Insurance Coverage for Chronic Diseases and Healthcare of Low-Income People: Evidence From Chinese Administrative Data.

Concern over rising health care costs has put pressure on providers to reduce costs, purportedly by reducing inpatient care and increasing outpatient care. Inpatient and outpatient claims were analyzed for adult users of mental health services (180,000/year on average) from a national study group of 3.9 million privately insured individuals per year from 1993 to 1995. Costs and treatment days per patient were compared across diagnostic groups and stratified by whether patients were hospitalized. Inpatient mental health costs fell $2,507 (30.4%) over the period, driven primarily by decreases in hospital days per patient per year (19.9%), with smaller changes in the proportion of enrollees who received inpatient care (increase of 0.8%) and a decrease in per diem costs (9.1%). Outpatient mental health costs also declined over the period, falling 13.6% for patients also using inpatient services and 14.6% for patients receiving only outpatient care. Patients whose primary diagnosis was mild to moderate depression saw the largest decreases in inpatient cost per patient (42.8%); those diagnosed with schizophrenia experienced the smallest decrease (23.5%). For patients using outpatient services only, those diagnosed with substance abuse experienced the largest decrease in costs (23.5%); those diagnosed with schizophrenia experienced the smallest decrease (8.6%). Substantial cost reductions for mental health services are primarily a result of reductions in inpatient and outpatient treatment days. Declines in inpatient service use were not accompanied by increases in outpatient service use, even for severely ill patients requiring hospitalization. Managed care has not caused a shift in the pattern of care but an overall reduction of care.

Universal health coverage (UHC) is a global priority, with the goal of ensuring that everyone has access to high-quality healthcare without suffering financial hardship. In Africa, most governments have prioritized UHC over the last two decades. Despite this, the transition to UHC in Africa is seen to be sluggish, with certain countries facing inertia. This study sought to examine the progress of UHC-focused health reform implementation in Africa, investigating the approaches utilized, the challenges faced, and potential solutions. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines, we scoped the literature to map out the evidence on UHC adoption, roll out, implementation, challenges, and opportunities in the African countries. Literature searches of the Cochrane database of systematic reviews, PUBMED, EBSCO, Eldis, SCOPUS, CINHAL, TRIP, and Google Scholar were conducted in 2023. Using predefined inclusion criteria, we focused on UHC adoption, rollout, implementation, and challenges and opportunities in African countries. Primary qualitative, quantitative, and mixed-methods evidence was included, as well as original analyses of secondary data. We employed thematic analysis to synthesize the evidence. We found 9633 documents published between May 2005 and December 2023, of which 167 papers were included for analysis. A significant portion of UHC implementation in Africa has focused on establishing social health protection schemes, while others have focused on strengthening primary healthcare systems, and a few have taken integrated approaches. While progress has been made in some areas, considerable obstacles still exist. Financial constraints and supply-side challenges, such as a shortage of healthcare workers, limited infrastructure, and insufficient medical supplies, remain significant barriers to UHC implementation throughout Africa. Some of the promising solutions include boosting public funding for healthcare systems, strengthening public health systems, ensuring equity and inclusion in access to healthcare services, and strengthening governance and community engagement mechanisms. Successful UHC implementation in Africa will require a multifaceted approach. This includes strengthening public health systems in addition to the health insurance schemes and exploring innovative financing mechanisms. Additionally, addressing the challenges of the informal sector, inequity in healthcare access, and ensuring political commitment and community engagement will be crucial in achieving sustainable and comprehensive healthcare coverage for all African citizens.

Indonesia has undergone significant healthcare system transformations over the past three decades, including the implementation of universal health coverage in 2014. However, comprehensive long-term analyses of maternal and child health (MCH) trends spanning nearly three decades remain limited. This study examines the evolution of key MCH indicators in Indonesia from 1995 to 2023 to assess progress, identify patterns, and inform future policy directions. We conducted a longitudinal trend analysis using data from the Indonesian National Health Survey (Riset Kesehatan Dasar/Riskesdas) covering the period from 1995 to 2023. Nine key indicators were analyzed: prevalence of health complaints, skilled birth attendance, childhood immunization coverage (BCG, DPT, polio, measles), and breastfeeding practices. Statistical methods included linear trend analysis, Bayesian changepoint detection, correlation analysis, and segmented regression to assess policy impacts. Healthcare utilization patterns, including outpatient care, inpatient care, self-medication, and traditional medicine use, were examined as contextual indicators. Substantial improvements were observed across most MCH indicators over the 28 years. Skilled birth attendance showed the most dramatic progress, increasing from 46.1% (1995) to 95.7% (2023), representing an annual improvement rate of 2.55%. Childhood immunization coverage achieved high levels (>85%) for most vaccines by the 2000s, though measles vaccination remained variable (54-80% range). Breastfeeding patterns showed a structural break in 2015 due to methodological changes, which complicated trend interpretation. Healthcare utilization evolved significantly, with outpatient care increasing from 20% to >50% before declining to 35% by 2023, while self-medication practices rose substantially to 80%. Correlation analysis revealed alignment between health needs and service utilization (r = 0.48 for outpatient care). Changepoint analysis identified accelerated improvements around 2000-2005 and 2014-2015, coinciding with healthcare decentralization and universal coverage implementation respectively. Indonesia achieved remarkable progress in maternal and child health over 28 years, with skilled birth attendance approaching universal coverage and immunization programs maintaining high performance. The implementation of universal health coverage in 2014 coincided with continued improvements, though some recent declines in vaccination coverage warrant attention. The evolution from traditional medicine to modern healthcare services, alongside increasing self-medication practices, reflects maturing health systems requiring adaptive policy responses. Indonesia's experience demonstrates that sustained MCH improvements are achievable in large middle-income countries through systematic health system strengthening, though maintaining momentum requires continuous adaptation to emerging challenges. These findings provide valuable insights for other countries pursuing similar health system transformation goals.

BackgroundMany countries have sought to promote well-being for their entire populations through the implementation of universal health coverage (UHC). To identify the extent to which UHC has been attained, it is necessary to evaluate equity of access to use of needed care and the cost burden of health services for the country’s entire population. This study considers income-related inequalities in health care utilization and spending in a long-term perspective for the case of the Republic of Korea.MethodsExploiting longitudinal data from a nationally representative health survey from 2008 to 2018, this study investigates how income-related inequalities in health care in Korea have varied over time and examines the extent to which need and non-need factors contribute those inequalities, using an in‐depth decomposition analysis, allowing for heterogeneous responses across income groups.ResultsThe empirical results show that overall health care utilization is disproportionately concentrated among the poor over both the short and long run. Income-group differences and non-need determinants, such as marital status and private health insurance, make larger pro-poor contributions to inequality in inpatient care use, while chronic disease prevalence greatly pushes outpatient care utilization in a pro-poor direction. The results regarding inpatient care expenses indicate a similar pattern of pro-poor bias. Long-run inequality favors the better-off in terms of outpatient care expenses, where the contribution of income-group differences has the largest impact.ConclusionMy findings suggest that it is important for health care policy in Korea to focus on improvements in the health status and well-being of low-income groups, as poor people are likely to be in poorer health. Non-need contributors could worsen pro-poor inequalities if the economic disparity across households were to increase due to the demographic transition. Higher spending on inpatient care may be a heavier financial burden for low-income people. Additional supportive measures should be provided to prevent them from suffering economic hardship. By contrast, people in high-income groups may spend most on costly services in outpatient care, including uninsured services, with the help of private health insurance. Nevertheless, the expansion of income disparity should be alleviated even from a health care policy perspective.

SummaryBackgroundPrimary health care (PHC) is a driving force for advancing towards universal health coverage (UHC). PHC-oriented health systems bring enormous benefits but require substantial financial investments. Here, we aim to present measures for PHC investments and project the associated resource needs.MethodsThis modelling study analysed data from 67 low-income and middle-income countries (LMICs). Recognising the variation in PHC services among countries, we propose three measures for PHC, with different scope for included interventions and system strengthening. Measure 1 is centred on public health interventions and outpatient care; measure 2 adds general inpatient care; and measure 3 further adds cross-sectoral activities. Cost components included in each measure were based on the Declaration of Astana, informed by work delineating PHC within health accounts, and finalised through an expert and country validation meeting. We extracted the subset of PHC costs for each measure from WHO's Sustainable Development Goal (SDG) price tag for the 67 LMICs, and projected the associated health impact. Estimates of financial resource need, health workforce, and outpatient visits are presented as PHC investment guide posts for LMICs.FindingsAn estimated additional US$200–328 billion per year is required for the various measures of PHC from 2020 to 2030. For measure 1, an additional $32 is needed per capita across the countries. Needs are greatest in low-income countries where PHC spending per capita needs to increase from $25 to $65. Overall health workforces would need to increase from 5·6 workers per 1000 population to 6·7 per 1000 population, delivering an average of 5·9 outpatient visits per capita per year. Increasing coverage of PHC interventions would avert an estimated 60·1 million deaths and increase average life expectancy by 3·7 years. By 2030, these incremental PHC costs would be about 3·3% of projected gross domestic product (GDP; median 1·7%, range 0·1–20·2). In a business-as-usual financing scenario, 25 of 67 countries will have funding gaps in 2030. If funding for PHC was increased by 1–2% of GDP across all countries, as few as 16 countries would see a funding gap by 2030.InterpretationThe resources required to strengthen PHC vary across countries, depending on demographic trends, disease burden, and health system capacity. The proposed PHC investment guide posts advance discussions around the budgetary implications of strengthening PHC, including relevant system investment needs and achievable health outcomes. Preliminary findings suggest that low-income and lower-middle-income countries would need to at least double current spending on PHC to strengthen their systems and universally provide essential PHC services. Investing in PHC will bring substantial health benefits and build human capital. At country level, PHC interventions need to be explicitly identified, and plans should be made for how to most appropriately reorient the health system towards PHC as a key lever towards achieving UHC and the health-related SDGs.FundingThe Bill & Melinda Gates Foundation.

To examine the prospective association between frequency of outpatient visits and subsequent inpatient admissions. Medical record data on 13,942 patients with HIV infection seen in 10 HIV speciality care sites across the United States. This observational study followed a cohort of HIV-infected patients who were in care in the first half of 2001. Numbers of inpatient admissions and outpatient visits were calculated for each patient for each 3-month period, from 2001 through 2004. Negative binomial and logistic regression analyses using random-effects models examined the effects of inpatient admissions and outpatient visits in the previous period on inpatient and outpatient service utilization, controlling for background characteristics and HIV disease stage. For 3-month periods, between 5 and 9 percent of patients had an inpatient admission. The linear association between number of outpatient visits and any inpatient admission in the subsequent period was positive (adjusted odds ratio=1.05; 95 percent confidence interval [CI]=1.04, 1.06). However, patients with zero prior outpatient visits had significantly greater admission rates than those with one prior visit. Hospitalization rates were also higher among those with a prior hospitalization and those with more advanced HIV disease. These results suggest a J-shaped relationship between outpatient use and inpatient use among persons with HIV disease. Those in worse health have greater utilization of both inpatient and outpatient care. However, having no outpatient visits may also increase the likelihood of subsequent hospitalization. Although outpatient care cannot be justified as a cost-saving mechanism, maintaining regular clinical monitoring of patients is important.

Diabetes Treatment Among VA Patients With Comorbid Serious Mental Illness

Governments in low- and middle-income countries are legitimizing the implementation of universal health coverage (UHC), following a United Nation’s resolution on UHC in 2012 and its reinforcement in the sustainable development goals set in 2015. UHC will differ in each country depending on country contexts and needs, as well as demand and supply in health care. Therefore, fundamental issues such as objectives, users and cost–effectiveness of UHC have been raised by policy-makers and stakeholders. While priority-setting is done on a daily basis by health authorities – implicitly or explicitly – it has not been made clear how priority-setting for UHC should be conducted. We provide justification for explicit health priority-setting and guidance to countries on how to set priorities for UHC.

Policy PointsUS policymakers considering proposals to expand public health care (such as “Medicare for all”) as a means of reducing inequalities in health care access and use could learn from the experiences of nations where well‐funded universal health care systems are already in place.In England, which has a publicly funded universal health care system, the use of core inpatient services by adults 65 years and older is equal across groups defined by education level, after controlling for health status. However, variation among these groups in the use of outpatient and emergency department care developed between 2010 and 2015, a period of relative financial austerity.Based on England's experience, introducing universal health care in the United States seems likely to reduce, but not entirely eliminate, inequalities in health care use across different population groups.ContextExpanding access to health care is once again high on the US political agenda, as is concern about those who are being “left behind.” But is universal health care that is largely free at the point of use sufficient to eliminate inequalities in health care use? To explore this question, we studied variation in the use of hospital care among education‐level‐defined groups of older adults in England, before and after controlling for differences in health status. In England, the National Health Service (NHS) provides health care free to all, but the growth rate for NHS funding has slowed markedly since 2010 during a widespread austerity program, potentially increasing inequalities in access and use.MethodsNovel linkage of data from six waves (2004‐2015) of the English Longitudinal Study of Ageing (ELSA) with participants’ hospital records (Hospital Episode Statistics [HES]) produced longitudinal data for 7,713 older adults (65 years and older) and 25,864 observations. We divided the sample into three groups by education level: low (no formal qualifications), mid (completed compulsory education), and high (at least some higher education). Four outcomes were examined: annual outpatient appointments, elective inpatient admissions, emergency inpatient admissions, and emergency department (ED) visits. We estimated regressions for the periods 2004‐2005 to 2008‐2009 and 2010‐2011 to 2014‐2015 to examine whether potential education‐related inequalities in hospital use increased after the growth rate for NHS funding slowed in 2010.FindingsFor the study period, our sample of ELSA respondents in the low‐education group made 2.44 annual outpatient visits. In comparison, after controlling for health status, we found that participants in the high‐education group made an additional 0.29 outpatient visits annually (95% confidence interval [CI], 0.11‐0.47). Additional outpatient health care use in the high‐education group was driven by follow‐up and routine appointments. This inequality widened after 2010. Between 2010 and 2015, individuals in the high‐education group made 0.48 (95% CI, 0.21‐0.74) more annual outpatient visits than those in the low‐education (16.9% [7.5% to 26.2%] of annual average 2.82 visits). In contrast, after 2010, the high‐education group made 0.04 (95% CI, −0.075 to 0.001) fewer annual ED visits than the low‐education group, which had a mean of 0.30 annual ED visits. No significant differences by education level were found for elective or emergency inpatient admissions in either period.ConclusionsAfter controlling for demographics and health status, there was no evidence of inequality in elective and emergency inpatient admissions among the education groups in our sample. However, a period of financial budget tightening for the NHS after 2010 was associated with the emergence of education gradients in other forms of hospital care, with respondents in the high‐education group using more outpatient care and less ED care than peers in the low‐education group. These estimates point to rising inequalities in the use of hospital care that, if not reversed, could exacerbate existing health inequalities in England. Although the US and UK settings differ in many ways, our results also suggest that a universal health care system would likely reduce inequality in US health care use.

BACKGROUND Glioblastoma (GBM), the most aggressive primary brain tumor, imposes severe physical, emotional, and financial burdens, especially in low- and middle-income countries (LMICs), where socioeconomic disparities restrict access to palliative and supportive care services that are essential for quality of life (QoL). This systematic review presents the first comprehensive synthesis of GBM care barriers in Asia, focusing on structural inequities and their impact on symptom management, psychosocial support, and end-of-life care. MATERIAL AND METHODS A systematic search of PubMed, Cochrane, Scopus, ScienceDirect, and Wiley Online Library (2000 to 2025) identified studies on GBM treatment access, socioeconomic factors, and outcomes in Asia and LMICs. Inclusion criteria targeted studies addressing income, education, insurance status, treatment adherence, and access to palliative care. Twenty-six studies were included and appraised using the CHEERS checklist and Newcastle-Ottawa Scale. A thematic synthesis was conducted to identify common barriers, systemic gaps, and implications for QoL and supportive care. RESULTS Socioeconomic disparities consistently increased symptom burden and delayed access to supportive care, reducing QoL. In the Philippines, 62 percent of patients discontinued adjuvant therapy due to financial constraints, with a median survival of 7.6 months and limited access to pain relief or psychological support. Uninsured patients had shorter survival (8.8 versus 15.2 months), exacerbating emotional distress and caregiver strain. In Taiwan, universal health coverage improved therapy access, but supportive care gaps persisted. Systemic barriers such as a significant neurosurgeon shortage in South Asia and limited availability of genomic diagnostics (only 9.4 percent of LMIC centers offered next-generation sequencing) hindered timely, personalized care. Financial toxicity frequently led to treatment abandonment and unmanaged end-of-life symptoms. CONCLUSION Socioeconomic inequities in Asia and LMICs critically limit access to palliative and supportive services for GBM patients, increasing distress and reducing QoL. Policy solutions should include expansion of publicly funded therapies, enhancement of neurosurgical and diagnostic capacity, and implementation of universal health coverage with strong financial protection to support equitable, patient-centered GBM care.

To support implementation of Universal Health Coverage, several low- and middle-income countries (LMIC) have begun digitization of their health care systems. Despite the successes achieved, digitization still poses several challenges such as lack of technical interoperability between information systems and lack of an internationally standardized nomenclature for billable health care services, although WHO states that this should be the basis for information exchange in the healthcare sector. Several international classifications and nomenclatures are available for sub-areas of care, but the question remains whether and how these can be merged into a single comprehensive nomenclature. Research was done in Burundi to develop Universal Nomenclature of Health Services (UNHS), a generic, comprehensive nomenclature for billable health services, based on international classifications and adapted to the context of LMIC. The need was clear as it was found that 2 or more different codes were used for billing of identical care services in 100% of the sampled health facilities. The UNHS succeeded to standardize 97.7% of common care services and for the remaining 2.3% of health services, national codes remain in use, mostly for operational reasons.

ObjectiveThis study assessed whether patients with potentially preventable emergency admissions had limited access to outpatient care immediately before admission and whether they received appropriate outpatient care during their outpatient visits.DesignRetrospective...

ObjectiveUnderstanding differences in outpatient care before and after mental health hospitalization for adolescents from diverse backgrounds is critical to ensuring effective and responsive care. The objective of the current study was to examine outpatient mental health care in the two years before and 30 days after a mental health hospitalization for adolescents from immigrant, refugee and non-immigrant backgrounds.MethodThis retrospective, population-based cohort study, conducted in British Columbia (BC), Canada, analyzed linked health service utilization data (practitioner billings, hospitalizations) and migration records to track outpatient care before and after mental health hospitalization. The study included adolescents (ages 10-18) with an unscheduled/urgent mental health hospitalization between January 1, 2008 and December 31, 2016 (n = 5,314) from a cohort of adolescents in 10 of the largest school districts in BC (between 1996 and 2016). The main analyses examined outpatient mental health visits (e.g., general practitioner/psychiatrist) (i) in the two years before hospitalization and (ii) in the 30 days after discharge. Sub-analyses focused on outpatient visits with psychiatrists.ResultsOverall, 30.4% had no outpatient mental health visit in the two years before hospitalization and 45.1% had none in the 30 days following discharge. First-generation immigrants and refugees and second-generation immigrant adolescents were significantly less likely than non-immigrants to have had an outpatient mental health visit in the two years before mental health hospitalization (aOR1st_gen_immg = 0.79, 95% CI, 0.63 to 0.98; aOR2nd_gen_immg = 0.75, 95% CI, 0.61 to 0.93; aOR1st_gen_ref = 0.40, 95% CI, 0.26 to 0.64). Second-generation immigrant adolescents were significantly more likely than non-immigrants to have had any outpatient mental health visit in the 30 days following hospitalization (aOR2nd_gen_immg = 1.34, 95% CI, 1.09 to 1.65).ConclusionsResults suggest outpatient care before and after mental health hospitalizations is limited for many adolescents in BC and differed by migration background. Implications for meeting standards of care are discussed.

Objectives. To examine the impact of health insurance coverage on utilization of outpatient, hospital, and emergency department care among justice-involved individuals in the United States.Methods. We performed repeated cross-sectional analyses with data from the National Survey of Drug Use and Health. The study population included 6086 adults with justice involvement within the past year. We used logistic regression to examine the odds of health care utilization based on either a dichotomous or categorical measure of health insurance coverage. We used negative binomial regression to examine the number of times a specific type of care was utilized with both a dichotomous measure of health insurance coverage and a categorical measure of type of health insurance.Results. Health insurance was associated with increased utilization of outpatient, inpatient, and emergency department care.Conclusions. Health insurance coverage was associated with increased utilization of outpatient, inpatient, and emergency department health care among justice-involved individuals. Therefore, expanding access to health insurance in this population has the potential to increase care utilization of all types and decrease barriers to medical services.

This study assessed patterns of mental health service use among adolescents who had attempted suicide and examined factors associated with their service use at individual, family, and community levels. Bivariate and multiple logistic regression analyses were conducted with data from 877 adolescents aged 12-17 who had attempted suicide in the past 12 months and who participated in the 2000 National Household Survey on Drug Abuse. Of the 877 adolescents, less than half (45%) reported that they had used mental health services in the past 12 months. Adolescents from racial-ethnic minority groups were less likely than whites to receive inpatient or outpatient mental health treatment, even when the analyses controlled for other demographic, individual, and family and community characteristics. Poor self-perceived health and living in a single-parent family were associated with use of inpatient services. Female gender, higher family income, participation in extracurricular activities, and the presence of symptoms of anxiety or disruptive disorders were associated with use of outpatient services. Use of school-based mental health services was associated only with participation in extracurricular activities. The mental health service needs of suicidal adolescents, especially those from ethnic minority groups and lower-income families, too frequently remain unmet. Larger racial-ethnic disparities were found in use of inpatient and outpatient mental health services than in use of school-based services. Mental health services offered within school settings can reach suicidal adolescents who need services but may experience barriers to standard types of care.