Inequalities in catastrophic health expenditures in conflict-affected areas and the Colombian peace agreement: an oaxaca-blinder change decomposition analysis

Decomposing the inequalities in the catastrophic health expenditures on the hospitalization in India: empirical evidence from national sample survey data

Introduction

Sustainable Development Goal (SDG) Target 3.8.2 entails financial protection against catastrophic health expenditure (CHE) by reducing out-of-pocket expenditure (OOPE) on healthcare. India is characterized by one of the highest OOPE on healthcare, in conjunction with the pervasive socio-economic disparities entrenched in the population. As a corollary, India has embarked on the trajectory of ensuring financial risk protection, particularly for the poor, with the launch of various flagship initiatives. Overall, the evidence on wealth-related inequities in the incidence of CHE in low- and middle-Income countries has been heterogenous. Thus, this study was conducted to estimate the income-related inequalities in the incidence of CHE on hospitalization and glean the individual contributions of wider socio-economic determinants in influencing these inequalities in India.

Methods

The study employed cross-sectional data from the nationally represented survey on morbidity and healthcare (75th round of National Sample Survey Organization) conducted during 2017-2018, which circumscribed a sample size of 1,13,823 households and 5,57,887 individuals. The inequalities and need-adjusted inequities in the incidence of CHE on hospitalization care were assessed via the Erreygers corrected concentration index. Need-standardized concentration indices were further used to unravel the inter- and intra-regional income-related inequities in the outcome of interest. The factors associated with the incidence of CHE were explored using multivariate logistic regression within the framework of Andersen's model of behavioral health. Additionally, regression-based decomposition was performed to delineate the individual contributions of legitimate and illegitimate factors in the measured inequalities of CHE.

Results

Our findings revealed pervasive wealth-related inequalities in the CHE for hospitalization care in India, with a profound gap between the poorest and richest income quintiles. The negative value of the concentration index (EI: -0.19) indicated that the inequalities were significantly concentrated among the poor. Furthermore, the need-adjusted inequalities also demonstrated the pro-poor concentration (EI: -0.26), denoting the unfair systemic inequalities in the CHE, which are disadvantageous to the poor. Multivariate logistic results indicated that households with older adult, smaller size, vulnerable caste affiliation, poorest income quintile, no insurance cover, hospitalization in a private facility, longer stay duration in the hospital, and residence in the region at a lower level of epidemiological transition level were associated with increased likelihood of incurring CHE on hospitalization. The decomposition analysis unraveled that the contribution of non-need/illegitimate factors (127.1%) in driving the inequality was positive and relatively high vis-à-vis negative low contribution of need/legitimate factors (35.3%). However, most of the unfair inequalities were accounted for by socio-structural factors such as the size of the household and enabling factors such as income group and utilization pattern.

Conclusion

The study underscored the skewed distribution of CHE as the poor were found to incur more CHE on hospitalization care despite the targeted programs by the government. Concomitantly, most of the inequality was driven by illegitimate factors amenable to policy change. Thus, policy interventions such as increasing the awareness, enrollment, and utilization of Publicly Financed Health Insurance schemes, strengthening the public hospitals to provide improved quality of specialized care and referral mechanisms, and increasing the overall budgetary share of healthcare to improve the institutional capacities are suggested.

Access to general health care among people with disabilities in Latin America and the Caribbean: a systematic review of quantitative research

In Latin America and the Caribbean (LAC), there are 85 million people with disabilities (PwD). They often experience barriers accessing healthcare and die, on average, 10-20 years earlier than those without disabilities. This study aimed to systematically review the quantitative literature on access to general healthcare among PwD, compared to those without disabilities, in LAC. A systematic review and narrative synthesis was conducted. We searched in EMBASE, MEDLINE, LILACS, MedCarib, PsycINFO, SciELO, CINAHL, and Web of Science. Eligible articles were peer-reviewed, published between January 2000 and April 2023, and compared healthcare access (utilization, coverage, quality, affordability) between PwD and without disabilities in LAC. The search retrieved 16,538 records and 30 studies were included, most of which had a medium or high risk of bias (n = 23; 76%). Overall, the studies indicated that PwD use healthcare services more than those without disabilities. Some evidence indicated that women with disabilities were less likely to have received cancer screening. Limited evidence showed that health services affordability and quality were lower among PwD. In LAC, PwD appear to experience health inequities, although large gaps exist in the current evidence. Harmonization of disability and health access data collection is urgently needed to address this issue.

The effect of conflict-related violence intensity and alcohol use on mental health: The case of Colombia

We investigated the causal impact of conflict-related violence on individual mental health and its potential pathways in Colombia. Using data from before and after the 2016 peace accord between the Colombian government and the Revolutionary Armed Forces of Colombia (FARC), we adopted a difference-in-differences empirical design combined with instrumental variables estimation. We also used formal mediation analysis to investigate a possible mediating role of alcohol consumption in the relationship between conflict exposure and mental health. Our results did not support the hypothesis that changes in exposure to conflict violence after the peace accord causally led to any changes in individual mental health. We were unable to identify a statistically significant mediating effect of alcohol consumption in the relationship between exposure to conflict violence and mental health.

Catastrophic health expenditure of households with hypertension: a comparative study in China

Objectives

The aim of this study was to understand the impact of multimorbidity on catastrophic health expenditures for people with hypertension.

Methods

Data were obtained from the China Health and Retirement Longitudinal Study (CHARLS) in 2018, 8,342 adults were included in our analysis. Propensity score matching method was used to compare the risk of catastrophic health expenditures between the hypertension patients (treatment group) and those without any chronic disease (control group) in middle-aged and older adults. Patients with hypertension were also divided into two groups: only hypertension and multimorbidity.

Results

Hypertension increased the likelihood of CHE by 11.3% in older adults. Further analysis showed that hypertension alone does not increase the risk of CHE, and the risk of CHE in hypertension patients with multimorbidity was 12.9% higher than those without chronic disease.

Conclusion

Our study highlights the importance of healthy management of patients with only hypertension and preventing them from developing multimorbidity.

Peace and health: exploring the nexus in the Americas

The relationship between peace and health is complex, multifactorial and fraught with challenges of definitions, measurements and outcomes. This exploratory commentary on this nexus within a focus on the Americas posits this challenge clearly and calls for more scholarship and empirical work on this issue from an interdisciplinary perspective. The overall goal of this paper is to try and explore the elements that impact the relationship between peace and health with a focus on the Americas (defined as countries spanning from Canada to Argentina) in the post-Cold war period. Focusing on the 1990s and onwards, we seek to underscore why violence continues to permeate these societies despite a third and lasting wave of democratisation in the hemisphere. We hope this will allow a more robust dialogue on peace and health in the regional and global health literature.

Desarrollo profesional permanente en salud por intermedio del Campus Virtual de Salud Pública en Colombia (2012-2019)

Objetivo.

Reconstruir la experiencia del Campus Virtual de Salud Pública (CVSP) desde el año 2012 al 2019 en Colombia.

Métodos.

Se realizó la sistematización de la experiencia del proceso de formación en salud pública para Colombia, por intermedio del Campus para el periodo de 2012 a 2019. La información se presenta en series transversales de periodos de tiempo para visibilizar la evolución histórica del CVSP en Colombia.

Resultados.

Se han capacitado 2 627 profesionales de la salud en cursos con tutoría y 34 012 en cursos de autoaprendizaje en temáticas relevantes, actualizadas y prioritarias en salud pública. Se destaca la oportunidad y acceso a regiones remotas que ha tenido el Campus mediante procesos de formación sin costo para el usuario final. La experiencia destaca la relevancia del Campus en la reducción de la brecha de actualización del talento humano en salud, mediante procesos de educación virtual, con diversidad en la modalidad y en la oferta formativa.

Conclusiones.

La reconstrucción de la experiencia en Colombia mostró la evolución y fortalecimiento del CVSP para ofertar procesos de formación con calidad para responder a los problemas y necesidades del país; la consolidación del Campus se debió al trabajo colaborativo entre las universidades y la Organización Panamericana de la Salud.