a strong, positive material interest in maintaining poverty. Poverty can be reduced in the United States only through popular mobilization of pressure that challenges the power of the dominant classes.

No insurance, public insurance, and private insurance: do these options contribute to differences in general health?

This paper examines the validity of two of the basic assumptions made about health care insurance and health, namely that having any insurance is associated with better health and, in particular, that having public, welfare-based insurance has better health consequences for the poor than does having no insurance. These questions were addressed using data from the National Medical Expenditure Survey, a national household-based survey in 1987 of more than 36,000 people who were asked to report in detail about their medical care use and expenditures, health insurance coverage, and health and functional status. The results of the analysis indicate that being without insurance is associated with having poorer general health compared to persons with private insurance, and that the health of persons who qualify for public insurance is the poorest of any group--poorer even than those without insurance.

Ability to obtain health care: recent estimates from the Robert Wood Johnson Foundation National Access to Care Survey

This DataWatch presents findings on Americans' ability to obtain health care. Data from the 1994 National Access to Care Survey sponsored by The Robert Wood Johnson Foundation suggest that earlier studies have underestimated the access problems facing Americans by not asking about supplementary services such as prescription drugs, eyeglasses, dental care, and mental health care or counseling. Using this more inclusive definition of health care needs, we estimate that 16.1 percent of Americans were unable to obtain at least one service they believed they needed. While income is highly correlated with unmet need, most persons reporting access problems are not poor.

Health promotion priorities of economically stressed cities

The authors surveyed the local health officers (LHOs) of 436 northeastern and midwestern cities about their priorities for promoting health through prevention. LHOs of the most economically stressed cities identified the following as the five most important public health prevention goals that are amenable to intervention: reducing the incidence of HIV infection and AIDS, improving maternal and infant health, controlling sexually transmitted diseases, reducing violent and abusive behavior, and immunizing against infectious diseases. Their judgments were almost identical to those of LHOs of the least economically stressed cities and of a sample of African American political and public health leaders. LHOs of the most stressed cities were more pessimistic than their counterparts about achieving the objectives. The results of this survey can be used by federal, state, and local governments as well as private organizations as a guide for allocating scarce resources.

The development of the Hill-Burton legislation: interests, issues and compromises

The Hill-Burton Hospital Survey and Construction Act has its roots in the social health and welfare programs of the New Deal. This paper traces its development and the positions of three groups-the hospital industry, the U.S. Public Health Service, and the Senate Subcommittee on Wartime Health and Education-on four issues: the nature of federal funding to states, the use of public funds by private hospitals, the oversight powers of a Federal Hospital Council, and health services for the poor. The analysis involves two lines of thought: the political strategy of incrementalism and the roles of the three interest groups in reaching compromises to quickly pass an "unsponsored" bill. Relevance to the current effort to pass a single payer national health insurance is explored.

Poverty, income inequality, and health care consumption in Thailand

The Thai economy has grown rapidly during the past three decades of modern industrialization. The structure of the economy has been changing from an agricultural to manufacturing based. Because industrial development policies has been biased toward Bangkok and surrounding provinces, regional income disparities have been widening. Despite the high growth record, Thailand has failed to distribute the benefits of economic growth equitably. This problem of income distribution could have many important consequences of relevance to the health of population.

The Rx to ease a community's burdens. A Detroit hospital helps low-income patients obtain prescription medication

St. John Hospital and Medical Center found itself with an increasing volume of indigent and low-income patients who had few or no resources with which to purchase prescription medications. With funding cutbacks in various federal, state, and local programs, the hospital's pharmaceutical resources had diminished to the point at which it could only occasionally meet a patient's needs. The Indigent Pharmaceutical Fund was established in 1992. Once a staff member from the hospital's Social Work and Discharge Planning Department has exhausted all patient or community resources, he or she requests assistance for a patient. In the first year of operation, the fund assisted 278 patients at a cost of just under $5,000.

Down and out in New York and London: a cross-national comparison of homelessness

OBJECTIVE

This study compared homelessness in New York City and London to examine the relative roles of individual pathology and structural forces in causing homelessness, the effect of sociopolitical and cultural differences on policy decisions toward solving homelessness, and the effect of broader structural forces on service programs for the homeless.

METHODS

A review of the scholarly literature and news reports was combined with interviews of staff members and homeless persons associated with various community agencies in London and New York City. Homelessness in the two cities was compared in relation to definition, demography, nonpsychiatric and psychiatric etiological factors, public policy, governmental responses, financial support, service strategies, and the practicalities of securing services and entitlements.

RESULTS AND CONCLUSIONS

The results indicate that characterizations of homelessness as a trait rather than a state reflect the tensions between social justice, public concepts, and a nation's economic resources. The absolute numbers of homeless persons, including those who are mentally ill, primarily reflect structural factors such as the availability of low-cost housing and public benefits. The commonalities that mentally ill homeless persons share with other vulnerable groups generally outweight their differences. The statutory rights to entitlements may be vitiated in times of shortage, especially for the least capable citizens. In both countries, efforts have been made to use the voluntary sector to serve the homeless, although it has been used much more extensively in Britain.

Role of the Essential Health Services Commission in health care reform

The New Jersey Essential Health Services Commission was established in 1992. The author reviews the role of the New Jersey Essential Health Services Commission in health care reform, including a subsidized health benefits program and payments to hospitals for charity care.

[The Bamako initiative: hope or illusion? Observations on the Benin experience]

In various countries in Africa, community financing has become the main source of finance for health services. In Benin, the "Bamako Initiative" experiment started in 1988 for many health structures and has subsequently been greatly expanded. After three years experience, the authors try to answer some important questions about community financing: To what extent does payment of fees have an influence on the use of health services? How are the funds collected and used and is embezzlement a serious problem? The question of equity is also considered as well as cost recovery, allowing an economics-based assessment of the Bamako Initiative which suggests that it has a promising future in Benin.

Variations in hypertension control in indigent rural primary care clinics in North Carolina

OBJECTIVE

To examine blood pressure control and prescribing practices in the treatment of hypertension, including the use of sample medications, in rural populations.

DESIGN

Retrospective chart review of 296 hypertensive patients and surveys of primary care providers serving these patients.

SETTING

Twenty-seven rural, primary care clinics in North Carolina.

OUTCOME MEASURE

Blood pressure control, with the practice site as the unit of analysis.

RESULTS

An average of 29% of patients per clinic had blood pressures that were inadequately controlled. Wide variations existed between clinics in blood pressure control and medication costs. Thirty-two percent of all blood pressure medications used were either angiotensin converting enzyme inhibitors or calcium channel blockers compared with 26% use of diuretics. Virtually all clinics used sample antihypertensive agents and reported that sample medications were an important source of free medications for their indigent patients. Reported sample use by practice was positively correlated with the mean daily hypertensive medication costs. Variations in blood pressure control were not explained by any measured variables, although the sample size was small.

CONCLUSIONS

Large variations exist within rural North Carolina primary care clinics in blood pressure control and medication costs. We need to study further the relationships of new antihypertensive agents, medication costs, and sample use with blood pressure control, health care costs, and other patient outcomes.

Medicaid program; limitations on aggregate payments to disproportionate share hospitals: federal fiscal year 1994--HCFA. Notice

This notice announces the preliminary Federal fiscal year (FFY) 1994 national target and individual State allotments for Medicaid payment adjustments made to hospitals that serve a disproportionate number of Medicaid recipients and low-income patients with special needs. We are publishing this notice in accordance with the provisions of section 1923(f)(1)(C) of the Social Security Act (the Act) and implementing regulations at 42 CFR 447.297 through 447.299. The preliminary FFY 1994 State DSH allotments published in this notice will be superseded by final FFY 1994 DSH allotments to be published in the Federal Register by April 1, 1994.

Medicaid program; freedom of choice waiver; conforming changes--HCFA. Interim final rule with comment period

This interim final rule amends existing Medicaid regulations on freedom of choice waivers granted under section 1915(b) of the Social Security Act (the Act) to conform them to the amendments made to the Act by sections 4604 and 4742 of the Omnibus Budget Reconciliation Act of 1990. This rule: Specifies that the Secretary may not waive the requirement that the State plan provide for adjustments in payment for inpatient hospital services furnished to infants under one year of age, or to children under 6 years of age who receive these services in disproportionate share hospitals. Extends to any provider participating under a section 1915(b)(4) waiver the same prompt payment standards that apply to all other health care practitioners furnishing Medicaid services. This rule also makes technical changes in the regulations relating to a recipient's free choice of providers of family planning services and cost-sharing requirements under waivers.

The Clinton plan: what happened to the tough choices?

This paper points out four difficult choices embedded in the Clinton plan. First, universal coverage is achieved, but with regressive head-tax financing on many workers-since the cost of the employer mandate ultimately will fall on workers' wages. Perhaps such an approach can be made politically acceptable. Second, cost containment is entrusted to global spending limits, which will limit the rate of improvement in quality. Third, the offering of choice among a variety of health plans of different costs and quality, although desirable in itself, may lead to inequity. Finally, the plan's financing will make it difficult for voters to tell what trade-offs they are making, because employer mandates and budget cuts disguise choices.

Public funding and policies for provision of the contraceptive implant, fiscal year 1992

According to results of a survey of state Medicaid, health and welfare agencies, these agencies spent $61 million in federal and state funds on the provision of the contraceptive implant to low-income women in FY 1992. Some $57 million of this was federal funds, with Medicaid accounting for 84% of all public funds spent on the implant; only nine states committed monies from their own coffers. The Medicaid agencies of 13 states reported restrictions on the number of subsidized implants a woman could receive over her reproductive lifetime. No Medicaid agency has provisions to cover required or requested removals of the device among users who become ineligible for Medicaid while the implant is in place; only eight health departments have policies ensuring subsidized removals for such women.

Impact of extending health care coverage to the uninsured

Changes in use of health services by the uninsured, when covered after health reform, are a key to the costs of reform. From data on persons under age sixty-five in the 1989 National Health Interview Survey, we estimated their expected use of hospitals (excluding obstetric deliveries) and doctor visits, adjusting for age, sex, and self-reported health status. If uninsured persons obtained private coverage distributed by the plan type of other persons in their home regions, nonobstetric hospital days for the formerly uninsured would increase 28 percent, and their visits to physicians' offices would increase 52 percent. If instead the uninsured enrolled entirely in group- or staff-model health maintenance organizations (HMOs) in their home regions, their nonobstetric hospital days would actually decrease 17 percent, and their visits to physicians' offices would increase 60 percent.