Impact of insurance and supply of health professionals on coverage of treatment for hypertension in Mexico: population based study

Effective access to health care in Mexico

OBJECTIVES

This paper assesses the impact of effective access on out-of-pocket health payments and catastrophic health expenditure. Effective access cannot be attained unless both health services and financial risk protection are accessible, affordable, and acceptable. Therefore, it represents a key determinant in the transition from fragmented health systems to universal coverage that many low- and middle-income countries face.

METHODS

We use a definition of effective access as the utilization of health insurance when available. We conducted a cross-sectional analysis using the 2018 Mexican National Health Survey (ENSANUT) at the household level. The analysis is performed in two stages. The first stage is a multinomial analysis that captures the factor associated with choosing effective access against the alternative of paying privately. The second stage consists of an impact analysis regarding the decision of not choosing effective access in terms of out-of-pocket (OOP) health payments and catastrophic health expenditures (CHE). The analysis corrects for both the decision to buy insurance and the decision to pay for health care.

RESULTS

We found that, on average, not choosing effective access increases OOP health payments by around 2300 pesos annually. Medicine payments are the most common factor in this increase. Nevertheless, outpatient and medicines health care are the main drivers of the increase in OOP health payments in all insurance beneficiaries. Not having effective access increases the probability of CHE health expenditures by 2.7 p.p. for the case of Social Security Insurance and 4.0 p.p. for Social Government insurance. Household enrolled in Prospera program for the poor are more likely to choose effective access while having household heads with more education and assets value does the opposite. Diabetes illnesses are associated with a higher probability of effective access.

CONCLUSION

Improving effective access is a middle step that cannot be disregarded when seeking universal coverage because OOP health payments and catastrophic outcomes are direct consequences. Public insurance in general, has around 50% effective access which remains a challenge in terms of health services utilization and health public policy design, calling for the need of better coordination across insurance types and pooling mechanisms to increase sustainability of needed health services.

A systematic review of the literature on the impact of the Seguro Popular

BACKGROUND

The Seguro Popular (SP) was launched in 2004 to increase access to healthcare and reduce catastrophic expenditures among the Mexican population. To document the evidence on its effectiveness, we conducted a systematic review of impact evaluations of the SP.

METHODS

We included papers using rigorous quasi-experimental designs to assess the effectiveness of the SP. We evaluated the quality of each study and presented the statistical significance of the effects by outcome category.

RESULTS

We identified 26 papers that met the inclusion criteria. Sixteen studies that evaluated the impact of SP on financial protection found consistent and statistically significant positive effects in 55% of the 65 outcomes analyzed. Nine studies evaluating utilization of health services for the general and infant populations found effectiveness on 40% of 30 outcomes analyzed. Concerning screening services for hypertension, diabetes, and cervical and prostate cancer, we found three studies evaluating 14 outcomes and finding significant effects on 50% of them. Studies looking at the impact of SP on diabetes, hypertension, and general health care and treatment evaluated 19 outcomes and found effects on 21% of them. One study assessed five diabetes monitoring services and found positive effects on four of them. The only study on morbidity and mortality found positive results on three of the four outcomes of interest.

CONCLUSION

We found mixed evidence on the impact of SP on financial protection, healthcare utilization, morbidity and mortality. In the 26 studies included in this review, researchers found positive effects in roughly half of the outcomes and null results on the rest.

Prevalence and inequality in persistent undiagnosed, untreated, and uncontrolled hypertension: Evidence from a cohort of older Mexicans

Hypertension is the leading risk factor for cardiovascular diseases (CVDs) and substantial gaps in diagnosis, treatment and control signal failure to avert premature deaths. Our aim was to estimate the prevalence and assess the socioeconomic distribution of hypertension that remained undiagnosed, untreated, and uncontrolled for at least five years among older Mexicans and to estimate rates of transition from those states to diagnosis, treatment and control. We used data from a cohort of Mexicans aged 50+ in two waves of the WHO Study on Global AGEing and adult health (SAGE) collected in 2009 and 2014. Blood pressure was measured, hypertension diagnosis and treatment self-reported. We estimated prevalence and transition rates over five years and calculated concentration indices to identify socioeconomic inequalities using a wealth index. Using probit models, we identify characteristics of those facing the greatest barriers in receiving hypertension care. More than 60 percent of individuals with full item response (N = 945) were classified as hypertensive. Over one third of those undiagnosed continued to be in that state five years later. More than two fifths of those initially untreated remained so, and over three fifths of those initially uncontrolled failed to achieve continued blood pressure control. While being classified as hypertensive was more concentrated among the rich, missing diagnosis, treatment and control were more prevalent among the poor. Men, singles, rural dwellers, uninsured, and those with overweight were more likely to have persistent undiagnosed, untreated, and uncontrolled hypertension. There is room for improvement in both hypertension diagnosis and treatment in Mexico. Clinical and public health attention is required, even for those who initially had their hypertension controlled. To ensure more equitable hypertension care and effectively prevent premature deaths, increased diagnosis and long-term treatment efforts should especially be directed towards men, singles, uninsured, and those with overweight.

Publicly provided healthcare and migration

Publicly provided healthcare has received growing attention. Debates have been fuelled by evidence on improved health and reduced poverty, and concerns over adverse labour market effects; concerns that are, to date, only supported by mixed empirical findings. This article examines whether publicly provided healthcare influences the decision to migrate. The spatial and temporal variation in the expansion of a non-contributory health insurance programme in Mexico, combined with the panel dimension and the timing of household survey data allows causal identification of the effect of increased coverage on migration. Difference-in-differences estimates reveal that accessing healthcare for free raises internal migration. The effect on international migration, costlier by nature, is statistically insignificant. Potential mechanisms include better health, the alleviation of financial constraints and a greater propensity to work. Results point to the relevance of including household members who have migrated in assessing the impacts of social health policies. They suggest that publicly provided healthcare could have multiplier effects on economic development and welfare by enabling labour force detachment of working-age members in affiliated households.

Social capital, depressive symptoms, and perceived quality of care among hypertensive patients in primary care

Background

Depression is an important issue in the management of hypertension. However, little attention has been paid to addressing such aspects of psychological health among patients with hypertension. We aimed to estimate the prevalence of depressive symptoms among patients with hypertension in primary care settings and to identify the potential role of social capital in predicting depressive symptoms. The influence of psychological well-being on the perceived quality of hypertensive care was also examined.

Methods

In Shenzhen, China, an on-site cross-sectional study was conducted from March to September 2017. In total, 1046 respondents completed a face-to-face survey interview. We examined the associations between social capital, depressive symptoms, and perceived quality of care.

Results

The results showed that 10.7% of patients with hypertension who attended primary care facilities had depressive symptoms. Two components of social capital—social ties (9.63 vs. 10.67; OR = 1.314, 95% CI 1.165–1.483; P < .001) and trust (3.46 vs. 3.89; OR = 2.535, 95% CI 1.741–3.691; P < .001)—were protective factors for depression among patients with hypertension in primary care settings. We also found that depressive symptoms were negatively associated with perceived quality of care (30.5 vs. 32.5; β = 1.341, 95% CI 0.463–2.219; P = .003)..

Conclusions

We found inverse associations between depressive symptoms and perceived quality of care and between social capital and the occurrence of symptoms of depression. Our findings suggest that strategies addressing both hypertension and depressive symptoms should be implemented to better manage hypertension. Appropriate social interventions should be designed and implemented.

Effective coverage for hypertension treatment among middle-aged adults and the older population in China, 2011 to 2013: A nationwide longitudinal study

Methods

We used the baseline survey and first follow-up surveys of the China Health and Retirement Longitudinal Study of middle-aged and older populations conducted between 2011 and 2013. Correlates of effective coverage and treatment coverage for hypertension were analysed using multivariate logistic regression models, after controlling for demographic characteristics.

Results

In 2011, 38.40% of 13 702 individuals surveyed were identified with hypertension. Overall, the effective treatment coverage among the middle-aged and older population in China from 2011 to 2013 was only 22.40% compared to the treatment coverage of 55.86%. Variations in effective coverage among patients enrolled in the three public health insurance schemes ranged from 22.60% to 29.31%.

Conclusions

The level of effective coverage for hypertension treatment in China was still very low, and that health insurance schemes play a significant role in improving treatment coverage and effective coverage for hypertension treatment. In the implementation of China’s health system reform, health equity and health care equality should be emphasised and enhanced by offering more equitable benefits packages across social health insurance schemes.

Comparing Regional Distribution Equity among Doctors in China before and after the 2009 Medical Reform Policy: A Data Analysis from 2002 to 2017

Background: Although China began implementing medical reforms in 2009 aimed at fair allocation of the regional distribution of doctors, little is known of their impact. This study analyzed the geographic distribution of doctors from 2002 to 2017. Methods: This study calculated the Gini coefficient and Theil index among doctors in the eastern, central, and western regions (Category 1) of China, and in urban and rural areas (Category 2). The statistical significance of fairness changes was analyzed using the Mann–Whitney U test. Results: The annual growth rates of the number of doctors for the periods from 2002 to 2009 and 2010 to 2017 were 2.38% and 4.44%. The Gini coefficients among Category 1 were lower than those in Category 2, and statistically decreased after the medical reforms (P < 0.01) but continued to increase in Category 2 (P = 0.463). In 2017, the Theil decomposition result of Category 1 was 74.33% for the between-group, and in Category 2, it was 95.22% for the within-group. Conclusions: The fairness among the regional distribution of doctors in Category 1 is now at a high level and is better than that before the reforms. While the fairness in Category 2 is worse than that before the reforms, it causes moderate inequality and is continually decreasing. Overall unfairness was found to be derived from the between-group.

Health-care coverage and access to health care in the context of type 2 diabetes and hypertension in rural Mexico: a systematic literature review

OBJECTIVE

We aimed to identify the coverage rates and use of health care and to explore barriers and facilitators of access in rural Mexico.

STUDY DESIGN

Systematic review of the literature.

METHODS

We undertook a structured search in the electronic databases EMBASE, Medline, and Scopus. Inclusion criteria comprised articles published in Spanish and English during the period 1986-2018. The studies were screened and selected by two independent reviewers in accordance with predefined criteria.

RESULTS

The review included 14 studies. Over the last 30 years, the rates of health-care coverage have increased from 30% to >50% in rural Mexico. Although the rates of health-care coverage increased, aspects such as lack of resources, language, and health-care professionals remained important barriers to health care. Cash transfer programs were identified as a facilitator.

CONCLUSIONS

Despite increased health-care coverage of >50% in the last three decades, action is needed to fulfill the needs of rural Mexican populations. It is important to increase the number of trained health professionals who practice in rural areas. Moreover, health programs should be developed and adapted to meet the needs of rural and indigenous populations.

Trends and Inequalities in the Health Care and Hypertension Outcomes in China, 2011 to 2015

Background: Hypertension is one of the most significant and common risk factors for cardiovascular disease, yet it remains poorly controlled in China. This study aims to examine trends and socioeconomic inequalities in the management of hypertension between 2011 and 2015 in China and to investigate the association between antihypertensive medication treatment and reduction of blood pressure, using nationally representative data. Methods: Concentration curve and concentration index were used to assess socioeconomic-related inequalities in hypertension care and health service utilisation. The fixed-effects analysis was performed to measure the impact of medication treatment on reduction of blood pressure among people with hypertension by using linear regression models. Results: Among hypertensive individuals, there were growing trends in the rates of awareness and treatment from 55.87% and 48.44% in 2011, to 68.31% in 2013 and 61.97% in 2015, respectively. The proportion of hypertension control was still below 30%. The fixed-effects models indicated that medication treatment was statistically significant and associated with the patients' systolic blood pressure (β: -13.483; 95% CI: -15.672, -11.293) and diastolic blood pressure (β: -5.367; 95% CI: -6.390, -4.344). Conclusions: China has made good progress in the hypertension diagnosis, medication treatment and coverage of health services over the last 10 years; however, pro-rich inequalities in hypertension care still exist, and there is considerable progress to be made in the prevention, treatment and effective control of hypertension.

Cross-Sectional Study on the Management and Control of Hypertension Among Migrants in Primary Care: What Is the Impact of Segmented Health Insurance Schemes?

Background Information is scarce regarding the impact of fragmented health insurance schemes on the management and control of hypertension among migrants in primary care. This study aimed to investigate the relationship between insurance status and management and control of hypertension among migrants in primary care and to examine whether social capital could facilitate migrants' participation in local health insurance schemes. Methods and Results A site-based, cross-sectional, face-to-face patient survey was administered in Shenzhen, China. Hypertensive primary care users who were migrants were selected using a systematic sampling design. The participants covered by local health insurance schemes were more likely than those without coverage to be managed by primary care facilities (82.6% versus 62.0%; odds ratio=2.63, 95% CI 1.41-4.89) and to take antihypertensive medications (87.9% versus 76.4%; odds ratio=2.38, 95% CI 1.34-4.24), and they had higher scores in first contact use (3.49 versus 3.23; β=0.17, 95% CI 0.05-0.29) and continuity of care (3.17 versus 3.02; β=0.11, 95% CI 0.01-0.21). The participants covered by local insurance schemes had higher scores in perceived generalized trust than their counterparts (4.23 versus 3.95; β=0.16, 95% CI 0.09-0.40). The hypertension control rate was also higher among the participants with local health insurance coverage (48.8% versus 42.2%; odds ratio=1.38, 95% CI 1.02-2.12). Conclusions In conclusion, local health insurance schemes are associated with optimal control of hypertension for migrants compared with social health insurance schemes. Our study implies that one form of social capital, namely perceived general trust, contributes to migrant hypertensive patients' participation in local health insurance schemes.

The interaction effect of health insurance reimbursement and health workforce on health care-seeking behaviour in China

OBJECTIVE

In China, patients generally seek health care at high-level hospitals, which is leading to escalating medical costs and overloaded hospitals. Some studies have suggested that the health system is an important factor influencing individuals' health care-seeking behaviour; however, this association has not been studied in much depth. We therefore examined the impact of the health system (in terms of the interaction between health insurance reimbursement and health workforce) on health care-seeking behaviour.

METHODS

Drawing on national survey data from 2008 and 2013, we linked individual-level data on choice of health care providers (our index of health care-seeking behaviour) with county-level data on the health workforce and health insurance. We then constructed a multilevel multinomial logistic model to examine the impacts of health insurance reimbursement (indexed as average reimbursement rate [ARR]) and the health workforce (number of registered physicians per 1000 population) at county hospitals and primary health care institutions (PHCs) on choice of inpatient care providers.

RESULTS

Increases in ARR at county hospitals were associated with a greater probability of visiting such hospitals (relative risk ratio [RRR] = 1.23), and this positive impact was even greater in county hospitals with higher physician densities (RRR = 2.76). Greater ARR in PHCs was associated with a 73% lower probability of visiting municipal- and higher-level hospitals; increasing ARR was associated with an even lower probability when physician density in PHCs was considered (RRR = 0.09).

CONCLUSION

Increases in the health insurance reimbursement and health workforce are necessary to improve health care access and thereby health care-seeking behaviour. Thus, comprehensive health system reform is necessary.

The Relationship Between Educational Attainment and Health Care Access and Use Among Mexicans, Mexican Americans, and U.S.-Mexico Migrants

The aim of the study was to assess the relationship between educational attainment and health care access and use among Mexican-origin populations. Data from the 2012 Mexican National Health and Nutrition Study, the 2013 Project Migrante Health Care Access and Utilization Survey, and the 2013-2014 California Health Interview Survey were used to examine educational gradients in health insurance, medical home, and hospitalization among Mexicans in Mexico, northbound, southbound, and deported migrants, and U.S.-and foreign-born Mexican Americans. College graduates had greater odds of being insured relative to those with less than a high school degree among Mexicans (AOR = 1.48, p < 0.001), northbound migrants (AOR = 3.69, p < 0.001), and the foreign-born (AOR = 2.01, p < 0.01), and of having a medical home among Mexicans (AOR = 1.95, p < 0.001) and the foreign-born (AOR = 2.14, p < 0.05). Eliminating differences by educational attainment in the U.S. will require policy changes like making immigrants eligible for public insurance. In Mexico, it will require targeted outreach to enroll underserved populations in existing public insurance programs.

[Hypertension in Mexican adults: prevalence, diagnosis and type of treatment. Ensanut MC 2016.]

OBJECTIVE

To describe the prevalence, awareness and proportion of adults with an adequate control of hypertension.

MATERIALS AND METHODS

Blood pressure was measured at 8 352 adults who participated in the Ensanut MC 2016. The adults who reported having diagnosis of hypertension or had systolic blood pressure values (TAS) ≥140mmHg or diastolic blood pressure (TAD) ≥90mmHg were classified as hypertensive. Hypertension was considered controlled when blood pressure was TAS <140mmHg and TAD <90mmHg.

RESULTS

The prevalence of hypertension was 25.5%. Of these, 40.0% were unaware of having high blood pressure. Of the hypertensive adults who had previous diagnosis of hypertension and receiving drug treatment (79.3%), 45.6% had blood pressure under control.

CONCLUSIONS

A high percentage of adults are unaware of having hypertension and nearly half have inadequate control. The relevance of current programmes for diagnosing hypertension should be assessed, as well as the effectiveness of their control strategies.

Preventive healthcare-seeking behavior among poor older adults in Mexico: the impact of Seguro Popular, 2000-2012

OBJECTIVE

Determine the effect of Seguro Popular (SP) on preventive care utilization among low-income SP beneficiaries and uninsured elders in Mexico.

MATERIALS AND METHODS

Fixed-effects instrumental-variable (FE-IV) pseudo-panel estimation from three rounds of the Mexican National Health and Nutrition Survey (2000, 2006 and 2012).

RESULTS

Our findings suggest that SP has no significant effect on the use of preventive services, including screening for diabetes, hypertension, breast cancer and cervical cancer, by adults aged 50 to 75 years.

CONCLUSIONS

Despite the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in healthcare access and utilization still exist in Mexico. The Mexican government must keep working on extending health insurance coverage to vulnerable adults. Additional efforts to increase health care coverage and to support preventive care are needed to reduce persistent disparities in healthcare utilization.

Challenges and dilemmas on universal coverage for non-communicable diseases in middle-income countries: evidence and lessons from Mexico

BACKGROUND

Despite more than 20 years of reform projects in health systems, the universal coverage strategy has not reached the expected results in most middle-income countries (MICs). Using evidence from the Mexican case on diabetes and hypertension as tracers of non-communicable diseases, the effective coverage rate barely surpasses half of the expected goals necessary to meet the challenges that these two diseases represent at the population level. Prevalence and incidence rates do not diminish either; they even grow. In terms of the economic burden, this means that lack of financial protection and catastrophic expense rates have increased, contrary to what could have been expected.

DISCUSSION

As any complex system, health systems present challenges and dilemmas that are difficult to solve. In terms of universal coverage, when contrasting normative coverage versus effective coverage, the epidemiological, cultural, organizational and economic challenges and barriers become evident. Such challenges have not allowed a greater effectiveness of the contributions of state of the art medicine in the resolution of health problems, particularly in relation to diabetes and hypertension.

CONCLUSIONS

Despite of the existence of many universal coverage projects, strategies and programs implemented in MICs, challenges remain and, far from disappearing, unresolved problems are still present, even with increasing trends. The model of care based on a curative biomedical approach was enough to respond to the health needs of the last century, but is no longer adapted to the needs of the present century. The dilemmas of continuity vs. rupture require to review and discuss the background and structure of health systems and their underlying models of care. These two elements have not allowed the different coverage schemes to guarantee greater effectiveness in the application of state of the art medicine, nor a greater health care financial protection for patients and their families. We thus can either accept the fragmented health systems and bio-medical-curative models of care approach or, instead, we can move towards integrated health systems that would be based on a socio-medical-preventive approach to health care.

Welfare effects of health insurance in Mexico: The case of Seguro Popular de Salud

This study contributes with original empirical evidence on the distributional and welfare effects of one of the most important health policies implemented by the Mexican government in the last decade, the Seguro Popular de Salud (SPS). We analyze the effect of SPS on households' welfare using a decomposable index that considers insured and uninsured households' response to out-of-pocket (OOP) payments using both social welfare weights and inequality aversion. The disaggregation of the welfare index allows us to explore the heterogeneity of the SPS impact on households' welfare. We applied propensity score matching to reduce the self-selection bias of being SPS insured. Overall results suggest non-conclusive results of the impact of SPS on households' welfare. When we disaggregated the welfare index by different sub-population groups, our results suggest that households' beneficiaries of SPS with older adults or living in larger cities are better protected against OOP health care payments than their uninsured counterparts. However, no effect was found among SPS-insured households living in rural and smaller cities, which is a result that could be attributed to limited access to health resources in these regions. Scaling up health insurance coverage is a necessary but not sufficient condition to ensure the protection of SPS coverage against financial risks among the poor.

Assessing out-of-pocket expenditures for primary health care: how responsive is the Democratic Republic of Congo health system to providing financial risk protection?

BACKGROUND

The goal of universal health coverage is challenging for chronically under-resourced health systems. Although household out-of-pocket payments are the most important source of health financing in low-income countries, relatively little is known about the drivers of primary health care expenditure and the predictability of the burden associated with high fee-for-service payments. This study describes out-of-pocket health expenditure and investigates demand- and supply-side drivers of excessive costs in the Democratic Republic of Congo (DRC), a central African country in the midst of a process of reforming its health financing system towards universal health coverage.

METHODS

A population-based household survey was conducted in four provinces of the DRC in 2014. Data included type, level and utilization of health care services, accessibility to care, patient satisfaction and disaggregated health care expenditure. Multivariate logistic regressions of excessive expenditure for outpatient care using alternative thresholds were performed to explore the incidence and predictors of atypically high expenditure incurred by individuals.

RESULTS

Over 17% (17.5%) of individuals living in sample households reported an illness or injury without being hospitalized. Of 3341 individuals reporting an event in the four-week period prior to the survey, 65.6% sought outpatient care with an average of one visit (SD = 0.0). The overall mean expenditure per visit was US$ 6.7 (SD = 10.4) with 29.4% incurring excessive expenditure. The main predictors of a financial risk burden included utilizing public services offering the complementary benefit package, dissatisfaction with care received, being a member of a large household, expenditure composition, severity of illness, residence and wealth (p < .05). The insured status influenced the expenditure level, with no association with catastrophe. Those who did not seek care when needed reported financial constraints as the major reason for postponing or foregoing care. Wealth-related inequities were found in service and population coverage and in out-of-pocket payment for outpatient care.

CONCLUSION

Burdensome expenditure for primary care and its key drivers are of utmost importance. Forthcoming health financing reform agendas must incorporate a strategy for getting data used in the design of financial risk protection. Realizing equitable and efficient access to outpatient care is a vital ingredient for sustainable health systems.

Efecto del Seguro Popular de Salud sobre los gastos catastróficos y empobrecedores en México, 2004-2012

Objetivos. Determinar el impacto del Seguro Popular (SPS) en los gastos catastróficos y empobrecedores de los hogares y la protección financiera del sistema de salud en México. Material y métodos. Se aplicó el método de pareo por puntaje de propensión sobre la afiliación al SPS y se determinó el efecto atribuible en el gasto en salud. Se hizo uso de la Encuesta Nacional de Ingresos y Gastos de los Hogares (ENIGH) de 2004 a 2012, del Instituto Nacio­nal de Estadística y Geografía. Resultados. El SPS tiene un efecto significativo reductor en la probabilidad de sufrir gastos empobrecedores. En lo que respecta a los gastos ca­tastróficos hubo reducción sin ser significativa entre grupos. Conclusión. Este estudio demuestra el efecto que el SPS, y en particular el aseguramiento en salud, tiene como un instrumento de protección financiera. Para futuros estudios se propone analizar la persistencia del alto porcentaje del gasto de bolsillo aprovechando series de tiempo más largas de la ENIGH.

Health Insurance and the Aging: Evidence From the Seguro Popular Program in Mexico

Aimed at covering the large fraction of workers in the informal sector without access to a social security program, the Mexican public health insurance program Seguro Popular began in 2002 and now reaches more than 50 million individuals. We estimate impacts of Seguro Popular for the population aged 50 and older on a set of indicators related to health care including utilization, diagnostic/preventive tests, and treatment conditional on being ill. Using the longitudinal Mexican Health and Aging Study over the period 2001-2012, we conduct before and after difference-in-difference matching impact estimators. Our results suggest large and important effects of the Program on utilization and diagnostic tests. We find overall smaller effects on the probability of being in treatment for individuals with chronic diseases, but these effects are concentrated in rural areas with relatively more health services versus rural areas with lower levels of health services. These results suggest that, to the extent that health services become more available in rural areas lacking services, effects of health insurance may increase.

The Impact of Social Health Insurance on Diabetes and Hypertension Process Indicators among Older Adults in Mexico

OBJECTIVE

To examine the impact of Seguro Popular (Mexican social health insurance for the poor; SP) on diabetes and hypertension care, intermediate process indicators for older adults (>50 years): pharmacological treatment, blood glucose tests, the use of complementary and alternative medicine (CAM), and adherence to their nutrition and exercise program. (CAM was defined as products or practices that were not part of the medical standard of care.)

DATA SOURCES/STUDY SETTING

Repeated cross-sectional surveys from Encuesta Nacional de Salud y Nutrición (Mexican Health and Nutrition Survey, ENSANUT), a nationally representative health and nutrition survey sampling N = 45,294 older adults in 2000, N = 45,241 older adults in 2005-2006, and N = 46,277 older adults in 2011-2012.

STUDY DESIGN

Fixed-effects instrumental variable (FE-IV) repeated cross-sectional at the individual level with municipality fixed-effects estimation was performed.

PRINCIPAL FINDINGS

We found a marginally significant effect of SP on the use of insulin and oral agents (40 percentage points). Contrary to that expected, no other significant differences were found for diabetes or hypertension treatment and care indicators.

CONCLUSIONS

Social health insurance for the poor improved some but not all health care process indicators among diabetic and hypertensive older people in Mexico.

Mexico's Seguro Popular Appears To Have Helped Reduce The Risk Of Preterm Delivery Among Women With Low Education

Beginning in 2001 Mexico established Seguro Popular, a health insurance scheme aimed at providing coverage to its large population of uninsured people. While recent studies have evaluated the health benefits of Seguro Popular, evidence on perinatal health outcomes is lacking. We conducted a population-based study using Mexican birth certificate data for 2010 to assess the relationship between enrollment in Seguro Popular and preterm delivery among first-time mothers with singleton births in Mexico. Seguro Popular enrollees with no formal education had a far greater reduction in risk of preterm delivery, while enrollees with any formal education experienced only slight reduction in risk, after maternal age, marital status, education level, mode of delivery, and trimester in which prenatal care was initiated were controlled for. Seguro Popular appears to facilitate access to health services among mothers with low levels of education, reducing their risk for preterm delivery. Providing broad-scale health insurance coverage may help improve perinatal health outcomes in this vulnerable population.

Self-Reported Health and Functional Characteristics of Mexican and Mexican American Adults Aged 80 and Over

OBJECTIVE

To examine the health and functional characteristics of Mexican and Mexican American adults aged ≥80.

METHOD

Data came from Wave I (2001) and Wave III (2012) of the Mexican Health and Aging Study (MHAS), and Wave IV (2000-2001) and Wave VII (2010-2011) of the Hispanic Established Populations for Epidemiologic Studies of the Elderly (HEPESE).

RESULTS

In 2000-2001, diabetes, arthritis, hypertension, and stroke were higher in the HEPESE than in the MHAS. In the HEPESE, activities of daily living (ADL) difficulties and all health conditions, except heart attack, were greater in 2010-2011 than in 2000-2001. In the MHAS, hypertension and ADL difficulties were greater, and arthritis was lower in 2012 compared with 2001. In 2010-2011, all self-reported health conditions were higher in the HEPESE compared with the 2012 observation of the MHAS.

DISCUSSION

The observed differences may reflect worse health for Mexican Americans, health care access, reporting bias, and more selective survival to very old age in Mexico.

Quality Improvement for Cardiovascular Disease Care in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

The majority of global cardiovascular disease (CVD) burden falls on people living in low- and middle-income countries (LMICs). In order to reduce preventable CVD mortality and morbidity, LMIC health systems and health care providers need to improve the delivery and quality of CVD care.

OBJECTIVES

As part of the Disease Control Priorities Three (DCP3) Study efforts addressing quality improvement, we reviewed and summarized currently available evidence on interventions to improve quality of clinic-based CVD prevention and management in LMICs.

METHODS

We conducted a narrative review of published comparative clinical trials that evaluated efficacy or effectiveness of clinic-based CVD prevention and management quality improvement interventions in LMICs. Conditions selected a priori included hypertension, diabetes, hyperlipidemia, coronary artery disease, stroke, rheumatic heart disease, and congestive heart failure. MEDLINE and EMBASE electronic databases were systematically searched. Studies were categorized as occurring at the system or patient/provider level and as treating the acute or chronic phase of CVD.

RESULTS

From 847 articles identified in the electronic search, 49 met full inclusion criteria and were selected for review. Selected studies were performed in 19 different LMICs. There were 10 studies of system level quality improvement interventions, 38 studies of patient/provider interventions, and one study that fit both criteria. At the patient/provider level, regardless of the specific intervention, intensified, team-based care generally led to improved medication adherence and hypertension control. At the system level, studies provided evidence that introduction of universal health insurance coverage improved hypertension and diabetes control. Studies of system and patient/provider level acute coronary syndrome quality improvement interventions yielded inconclusive results. The duration of most studies was less than 12 months.

CONCLUSIONS

The results of this review suggest that CVD care quality improvement can be successfully implemented in LMICs. Most studies focused on chronic CVD conditions; more acute CVD care quality improvement studies are needed. Longer term interventions and follow-up will be needed in order to assess the sustainability of quality improvement efforts in LMICs.

Access to Medications for Cardiovascular Diseases in Low- and Middle-Income Countries

Cardiovascular diseases (CVD) represent the highest burden of disease globally. Medicines are a critical intervention used to prevent and treat CVD. This review describes access to medication for CVD from a health system perspective and strategies that have been used to promote access, including providing medicines at lower cost, improving medication supply, ensuring medicine quality, promoting appropriate use, and managing intellectual property issues. Using key evidence in published and gray literature and systematic reviews, we summarize advances in access to cardiovascular medicines using the 5 health system dimensions of access: availability, affordability, accessibility, acceptability, and quality of medicines. There are multiple barriers to access of CVD medicines, particularly in low- and middle-income countries. Low availability of CVD medicines has been reported in public and private healthcare facilities. When patients lack insurance and pay out of pocket to purchase medicines, medicines can be unaffordable. Accessibility and acceptability are low for medicines used in secondary prevention; increasing use is positively related to country income. Fixed-dose combinations have shown a positive effect on adherence and intermediate outcome measures such as blood pressure and cholesterol. We have a new opportunity to improve access to CVD medicines by using strategies such as efficient procurement of low-cost, quality-assured generic medicines, development of fixed-dose combination medicines, and promotion of adherence through insurance schemes that waive copayment for long-term medications. Monitoring progress at all levels, institutional, regional, national, and international, is vital to identifying gaps in access and implementing adequate policies.

Changing tides: Adaptive monitoring, assessment, and management of pharmaceutical hazards in the environment through time

Pharmaceuticals are ubiquitous contaminants in aquatic ecosystems. Adaptive monitoring, assessment, and management programs will be required to reduce the environmental hazards of pharmaceuticals of concern. Potentially underappreciated factors that drive the environmental dose of pharmaceuticals include regulatory approvals, marketing campaigns, pharmaceutical subsidies and reimbursement schemes, and societal acceptance. Sales data for 5 common antidepressants (duloxetine [Cymbalta], escitalopram [Lexapro], venlafaxine [Effexor], bupropion [Wellbutrin], and sertraline [Zoloft]) in the United States from 2004 to 2008 were modeled to explore how environmental hazards in aquatic ecosystems changed after patents were obtained or expired. Therapeutic hazard ratios for Effexor and Lexapro did not exceed 1; however, the therapeutic hazard ratio for Zoloft declined whereas the therapeutic hazard ratio for Cymbalta increased as a function of patent protection and sale patterns. These changes in therapeutic hazard ratios highlight the importance of considering current and future drivers of pharmaceutical use when prioritizing pharmaceuticals for water quality monitoring programs. When urban systems receiving discharges of environmental contaminants are examined, water quality efforts should identify, prioritize, and select target analytes presently in commerce for effluent monitoring and surveillance.

Sustained effect of health insurance and facility quality improvement on blood pressure in adults with hypertension in Nigeria: A population-based study

BACKGROUND

Hypertension is a leading risk factor for death in sub-Saharan Africa. Quality treatment is often not available nor affordable. We assessed the effect of a voluntary health insurance program, including quality improvement of healthcare facilities, on blood pressure (BP) in hypertensive adults in rural Nigeria.

METHODS

We compared changes in outcomes from baseline (2009) to midline (2011) and endline (2013) between non-pregnant hypertensive adults in the insurance program area (PA) and a control area (CA), through household surveys. The primary outcome was the difference between the PA and CA in change in BP, using difference-in-differences analysis.

RESULTS

Of 1500 eligible households, 1450 (96.7%) participated, including 559 (20.8%) hypertensive individuals, of which 332 (59.4%) had follow-up data. Insurance coverage increased from 0% at baseline to 41.8% at endline in the PA and remained under 1% in the CA. The PA showed a 4.97 mm Hg (95% CI: -0.76 to +10.71 mm Hg) greater decrease in systolic BP and a 1.81 mm Hg (-1.06 to +4.68 mm Hg) greater decrease in diastolic BP from baseline to endline compared to the CA. Respondents with stage 2 hypertension showed an 11.43 mm Hg (95% CI: 1.62 to 21.23 mm Hg) greater reduction in systolic BP and 3.15 mm Hg (-1.22 to +7.53 mm Hg) greater reduction in diastolic BP in the PA compared to the CA. Attrition did not affect the results.

CONCLUSION

Access to improved quality healthcare through an insurance program in rural Nigeria was associated with a significant longer-term reduction in systolic BP in subjects with moderate or severe hypertension.

Type of Insurance and Use of Preventive Health Services Among Older Adults in Mexico

OBJECTIVE

The main purpose of this article was to assess the differences between Seguro Popular (SP) and employer-based health insurance in the use of preventive services, including screening tests for diabetes, cholesterol, hypertension, cervical cancer, and prostate cancer among older adults at more than a decade of health care reform in Mexico.

METHOD

Logistic regression models were used with data from the Mexican Health and Nutrition Survey, 2012.

RESULTS

After adjusting for other factors influencing preventive service utilization, SP enrollees were more likely to use screening tests for diabetes, cholesterol, hypertension, and cervical cancer than the uninsured; however, those in employment-based and private insurances had higher odds of using preventive care for most of these services, except Pap smears.

DISCUSSION

Despite all the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in health care access and utilization still exist in Mexico.

Prescription drug insurance coverage and patient health outcomes: a systematic review

Previous reviews have shown that changes in prescription drug insurance benefits can affect medication use and adherence. We conducted a systematic review of the literature to identify studies addressing the association between prescription drug coverage and health outcomes. Studies were included if they collected empirical data on expansions or restrictions of prescription drug coverage and if they reported clinical outcomes. We found 23 studies demonstrating that broader prescription drug insurance reduces use of other health care services and has a positive impact on patient outcomes. Coverage gaps or caps on drug insurance generally led to worse outcomes. States should consider implementing the Affordable Care Act expansions in drug coverage to improve the health of low-income patients receiving state-based health insurance.

A comparison of the quality of hypertension management in primary care between Shanghai and Shenzhen: a cohort study of 3196 patients

Strong primary care is in urgent need for the management and control of hypertension. This study aimed to compare the quality of hypertensive care delivered by community health centers (CHCs) in Shanghai and Shenzhen. Multistage random sampling method was used to select 4 CHCs in each city as study settings. A cohort of hypertensive patients under the hypertensive management program in the CHCs was selected from the electronic information system by using a systematic random sampling method. Binary logistic regression models were constructed for comparison between the 2 cities. A total of 3196 patients' records were assessed. The proportions of hypertensive patients who received advice on smoking cessation (33.8 vs 7.7%, P < 0.001), increasing physical activity (52.4 vs 16.8%, P < 0.001), low-sodium diet (72.0 vs 64.1%, P < 0.001), and regular follow-up (37.8 vs 8.6%, P < 0.001) were higher in Shenzhen than in Shanghai. However, the drug treatment rate in Shenzhen was lower than that in Shanghai (74.2 vs 95.2%, P < 0.001). The hypertension control rate in Shenzhen was lower than that in Shanghai (76.3 vs 83.2%, P < 0.001). Better performance in the process of hypertensive care in terms of increasing physical activity advice, low-sodium diet advice, regular follow-up, and drug prescription was associated with a higher rate of hypertension control. The study indicates that primary care is effective in managing hypertension irrespective of management and operation models of CHCs in urban China. Our study suggests that improvements in the process of hypertensive care may lead to better hypertension control.

The prevalence, awareness, and control of hypertension among workers in West Africa: a systematic review

BACKGROUND

: Interventions in workplace settings are considered to be cost-effective in preventing cardiovascular diseases. A systematic review was conducted to assess the prevalence of hypertension and the level of awareness and control among workers in West Africa.

DESIGN

A systematic search for studies on formal and informal sector workers aged ≥15 years in West Africa published between 1980 and September 2014 was undertaken using the Ovid Medline, Embase, PubMed, and Google Scholar databases. Clinical and obstetric studies and studies that did not report prevalence were excluded. Data on study settings, characteristics of workers, blood pressure (BP) levels, prevalence of hypertension, and associated demographic factors were extracted.

RESULTS

A total of 45 studies from six countries were identified involving 30,727 formal and informal sector workers. In 40 studies with a common definition of hypertension, the prevalence ranged from 12.0% among automobile garage workers to 68.9% among traditional chiefs. In 15 of these studies, the prevalence exceeded 30%. Typically sedentary workers such as traders, bank workers, civil servants, and chiefs were at high risk. Among health care workers, the prevalence ranged from 17.5 to 37.5%. The prevalence increased with age and was higher among males and workers with higher socio-economic status. Complications of hypertension, co-morbidities, and clustering of risk factors were common. The crude prevalence of hypertension increased progressively from 12.9% in studies published in the 1980s to 34.4% in those published in 2010-2014. The proportion of hypertensives who were previously aware of their diagnosis, were on treatment or had their BP controlled was 19.6-84.0%, 0-79.2%, and 0-12.7%, respectively. Hypertensive subjects, including health workers, rarely checked their BP except when they were ill.

CONCLUSIONS

There is a high prevalence of hypertension among West Africa's workforce, of which a significant proportion is undiagnosed, severe or complicated. The clustering of risk factors, co-morbidities, and general low awareness warrant an integrated and multisectoral approach. Models for workplace health programmes aiming to improve cardiovascular health should be extended to informal sector workers.

Heterogeneity in the effect of public health insurance on catastrophic out-of-pocket health expenditures: the case of Mexico

Low- and middle-income countries increasingly provide broad-based public health coverage to their residents. One of the goals of such programmes is to reduce the extent to which beneficiaries incur catastrophic out-of-pocket expenditures on health care. A recent field experiment showed that on average Mexico's new public insurance programme reduced such expenditures in rural areas. Our reanalysis of that data, augmented with administrative data on health infrastructure, shows that this effect depends strongly on the type of health facility to which the beneficiary has access. A second analysis, based on data from Mexico's National Household Income and Expenditure Surveys (abbreviated ENIGH for its name in Spanish), substantiates those findings. It shows that catastrophic expenditures have fallen sharply for rural households with access to well-staffed facilities, but that they have fallen little if at all for rural households with access to poorly staffed facilities. Our analysis of the ENIGH also shows that Mexico's public health insurance programme has sharply reduced catastrophic spending among urban households. Considering that most Mexicans live either in urban areas or in rural areas with access to well-staffed facilities, our results show that the public health insurance programme has been largely successful in achieving one of its key goals. At the same time, our results show how difficult it can be to provide effective protection against catastrophic health expenditures for residents of remote rural areas.

Use of electronic health records to evaluate the quality of care for hypertensive patients in Mexican family medicine clinics

OBJECTIVES

Patients with hypertension require life-long care and should be monitored to identify whether they are receiving the appropriate healthcare and reach their expected health outcomes. Our objectives were to develop quality of healthcare indicators (QCI) and evaluate the quality of care that hypertensive patients receive in family medicine clinics at the Mexican Institute of Social Security.

METHOD

We used a two-stage mixed methods approach: development of QCIs following the RAND-UCLA method; quality of care evaluation using electronic health record (EHR) data from 47 150 hypertensive patients who received care in 2009. We developed 15 QCIs, which were possible to construct using EHR data. The QCIs evaluated the process of care and health outcomes.

RESULTS

Most hypertensive patients were women (64%) more than 60 years old; 79% were overweight/obese and 31% had diabetes. On average, these patients attended regularly to the family doctor (≥7 visits a year); however, they received only 27% of recommended care. Among the hypertensive patients without comorbidity, 62% had achieved blood pressure (BP) control, whereas in the group of hypertensive patients with diabetes or chronic kidney disease, only 7% had achieved BP control.

CONCLUSION

EHR can become a source of information to evaluate routinely quality of care in developing countries that are beginning to modernize their health information systems.

Hypertension among older adults in low- and middle-income countries: prevalence, awareness and control

BACKGROUND

This study uses data from the World Health Organization's Study on Global Ageing and Adult Health (SAGE) to examine patterns of hypertension prevalence, awareness, treatment and control for people aged 50 years and over in China, Ghana, India, Mexico, the Russian Federation and South Africa.

METHODS

The SAGE sample comprises of 35 125 people aged 50 years and older, selected randomly. Hypertension was defined as ≥140 mmHg (systolic blood pressure) or ≥90 mmHg (diastolic blood pressure) or by currently taking antihypertensives. Control of hypertension was defined as blood pressure below 140/90 mmHg on treatment. A person was defined as aware if he/she was hypertensive and self-reported the condition.

RESULTS

Prevalence rates in all countries are broadly comparable to those of developed countries (52.9%; range 32.3% in India to 77.9% in South Africa). Hypertension was associated with overweight/obesity and was more common in women, those in the lowest wealth quintile and in heavy alcohol consumers. Awareness was found to be low for all countries, albeit with substantial national variations (48.3%; range 23.3% in Ghana to 72.1% in the Russian Federation). This was also the case for control (10.2%; range 4.1% in Ghana to 14.1% India) and treatment efficacy (26.3%; range 17.4% in the Russian Federation to 55.2% in India). Awareness was associated with increasing age, being female and being overweight or obese. Effective control of hypertension was more likely in older people, women and in the richest quintile. Obesity was associated with poorer control.

CONCLUSIONS

The high rates of hypertension in low- and middle-income countries are striking. Levels of treatment and control are inadequate despite half those sampled being aware of their condition. Since cardiovascular disease is by far the largest cause of years of life lost in these settings, these findings emphasize the need for new approaches towards control of this major risk factor.

The influence of health systems on hypertension awareness, treatment, and control: a systematic literature review

BACKGROUND

Hypertension (HT) affects an estimated one billion people worldwide, nearly three-quarters of whom live in low- or middle-income countries (LMICs). In both developed and developing countries, only a minority of individuals with HT are adequately treated. The reasons are many but, as with other chronic diseases, they include weaknesses in health systems. We conducted a systematic review of the influence of national or regional health systems on HT awareness, treatment, and control.

METHODS AND FINDINGS

Eligible studies were those that analyzed the impact of health systems arrangements at the regional or national level on HT awareness, treatment, control, or antihypertensive medication adherence. The following databases were searched on 13th May 2013: Medline, Embase, Global Health, LILACS, Africa-Wide Information, IMSEAR, IMEMR, and WPRIM. There were no date or language restrictions. Two authors independently assessed papers for inclusion, extracted data, and assessed risk of bias. A narrative synthesis of the findings was conducted. Meta-analysis was not conducted due to substantial methodological heterogeneity in included studies. 53 studies were included, 11 of which were carried out in LMICs. Most studies evaluated health system financing and only four evaluated the effect of either human, physical, social, or intellectual resources on HT outcomes. Reduced medication co-payments were associated with improved HT control and treatment adherence, mainly evaluated in US settings. On balance, health insurance coverage was associated with improved outcomes of HT care in US settings. Having a routine place of care or physician was associated with improved HT care.

CONCLUSIONS

This review supports the minimization of medication co-payments in health insurance plans, and although studies were largely conducted in the US, the principle is likely to apply more generally. Studies that identify and analyze complexities and links between health systems arrangements and their effects on HT management are required, particularly in LMICs. Please see later in the article for the Editors' Summary.

The quest for universal health coverage: achieving social protection for all in Mexico

Mexico is reaching universal health coverage in 2012. A national health insurance programme called Seguro Popular, introduced in 2003, is providing access to a package of comprehensive health services with financial protection for more than 50 million Mexicans previously excluded from insurance. Universal coverage in Mexico is synonymous with social protection of health. This report analyses the road to universal coverage along three dimensions of protection: against health risks, for patients through quality assurance of health care, and against the financial consequences of disease and injury. We present a conceptual discussion of the transition from labour-based social security to social protection of health, which implies access to effective health care as a universal right based on citizenship, the ethical basis of the Mexican reform. We discuss the conditions that prompted the reform, as well as its design and inception, and we describe the 9-year, evidence-driven implementation process, including updates and improvements to the original programme. The core of the report concentrates on the effects and impacts of the reform, based on analysis of all published and publically available scientific literature and new data. Evidence indicates that Seguro Popular is improving access to health services and reducing the prevalence of catastrophic and impoverishing health expenditures, especially for the poor. Recent studies also show improvement in effective coverage. This research then addresses persistent challenges, including the need to translate financial resources into more effective, equitable and responsive health services. A next generation of reforms will be required and these include systemic measures to complete the reorganisation of the health system by functions. The paper concludes with a discussion of the implications of the Mexican quest to achieve universal health coverage and its relevance for other low-income and middle-income countries.

Malaria prevention in pregnancy, birthweight, and neonatal mortality: a meta-analysis of 32 national cross-sectional datasets in Africa

BACKGROUND

Low birthweight is a significant risk factor for neonatal and infant death. A prominent cause of low birthweight is infection with Plasmodium falciparum during pregnancy. Antimalarial intermittent preventive therapy in pregnancy (IPTp) and insecticide-treated mosquito nets (ITNs) significantly reduce the risk of low birthweight in regions of stable malaria transmission. We aimed to assess the effectiveness of malaria prevention in pregnancy (IPTp or ITNs) at preventing low birthweight and neonatal mortality under routine programme conditions in malaria endemic countries of Africa.

METHODS

We used a retrospective birth cohort from national cross-sectional datasets in 25 African countries from 2000-10. We used all available datasets from multiple indicator cluster surveys, demographic and health surveys, malaria indicator surveys, and AIDS indicator surveys that were publically available as of 2011. We tried to limit confounding bias through exact matching on potential confounding factors associated with both exposure to malaria prevention (ITNs or IPTp with sulfadoxine-pyrimethamine) in pregnancy and birth outcomes, including local malaria transmission, neonatal tetanus vaccination, maternal age and education, and household wealth. We used a logistic regression model to test for associations between malaria prevention in pregnancy and low birthweight, and a Poisson model for the outcome of neonatal mortality. Both models incorporated the matched strata as a random effect, while accounting for additional potential confounding factors with fixed effect covariates.

FINDINGS

We analysed 32 national cross-sectional datasets. Exposure of women in their first or second pregnancy to full malaria prevention with IPTp or ITNs was significantly associated with decreased risk of neonatal mortality (protective efficacy [PE] 18%, 95% CI 4-30; incidence rate ratio [IRR] 0·820, 95% CI 0·698-0·962), compared with newborn babies of mothers with no protection, after exact matching and controlling for potential confounding factors. Compared with women with no protection, exposure of pregnant women during their first two pregnancies to full malaria prevention in pregnancy through IPTp or ITNs was significantly associated with reduced odds of low birthweight (PE 21%, 14-27; IRR 0·792, 0·732-0·857), as measured by a combination of weight and birth size perceived by the mother, after exact matching and controlling for potential confounding factors.

INTERPRETATION

Malaria prevention in pregnancy is associated with substantial reductions in neonatal mortality and low birthweight under routine malaria control programme conditions. Malaria control programmes should strive to achieve full protection in pregnant women by both IPTp and ITNs to maximise their benefits. Despite an attempt to mitigate bias and potential confounding by matching women on factors thought to be associated with access to malaria prevention in pregnancy and birth outcomes, some level of confounding bias possibly remains.

Moral hazard and selection among the poor: evidence from a randomized experiment

Not only does economic theory predict high-risk individuals to be more likely to purchase insurance, but insurance coverage is also thought to crowd out precautionary activities. In spite of stark theoretical predictions, there is conflicting empirical evidence on adverse selection, and evidence on ex ante moral hazard is very scarce. Using data from the Seguro Popular Experiment in Mexico, this paper documents patterns of selection on observables into health insurance as well as the existence of non-negligible ex ante moral hazard. More specifically, the findings indicate that (i) agents in poor self-assessed health prior to the intervention have, all else equal, a higher propensity to take up insurance; and (ii) insurance coverage reduces the demand for self-protection in the form of preventive care. Curiously, however, individuals do not sort based on objective measures of their health.

[Diagnostic approach and treatment of hypertension in healthcare workers in Abidjan's district (Ivory Coast)]

BACKGROUND

Epidemiological data concerning hypertension among health care workers are scarce.

PURPOSE

The aim of this study was to assess the diagnostic process and treatment of hypertension among a healthcare worker population in order to improve treatment.

METHODS

This was a prospective study including 821 healthcare workers from Abidjan's publics hospitals. There were 208 medical doctors, 464 nurses and 149 assistant nurses. There were 59% women, 41% men. The mean age was 42.9 years.

RESULTS

The prevalence of hypertension was 17.5%: 48.1% among teaching medical doctors, 13.6% in the group of other medical doctors, 14.9% in the nurses group and 18.8% in the assistant nurse group. After recruitment as a healthcare worker, 86.9% of the cases of hypertension were diagnosed. When hypertension was diagnosed, 74.3% had presented symptoms. The disease was diagnosed by a physician in 77.8% of cases and by a nurse in 22%. In many cases (67.8%), the follow-up was done by a cardiologist; 15.7% by general practitioners. However, 10.7% of the healthcare workers with hypertension had no medical follow-up. Single-drug treatment was most commonly used (49.7%); 36.4% were taking two drugs. Poor compliance with treatment was noted in 71.1% of he healthcare workers with hypertension (clearly poor compliance for 40.5% and problems with compliance for 30.6%). Among those with clearly poor compliance, 29% had stopped taking their medication and seven individuals had declined taking any medication. Poor compliance was most commonly observed among assistant nurses (52.9%) and nurses (42.6%). People taking a combination of two or three drugs complied better with their treatment.

Analysis of changes in the association of income and the utilization of curative health services in Mexico between 2000 and 2006

BACKGROUND

A common characteristic of health systems in most developing countries is unequal access to health services. As a result, members of the poorest population groups often do not receive formal attention for health services, because they cannot afford it. In 2001 in Mexico, to address income-related differences in the use of health services, the government launched a major healthcare reform, which includes a health insurance program called Seguro Popular, aimed at improving healthcare access among poor, uninsured residents. This paper analyzes the before and after changes in the demand for curative ambulatory health services focusing on the association of income-related characteristics and the utilization of formal healthcare providers vs. no healthcare service utilization.

METHODS

By using two nationally representative health surveys (ENSA-2000 and ENSANUT-2006), we modeled an individual's decision when experiencing an illness to use services provided by the (1) Ministry of Health (MoH), (2) social security, (3) private entities, or (4) to not use formal services (no healthcare service utilization).

RESULTS

Poorer individuals were more likely in 2006 than in 2000 to respond to an illness by using formal healthcare providers. Trends in provider selection differed, however. The probability of using public services from the MoH increased among the poorest population, while the findings indicated an increase in utilization of private health services among members of low- and middle-income groups. No significant change was seen among formal workers -covered by social security services-, regardless of socioeconomic status.

CONCLUSIONS

Overall, for 2006 the Mexican population appears less differentiated in using healthcare across economic groups than in 2000. This may be related, in part, to the implementation of Seguro Popular, which seems to be stimulating healthcare demand among the poorest and previously uninsured segment of the population. Still, public health authorities need to address the remaining income-related healthcare utilization differences, the differences in quality between public and private health services, and the general perception that MoH facilities offer inferior services.

Net benefits: a multicountry analysis of observational data examining associations between insecticide-treated mosquito nets and health outcomes

BACKGROUND

Several sub-Saharan African countries have rapidly scaled up the number of households that own insecticide-treated mosquito nets (ITNs). Although the efficacy of ITNs in trials has been shown, evidence on their impact under routine conditions is limited to a few countries and the extent to which the scale-up of ITNs has improved population health remains uncertain.

METHODS AND FINDINGS

We used matched logistic regression to assess the individual-level association between household ITN ownership or use in children under 5 years of age and the prevalence of parasitemia among children using six malaria indicator surveys (MIS) and one demographic and health survey. We used Cox proportional hazards models to assess the relationship between ITN household ownership and child mortality using 29 demographic and health surveys. The pooled relative reduction in parasitemia prevalence from random effects meta-analysis associated with household ownership of at least one ITN was 20% (95% confidence interval [CI] 3%-35%; I² = 73.5%, p<0.01 for I² value). Sleeping under an ITN was associated with a pooled relative reduction in parasitemia prevalence in children of 24% (95% CI 1%-42%; I² = 79.5%, p<0.001 for I² value). Ownership of at least one ITN was associated with a pooled relative reduction in mortality between 1 month and 5 years of age of 23% (95% CI 13-31%; I² = 25.6%, p>0.05 for I² value).

CONCLUSIONS

Our findings across a number of sub-Saharan African countries were highly consistent with results from previous clinical trials. These findings suggest that the recent scale-up in ITN coverage has likely been accompanied by significant reductions in child mortality and that additional health gains could be achieved with further increases in ITN coverage in populations at risk of malaria. Please see later in the article for the Editors' Summary.

Analysis of the distributional impact of out-of-pocket health payments: evidence from a public health insurance program for the poor in Mexico

Many governments have health programs focused on improving health among the poor and these have an impact on out-of-pocket health payments made by individuals. Therefore, one of the objectives of these programs is to reach the poorest and reduce their out-of-pocket expenditure. In this paper we propose the distributional poverty impact approach to measure the poverty impact of out-of-pocket health payments of different health financing policies. This approach is comparable to the impoverishment methodology proposed by Wagstaff and van Doorslaer (2003) that compares poverty indices before and after out-of-pocket health payments. In order to escape the specification of a particular poverty index, we use the marginal dominance approach that uses non-intersecting curves and can rank poverty reducing health financing policies. We present an empirical application of the out-of-pocket health payments for an innovative social financing policy implemented in Mexico named Seguro Popular. The paper finds evidence that Seguro Popular program has a better distributional poverty impact when families face illness when compared to other poverty reducing policies. The empirical dominance approach uses data from Mexico in 2006 and considers international poverty standards of $2 per person per day.

An Integrated, Clinician-focused Telehealth Monitoring System to Reduce Hospitalization Rates for Home Health Care Patients with Diabetes

Diabetes is one of the leading causes of death and disability in the United States, and hospitalization rates related to this health condition are high and costly to the United States health care system. The purpose of this study was to examine the effect of an integrated, clinician-focused telehealth monitoring system on the probability of hospitalization for home health care patients with diabetes. The study included 2009 data from 699 Medicare beneficiaries receiving home health services in Texas and Louisiana. Propensity score matching, logistic regression, and post-estimation parameter simulation were used to assess how telehealth affects the probability of hospitalization during the first 30 days of home health care. The 30-day hospitalization probability for telehealth and non-telehealth patients was 7% and 19%, respectively. Patients in the telehealth group had a 12 (95% confidence interval = 4.2-20.3) percentage point-lower probability of hospitalization within the first 30 days of home health care than non-telehealth matched patients. The results suggest that telehealth monitoring systems that integrate skilled clinicians with critical care experience can lead to substantially lower hospitalization rates during the first 30 days of home health care, large cost savings, and more effective home health management of patients with diabetes.

Active pharmaceutical management strategies of health insurance systems to improve cost-effective use of medicines in low- and middle-income countries: a systematic review of current evidence

OBJECTIVES

Health insurance systems have great potential to improve the cost-effective use of medicines by leveraging better provider prescribing, more cost-effective use by consumers, and lower prices from industry. Despite ample evidence from high-income countries, little is known about insurance system strategies targeting medicines in low- and middle-income countries (LMIC). This paper provides a critical review of the literature on these strategies and their impacts in LMIC.

METHODS

We conducted a systematic review of published peer-reviewed and grey literature and organized the insurance system strategies into four categories: medicines selection, purchasing, contracting and utilization management.

RESULTS

In n=63 reviewed publications we found reasonable evidence supporting the use of insurance as an overall strategy to improve access to pharmaceuticals and outcomes in LMIC. Beyond this, most of the literature focused on provider contracting strategies to influence prescribing. There was very little evidence on medicines selection, purchasing, or utilization management strategies.

CONCLUSIONS

There is a paucity of published evidence on the impact of insurance system strategies on improving the use of medicines in LMIC. The existing evidence is questionable since the majority of the published studies utilize weak study designs. This review highlights the need for well-designed studies to build an evidence base on the impact of medicines management strategies deployed by LMIC insurance programs.

On the origins of physicians: Darwinian or Lamarckian evolution?

Achieving acceptance to a North American and some European medical schools is one of the most difficult academic tasks faced by undergraduate students. The limited number of spots allows for only a fraction of the most highly promising applicants to be accepted each year. Perhaps one of the difficulties that many students face when applying to medical school is that due to the current restriction on enrollment, the application process poses selective pressures, independent of the applicants' suitability for the medical profession. Here I discuss, based on personal experiences, how I believe the process could become more just to all applicants. Allowing public needs and student interest to better dictate the number of graduating physicians could help relieve some of the current admission pressures, including the rather arbitrary selection of a small fraction of applicants from a large group of sufficiently proficient students. I believe that this proposal, if implemented, will likely not only remove some biases of our admission system, but also sufficiently change the landscape of those accepted, to include students with a genuine professional interest in the underserviced field of family practice.