Showing papers in "International Journal for Equity in Health in 2019"
TL;DR: A definition for cultural safety is proposed that is more fit for purpose in achieving health equity, and the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development are clarified.
Abstract: Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them. A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa – Māori Medical Practitioners Association (Te ORA) and consultation with Māori medical practitioners via Te ORA. Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’ power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming ‘competent’ in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity. A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.
391 citations
TL;DR: The Health Equity Measurement Framework (HEMF) is presented, which was specifically designed to measure the direct and indirect effects of SDOH to support improved statistical modelling and measurement of health equity.
Abstract: Despite the wealth of frameworks on social determinants of health (SDOH), two current limitations include the relative superficial description of factors affecting health and a lack of focus on measuring health equity. The Health Equity Measurement Framework (HEMF) addresses these gaps by providing a more encompassing view of the multitude of SDOH and drivers of health service utilisation and by guiding quantitative analysis for public health surveillance and policy development. The objective of this paper is to present the HEMF, which was specifically designed to measure the direct and indirect effects of SDOH to support improved statistical modelling and measurement of health equity. Based on a framework synthesis, the HEMF development involved initially integrating theoretical components from existing SDOH and health system utilisation frameworks. To further develop the framework, relevant publications on SDOH and health equity were identified through a literature review in major electronic databases. White and grey literatures were critically reviewed to identify strengths and gaps in the existing frameworks in order to inform the development of a unique health equity measurement framework. Finally, over a two-year period of consultation, scholars, health practitioners, and local policy influencers from municipal and provincial governments provided critical feedback on the framework regarding its components and causal relationships. This unified framework includes the socioeconomic, cultural, and political context, health policy context, social stratification, social location, material and social circumstances, environment, biological factors, health-related behaviours and beliefs, stress, quality of care, and healthcare utilisation. Alongside the HEMF’s self-exploratory diagram showing the causal pathways in-depth, a number of examples are provided to illustrate the framework’s usefulness in measuring and monitoring health equity as well as informing policy-making. The HEMF highlights intervention areas to be influenced by strategic public policy for any organisation whose purview has an effect on health, including helping non-health sectors (such as education and labour) to better understand how their policies influence population health and perceive their role in health equity promotion. The HEMF recognises the complexity surrounding the SDOH and provides a clear, overarching direction for empirical work on health equity.
77 citations
TL;DR: The study found the inverse relationship between district’s economic development with childhood stunting and underweight with the concentration of stunted as well as underweight children were found in least developed districts of India.
Abstract: Despite a fast-growing economy and the largest anti-malnutrition programme, India has the world’s worst level of child malnutrition. Despite India’s 50% increase in GDP since 1991, more than one third of the world’s malnourished children live in India. Among these, half of the children under age 3 years are underweight and a third of wealthiest children are over-nutrient. One of the major causes for malnutrition in India is economic inequality. Therefore, using the data from the fourth round of National Family Health Survey (2015–16), present study aims to examine the socio-economic inequality in childhood malnutrition across 640 districts of India. Concentration curve and generalized concentration index were used to examine the socioeconomic inequalities in malnutrition. However, regression-based decomposition methodology was used to decomposes the causes of inequality in childhood malnutrition. Result shows that about 38% children in India were stunted and 35% were underweight during 2015–16. Prevalence of stunting and underweight children varies considerably across Indian districts (13 to 65% and 7 to 67% respectively). Districts having the higher share of undernourished children is coming from the particular regions like central, east and west part of the country. On an average about 35% of household in a district having the access of safe drinking water and 42% of household in a district exposed to open defecation. The study found the inverse relationship between district’s economic development with childhood stunting and underweight. The concentration of stunted as well as underweight children were found in least developed districts of India. Decomposition approach found that practice of open defecation is positively influenced the inequality in stunting and underweight. Further, inequality in undernutrition is accelerated by the height and education of the mother, and availability of safe drinking water in a district. The districts that lied out in a spectrum of developmental diversity are required some specific set of information’s that covering socio-economic, demographic and health-related quality of life of people in those backward districts. More generally, policies to avail improved water and sanitation facility to public and female literacy should be continued. It is also important to see that the benefits of both infrastructure and more general economic development are spread more evenly across districts.
63 citations
TL;DR: Examination of changes made since the implementation of Canadian policies on the representation of women in clinical trials, the analysis of sex and gender, as well as the discourses that are prominent among researchers suggest that women continue to be underrepresented or excluded from important research, highlighting ongoing ethical and justice concerns.
Abstract: Health equity in pharmaceutical research is concerned with creating equal opportunities for men and women to partake in clinical trials. Equitable representation is imperative for determining the safety, effectiveness, and tolerance of drugs for all consumers. Historically, women have been excluded from participating in clinical research leading to a lack of knowledge regarding drug effects and their consequences. This paper examines the changes made since the implementation of Canadian policies on the representation of women in clinical trials, the analysis of sex and gender, as well as the discourses that are prominent among researchers. A feminist ethics framework is used to examine the structures that endeavor to elucidate women’s involvement in trials, as experienced under extensive patriarchal history. Scholarly literature and Canadian government policy documents are used to explore the development of clinical trials as pertaining to sex and gender. Findings suggest that women continue to be underrepresented or excluded from important research, highlighting ongoing ethical and justice concerns. Improvement recommendations for policies are outlined.
60 citations
TL;DR: The experiences of healthcare services among the homeless and vulnerable housed do not meet the standards of universally accessible patient-centered care and EOHC could provide a framework for changes to the healthcare system, creating a system that is more trauma-informed, equity-enhancing, and accessible to people experiencing homelessness.
Abstract: People experiencing homelessness are often marginalized and are known to face barriers to accessing acceptable and respectful healthcare services. This study examines the experience of accessing hospital-based services of persons experiencing homelessness or vulnerable housing in southeastern Ontario and considers the potential of Equity-Oriented Health Care (EOHC) as an approach to improving care. Focus groups and in-depth interviews with people with lived experience of homelessness (n=31), as well as in-depth interviews of health and social service provider key informants (n=10) were combined with qualitative data from a survey of health and social service providers (n=136). Interview transcripts and written survey responses were analyzed using directed content analysis to examine experiences of people with lived experience of homelessness within the healthcare system. Healthcare services were experienced as stigmatizing and shaming particularly for patients with concurrent substance use. These negative experiences could lead to avoidance or abandonment of care. Despite supposed universality, participants felt that the healthcare system was not accountable to them or to other equity-seeking populations. Participants identified a system that was inflexible, designed for a perceived middle-class population, and that failed to take into account the needs and realities of equity-seeking groups. Finally, participants did identify positive healthcare interactions, highlighting the importance of care delivered with dignity, trust, and compassion. The experiences of healthcare services among the homeless and vulnerably housed do not meet the standards of universally accessible patient-centered care. EOHC could provide a framework for changes to the healthcare system, creating a system that is more trauma-informed, equity-enhancing, and accessible to people experiencing homelessness, thus limiting identified barriers and negative experiences of care.
56 citations
TL;DR: Socioeconomic inequalities in smoking have increased in parallel with the implementation of tobacco control policies and should be developed to decrease socioeconomic inequalities in cigarette use in Korea.
Abstract: The aim of this study was to investigate long-term trends in smoking prevalence and its socioeconomic inequalities in Korea. Data were collected from 10 rounds of the Social Survey of Statistics Korea between 1992 and 2016. A total of 524,866 men and women aged 19 or over were analyzed. Age-adjusted smoking prevalence was calculated according to three major socioeconomic position indicators: education, occupational class, and income. The prevalence difference, prevalence ratio, slope index of inequality (SII), and relative index of inequality (RII) were calculated to examine the magnitude of inequality in smoking. Smoking prevalence among men decreased from 71.7% in 1992 to 39.7% in 2016, while smoking prevalence among women decreased from 6.5% in 1992 to 3.3% in 2016. Socioeconomic inequalities in smoking prevalence according to the three socioeconomic position indicators were found in both men and women throughout the study period. In general, absolute and relative socioeconomic inequalities in smoking, measured by prevalence difference and prevalence ratio for education and occupational class, widened during the study period among Korean men and women. In men, the SII for income increased from 7.6% in 1999 to 10.8% in 2016 and the RII for income also increased from 1.11 in 1999 to 1.31 in 2016. In women, the SII for income increased from 0.1% in 1999 to 2.4% in 2016 and the RII for income increased from 1.39 in 1999 to 2.25 in 2016. Pro-rich socioeconomic inequalities in smoking prevalence were found in men and women. Socioeconomic inequalities in smoking have increased in parallel with the implementation of tobacco control policies. Tobacco control policies should be developed to decrease socioeconomic inequalities in cigarette use in Korea.
56 citations
TL;DR: Assessment of how intersectionality-informed studies in epidemiological research considered different social dimensions in their multivariable and multivariate analyses suggested that systematic integration of solution-linked variables indicating modifiable aspects of sex/ gender-related living conditions and disadvantages could improve sex/gender sensitivity as part of intersectionality -based quantitative data analysis in health research.
Abstract: The implementation of a theoretical intersectionality framework into quantitative data analyses is gaining increasing interest in health research. The substantive foundation of intersectionality was established in the U.S., based on the claim of black feminists to broaden the scope of contemporary gender studies by considering the intersection between sex/gender and race/ethnicity more firmly. The aim of our scoping review with particular emphasis on sex/gender was to assess how intersectionality-informed studies in epidemiological research considered different social dimensions in their multivariable and multivariate analyses. Following the PRISMA Extension for Scoping Reviews (PRISMA-ScR), we conducted a literature review in PubMed. Three distinct health-related fields were brought into focus: diabetes representing a frequent chronic disease, smoking as a wide-spread behavioural health determinant and physical activity as a central target for health promotion. Initially, we compared which and how different social dimensions were accounted for and how inter-categorical and intersectionality-informed analyses were conducted. Further, we assessed sex/gender sensitivity by comparing operationalisation of sex/gender, how sex/gender theories were used and which central theoretical sex/gender concepts were referred to when aiming at explanation of (intersectional) sex/gender differences. Our results suggest, that intersectionality-based analyses within the three selected health-related fields are mainly conducted in the U.S. and focused on the intersection between sex/gender and race/ethnicity by using them jointly as subgrouping variables and as parts of interaction terms in regression analyses. Income and education as proxies for social class as well as age are mainly used for adjustment in quantitative analyses. Other approaches for calculating interactions (i.a. synergy-index, CART-analysis) are an exception. Even though sex/gender was considered in every included study and Gender was the most frequent theoretical sex/gender concept referred to when theoretically explaining sex/gender differences, it was exclusively operationalised as binary and solution-linked sex/gender variables were hardly considered in quantitative analyses. The systematic integration of solution-linked variables indicating modifiable aspects of sex/gender-related living conditions and disadvantages could improve sex/gender sensitivity as part of intersectionality-based quantitative data analysis in health research.
53 citations
TL;DR: Elderly patients with hypertension from lower socio-economic background have various unmet needs in managing their hypertension and other comorbidities and policy decisions to address these needs require an integrated multi-sectoral approach grounded in the principles of health equity.
Abstract: In Singapore, the burden of hypertension disproportionately falls on the elderly population of low socio-economic status. Despite availability of effective treatment, studies have shown high prevalence of sub-optimal blood pressure control in this group. Poor hypertension management can be attributed to a number of personal factors including awareness, management skills and overall adherence to treatment. However, these factors are also closely linked to a broader range of community and policy factors. This paper explores the perceived social and physical environments of low socio-economic status and elderly patients with hypertension; and how the interplay of factors within these environments influences their ability to mobilise resources for hypertension management. In-depth interviews were conducted in English, Chinese, Chinese dialects and Malay with 20 hypertensive patients of various ethnic backgrounds. Purposive sampling was adopted for recruitment of participants from a previous community health screening campaign. Interviews were translated into English and transcribed verbatim. We deductively analysed leveraging on the Social Model of Health to identify key themes, while inductive analysis was used simultaneously to allow sub-themes to emerge. Our finding shows that financing is an overarching topic embedded in most themes. Despite the availability of multiple safety nets, some patients were left out and lacked capital to navigate systems effectively, which resulted in delayed treatment or debt. The built environment played a significant role in enabling patients to access care easily and lead a more active lifestyle. A closer look is needed to enhance the capacity of patients with mobility challenges to enjoy equitable access. Furthermore, the establishment of community based elderly centres has enabled patients to engage in meaningful and healthy social activities. In contrast, participants’ descriptions showed that their communication with healthcare professionals remained brief, and that personalised and meaningful interactions that are context and culturally specific are essential to advocate for patients’ overall treatment adherence and lifestyle modification. Elderly patients with hypertension from lower socio-economic background have various unmet needs in managing their hypertension and other comorbidities. These needs are closely related to broader societal factors such as socio-demographic characteristics, support systems, urban planning and public policies, and health systems factors. Policy decisions to address these needs require an integrated multi-sectoral approach grounded in the principles of health equity.
52 citations
TL;DR: EquIR is a conceptual framework proposed for use by decision makers and researchers during the implementation of programs, policies or health interventions, with a focus on equity, which aims to reduce or prevent the increase of existing inequalities during implementation.
Abstract: Implementation research is increasingly used to identify common implementation problems and key barriers and facilitators influencing efficient access to health interventions. To develop and propose an equity-based framework for Implementation Research (EquIR) of health programs, policies and systems. A systematic search of models and conceptual frameworks involving equity in the implementation of health programs, policies and systems was conducted in Medline (PubMed), Embase, LILACS, Scopus and grey literature. Key characteristics of models and conceptual frameworks were summarized. We identified key aspects of equity in the context of seven Latin American countries-focused health programs We gathered information related to the awareness of inequalities in health policy, systems and programs, the potential negative impact of increasing inequalities in disadvantaged populations, and the strategies used to reduce them. A conceptual framework of EquIR was developed. It includes elements of equity-focused implementation research, but it also links the population health status before and after the implementation, including relevant aspects of health equity before, during and after the implementation. Additionally, health sectors were included, linked with social determinants of health through the “health in all policies” proposal affecting universal health and the potential impact of the public health and public policies. EquIR is a conceptual framework that is proposed for use by decision makers and researchers during the implementation of programs, policies or health interventions, with a focus on equity, which aims to reduce or prevent the increase of existing inequalities during implementation.
50 citations
TL;DR: Significant socioeconomic inequalities were observed in low back pain among older individuals in Japan and policymakers and clinicians must understand the nature of these inequalities.
Abstract: Low back pain is an important public health issue across the world. However, it is unclear whether socioeconomic status (SES) is associated with low back pain. This study determines an association between SES and low back pain among older people. We used cross-sectional data derived from the year 2013 across 30 Japanese municipalities. The survey was conducted between October 2013 to December 2013. Functionally independent community-dwelling older adults aged 65 and above (n = 26,037) were eligible for the study. Multilevel Poisson regression analysis with a robust variance estimator was used to examine the association between SES and low back pain. Self-reported low back pain in the past year was used as a dependent variable. Educational attainment, past occupation, equivalized household income, wealth, and subjective economic situation represented SES and were separately analyzed as independent variables, adjusted for covariates including age and sex. The prevalence of low back pain was 63.4%. Overall, lower SES were more likely to suffer from low back pain compared with that for the highest. First, as for the educational attainment, the prevalence ratio (PR) (95% credible interval (CI)) for the lowest level was 1.07 (1.02–1.12). Second, as for the past occupation, the PR (95% CI) for the blue-collared workers compared with professionals was 1.06 (1.01–1.11). Third, as for the equalized household income, the PRs (95% CI) for lower middle and the lowest income levels were 1.08 (1.02–1.13) and 1.16 (1.10–1.23), respectively. Fourth, as for the wealth, the PRs (95% CI) for lower middle and the lowest wealth levels were 1.11 (1.04–1.19) and 1.18 (1.11–1.27), respectively. Fifth, as for the subjective economic situation, the PRs (95% CI) for lower middle and the lowest financial conditions were 1.18 (1.10–1.26) and 1.32 (1.22–1.44), respectively. Significant socioeconomic inequalities were observed in low back pain among older individuals in Japan. Policymakers and clinicians must understand the nature of these inequalities.
48 citations
TL;DR: Gender and racial disparities rooted in structural and contextual inequalities remain important factors for the maintenance of the generalized HIV epidemic in South Africa.
Abstract: In South Africa, persistence of the HIV epidemic and associated gender and racial disparities is a major concern after more than 20 years of democratic dispensation and efforts to create a more healthy and equal society. This paper profiles HIV prevalence and related factors among Black African men and women compared to other race groups in South Africa using the 2012 population-based national household HIV survey. This secondary data analysis was based on the 2012 population-based nationally representative multi-stage stratified cluster random household sample. Bivariate and multiple logistic regression analysis were used to assess the relationship between HIV prevalence and associated factors by gender and racial profile. Overall HIV prevalence was significantly higher (p < 0.001) among both Black African males (16.6%; 95% CI: 15.0–18.4) and females (24.1%; 95% CI: 22.4–26.0) compared to their counterparts from other races. Among Black African males, increased risk of HIV was significantly associated with age group 25–49 years and those 50 years and older compared with young males 15–25 years. Among all males, reported condom use at last sex was significantly associated with increased risk of HIV. High socio-economic status (SES) and perceived risk of HIV were associated with a decreased risk of HIV. Among female condom use at last sex and ever testing for HIV was associated with increased prevalence of HIV only among Black African females. Lower prevalence of HIV was associated with marriage, tertiary education, high SES, having a partner five years younger, perceived risk of HIV, and awareness of HIV status among Black African females. Gender and racial disparities rooted in structural and contextual inequalities remain important factors for the maintenance of the generalized HIV epidemic in the country. HIV prevention interventions need to cut across all strata of society but also target risk factors salient for specific groups. Alleviating vulnerability to HIV along gender and racial lines should also be viewed as part of a broader public health strategy.
TL;DR: The pattern of suicide in China has changed in recent years following urbanisation and aging, and differences in suicide rates amongst the elderly exist between rural and urban areas.
Abstract: China has an unusual pattern of suicides, with overall suicide rates in rural areas higher than urban areas. While suicide rates have decreased dramatically, older people increasingly contribute to the overall burden of suicide. However, it is unclear if elderly people within rural areas experience greater suicide risk than those in urban areas. We aimed to systematically review the incidence of suicide in rural and urban China among the elderly (aged over 60 years), with a view to describing the difference in rates between rural and urban areas and trends over time. Chinese and English language articles were searched for using four databases: EMBASE (Ovid), MEDLINE (Ovid), PsycINFO (EBSCOhost) and CNKI (in Chinese). Articles describing completed suicide among elderly people in both rural and urban areas in mainland China were included. The adapted Newcastle-Ottawa Scale (NOS) was used to assess risk of bias. One reviewer (ML) assessed eligibility, performed data extraction and assessed risk of bias, with areas of uncertainty discussed with the second reviewer (SVK). Random effects meta-analysis was conducted. Suicide methods in different areas were narratively summarised. Out of a total 3065 hits, 24 articles were included and seven contributed data to meta-analysis. The sample size of included studies ranged from 895 to 323.8 million. The suicide rate in the general population of China has decreased in recent decades over previous urban and rural areas. Suicide rates amongst the elderly in rural areas are higher than those in urban areas (OR = 3.35; 95% CI of 2.48 to 4.51; I2 = 99.6%), but the latter have increased in recent years. Insecticide poisoning and hanging are the most common suicide methods in rural and urban areas respectively. Suicide rates for these two methods increase with age, being especially high in elderly people. The pattern of suicide in China has changed in recent years following urbanisation and aging. Differences in suicide rates amongst the elderly exist between rural and urban areas. Addressing the high suicide rate amongst the elderly in rural China requires a policy response, such as considering measures to restrict access to poisons.
TL;DR: This is the first published practical guide on keys to academic success for URM young investigators, and identified keys to success included having multiple mentors, writing prolifically, being tenaciously persistent, having mentors who are invested in you.
Abstract: Although Latinos, African-Americans, and American Indians/Alaska Natives comprise 34% of Americans, these under-represented minorities (URMs) account for only 7% of US medical-school faculty. Even when URMs become faculty, they face many substantial challenges to success. Little has been published, however, on keys to academic success for URM young faculty investigators. The Research in Academic Pediatrics Initiative on Diversity (RAPID) goal is to enhance the professional advancement of URM junior faculty pursuing research careers in general academic pediatrics. One important RAPID component is the annual mentoring/career-development conference, which targets URM residents, fellows, and junior faculty, and has included 62 URM participants since its 2013 inception. A conference highlight is the panel discussion on keys to academic success for URM young investigators, conducted by the RAPID National Advisory Committee, a diverse group of leading senior researchers. The article aim was to provide a guide to academic success for URM young investigators using the 2018 RAPID Conference panel discussion. A modified Delphi technique was used to provide a systematic approach to obtaining answers to six key questions using an expert panel: the single most important key to success for URM young investigators; ensuring optimal mentorship; how to respond when patients/families say, “I don’t want you to see my child because you are ____”; best strategies for maximizing funding success; how to balance serving on time-consuming committees with enough time to advance research/career objectives; and the single thing you wish someone had told you which would have substantially enhanced your success early on. This is the first published practical guide on keys to academic success for URM young investigators. Identified keys to success included having multiple mentors, writing prolifically, being tenaciously persistent, having mentors who are invested in you, dealing with families who do not want you to care for their child because of your race/ethnicity by seeking to understand the reasons and debriefing with colleagues, seeking non-traditional funding streams, balancing committee work with having enough time to advance one’s research and career by using these opportunities to generate scholarly products, and asking for all needed resources when negotiating for new jobs.
TL;DR: This study demonstrates that the health poverty alleviation project significantly improves financial risk protection by reducing out-of-pocket payments and decreasing the probability of incurring catastrophic or impoverishing levels of health expenditure.
Abstract: Illness is the leading cause (44%) of poverty in China. Since 2016, The health poverty alleviation project, an integral component of the Targeted Poverty Alleviation in China, was implemented in 2016 to strengthen financial risk protection against illness for financially backward segments of the population. However, the effects of the health poverty alleviation project on financial risk protection have not been explored in the literature, this paper aims to bridge the gap. Using panel data on 63,426 rural households in Chishui City, China, from 2014 to 2017, the difference-in-differences with propensity score matching method was employed. The health poverty alleviation project reduces out-of-pocket payments by 15% on average and decreases the probability of catastrophic health expenditure (annual out-of-pocket payments exceeding 10% of annual household income) and impoverishing health spending occurrence (out-of-pocket payments are forcing a household into poverty or into deeper poverty) by 7.7 and 11.7%, respectively. Additionally, the project increases the number of annual hospitalizations per household by 0.035. Our study demonstrates that the health poverty alleviation project significantly improves financial risk protection by reducing out-of-pocket payments and decreasing the probability of incurring catastrophic or impoverishing levels of health expenditure. Our study has implications for the poverty reduction policies and reform of the Chinese health financing system.
TL;DR: The decomposition results show that access to National Health Insurance Scheme and women’s education levels were the most important contributors to the reduction in inequality in maternal health care utilization.
Abstract: Improving maternal and child health remains a public health priority in Ghana. Despite efforts made towards universal coverage, there are still challenges with access to and utilization of maternal health care. This study examined socioeconomic inequalities in maternal health care utilization related to pregnancy and identified factors that account for these inequalities. We used data from three rounds of the Ghana Demographic and Health Surveys (2003, 2008 and 2014). Two health care utilization measures were used; (i) four or more antenatal care (ANC) visits and (ii) delivery by trained attendants (DTA). We first constructed the concentration curve (CC) and estimated concentration indices (CI) to examine the trend in inequality. Secondly, the CI was decomposed to estimate the contribution of various factors to inequality in these outcomes. The CCs show that utilization of at least four ANC visits and DTA were concentrated among women from wealthier households. However, the trends show the levels of inequality decreased in 2014. The CI of at least four ANC visits was 0.30 in 2003 and 0.18 in 2014. Similarly, the CIs for DTA was 0.60 in 2003 and 0.42 in 2014. The decomposition results show that access to National Health Insurance Scheme (NHIS) and women’s education levels were the most important contributors to the reduction in inequality in maternal health care utilization. The findings highlight the importance of the NHIS and formal education in bridging the socioeconomic gap in maternal health care utilization.
TL;DR: An explanatory critical realist model integrating the identified generative mechanisms, external and internalised barriers was developed to explain why the Health service Utilization of homeless people differs from the domiciled populations.
Abstract: Homeless people have poor health and mortality indices. Despite this they make poor usage of health services. This study sought to understand why they use health services differently from the domiciled population. Ethnographic observations were conducted at several homeless services, in Dublin. This was supplemented with 47 semi-structured interviews with homeless people and two focus groups of homeless people and hospital doctors. A critical-realist approach was adopted for interpretation of the data. Homeless people tended to present late in their illness; default early from treatment; have low usage of primary-care, preventative and outpatient services; have high usage of Emergency and Inpatient services; and poor compliance with medication. They tended to avoid psychiatric services. A number of external barriers were identified. These were classified as physical (distance) administrative (application process for medical care; appointments; queues; the management of addiction in hospital; rules of service; and information providing processes); and attitudinal (stigma; differing attitudes as to appropriate use of services. A new form of barrier, Conversations of Exclusion was identified and described. Internalised barriers were identified which were in nature, either cognitive (fatalistic, denial, deferral to future, presumption of poor treatment or discrimination, self blame and survival cognitions) or emotional (fear; embarrassment, hopelessness and poor self-esteem). Generative mechanisms for these factors were identified which either affected participants prior to homelessness (marginalization causing hopelessness, familial dysfunction, substance misuse, fear of authority, illiteracy; mental health; and poor English) or after becoming homeless (homelessness; ubiquity of premature death; substance misuse; prioritization of survival over health; threat of violence; chaotic nature of homelessness; negative experiences of authority; and stigma. An explanatory critical realist model integrating the identified generative mechanisms, external and internalised barriers was developed to explain why the Health service Utilization of homeless people differs from the domiciled populations. This new model has implications for health service policy makers and providers in how they design and deliver accessible health services to homeless people.
TL;DR: How teachers perceive the curriculum and practice discretion when implementing the CSE in mid-level schools in Nyimba district in Zambia is explored, which results in arbitrary teaching thus affecting the acquisition of comprehensive sexual and reproductive health knowledge among learners.
Abstract: Reproductive health problems such as HIV, unwanted pregnancy and unsafe abortion among adolescents are closely linked to insufficient knowledge about sexuality and reproduction and lack of access to contraceptives. Supported by international agencies, Zambia has introduced an ambitious nation-wide program for comprehensive sexuality education (CSE) to be implemented into ordinary school activities by teachers. The curriculum is firmly based in a discourse of sexual and reproductive rights, not commonly found in the public debate on sexuality in Zambia. This paper explores how teachers perceive the curriculum and practice discretion when implementing the CSE in mid-level schools in Nyimba district in Zambia. Using a case study design, data were collected through in-depth interviews with 18 teachers and analyzed thematically drawing upon theories of discretion and policy implementation. Individual teachers make decisions on their own regarding what and when to teach CSE. This discretion implies holding back information from the learners, teaching abstinence as the only way of preventing pregnancy or cancelling sexuality education sessions altogether. Teachers’ choices about the CSE program were linked to lack of guidance on teaching of the curriculum, especially with regards to how to integrate sexuality education into existing subjects. Limited prioritization of CSE in the educational sector was observed. The incompatibility of CSE with local norms and understandings about adolescent sexuality combined with teacher-parent role dilemmas emerged as problematic in implementing the policy. Limited ownership of the new curriculum further undermined teachers’ motivation to actively include CSE in daily teaching activities. Use of discretion has resulted in arbitrary teaching thus affecting the acquisition of comprehensive sexual and reproductive health knowledge among learners. The CSE had limited legitimacy in the community and was met with resistance from teachers tasked with its’ implementation. In order to enhance ownership to the CSE program, local concerns about the contents of the curriculum and the parent-teacher role dilemma must be taken into consideration. Not addressing these challenges may undermine the policy’s intention of increasing knowledge about sexuality and reproduction and empowering adolescents to access contraceptive services and avoid unwanted pregnancies.
TL;DR: Māori consumer experiences mapped to social determinants of health inequities were most frequently related to direct interactions with health services and programs, particularly patient-clinician interactions and cultural competencies of clinicians and the system.
Abstract: Persistent inequities in health experiences and outcomes are observed for Māori compared to non-Māori in Aotearoa New Zealand. We conceptualised factors associated with Māori consumer experiences of health programs and services and characterise how the recommendations arising from qualitative research inform strategies to address inequities. In this systematic review, electronic literature searching was conducted in February 2018. Qualitative studies reporting Māori consumer experiences of health services and programs in Aotearoa New Zealand were eligible. Māori consumer experiences of health services were mapped to the WHO Commission of Social Determinants of Health (CSDH) conceptual framework on health inequities as related to: (i) the socioeconomic and political context; (ii) socioeconomic positioning; or (iii) intermediary factors that increase exposure to health-compromising conditions. Recommendations to improve consumer experiences were mapped to the CSDH framework for tackling social determinants of health inequities as policy directions on: (i) unequal consequences of illness (individual interaction); (ii) risks of exposure to health-damaging factors (community); (iii) exposures to health-damaging factors (public policies); and (iv) mitigating effects of socioeconomic and political stratification (environment). Fifty-four studies were included. Māori consumer experiences mapped to social determinants of health inequities were most frequently related to direct interactions with health services and programs, particularly patient-clinician interactions (communication, relationships) and cultural competencies of clinicians and the system. Key recommendations by researchers mapped to potential strategies to address inequity were identified at all levels of the political, social and health system from individual interactions, community change, and broader public and system-level strategies. Recommendations were predominantly focused on actions to reduce risks of exposure to health-damaging factors including health literacy interventions, increased resources in cultural competencies and Māori capacity in health service development and workforce. Māori consumer experiences of health services and programs are an important informer of variables that impact health inequity. Strategies to tackle health inequities informed by Māori consumer experiences can be drawn from existing empirical research. Future qualitative exploration of how socioeconomic, political and public policies influence Māori consumer experiences of health services and programs could inform a broader range of structural policies to address health inequities.
TL;DR: Taking actions to help patients to understand NCDs as preventable, for HCPs and patients to advocate together for health system reform regarding medication accessibility, and for promoting education, screening, and monitoring activities to be conducted on a community level in collaboration with village health team members are recommended.
Abstract: The prevalence of hypertension and diabetes are expected to increase in sub-Saharan Africa over the next decade. Some studies have documented that lifestyle factors and lack of awareness are directly influencing the control of these diseases. Yet, few studies have attempted to understand the barriers to control of these conditions in rural settings. The main objective of this study was to understand the challenges to hypertension and diabetes care in rural Uganda. We conducted semi-structured interviews with 24 patients with hypertension and/or diabetes, 11 health care professionals (HCPs), and 12 community health workers (known as village health team members [VHTs]) in Nakaseke District, Uganda. Data were coded using NVivo software and analyzed using a thematic approach. The results replicated several findings from other settings, and identified some previously undocumented challenges including patients’ knowledge gaps regarding the preventable aspects of HTN and DM, patients’ mistrust in the Ugandan health care system rather than in individual HCPs, and skepticism from both HCPs and patients regarding a potential role for VHTs in HTN and DM management. In order to improve hypertension and diabetes management in this setting, we recommend taking actions to help patients to understand NCDs as preventable, for HCPs and patients to advocate together for health system reform regarding medication accessibility, and for promoting education, screening, and monitoring activities to be conducted on a community level in collaboration with village health team members.
TL;DR: Significant inequality and inequity in the use of all types of care services favouring richer population groups are found, with particularly pronounced levels for preventive and inpatient care services.
Abstract: Kenya is experiencing persistently high levels of inequity in health and access to care services. In 2018, decades of sustained policy efforts to promote equitable, affordable and quality health services have culminated in the launch of a universal health coverage scheme, initially piloted in four Kenyan counties and planned for national rollout by 2022. Our study aims to contribute to monitoring and evaluation efforts alongside policy implementation, by establishing a detailed, baseline assessment of socio-economic inequality and inequity in health care utilization in Kenya shortly before the policy launch. We use concentration curves and corrected concentration indexes to measure socio-economic inequality in care use and the horizontal inequity index as a measure of inequity in care utilization for three types of care services: outpatient care, inpatient care and preventive and promotive care. Further insights into the individual and household level characteristics that determine observed inequality are derived through decomposition analysis. We find significant inequality and inequity in the use of all types of care services favouring richer population groups, with particularly pronounced levels for preventive and inpatient care services. These are driven primarily by differences in living standards and educational achievement, while the region of residence is a key driver for inequality in preventive care use only. Pro-rich inequalities are particularly pronounced for care provided in privately owned facilities, while public providers serve a much larger share of individuals from lower socio-economic groups. Through its focus on increasing affordability of care for all Kenyans, the newly launched universal health coverage scheme represents a crucial step towards reducing disparities in health care utilization. However in order to achieve equity in health and access to care such efforts must be paralleled by multi-sectoral approaches to address all key drivers of inequity: persistent poverty, disparities in living standards and educational achievement, as well as regional differences in availability and accessibility of care.
TL;DR: The extent of distress financing was high in poorer state of Bihar and Odisha and in the state of Telangana that had highest prevalence of caesarean delivery and savings was more prevalent among mothers compared to those who met the OOPE by borrowing/selling of assets.
Abstract: Despite large investment in central and state sponsored schemes for maternal care, out-of-pocket expenditure (OOPE) and catastrophic health spending (CHS) on institutional delivery remain high over time, across states and across socio-economic groups. Though many studies have examined the OOPE and CHS, few studies have examined the nature and extent of distress financing on institutional delivery in India. Data from the fourth round of National Family Health Survey (NFHS 4), 2015–16 was used for the analysis. Distress financing was defined as borrowing money or selling assets to meet the OOPE on delivery care. Composite variables, descriptive analyses, concentration index (CI), concentration curve (CC) and predicted probability were used to estimate the extent of distress financing for institutional delivery in India. The OOPE on institutional delivery has strong economic and educational gradient. One in four mothers resorted to borrowing or selling to meet the OOPE on institutional delivery. The extent of distress financing on institutional delivery was high in poorer state of Bihar and Odisha and in the state of Telangana that had highest prevalence of caesarean delivery. Savings was more prevalent among mothers compared to those who met the OOPE by borrowing/selling of assets. Finding are robust across the states of India. The predicted probability of incurring distress financing was 0.31 among mothers belonging to the poorest wealth quintile compared to 0.09 in the richest quintile, and 0.40 for those who incurred OOPE of more than INR 20,000. The probability of incurring distress financing was higher for mothers who had caesarean birth, delivered in private health centers and incurred high OOPE on institutional delivery. Distress financing on institutional delivery was higher among the less educated, poor and in private health centers. Increasing use of public health centers, reducing caesarean births, improving the availability of medicine and diagnostic services can reduce the extent of distress financing in India.
TL;DR: The compounding effects of multiple discrimination and access barriers were experienced more strongly for young people belonging to mutiple marginalised groups, and several areas for improving clinical practice and policy are identified.
Abstract: Young people have unique social, emotional and developmental needs that require a welcoming and responsive health system, and policies that support their access to health care. Those who are socially or culturally marginalised may face additional challenges in navigating health care, contributing to health inequity. The aim of this study was to understand health system navigation, including the role of technology, for young people belonging to one or more marginalised groups, in order to inform youth health policy in New South Wales, Australia. This qualitative longitudinal study involved 2–4 interviews each over 6 to 12 months with marginalised young people aged 12–24 years living in NSW. The analysis used Nvivo software and grounded theory. We interviewed 41 young people at baseline who were living in rural or remote areas, sexuality and/or gender diverse, refugee, homeless, and/or Aboriginal. A retention rate of over 85% was achieved. Nineteen belonged to more than one marginalised group allowing an exploration of intersectionality. General practitioners (family physicians) were the most commonly accessed service throughout the study period. Participants were ambivalent about their healthcare journeys. Qualitative analysis identified five themes:
The compounding effects of multiple discrimination and access barriers were experienced more strongly for young people belonging to mutiple marginalised groups. We identify several areas for improving clinical practice and policy. Integrating technology and social media into processes that facilitate access and navigation, providing respectful and welcoming services that recognise diversity, improving health literacy and involving professionals in advocacy and navigation support may help to address these issues.
TL;DR: Evidence-based diabetes self-management programs need to become more accessible, taking into consideration the social determinants of health and building upon current initiatives to improve early diagnosis and treatment of T2D.
Abstract: The prevalence of type 2 diabetes (T2D) in Mexico is one of the highest in the world, with high morbidity and mortality, and difficulty meeting glycemic targets. The purpose of this study was to identify the challenges for T2D self-management as perceived by both adults with T2D and health care providers in primary health clinics from Seguro Popular in Mexico City. This was a qualitative descriptive study conducted in three Seguro Popular primary care clinics in Mexico City using convenience sampling. Semi-structured interviews were conducted with participants and data were analyzed using a content analysis approach. The sample included 20 adults with T2D [52.5 years old (SD = 9.9), diagnosed with T2D for 12.3 years (SD = 6.3), mean A1C of 9.8% (SD = 2.4), 80% female, 90% with financial insecurity] and 19 providers [primarily female (78.9%), mean age of 41.6 years old (SD = 11.4), 12.3 mean years in practice (SD = 8.50)]. Personal challenges included cultural beliefs, lack of resources, challenges to lifestyle modification, lack of family support/competing demands, and mental health issues. System level challenges included lack of resources, perceived quality of care, and patient engagement barriers. Evidence-based diabetes self-management programs need to become more accessible, taking into consideration the social determinants of health and building upon current initiatives to improve early diagnosis and treatment of T2D. Cultural beliefs, personal control, and low health literacy influence diabetes self-management in adults with T2D with limited resources. Mental health and financial challenges of adults with T2D will require multidisciplinary team-based care. Future research on best practices to implement and scale-up evidence-based patient-centered T2D prevention and DSME programs for the poor and underserved is warranted in Mexico and world-wide.
TL;DR: Social integration factors play a central role in explaining the mental health inequality between natives and migrants in Sweden, and public health actions targeting mental health gaps could benefit from focusing on inequalities in social and economic recourses.
Abstract: The increasing mental health inequalities between native- and foreign-born persons in Sweden is an important public health issue. Improving social integration has been stressed as a key strategy to combat this development. While a vast amount of studies have confirmed the importance of social integration for good mental health, less is known about the role of different types of social integration, and how they relate to mental health inequalities. This study aimed to examine the extent to which indicators of social integration explained mental health inequalities between the native- and foreign-born. Based on the Health on Equal Terms survey from 2011/2015 in Vastra Gotaland, Sweden (n = 71,643), a non-linear Oaxaca–Blinder decomposition analysis was performed comparing native- and foreign-born individuals from Nordic-, European- and non-European countries. The General Health Questionnaire was used to assess psychological distress, while 11 items assessed employment conditions and economic disparities, social relations, and experiences of discrimination to measure different aspects of social integration. Differences in social integration explained large proportions of observed mental health differences between the native- and foreign-born. Important indicators included low levels of social activity (20%), trust in others (17%) and social support (16%), but also labour market disadvantages, such as being outside the labour market (15%), unemployment (10%) and experiencing financial strain (16%). In analyses stratified by region of origin, low trust in others and discrimination contributed to the mental health gap between the native-born and European-born (17 and 9%, respectively), and the native-born and non-European-born (19 and 10%, respectively). Precarious labour market position was a particularly important factor in the mental health gap between the native-born and Nordic-origin (22%), and non-European origin (36%) populations. Social integration factors play a central role in explaining the mental health inequality between natives and migrants in Sweden. Our findings suggest that public health actions targeting mental health gaps could benefit from focusing on inequalities in social and economic recourses between natives and migrants in Sweden. Areas of priority include improving migrants’ financial strain, as well as increasing trust in others and social support and opportunities for civic engagement.
TL;DR: This study showed that a large proportion of the cases with hypertension are remained undiagnosed in Bangladesh, especially among the poor and low educated population, and Screening and awareness building initiatives on hypertension should be taken for this group of population to reduce the burden of undiagging hypertension.
Abstract: In recent years, developing countries like Bangladesh are facing a higher burden of non-communicable diseases such as hypertension as a result of demographic transition. Prevalence of hypertension is often studied in this setting. However, evidence on undiagnosed hypertension is not widely available in the existing literature. Therefore, the current study focuses on inequalities in the prevalence of undiagnosed hypertension in Bangladesh. A total of 8835 participants aged 35+ years were included in this study using nationally representative Bangladesh Demographic and Health Survey 2011 (BDHS). In the survey, systolic blood pressure (SBP) and diastolic blood pressure (DBP) of these participants were measured three times with approximately 10 minutes of an interval between each measurement. Any respondent with either SBP ≥ 140 mmHg or DBP ≥ 90 mmHg was considered as patient with hypertension as per the guidelines from American Heart Association. Among the participants, undiagnosed hypertension was defined as having SBP > =140 mmHg or DBP > =90 mmHg and never taking prescribed medicine or being told by health professionals to lower/control blood pressure. Multiple logistic regression analysis was applied for identifying factors associated with undiagnosed hypertension. Further, socioeconomic inequalities in the prevalence of undiagnosed hypertension were estimated using Concentration Index (C). We found 978 (59.9% of the total) were undiagnosed among 1685 hypertensive patients studied. Regression analysis showed individuals with being underweight, having poor socioeconomic conditions, and lower educational qualifications were more likely to have undiagnosed hypertension. A similar association between undiagnosed hypertension and socioeconomic quintiles was observed using concentration index (C = − 0.07). On the other hand, individuals from higher age group (50–64 or above), female sex, and Sylhet region were at lower risk of undiagnosed hypertension. This study showed that a large proportion of the cases with hypertension are remained undiagnosed in Bangladesh, especially among the poor and low educated population. Screening and awareness building initiatives on hypertension should be taken for this group of population to reduce the burden of undiagnosed hypertension.
TL;DR: Understanding of the needs and perceptions regarding healthy eating in this target group could inform future development of potential interventions aiming at helping people at risk of experiencing food insecurity to improve healthy eating, thereby decreasing the risk of diet-related diseases.
Abstract: Healthy eating behaviour is an essential determinant of overall health. This behaviour is generally poor among people at risk of experiencing food insecurity, which may be caused by many factors including perceived higher costs of healthy foods, financial stress, inadequate nutritional knowledge, and inadequate skills required for healthy food preparation. Few studies have examined how these factors influence eating behaviour among people at risk of experiencing food insecurity. We therefore aimed to gain a better understanding of the needs and perceptions regarding healthy eating in this target group. We conducted a qualitative exploration grounded in data using inductive analyses with 10 participants at risk of experiencing food insecurity. The analysis using an inductive approach identified four core factors influencing eating behaviour: Health related topics; Social and cultural influences; Influences by the physical environment; and Financial influences. Overall, participants showed adequate nutrition knowledge. However, eating behaviour was strongly influenced by both social factors (e.g. child food preferences and cultural food habits), and physical environmental factors (e.g. temptations in the local food environment). Perceived barriers for healthy eating behaviour included poor mental health, financial stress, and high food prices. Participants had a generally conscious attitude towards their financial situation, reflected in their strategies to cope with a limited budget. Food insecurity was mostly mentioned in reference to the past or to others and not to participants’ own current experiences. Participants were familiar with several existing resources to reduce food-related financial strain (e.g. debt assistance) and generally had a positive attitude towards these resources. An exception was the Food Bank, of which the food parcel content was not well appreciated. Proposed interventions to reduce food-related financial strain included distributing free meals, facilitating social contacts, increasing healthy food supply in the neighbourhood, and lowering prices of healthy foods. The insights from this study increase understanding of factors influencing eating behaviour of people at risk of food insecurity. Therefore, this study could inform future development of potential interventions aiming at helping people at risk of experiencing food insecurity to improve healthy eating, thereby decreasing the risk of diet-related diseases.
TL;DR: A high proportion of elderly with poor SRH, and health inequality in the Chinese, is confirmed and some socioeconomic strategies should be conducted to reduce this health inequality among the elderly, such as reducing income disparities, consolidating health insurance schemes, and narrowing urban-rural and regional gaps.
Abstract: Population ageing in China has brought increasing attention to the health inequalities of the elderly. The purpose of this paper is to measure income-related health inequality among the elderly in China and decompose its causes. The data are from the China Health and Retirement Longitudinal Study (CHARLS) survey in 2013, which contains 6176 individuals aged 60 years and above. A multiple linear regression model was used to analyze the influencing factors of self-rated health (SRH) among the elder people. Furthermore, the corrected concentration index were used to measure income-related health inequality. Wagstaff-type decomposition analysis was employed to explore the cause of inequality. The measurement and decomposition of health inequality was also performed separately in the male and female subgroups. Most elderly declared their health status as “fair” (51.33%) or “poor” (21.88%). Income, gender, residence, region, health insurance and other factors had significant association with SRH (P < 0.05). The corrected concentration index (CCI) was 0.06, indicating pro-rich inequality in health among the elderly. Decomposition analyses revealed that the main contributors to health inequality included income, residence, region, health insurance, and employment. For female elderly, most of the inequality was due to residence (50.78%) and income (49.51%); for male elderly, most of the inequality was due to insurance (38.65%) and income (22.26%); for the total sample, employment had a negative contribution to health inequality (− 25.83%). The findings confirm a high proportion of elderly with poor SRH, and health inequality in the Chinese. Some socioeconomic strategies should be conducted to reduce this health inequality among the elderly, such as reducing income disparities, consolidating health insurance schemes, and narrowing urban-rural and regional gaps. Older females with low incomes in rural areas are a vulnerable subgroup and warrant targeted policy attention.
TL;DR: The results show that the HEE and DHEE values exhibit unstable trends over time and the Chinese government could improve the efficiency of rural health resources allocation by improving the rural health service system, optimizing the allocation of material resources and enhancing the level of health of financial resources allocation.
Abstract: Health expenditure efficiency (HEE) is an important research area in health economics. As a large agricultural country, China is faced with the daunting challenge of maintaining equality and efficiency in health resource allocation and health services utilization in the context of rapid economic growth in rural areas. The reasonable allocation of limited rural health resources may be achieved by scientifically measuring the current rural HEE. This subject may help to formulate effective policy or provide incentives for the health sector. The combination of a super-slack-based measure (SBM) model with the Malmquist productivity index (MPI) is proposed to evaluate the static health expenditure efficiency (HEE) and dynamic health expenditure efficiency (DHEE) in rural China from 2007 to 2016. The results show that the HEE and DHEE values exhibit unstable trends over time. The HEE does not follow China’s economic development and presents an average of 0.598 (< 1); and the DHEE presents an average value of approximately 0.949 (< 1), indicating that the DHEE of most provinces is not moving in a desirable direction. The level of technological progress and scale optimization are the main factors hindering total factor productivity (TFP) growth. The Chinese government could improve the efficiency of rural health resources allocation by improving the rural health service system, optimizing the allocation of material resources and enhancing the level of health of financial resources allocation. The state should continue to moderate policy for different regions. Moreover, scientific and technological advancements should be introduced to improve the scale optimization levels.
TL;DR: This paper shows that inequity still exists in rural areas after the integration of urban-rural medical insurance schemes, and there is still a certain gap between the actual and the expected goal of URRBMI.
Abstract: The inequity of healthcare utilization in rural China is serious, and the urban-rural segmentation of the medical insurance system intensifies this problem. To guarantee that the rural population enjoys the same medical insurance benefits, China began to establish Urban and Rural Resident Basic Medical Insurance (URRBMI) nationwide in 2016. Against this backdrop, this paper aims to compare the healthcare utilization inequity between URRBMI and New Cooperative Medical Schemes (NCMS) and to analyze whether the inequity is reduced under URRBMI in rural China. Using the data from a national representative survey, the China Health and Retirement Longitudinal Study (CHARLS), which was conducted in 2015, a binary logistic regression model was applied to analyze the influence of income on healthcare utilization, and the decomposition of the concentration index was adopted to compare the Horizontal inequity index (HI index) of healthcare utilization among the individuals insured by URRBMI and NCMS. There is no statistically significant difference in healthcare utilization between URRBMI and NCMS, but in outpatient utilization, there are significant differences among different income groups in NCMS; high-income groups utilize more outpatient care. The Horizontal inequity indexes (HI indexes) in outpatient utilization for individuals insured by URRBMI and NCMS are 0.024 and 0.012, respectively, indicating a pro-rich inequity. Meanwhile, the HI indexes in inpatient utilization under the two groups are − 0.043 and − 0.028, respectively, meaning a pro-poor inequity. For both the outpatient and inpatient care, the inequity degree of URRBMI is larger than that of NCMS. This paper shows that inequity still exists in rural areas after the integration of urban-rural medical insurance schemes, and there is still a certain gap between the actual and the expected goal of URRBMI. Specifically, compared to NCMS, the pro-rich inequity in outpatient care and the pro-poor inequity in inpatient care are more serious in URRBMI. More chronic diseases should be covered and moral hazard should be avoided in URRBMI. For the vulnerable groups, special policies such as reducing the deductible and covering these groups with catastrophic medical insurance could be considered.
TL;DR: Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.
Abstract: One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC. We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care. The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments. Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.