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Glaus H, Drewniak D, März JW, Biller-Andorno N. Blacklisting Health Insurance Premium Defaulters: Is Denial of Medical Care Ethically Justifiable? HEALTH CARE ANALYSIS 2023; 31:156-168. [PMID: 37498417 PMCID: PMC10693506 DOI: 10.1007/s10728-023-00464-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2023] [Indexed: 07/28/2023]
Abstract
Rising health insurance costs and the cost of living crisis are likely leading to an increase in unpaid health insurance bills in many countries. In Switzerland, a particularly drastic measure to sanction defaulting insurance payers is employed. Since 2012, Swiss cantons - who have to cover most of the bills of defaulting payers - are allowed by federal law to blacklist them and to restrict their access to medical care to emergencies.In our paper, we briefly describe blacklisting in the context of the Swiss healthcare system before we examine the ethical issues involved in light of what is known about its social and health impacts. We found no evidence that blacklisting serves as an effective way of recovering unpaid health insurance contributions or of strengthening solidarity within the health insurance system. Furthermore, the ambiguous definitions of what constitutes an emergency treatment and the incompatibility of the denial of medical care with the obligation to provide professional assistance complicate the implementation of blacklists and expose care providers to enormous pressure.Therefore, we conclude that blacklists and the (partial) denial of medical care not only pose profound ethical problems but are also unsuitable for fulfilling the purpose for which they were introduced.
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Affiliation(s)
- Hanna Glaus
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Winterthurerstrasse 30, Zürich, 8006, Switzerland
| | - Daniel Drewniak
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Winterthurerstrasse 30, Zürich, 8006, Switzerland
| | - Julian W März
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Winterthurerstrasse 30, Zürich, 8006, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Winterthurerstrasse 30, Zürich, 8006, Switzerland.
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Lubaki JPF, Francis JM, Omole OB. Perspectives for glycaemic control in type 2 diabetes in Kinshasa, Democratic Republic of the Congo. Health Promot Int 2023; 38:daad128. [PMID: 37815062 PMCID: PMC10563016 DOI: 10.1093/heapro/daad128] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023] Open
Abstract
Glycaemic control is a significant problem in the Democratic Republic of the Congo (DRC), the perspectives associated with glycaemic control are not fully known as previous studies rarely explored patients' perspectives and lived experiences. This qualitative study described the perspectives regarding glycaemic control among persons with type 2 diabetes in Kinshasa, DRC. A total of 23 participants were purposively selected in seven health centres in Kinshasa. In-depth interviews were used for data collection. The study used a phenomenology approach, and deductive, constructionist and thematic analysis. Data analysis was performed using the MAXQDA 2022. Five themes were identified as perspectives for glycaemic control in Kinshasa: financial constraints, limited social and relational support, difficulties with lifestyle changes, beliefs and practices about diabetes and ability to adapt for caring for the illness. Themes were integrated using social cognitive theory. Participants expressed that they were unable to achieve better glycaemic control due to financial constraints, limited social and relational support and difficulty in changing their lifestyle. Their beliefs and practices about diabetes also constituted a barrier. Our results showed that lack of adequate funding is a major determinant of glycaemic control and therefore it is crucial to integrate a consistent and reliable funding system for care of people living with diabetes. Persons with diabetes must be empowered to successfully adapt to the requirements of diabetes care. In this process, support for people living with type 2 diabetes is also essential and should involve their families as well as healthcare providers.
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Affiliation(s)
- Jean-Pierre Fina Lubaki
- Department of Family Medicine and Primary Care, University of the Witwatersrand, Phillip V Tobias Health Sciences Building, 29 Princess of Wales, Parktown, Johannesburg 2193, South Africa
- Department of Family Medicine and Primary Care,Protestant University of Congo, Croisement des Avenues Libération et Triomphale, Commune de Lingwala, Kinshasa, Democratic Republic of the Congo
| | - Joel Msafiri Francis
- Department of Family Medicine and Primary Care,University of the Witwatersrand, Phillip V Tobias Health Sciences Building, 29 Princess of Wales, Parktown, Johannesburg 2193, South Africa
| | - Olufemi Babatunde Omole
- Department of Family Medicine and Primary Care,University of the Witwatersrand, Phillip V Tobias Health Sciences Building, 29 Princess of Wales, Parktown, Johannesburg 2193, South Africa
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Fina Lubaki JP, Omole OB, Francis JM. Glycaemic control among type 2 diabetes patients in sub-Saharan Africa from 2012 to 2022: a systematic review and meta-analysis. Diabetol Metab Syndr 2022; 14:134. [PMID: 36127712 PMCID: PMC9487067 DOI: 10.1186/s13098-022-00902-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/05/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is an increased burden of diabetes globally including in sub-Saharan Africa. The literature shows that glycaemic control among type 2 diabetes patients is poor in most countries in sub-Saharan Africa. Understanding the factors influencing glycaemic control in this region is therefore important to develop interventions to optimize glycaemic control. We carried out a systematic review to determine the prevalence and factors associated with glycaemic control in sub-Saharan Africa to inform the development of a glycaemic control framework in the Democratic Republic of the Congo. METHODS We searched five databases (African Index Medicus, Africa-Wide Information, Global Health, PubMed, and Web of Science) using the following search terms: type-2 diabetes, glycaemic control, and sub-Saharan Africa. Only peer-reviewed articles from January 2012 to May 2022 were eligible for this review. Two reviewers, independently, selected articles, assessed their methodological quality using Joanna Briggs checklists, and extracted data. A meta-analysis was performed to estimate the prevalence of glycaemic control. Factors associated with glycaemic control were presented as a narrative synthesis due to heterogeneity as assessed by the I2. RESULTS A total of 74 studies, involving 21,133 participants were included in the review. The pooled prevalence of good glycaemic control was 30% (95% CI:27.6-32.9). The glycaemic control prevalence ranged from 10-60%. Younger and older age, gender, lower income, absence of health insurance, low level of education, place of residence, family history of diabetes, longer duration of diabetes, pill burden, treatment regimen, side effects, use of statins or antihypertensives, alcohol consumption, smoking, presence of comorbidities/complications, and poor management were associated with poor glycaemic control. On the other hand, positive perceived family support, adequate coping strategies, high diabetes health literacy, dietary adherence, exercise practice, attendance to follow-up, and medication adherence were associated with good glycaemic control. CONCLUSION Suboptimal glycaemic control is pervasive among patients with type-2 diabetes in sub-Saharan Africa and poses a significant public health challenge. While urgent interventions are required to optimize glycaemic control in this region, these should consider sociodemographic, lifestyle, clinical, and treatment-related factors. This systematic review and meta-analysis protocol is registered in PROSPERO under CRD 42021237941.
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Affiliation(s)
- Jean-Pierre Fina Lubaki
- Department of Family Medicine and Primary Care, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Family Medicine and Primary Care, Protestant University of Congo, Kinshasa, Democratic Republic of the Congo.
| | - Olufemi Babatunde Omole
- Department of Family Medicine and Primary Care, University of the Witwatersrand, Johannesburg, South Africa
| | - Joel Msafiri Francis
- Department of Family Medicine and Primary Care, University of the Witwatersrand, Johannesburg, South Africa
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Linke C, Heintze C, Holzinger F. 'Managing scarcity'- a qualitative study on volunteer-based healthcare for chronically ill, uninsured migrants in Berlin, Germany. BMJ Open 2019; 9:e025018. [PMID: 30904858 PMCID: PMC6475233 DOI: 10.1136/bmjopen-2018-025018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES In Germany, healthcare for people lacking legal residency status and European Union citizens without health insurance is often provided by non-governmental organisations. Scientific studies assessing the situation of the patients with chronic diseases in this context are scarce. We aimed to characterise medical care for chronically ill migrants without health insurance and outline its possibilities and limitations from the treating physicians' perspective. DESIGN Qualitative semi-structured interviews; qualitative content analysis. SETTING Organisations and facilities providing healthcare for uninsured migrants: free clinics, medical practices and public health services. PARTICIPANTS 14 physicians working regularly in healthcare for uninsured migrants. RESULTS Delayed contact to the healthcare system was frequently addressed in the interviews. Care was described as constrained by a scarcity of resources that often impedes adequate treatment for many conditions, most pronounced in the case of oncological diseases or chronic viral infections (HIV, hepatitis). For other chronic conditions such as cardiovascular diseases or diabetes, some diagnostics and basic medications were described as partially available, while management of complications or rehabilitative measures are frequently unfeasible. For the patients with mental health problems, attainability of psychotherapeutic treatment is reported as severely limited. Care is predominantly described as fragmented with limitations to information flow and continuity. Which level of care a patient receives appears to depend markedly on the respective non-governmental organisation and the individual commitment, subjective decisions and personal connections of the treating physician. CONCLUSIONS Restrictions in medical care for uninsured migrants have even more impact on chronically ill patients. Volunteer-based care often constitutes an inadequate compensation for regular access to the healthcare system, as it is strongly influenced by the limitation of its resources and its arbitrariness.
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Affiliation(s)
- Charlotte Linke
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
| | - Christoph Heintze
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
| | - Felix Holzinger
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
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Jackson Y, Paignon A, Wolff H, Delicado N. Health of undocumented migrants in primary care in Switzerland. PLoS One 2018; 13:e0201313. [PMID: 30052674 PMCID: PMC6063438 DOI: 10.1371/journal.pone.0201313] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 07/12/2018] [Indexed: 12/15/2022] Open
Abstract
Background Undocumented migrants endure adverse living conditions while facing barriers to access healthcare. Evidence is lacking regarding their healthcare needs, notably in regards to chronic diseases. Our goal was to investigate health conditions in undocumented migrants attended in primary care setting. Methods This study was conducted at the primary care outpatient clinic, Geneva University Hospitals, Switzerland. We retrospectively recorded and coded all medical conditions of a random sample of 731 undocumented migrants using the International Classification of Primary Care, 2nd version (ICPC-2). We dichotomized conditions as chronic or non-chronic and considered multimorbidity in the presence of three or more chronic conditions. Results Participants originated from 72 countries and were mainly female (65.5%) with a mean age of 42.4 (standard deviation [SD]: 11.4) years. They presented a mean of 2.9 (SD: 2.1; range: 1–17) health conditions. In multivariable analysis, the number of conditions was associated with female gender (p = 0.011) and older age (p <0.001), but not with origin (p = 0.373). The body systems most frequently affected were endocrine, metabolic and nutritional (n = 386; 18.4%), musculoskeletal (n = 308, 14.7%) and digestive (n = 266, 12.8%). Hypertension (17.9%; 95% CI: 15.2%, 29.9%), obesity or overweight (16%; 95% CI: 13.4%, 18.9%) and gastric problems (14.1%; 95% CI: 11.6%, 16.8%) were most prevalent. Overall, 71.8% (95% CI: 68.5%, 75%) participants had at least one chronic condition while 20% (95% CI: 17.2%, 23.1%) had three or more. In multivariable analysis, age (p <0.001) was the only predictor of presenting at least one or three or more chronic conditions. Conclusions Undocumented migrants present multiple health problems in primary care settings and bear an important burden of chronic diseases. The extent of multimorbidity highlights the need to provide and facilitate the access to comprehensive and long-term primary healthcare services.
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Affiliation(s)
- Yves Jackson
- Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
- Global Health Institute, University of Geneva, Geneva, Switzerland
- * E-mail:
| | - Adeline Paignon
- HES-SO University of Applied Sciences and Arts Western Switzerland, School of Health Sciences, Geneva, Switzerland
| | - Hans Wolff
- Division of Prison Health, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Noelia Delicado
- HES-SO University of Applied Sciences and Arts Western Switzerland, School of Health Sciences, Geneva, Switzerland
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Nagy A, Kovács N, Pálinkás A, Sipos V, Vincze F, Szőllősi G, Csenteri O, Ádány R, Sándor J. Exploring quality of care and social inequalities related to type 2 diabetes in Hungary: Nationwide representative survey. Prim Care Diabetes 2018; 12:199-211. [PMID: 29326023 DOI: 10.1016/j.pcd.2017.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 12/05/2017] [Accepted: 12/17/2017] [Indexed: 01/23/2023]
Abstract
AIMS The study aimed to launch a T2DM adult cohort that is representative of Hungary through a cross-sectional study, to produce the most important quality indicators for T2DM care, to describe social inequalities, and to estimate the absolute number of T2DM adult patients with uncontrolled HbA1c levels in Hungary. METHODS A representative sample of the Hungarian T2DM adults (N=1280) was selected in 2016. GPs collected data on socio-demographic status by questionnaire, and on history and laboratory parameters from medical records. The process and outcome indicators used in the international monitoring practice were calculated. The socio-economic status influence was determined by multivariate logistic regression models. RESULTS Target achievement was 61.66%, 53.48%, and 54.00% for HbA1c, LDL-C, and blood pressure, respectively, in the studied sample (N=1176). In Hungary, 294,534 patients have above target HbA1c value out of 495,801 T2DM adults. The education-dependent positive association with majority of process indicators was not reflected in HbA1c, LDL-C, and blood pressure target achievements. The risk of microvascular complications and requirement of insulin treatment were higher among less educated. CONCLUSIONS According to our observations, the education-independent target achievement for HbA1c and LDL-C is similar as, for blood pressure is less effective in Hungary than in Europe.
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Affiliation(s)
- Attila Nagy
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Nóra Kovács
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Anita Pálinkás
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Valéria Sipos
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Ferenc Vincze
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Gergő Szőllősi
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Orsolya Csenteri
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Róza Ádány
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary; MTA-DE Public Health Research Group of the Hungarian Academy of Sciences, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - János Sándor
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary.
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