Sexual Violence and Substance Use Diagnosed in Emergency Department Discharges in Hawaii, 2005-2014

BACKGROUND

Substance use (SU) and sexual violence (SV) present unique challenges when contextualizing their relationship due to underreporting of SU and SV. Both are significant public health concerns with a large magnitude and expense to the overall U.S. and to the state of Hawaii, which is identified as a high-intensity drug-trafficking area. Since substance users have a higher risk for sexual violence than the general public, this study aims to analyze the proportion and demographics of emergency department (ED) visit individuals reporting sexual violence with or without substance use disorder and examine how the number of ED visits of individuals diagnosed with SV and SU disorder compare to all individuals.

METHODS

Data from the Healthcare Cost and Utilization Project was used to examine the relationship between SV and SU. The database contained 3.5 million observations for 24 Hawaii hospitals from 2005-2014. The data was summarized in descriptive statistics and Chi-square tests were run to assess statistical significance for variables of interest.

RESULTS

A greater proportion of individuals reporting sexual violence also reported substance use disorders compared to the general population of individuals. While 8% of all ED visits were related to SU, 17% of ED visits involving SV were also related to SU, demonstrating a statistically significant association between SV and SU.

CONCLUSIONS

There is a greater need to further understand the complexity of the relationship between substance use and sexual violence. Sexual violence and substance use disorders share a complex relationship; survivors of sexual abuse may develop a substance use disorder, and those who use drugs and alcohol may be at an increased risk for sexual violence. Results from this study demonstrate visits for individuals reporting sexual violence have a greater proportion of substance use disorder than visits for the general population.

Planning and Implementation of COVID-19 Isolation and Quarantine Facilities in Hawaii: A Public Health Case Report

In response to the second surge of COVID-19 cases in Hawaii in the fall of 2020, the Hawaii State Department of Health Behavioral Health Administration led and contracted a coalition of agencies to plan and implement an isolation and quarantine facility placement service that included food, testing, and transportation assistance for a state capitol and major urban center. The goal of the program was to provide safe isolation and quarantine options for individual residents at risk of not being able to comply with isolation and quarantine mandates. Drawing upon historical lived experiences in planning and implementing the system for isolation and quarantine facilities, this qualitative public health case study report applies the plan-do-study-act (PDSA) improvement model and framework to review and summarize the implementation of this system. This case study also offers lessons for a unique opportunity for collaboration led by a public behavioral health leadership that expands upon traditionally narrow infectious disease control, by developing a continuum of care that not only addresses immediate COVID-19 concerns but also longer-term supports and services including housing, access to mental health services, and other social services. This case study highlights the role of a state agency in building a coalition of agencies, including a public university, to respond to the pandemic. The case study also discusses how continuous learning was executed to improve delivery of care.

Mitigation Planning and Policies Informed by COVID-19 Modeling: A Framework and Case Study of the State of Hawaii

In the face of great uncertainty and a global crisis from COVID-19, mathematical and epidemiologic COVID-19 models proliferated during the pandemic. Yet, many models were not created with the explicit audience of policymakers, the intention of informing specific scenarios, or explicit communication of assumptions, limitations, and complexities. This study presents a case study of the roles, uses, and approaches to COVID-19 modeling and forecasting in one state jurisdiction in the United States. Based on an account of the historical real-world events through lived experiences, we first examine the specific modeling considerations used to inform policy decisions. Then, we review the real-world policy use cases and key decisions that were informed by modeling during the pandemic including the role of modeling in informing planning for hospital capacity, isolation and quarantine facilities, and broad public communication. Key lessons are examined through the real-world application of modeling, noting the importance of locally tailored models, the role of a scientific and technical advisory group, and the challenges of communicating technical considerations to a public audience.

The broad socioeconomic benefits of vaccination

Evaluating vaccination programs according to their broad socioeconomic benefits, beyond their health benefits, will help to address the twin problems of vaccine underutilization and weak incentives for vaccine innovation.

Living Alone and Homelessness as Predictors of 30-Day Potentially Preventable Hospital Readmission

Introduction

The effect of social factors on health care outcomes is widely recognized. Health care systems are encouraged to add social and behavioral measures to electronic health records (EHRs), but limited research demonstrates how to leverage this information. We assessed 2 social factors collected from EHRs — social isolation and homelessness — in predicting 30-day potentially preventable readmissions (PPRs) to hospital.

Methods

EHR data were collected from May 2015 through April 2017 from inpatients at 2 urban hospitals on O‘ahu, Hawai‘i (N = 21,274). We performed multivariable logistic regression models predicting 30-day PPR by living alone versus living with others and by documented homelessness versus no documented homelessness, controlling for relevant factors, including age group, race/ethnicity, sex, and comorbid conditions.

Results

Among the 21,274 index hospitalizations, 16.5% (3,504) were people living alone and 11.2% (2,385) were homeless; 4.2% (899) hospitalizations had a 30-day PPR. In bivariate analysis, living alone did not significantly affect likelihood of a 30-day PPR (16.6% [3,376 hospitalizations] without PPR vs 14.4% [128 hospitalizations] with PPR; P = .09). However, documented homelessness did show a significant effect on the likelihood of 30-day PPR in the bivariate analysis (11.1% [2,259 hospitalizations] without PPR vs 14.1% [126 hospitalizations] with PPR; P = .006). In multivariable models, neither living alone nor homelessness was significantly associated with PPR. Factors that were significantly associated with PPR were comorbid conditions, discharge disposition, and use of an assistive device.

Conclusion

Homelessness predicted PPR in descriptive analyses. Neither living alone nor homelessness predicted PPR once other factors were controlled. Instead, indicators of physical frailty (ie, use of an assistive device) and medical complexity (eg, hospitalizations that required assistive care post-discharge, people with a high number of comorbid conditions) were significant. Future research should focus on refining, collecting, and applying social factor data obtained through acute care EHRs.

Priority setting in health: development and application of a multi-criteria algorithm for the population of New Zealand's Waikato region

Background

Priority setting in a climate of diverse needs and limited resources is one of the most significant challenges faced by health care policymakers. This paper develops and applies a comprehensive multi-criteria algorithm to help determine the relative importance of health conditions that affect a defined population.

Methods

Our algorithm is implemented in the context of the Waikato District Health Board (WDHB) in New Zealand, which serves approximately 10% of the New Zealand population. Strategic priorities of the WDHB are operationalized into five criteria along which the algorithm is structured—scale of disease, household financial impact of disease, health equity, cost-effectiveness, and multimorbidity burden. Using national-level data and published literature from New Zealand, the World Health Organization, and other high-income Commonwealth countries, 25 health conditions in Waikato are identified and mapped to these five criteria. These disease-criteria mappings are weighted with data from an ordered choice survey administered to the general public of the Waikato region. The resulting output of health conditions ranked in order of relative importance is validated against an explicit list of health concerns, provided by the survey respondents.

Results

Heart disease and cancerous disorders are assigned highest priority rankings according to both the algorithm and the survey data, suggesting that our model is aligned with the primary health concerns of the general public. All five criteria are weighted near-equal across survey respondents, though the average health equity preference score is 9.2% higher for Māori compared to non-Māori respondents. Older respondents (50 years and above) ranked issues of multimorbidity 4.2% higher than younger respondents.

Conclusions

Health preferences of the general population can be elicited using ordered-choice surveys and can be used to weight data for health conditions across multiple criteria, providing policymakers with a practical tool to inform which health conditions deserve the most attention. Our model connects public health strategic priorities, the health impacts and financial costs of particular health conditions, and the underlying preferences of the general public. We illustrate a practical approach to quantifying the foundational criteria that drive public preferences, for the purpose of relevant, legitimate, and evidence-based priority setting in health.

Electronic supplementary material

The online version of this article (10.1186/s12962-018-0121-z) contains supplementary material, which is available to authorized users.

Multi-criteria decision analysis: of politics, policy entrepreneurs, and processes

Multi-criteria decision analysis (MCDA) has the potential to increase the consistency, transparency and rigour with which these criteria inform decisions. Political context is relevant not only as a motivation for turning to MCDA but also the context in which MCDA can be successfully implemented. A policy entrepreneur can spearhead the creation of a process to carry out MCDA and can help to create and build the capacity of a public institution that observes and convenes this process, an institution that has legal authority to carry out such a function.

Reducing costs at the end of life through provider incentives for hospice care: A retrospective cohort study

BACKGROUND

Costs of medical care have been found to be highest at the end of life.

AIM

To evaluate the effect of provider reimbursement for hospice care on end-of-life costs.

DESIGN

The policy expanded access to hospice care for end-stage renal disease patients, a policy previously limited to cancer patients only. This study employed a difference-in-differences analysis using a generalized linear model. The main outcome is inpatient expenditures in the last 30 days of life.

SETTING/PARTICIPANTS

A cohort of 151,509 patients with chronic kidney disease or cancer, aged 65 years or older, who died between 2005 and 2012 in the National Health Insurance Research Database, which contains all enrollment and inpatient claims data for Taiwan.

RESULTS

Even as end-of-life costs for cancer are declining over time, expanding hospice care benefits to end-stage renal disease patients is associated with an additional reduction of 7.3% in end-of-life costs per decedent, holding constant patient and provider characteristics. On average, end-of-life costs are also high for end-stage renal disease (1.88 times higher than those for cancer). The cost savings were larger among older patients-among those who died at 80 years of age or higher, the cost reduction was 9.8%.

CONCLUSION

By expanding hospice care benefits through a provider reimbursement policy, significant costs at the end of life were saved.

Should There Be a Disclosure Mandate for Physicians Caring for Perinatally Infected Adolescents Who Don't Know Their HIV Serostatus?

With advances in antiretroviral therapies, perinatally infected children are now living with HIV well beyond adolescence. Parents and health care practitioners thus face the challenge of deciding how best to disclose positive serostatus to children living with HIV. Although many adolescents living with HIV are sexually active, parents often delay disclosure, which presents US physicians with an ethical dilemma because there is no legal requirement to follow clinical guidelines recommending disclosure prior to adolescence. When they become adults, US adolescents could face criminal penalties if they fail to disclose their positive serostatus to needle-sharing or sex partners despite there being no legal mandates to ensure that adolescents are first properly informed of their own diagnoses. We argue that there is an urgent need to bridge this gap between adolescent and adult HIV serostatus disclosure policies.

Comparing Birth Outcomes in Hawai'i between US- and Foreign-Born Women

The objective of this study is to examine the relationship between maternal nativity status and preterm birth (PTB) or low birth weight (LBW) for Hawai'i resident mothers, to compare these relationships across different maternal race/ethnicity groups, and to identify other potential risk and protective factors related to PTB and LBW. Using the 2004 Natality Birth Data from the National Vital Statistic System of the National Center for Health Statistics, crude and adjusted odds ratios were calculated using logistic regression to determine maternal racial/ethnic-specific nativity effects on PTB and LBW. Other Asian or Pacific Islander foreign-born mothers had higher unadjusted rates of PTB, and Samoan foreign-born mothers had lower rates of LBW after adjusting for the socio-demographic covariates compared to their native-born counterparts. Given the limitation of this study particularly relating to data quality, further research is needed to identify socio-contextual factors that are involved in the relationship between nativity status and PTB/LBW.

Pandemic risk: how large are the expected losses?

There is an unmet need for greater investment in preparedness against major epidemics and pandemics. The arguments in favour of such investment have been largely based on estimates of the losses in national incomes that might occur as the result of a major epidemic or pandemic. Recently, we extended the estimate to include the valuation of the lives lost as a result of pandemic-related increases in mortality. This produced markedly higher estimates of the full value of loss that might occur as the result of a future pandemic. We parametrized an exceedance probability function for a global influenza pandemic and estimated that the expected number of influenza-pandemic-related deaths is about 720 000 per year. We calculated that the expected annual losses from pandemic risk to be about 500 billion United States dollars - or 0.6% of global income - per year. This estimate falls within - but towards the lower end of - the Intergovernmental Panel on Climate Change's estimates of the value of the losses from global warming, which range from 0.2% to 2% of global income. The estimated percentage of annual national income represented by the expected value of losses varied by country income grouping: from a little over 0.3% in high-income countries to 1.6% in lower-middle-income countries. Most of the losses from influenza pandemics come from rare, severe events.

Pandemic risk: how large are the expected losses?

There is an unmet need for greater investment in preparedness against major epidemics and pandemics. The arguments in favour of such investment have been largely based on estimates of the losses in national incomes that might occur as the result of a major epidemic or pandemic. Recently, we extended the estimate to include the valuation of the lives lost as a result of pandemic-related increases in mortality. This produced markedly higher estimates of the full value of loss that might occur as the result of a future pandemic. We parametrized an exceedance probability function for a global influenza pandemic and estimated that the expected number of influenza-pandemic-related deaths is about 720 000 per year. We calculated that the expected annual losses from pandemic risk to be about 500 billion United States dollars - or 0.6% of global income - per year. This estimate falls within - but towards the lower end of - the Intergovernmental Panel on Climate Change's estimates of the value of the losses from global warming, which range from 0.2% to 2% of global income. The estimated percentage of annual national income represented by the expected value of losses varied by country income grouping: from a little over 0.3% in high-income countries to 1.6% in lower-middle-income countries. Most of the losses from influenza pandemics come from rare, severe events.

Aligning Funding and Need for Family Planning: A Diagnostic Methodology

With limited international resources for family planning, donors must decide how to allocate their funds to different countries. How can a donor for family planning decide whether countries are adequately prioritized for funding? This article proposes an ordinal ranking framework to identify under‐prioritized countries by rank‐ordering countries by their need for family planning and separately rank‐ordering them by their development assistance for family planning. Countries for which the rank of the need for family planning is lower than the rank of its funding are deemed under‐prioritized. We implement this diagnostic methodology to identify under‐prioritized countries that have a higher need but lower development assistance for family planning. This approach indicates whether a country is receiving less compared to other countries with similar levels of need.

Economic evaluation of dental sealants: A systematic literature review

OBJECTIVES

To systematically review the literature on economic evaluations of dental sealants and examine the costs and effectiveness of caries prevention using sealants.

METHODS

Of 21 full-text articles examined, a total of 13 were included in this study. These studies are grouped by the type of intervention as follows: (i) sealants compared with no sealants; (ii) sealants compared with other forms of caries prevention; (iii) resin-based sealants compared with glass-ionomer sealants; (iv) different sealing strategies in primary teeth; (v) different sealing strategies in permanent teeth; and (vi) sealants based on school- or clinic-based setting of delivery. All currency is reported in constant 2010 US$.

RESULTS

Cost-effectiveness analyses differed due to varying study designs, assumptions, sealant delivery settings, outcomes, caries risk assessment and study durations. Findings varied on the cost-effectiveness of sealants compared with other caries-preventive strategies. Under the assumption of equal caries risk, always sealing primary molars appeared to be the most effective strategy, whereas risk-based sealing was the optimal strategy with differing caries risk. Studies that assessed sealing strategies in permanent teeth reported that risk-based sealing was more cost-effective than not sealing, but they differed on the cost-effectiveness of risk-based seal compared with non-risk-based seal. Sealants delivered in school settings had mixed results on costs but were as equally effective as sealants delivered in private practices.

CONCLUSIONS

The cost-effectiveness of sealants is dependent on the conditions of delivery. The list of cost-effectiveness ratios for each intervention can support policy makers to estimate expected returns on their investments in dental sealants.

Fiscal transfers based on inputs or outcomes? Lessons from the Twelfth and Thirteenth Finance Commission in India

Background

There is limited empirical evidence about the efficacy of fiscal transfers for a specific purpose, including for health which represents an important source of funds for the delivery of public services especially in large populous countries such as India.

Objective

To examine two distinct methodologies for allocating specific‐purpose centre‐to‐state transfers, one using an input‐based formula focused on equity and the other using an outcome‐based formula focused on performance.

Materials and Methods

We examine the Twelfth Finance Commission (12FC)'s use of Equalization Grants for Health (EGH) as an input‐based formula and the Thirteenth Finance Commission (13FC)'s use of Incentive Grants for Health (IGH) as an outcome‐based formula. We simulate and replicate the allocation of these two transfer methodologies and examine the consequences of these fiscal transfer mechanisms.

Results

The EGH placed conditions for releasing funds, but states varied in their ability to meet those conditions, and hence their allocations varied, eg, Madhya Pradesh received 100% and Odisha 67% of its expected allocation. Due to the design of the IGH formula, IGH allocations were unequally distributed and highly concentrated in 4 states (Manipur, Sikkim, Tamil Nadu, Nagaland), which received over half the national IGH allocation.

Discussion

The EGH had limited impact in achieving equalization, whereas the IGH rewards were concentrated in states which were already doing better. Greater transparency and accountability of centre‐to‐state allocations and specifically their methodologies are needed to ensure that allocation objectives are aligned to performance.

Evolution and patterns of global health financing 1995-2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries

BACKGROUND

An adequate amount of prepaid resources for health is important to ensure access to health services and for the pursuit of universal health coverage. Previous studies on global health financing have described the relationship between economic development and health financing. In this study, we further explore global health financing trends and examine how the sources of funds used, types of services purchased, and development assistance for health disbursed change with economic development. We also identify countries that deviate from the trends.

METHODS

We estimated national health spending by type of care and by source, including development assistance for health, based on a diverse set of data including programme reports, budget data, national estimates, and 964 National Health Accounts. These data represent health spending for 184 countries from 1995 through 2014. We converted these data into a common inflation-adjusted and purchasing power-adjusted currency, and used non-linear regression methods to model the relationship between health financing, time, and economic development.

FINDINGS

Between 1995 and 2014, economic development was positively associated with total health spending and a shift away from a reliance on development assistance and out-of-pocket (OOP) towards government spending. The largest absolute increase in spending was in high-income countries, which increased to purchasing power-adjusted $5221 per capita based on an annual growth rate of 3·0%. The largest health spending growth rates were in upper-middle-income (5·9) and lower-middle-income groups (5·0), which both increased spending at more than 5% per year, and spent $914 and $267 per capita in 2014, respectively. Spending in low-income countries grew nearly as fast, at 4·6%, and health spending increased from $51 to $120 per capita. In 2014, 59·2% of all health spending was financed by the government, although in low-income and lower-middle-income countries, 29·1% and 58·0% of spending was OOP spending and 35·7% and 3·0% of spending was development assistance. Recent growth in development assistance for health has been tepid; between 2010 and 2016, it grew annually at 1·8%, and reached US$37·6 billion in 2016. Nonetheless, there is a great deal of variation revolving around these averages. 29 countries spend at least 50% more than expected per capita, based on their level of economic development alone, whereas 11 countries spend less than 50% their expected amount.

INTERPRETATION

Health spending remains disparate, with low-income and lower-middle-income countries increasing spending in absolute terms the least, and relying heavily on OOP spending and development assistance. Moreover, tremendous variation shows that neither time nor economic development guarantee adequate prepaid health resources, which are vital for the pursuit of universal health coverage.

FUNDING

The Bill & Melinda Gates Foundation.

Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study

Background

Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD.

Methods

We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients.

Results

During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care.

Conclusions

Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.

Dedicated health systems strengthening of the Global Fund to Fight AIDS, Tuberculosis, and Malaria: an analysis of grants

BACKGROUND

This study aims to understand the determinants of the Global Fund to Fight AIDS, Tuberculosis, and Malaria's dedicated channel for health systems strengthening (HSS) funding across countries and to analyze their health system priorities expressed in budgets and performance indicators.

METHODS

We obtained publicly available data for disease-specific and HSS grants from the Global Fund over 2004-2013 prior to the new funding model. Regression analysis was employed to assess the determinants of dedicated HSS funding across 111 countries. Documents for 27 dedicated HSS grants including budgets and performance indicators were collected, and activities were analyzed by health system functions.

RESULTS

HSS funding per capita is significantly associated with TB and HIV funding per capita, but not per capita income and health worker density. Of 27 dedicated HSS grants, 11 had line-item budgets publicly available, in which health workforce and medical products form the majority (89% or US$132 million of US$148 million) of funds. Yet these areas accounted for 41.7% (215) of total 516 performance indicators.

CONCLUSIONS

Health worker densities were not correlated with HSS funding, despite the emphasis on health workforce in budgets and performance indicators. Priorities in health systems in line-item budgets differ from the numbers of indicators used.

Global Budget Payment: Proposing the CAP Framework

To control ever-increasing costs, global budget payment has gained attention but has unclear impacts on health care systems. We propose the CAP framework that helps navigate 3 domains of difficult design choices in global budget payment: Constraints in resources (capitation vs facility-based budgeting; hard vs soft budget constraints), Agent-principal in resource allocation (individual vs group providers in resource allocation; single vs multiple pipes), and Price adjustment. We illustrate the framework with empirical examples and draw implications for policy makers.

The Differential Impact of User-Fee Exemption Compared to Conditional Cash Transfers on Safe Deliveries in Nepal

OBJECTIVE

To assess the differential impact of a copayment exemption compared to a cash incentive on increasing skilled birth attendance (i.e., birth attended by a skilled health worker) in Nepal.

DATA SOURCES/STUDY SETTING

This study used data on 8,785 children born between July 2005 and December 2008, obtained from the nationally representative Demographic and Health Surveys, 2006 and 2011.

STUDY DESIGN

Twenty-five districts received both the policy interventions, and the remaining 50 control districts received only the cash incentive. We employed a difference-in-differences model to compare children born in districts with both interventions to those in districts with conditional cash transfers only. Average marginal effects of the difference-in-difference coefficient on skilled birth attendance measures are estimated.

PRINCIPAL FINDINGS

Skilled birth attendance in districts with both interventions was no higher on average than in districts with only the cash incentive. In areas with adequate road networks, however, significantly higher skilled birth attendance was observed in districts with both interventions compared to those with only the cash incentive.

CONCLUSIONS

The added incentive of the user-fee exemption did not significantly increase skilled birth attendance relative to the presence of the cash incentive. User-fee exemptions may not be effective in areas with inadequate road infrastructure.

The impact of internal displacement on child mortality in post-earthquake Haiti: a difference-in-differences analysis

Background

The Haiti earthquake in 2010 resulted in 1.5 million internally displaced people (IDP), yet little is known about the impact of displacement on health. In this study, we estimate the impact of displacement on infant and child mortality and key health-behavior mechanisms.

Methods

We employ a difference-in-differences (DID) design with coarsened exact matching (CEM) to ensure comparability among groups with different displacement status using the 2012 Haiti Demographic and Health Survey (DHS). The participants are 21,417 births reported by a nationally representative sample of 14,287 women aged 15–49. The main independent variables are household displacement status which includes households living in camps, IDP households (not in camps), and households not displaced. The main outcomes are infant and child mortality; health status (height-for-age, anemia); uptake of public health interventions (bed net use, spraying against mosquitoes, and vaccinations); and other conditions (hunger; cholera).

Results

Births from the camp households have higher infant mortality (OR = 2.34, 95 % CI 1.15 to 4.75) and child mortality (OR = 2.34, 95 % CI 1.10 to 5.00) than those in non-camp IDP households following the earthquake. These odds are higher despite better access to food, water, bed net use, mosquito spraying, and vaccines among camp households.

Conclusions

IDP populations are heterogeneous and households that are displaced outside of camps may be self-selected or self-insured. Meanwhile, even households not displaced by a disaster may face challenges in access to basic necessities and health services. Efforts are needed to identify vulnerable populations to provide targeted assistance in post-disaster relief.

Perspective and investments in health system strengthening of Gavi, the Vaccine Alliance: a content analysis of health system strengthening-specific funding

BACKGROUND

This paper aimed to compare the health systems strengthening (HSS) framework of Gavi and WHO and to analyze resource allocation in HSS by Gavi.

METHODS

Among 76 countries which received HSS funding from Gavi from 2006 to 2013, summary reports of 44 countries and approved proposals of 10 countries were collected. After comparing the HSS framework of WHO and Gavi, each activity described in documents was categorized according to Gavi's framework and funding allocation was analyzed.

RESULTS

Compared with WHO's HSS framework, Gavi's has a distinctive function within the building block 'Drugs, Equipment, Supplies, Facilities' and a distinctive function of 'providing incentive and bonuses' under the building block 'Human Resource/Performance Management'. Gavi has steadily invested 10% of their total budget on HSS, but 47% were allocated in these categories, whereas 78% were for activities arguably not covered by WHO's HSS framework. In Africa, 70% of Gavi's budget fell under 'Drugs, Equipment, Supplies, Facilities' and 92.8% were for activities arguably not deemed as HSS by WHO.

CONCLUSIONS

Gavi's HSS support emphasized inputs with short-term measurable outcomes. Harmonization of the concept of HSS and collaboration between Gavi and multilateral international agencies, such as World Bank and WHO, are needed.

Insights in public health: a tale of two polities: health in Independent and American Samoa

Independent and American Samoa have a shared cultural, genetic, ethnolinguistic, and historical background but have been politically separated since 1899. In this essay, we examine the health of these two polities and identify two key health patterns that have emerged even as American Samoa has achieved a higher per capita income than Independent Samoa. Whereas the gender gap in life expectancy at birth has narrowed in Independent Samoa, this gap has not narrowed in American Samoa and its male life expectancy now lags behind that of Independent Samoa. Neonatal mortality rates in American Samoa are slightly higher than in Independent Samoa. These patterns may be linked to the higher rates of obesity and urbanization observed in American Samoa compared to Independent Samoa, as well as the differing political and institutional arrangements of the two polities. Limited data remains a persistent challenge to conducting analysis of public health in the Pacific islands, particularly in American Samoa.

China's role as a global health donor in Africa: what can we learn from studying under reported resource flows?

Background

There is a growing recognition of China’s role as a global health donor, in particular in Africa, but there have been few systematic studies of the level, destination, trends, or composition of these development finance flows or a comparison of China’s engagement as a donor with that of more traditional global health donors.

Methods

Using newly released data from AidData on China’s development finance activities in Africa, developed to track under reported resource flows, we identified 255 health, population, water, and sanitation (HPWS) projects from 2000–2012, which we descriptively analyze by activity sector, recipient country, project type, and planned activity. We compare China’s activities to projects from traditional donors using data from the OECD’s Development Assistance Committee (DAC) Creditor Reporting System.

Results

Since 2000, China increased the number of HPWS projects it supported in Africa and health has increased as a development priority for China. China’s contributions are large, ranking it among the top 10 bilateral global health donors to Africa. Over 50% of the HPWS projects target infrastructure, 40% target human resource development, and the provision of equipment and drugs is also common. Malaria is an important disease priority but HIV is not. We find little evidence that China targets health aid preferentially to natural resource rich countries.

Conclusions

China is an important global health donor to Africa but contrasts with traditional DAC donors through China’s focus on health system inputs and on malaria. Although better data are needed, particularly through more transparent aid data reporting across ministries and agencies, China’s approach to South-South cooperation represents an important and distinct source of financial assistance for health in Africa.

How a new funding model will shift allocations from the Global Fund to Fight AIDS, tuberculosis, and malaria

Policy makers deciding how to fund global health programs in low- and middle-income countries face important but difficult questions about how to allocate resources across countries. In this article we present a typology of three allocation methodologies to align allocations with priorities. We then apply our typology to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. We examined the Global Fund's historical HIV allocations and its predicted allocations under a new funding model that creates an explicit allocation methodology. We found that under the new funding model, substantial shifts in the Global Fund's portfolio are likely to result from concentrating resources in countries with more HIV cases and lower per capita incomes. For example, South Africa, which had 15.8 percent of global HIV cases in 2009, could see its Global Fund HIV funding more than triple, from historic levels that averaged 3.0 percent to 9.7 percent of total Global Fund allocations. The new funding model methodology is expected, but not guaranteed, to improve the efficiency of Global Fund allocations in comparison to historical practice. We conclude with recommendations for the Global Fund and other global health donors to further develop their allocation methodologies and processes to improve efficiency and transparency.

The health financing transition: a conceptual framework and empirical evidence

Almost every country exhibits two important health financing trends: health spending per person rises and the share of out-of-pocket spending on health services declines. We describe these trends as a "health financing transition" to provide a conceptual framework for understanding health markets and public policy. Using data over 1995-2009 from 126 countries, we examine the various explanations for changes in health spending and its composition with regressions in levels and first differences. We estimate that the income elasticity of health spending is about 0.7, consistent with recent comparable studies. Our analysis also shows a significant trend in health spending - rising about 1 per cent annually - which is associated with a combination of changing technology and medical practices, cost pressures and institutions that finance and manage healthcare. The out-of-pocket share of total health spending is not related to income, but is influenced by a country's capacity to raise general revenues. These results support the existence of a health financing transition and characterize how public policy influences these trends.

Performance-based financing at the Global Fund to Fight AIDS, Tuberculosis and Malaria: an analysis of grant ratings and funding, 2003-12

BACKGROUND

Performance-based financing can be used by global health funding agencies to improve programme performance and thus value for money. The Global Fund to Fight AIDS, Tuberculosis and Malaria was one of the first global-health funders to deploy a performance-based financing system. However, its complex, multistep system for calculating and paying on grant ratings has several components that are subjective and discretionary. We aimed to test the association between grant ratings and disbursements, an indication of the extent to which incentives for performance are transmitted to grant recipients.

METHODS

We obtained publicly available data for 508 Global Fund grants from 2003 to 2012 with performance ratings and corresponding disbursements, merged with other datasets that contained data for relevant country characteristics. We used regression analysis to identify predictors of grant disbursements in phase 2 (typically the latter 3 of 5 years of a grant), using two dependent variables: whether a grant had any phase-2 disbursements, and the phase-2 disbursement amount. In a separate analysis, we also investigated the predictors of grant performance ratings.

FINDINGS

Grant performance rating in phase 1 was positively associated with having any disbursements in phase 2, but no association was seen between phase-1 ratings and phase-2 disbursement amounts. Furthermore, performance ratings are not replicable by external observers, both because subjective and discretionary decisions are made in the generation of performance measures and because the underlying data are not available.

INTERPRETATION

The Global Fund's present performance-based funding system does not adequately convey incentives for performance to recipients, and the organisation should redesign this system to explicitly link a portion of the funds to a simple performance measure in health coverage or outcomes, measured independently and robustly.

FUNDING

Bill & Melinda Gates Foundation.

The economic burden of cancers on Indian households

We assessed the burden of cancer on households’ out-of-pocket health spending, non-medical consumption, workforce participation, and debt and asset sales using data from a nationally representative health and morbidity survey in India for 2004 of nearly 74 thousand households. Propensity scores were used to match households containing a member diagnosed with cancer (i.e. cancer-affected households) to households with similar socioeconomic and demographic characteristics (controls). Our estimates are based on data from 1,645 households chosen through matching. Cancer-affected households experienced higher levels of outpatient visits and hospital admissions and increased out-of-pocket health expenditures per member, relative to controls. Cancer-affected households spent between Indian Rupees (INR) 66 and INR 85 more per member on healthcare over a 15-day reference period, than controls and additional expenditures (per member) incurred on inpatient care by cancer-affected households annually is equivalent to 36% to 44% of annual household expenditures of matched controls. Members without cancer in cancer-affected households used less health-care and spent less on healthcare. Overall, adult workforce participation rates were lower by between 2.4 and 3.2 percentage points compared to controls; whereas workforce participation rates among adult members without cancer were higher than in control households. Cancer-affected households also had significantly higher rates of borrowing and asset sales for financing outpatient care that were 3.3% to 4.0% higher compared to control households; and even higher for inpatient care.

"Silent virtuous teachers": anatomical dissection in Taiwan

Steven C Lin, Julia Hsu, and Victoria Y Fan describe how the dissection course at Tzu Chi College of Medicine in Taiwan has motivated and inspired people to donate their bodies for scientific endeavours, an otherwise culturally avoided gesture in the East.

China's human resources for health: quantity, quality, and distribution

In this paper, we analyse China's current health workforce in terms of quantity, quality, and distribution. Unlike most countries, China has more doctors than nurses-in 2005, there were 1.9 million licensed doctors and 1.4 million nurses. Doctor density in urban areas was more than twice that in rural areas, with nurse density showing more than a three-fold difference. Most of China's doctors (67.2%) and nurses (97.5%) have been educated up to only junior college or secondary school level. Since 1998 there has been a massive expansion of medical education, with an excess in the production of health workers over absorption into the health workforce. Inter-county inequality in the distribution of both doctors and nurses is very high, with most of this inequality accounted for by within-province inequalities (82% or more) rather than by between-province inequalities. Urban-rural disparities in doctor and nurse density account for about a third of overall inter-county inequality. These inequalities matter greatly with respect to health outcomes across counties, provinces, and strata in China; for instance, a cross-county multiple regression analysis using data from the 2000 census shows that the density of health workers is highly significant in explaining infant mortality.