Contributory Health Research Articles

Technology And Innovation In HR

In India, the high cost of medical education, particularly for an MBBS degree, poses significant challenges for new doctors, who often find that their qualifications do not justify the Expenses incurred. This financial strain is exacerbated when these highly trained professionals are employed for routine tasks such as insurance treatment and billing verification, roles that are not commercially viable given their level of education and potential. As a cost-effective measure, many insurance companies and third-party administrators (TPAs) opt to employ doctors with BHMS or BMS degrees for these tasks. However, these professionals are often underqualified for the complexities of medical verification, leading to inefficiencies and errors in treatment validation and anomaly detection. The situation also adversely affects programs like the Ex-Servicemen Contributory Health Scheme (ECHS), where the need for accurate and efficient cashless medical services is critical. Delays and inaccuracies in medical verification can complicate the provision of timely healthcare to veterans and their families, underscoring the need for improvement in these processes. This paper proposes the implementation of an Artificial Intelligence (AI) ecosystem designed to function as highly qualified medical agents. This AI system will be capable of independently verifying diagnoses, treatment plans, and medical reports for accuracy while also identifying procedural anomalies. The primary objective is to augment the capabilities of the current workforce, enhancing overall efficiency and effectiveness in medical management. By deploying AI medical agents, the project aims to not only address the gap in qualification and task complexity but also improve the accuracy and reliability of medical administrative processes. This initiative promises to revolutionize the way medical verifications are handled, providing a sustainable, scalable solution to a pressing healthcare management issue in India.

Barriers to Enrolment into Health Insurance Schemes in Nigeria: The case of Niger State Contributory Health Insurance Scheme

Niger State government has keyed into the health insurance program of the federal government since 2019, with the establishment of the Niger State Health Insurance Scheme. Although the scheme has beautiful mission for the formal and the informal sector workers as well as the students in tertiary institutions and the vulnerable groups, it is yet to enjoy reasonable patronage. Studies on barriers to enrolment into health insurance were mostly conducted in matured health insurance settings, where barriers to enrolment do with operational concerns. It is not clear whether operational concerns may affect enrolment in Niger State where the health insurance scheme is at the take-off stage. Using qualitative research design to explore the enrolment barriers, this study has drawn a sample of 22 respondents across the major tribes, religions, enrolment category and senatorial zones of the state. Four enrolment officers were also part of the respondents. An in-depth interview was conducted on the respondent and the results were analysed in themes. The findings of the study showed that lack of trust in anything government is the major barrier to enrolment among the public sector workers due to their prior experiences of failed schemes run by government. However, inadequate sensitization about the requirements, procedures for enrolment, cost and benefits of the scheme were the barriers to enrolment among the informal and the private sector workers. The enrolment of the vulnerable groups is undermined by the lack of social register from where the list of the qualified people would be extracted. In addition, the lack of National Identification Number, which is the pre-requisite for enrolment, deters enrolment of the vulnerable groups. The problem of insecurity in the state also affects outreach and enrolment. Necessary suggestions are given to the government.

Incremental Healthcare Costs of Diabetes Mellitus in a Middle-Income Country Using Administrative Healthcare Data

ObjectivesTo estimate the incremental medical cost of diabetes mellitus using information from administrative databases in Colombia. MethodsWe carried out a retrospective cohort study with administrative health databases from Colombian population affiliated in the contributory health insurance scheme. We used an operative definition to select the cohort with diabetes. Incremental cost and cost ratio of diabetes were estimated using an inverse probability weighting of treatment approach to find the causal effect of having the disease. Weights were calculated by a propensity score method using a Random Forest model. The flexibility of this machine learning algorithm allows to have a better specification and bias reduction. Additionally, we reported incremental costs and cost ratios with confidence intervals using bootstrapping and analyzed costs by age groups and complications associated with diabetes. ResultsThe estimated prevalence of diabetes was 2834 per 100 000 cases, in 2018. The group with diabetes was comprised 634 015 people and the control group 1 524 808. The calculated annual direct medical cost was $860, for which the incremental cost was $493 and the cost ratio 2.34. The incremental annual cost for some type of complication ranges from $1239 to $2043, renal complication being the most expensive. Incremental cost by age groups ranges from $347 to $878, being higher in younger people. ConclusionsAlthough the cost of diabetes in Colombia ranges among the global averages and is similar to other Latin-American countries, a greater incremental cost was found in patients with renal, circulatory, and neurologic complications.

Re-envisioning contributory health schemes to achieve equity in the design of financial protection mechanisms in low- and middle-income countries.

Universal health coverage has emerged as a global health priority, requiring that financing strategies that ensure low-income and medically and financially at-risk individuals can access health services without the threat of financial catastrophe. Contributory financing schemes and social health insurance (SHI) schemes, in particular, predominate in low- and middle-income countries (LMICs), despite evidence that suggests the most vulnerable remain excluded from such schemes. In this commentary, we discuss the need to re-envision schemes to prioritize equity, offering 3 concrete recommendations: adopt participatory designs for the co-design of schemes with beneficiaries, establish linkages between contributory financial protection schemes with economic empowerment initiatives, and prioritize the needs and preferences of beneficiaries over political expediency. Co-design alone does not necessarily translate into more equitable schemes, underscoring the need for greater monitoring and evaluation of these schemes that consider differential impacts across contexts and subgroups. In doing so, SHI schemes can be both attractive and accessible to populations that have long been excluded from financial protections in LMICs, acting as 1 channel in a broader financing strategy to achieve universal health coverage.

Impact of Communication in the Success of Health Insurance Schemes in Nigeria: The Plateau State Contributory Healthcare Management Agency Perspective

The importance of communication in the success of health insurance has become glaring over the years. Communication principles are used today as Health communication control strategies, educating patients about medical care options on various disease prevention, advocacy on marketing health plans and products etc. This study evaluated the communication strategies of the Plateau State Contributory Health Insurance Agency (PLASCHEMA) on the Plateau citizens. The method of study was mixed; quantitative and qualitative approach. Both primary and secondary sources were employed in obtaining data. The population of the study consists of 6 Local Government Areas in Plateau State. Findings established that PLASCHEMA as an organization utilizes the corporate communication strategies and that there is good level of awareness of PLASCHEMA activities. The study concluded that the communication processes in place by PLASCHEMA have been yielding average level of outcomes. For better impact, the study recommended that the agency needs to diversify its communication approaches, adopt strategies to step down their campaigns in local languages, hire the services of information professional and public relation consultants as parts of the envisaged capacity building.

Age and sex dynamics in the incidence of diabetes in Contributory Health Services Scheme beneficiaries: A retrospective cohort study in Mumbai

ABSTRACT Introduction: A comprehensive body of literature addresses self-reported diabetes prevalence, yet a notable gap exists in research investigating the clinically ascertained incidence of diabetes in India through rigorous longitudinal data analysis. This study aimed to determine the incidence of clinically diagnosed diabetes in a nondiabetic cohort. Materials and Methods: The research gathered data from 1669 participants (aged 30 years and above) enrolled in a government hospital’s Contributory Health Services Scheme, utilizing electronic medical records. Clinical diagnosis of diabetes relied on three laboratory tests. A cohort of initially diabetes-free individuals in 2011–2012 was tracked for 10 years to assess diabetes incidence. Age-adjusted incidence rates were determined through survival analysis techniques. Results: Over a decade-long observational period, 552 beneficiaries within the study cohort were clinically diagnosed with diabetes, yielding an age-adjusted incidence rate of 38.9 cases per 1000 person-years (PYs) spanning from 2013 to 2021. Stratifying by gender, age-adjusted incidence rates were notably elevated in males compared to females, with rates of 41.5 versus 38.5 cases per 1000 PYs, respectively. Further analysis revealed the highest incidence rates among males aged 55–59 years (60.5 per 1000 PYs) and females aged 65–69 years (83.4 per 1000 PYs). Conclusion: This extended follow-up investigation transpired in a setting characterized by uniform health-care provision, devoid of discernible access differentials, or inequalities, thereby enhancing the credibility of the ascertained diabetes incidence rates.

Baseline Study on the Discriminatory Laws, Attitudes and Societal Practices Hindering Diverse Sex Workers’ Access to Sexual and Reproductive Health and Rights Services in Selected Senatorial Local Governments in Rivers State, Nigeria

Achieving comprehensive access to Sexual and Reproductive Health and Rights (SRHR) services remains a pressing global health challenge, particularly for marginalized populations such as sex workers, who face the highest unmet needs. This study exposes the baseline issues related to discriminatory laws, attitudes, and societal practices that hinder diverse sex workers’ access to comprehensive SRHR services in Rivers State, Nigeria. Specifically, the study identified key barriers affecting sex workers’ access to SRHR services, evaluated their satisfaction with these service deliveries, examined the effects of societal inequalities and discriminatory legal practices on their health outcomes, and proposed sensitivity and rights-based approaches for improving service delivery. The study adopted stratified sampling methodology and collated both quantitative and qualitative data through desk reviews and analysis of existing state health policies, in-depth focus group discussions with 300 diverse sex workers, and analysis of 2000 feedbacks collected through questionnaires embedded in the Kobo Collect app. Key study findings revealed that significant majority (91.1%) of sex workers have experienced discrimination when accessing SRHR services in formal healthcare facilities, with primary sources of these discriminations perpetuated by healthcare workers (77.4%), brothel owners (47.1%), and family members (43.9%). Consequently, 89.9% of respondents have avoided formal healthcare facilities, opting instead for local pharmacies (66%), traditional medical specialists (56.8%), and self-medication (48.4%), despite its adverse effects such as recurrent Sexual Transmitted Infections (STIs) (57.5%), worsening STIs to Sexual Transmitted Diseases (STDs) (58.3%), unwanted pregnancies (18%), post-abortion complications (27.1%), adverse drug reactions (49.1%), and drug abuse/overdose (48.4%). In addition, there was notable dissatisfaction among respondents regarding SRHR services as 61.4% of engaged sex workers rated “Poor to Very Poor” for service affordability, a mixed opinions for availability and accessibility as respondents rated “Fair to Poor” (57.4% for availability and 68% for accessibility) and 75% of the respondents criticized the accountability system to be “Poor to Very Poor”. Qualitative analyses of existing laws and policies in the State revealed an institutional neglect and exclusion of sex workers from health service protections as some state laws and policies, such as Rivers State Reproductive Law, Rivers State Contributory Health Protection Programme, Rivers State Strategic Health Development Plan, and the Rivers State HIV/AIDS Anti-Discrimination Law, were non-inclusive and perpetuate discriminatory practices against sex workers in SRHR service provision. To close-in the gaps, the study recommended implementing non-discrimination policies, reducing waiting times, ensuring strict privacy and confidentiality measures, reforming laws to ensure inclusive service delivery, providing non-clinical training on gender identity and sexual orientation for healthcare providers, appointing focal persons for key populations, and enforcing accountability systems across healthcare facilities as a right based model for enhancing SRHR outcomes for diverse sex workers in Rivers State.

Genetic ancestry is related to potential sources of breast cancer health disparities among Colombian women.

Breast cancer health disparities are linked to clinical-pathological determinants, socioeconomic inequities, and biological factors such as genetic ancestry. These factors collectively interact in complex ways, influencing disease behavior, especially among highly admixed populations like Colombians. In this study, we assessed contributing factors to breast cancer health disparities according to genetic ancestry in Colombian patients from a national cancer reference center. We collected non-tumoral paraffin embedded (FFPE) blocks from 361 women diagnosed with breast cancer at the National Cancer Institute (NCI) to estimate genetic ancestry using a 106-ancestry informative marker (AIM) panel. Differences in European, Indigenous American (IA) and African ancestry fractions were analyzed according to potential sources of breast cancer health disparities, like etiology, tumor-biology, treatment administration, and socioeconomic-related factors using a Kruskal-Wallis test. Our analysis revealed a significantly higher IA ancestry among overweight patients with larger tumors and those covered by a subsidized health insurance. Conversely, we found a significantly higher European ancestry among patients with smaller tumors, residing in middle-income households, and affiliated to the contributory health regime, whereas a higher median of African ancestry was observed among patients with either a clinical, pathological, or stable response to neoadjuvant treatment. Altogether, our results suggest that the genetic legacy among Colombian patients, measured as genetic ancestry fractions, may be reflected in many of the clinical-pathological variables and socioeconomic factors that end up contributing to health disparities for this disease.

Clinical Features and Prognostic Factors in Multiple Myeloma Patients from Colombia. Real-World Data from Renehoc Registry

Background: The prognosis for patients with multiple myeloma (MM) has improved over time, but there is considerable heterogeneity in disease outcomes. Currently used risk models have been validated using data from patients in clinical trials, but their applicability to real-world populations may be limited. To provide clinicians with better tools for decision-making, it is essential to identify factors associated with overall survival (OS) in a local setting. This study aims to identify clinical factors associated with OS in a real-world cohort of Colombian patients with newly diagnosed multiple myeloma (NDMM) using data from the registry on hematologic diseases (RENEHOC). Methods: RENEHOC is an electronic healthcare record (EHR) system comprising data from 25 active centers in 6 Colombian cities as of July 2023. The study population was characterized using descriptive methodology. Two cohorts of patients were defined: Cohort A included patients who died within 5 years after diagnosis, and Cohort B included patients who were either alive or censored 5 years after diagnosis. Variables with a high proportion of missing information were evaluated in terms of magnitude and proportion. Univariate logistic regression was used to identify variables associated with OS, with those having a P value less than 0.2 considered for multivariate analysis. The results were presented as odds ratios (OR) with 95% confidence intervals (CI), and P values were calculated using the LR-test. Results: The analysis included 1579 patients with NDMM. The median age was 67 years (IQR 60-75), and 51.1% (n=808) of the patients were male. Most patients were insured through the contributory health system plan. At diagnosis, 36.9% (n=582) of patients had a bone fracture (n=425) and 26.9% (n=425) had renal insufficiency, with 9.8% requiring dialysis. Cytogenetic analysis was performed in 22.9% (n=361) of patients, and 24.1% (n=87) of them had high-risk features. Half of the patients were classified as ISS III at diagnosis. The median OS for the entire cohort was 98.4 months. According to the international staging system (ISS), OS varied significantly: 106.2 months for ISS I, and 79.1 and 63.1 months for ISS II and ISS III, respectively (p < 0.001). First-line treatment for 90% (n=1407) of patients included chemotherapy, with 70% of patients treated with Bortezomib-based triplets, with VCD (Bortezomib, Cyclophosphamide, and Dexamethasone) being the most frequently used of them (30.7%, n=486). Only 21.7% of patients were consolidated with autologous stem cell transplantation (ASCT) in the first line. Cohort A comprised 341 (21.6%) patients who died within 5 years after diagnosis. Univariate analysis showed a significantly higher proportion of patients ≥65 years, from the subsidized health plan, with renal insufficiency requiring dialysis, elevated B2-microglobulin levels at diagnosis, and who did not receive ASCT in this cohort. After multivariate logistic regression, four variables remained statistically significant predictors of OS: age ≥65 years, elevated B2-microglobulin levels, not receiving ASCT, and higher albumin values at diagnosis. These variables were associated with higher mortality risk, except for higher albumin values, which were associated with better survival (Table I). Conclusions: This study contributes to the growing body of evidence on multiple myeloma prognosis in the Colombian context. These findings provide valuable insights for clinicians in the local setting and may aid them in making informed decisions for individual patients. Nevertheless, future research and validation studies are warranted to confirm and build upon these findings.

Impacto del uso de fototerapia ultravioleta B de banda estrecha en la variación de la calidad de vida evaluada con la escala Skindex-29 en pacientes adultos

BackgroundThe assessment of health-related quality of life (HRQoL) is progressively gaining importance in the evaluation of the effectiveness of interventions in dermatology. The Skindex-29 is an instrument adapted and validated for Colombia that allows the assessment of HRQoL by measuring the dimensions of emotions, symptoms and functioning, in addition to providing a global concept. Narrowband ultraviolet B phototherapy (UVB-BE) is a therapeutic tool in which there is little research in our context. Material and methodsA quasi-experimental before-after study was carried out in adults who started treatment in the UVB-BE phototherapy unit, evaluating HRQoL using Skindex-29 in the first session and subsequently in session 48 and/or 4 months after the initial session. ResultsForty-nine patients participated. 39% were men and 61% women. The mean age was 52 years and 91% belonged to the contributory health system. The most frequent phototype was III (30.6%) and the 2 most prevalent diseases were vitiligo and psoriasis (65%). A statistically significant decrease in scores was observed in all dimensions assessed using the Skindex-29 scale. ConclusionsIn the context of the Colombian health system UVB-BE phototherapy represents an effective complementary intervention to decrease the impact on HRQoL in some dermatological diseases.

Enrolment, utilisation, and best practices followed by hemodialysis patients concerning government and private health insurance schemes in tertiary care hospital

BackgroundEnd-stage renal disease (ESRD) consequences have reached epidemic proportions in India, and disease rates are expected to rise further. Every year, around 0.22 million new patients with renal diseases are diagnosed in India. ESRD poses a significant hurdle to receiving affordable therapy due to the exorbitant charges associated with accessing treatment in corporate hospitals. ObjectiveTo investigate hemodialysis patients' enrolment patterns, utilisation rates, and best practices concerning government and private health insurance schemes in a tertiary care hospital setting. MethodsA multi-centric and prospective cross-sectional study was conducted at tertiary care hospitals. Sources of data collection were patients and family members. The questionnaires included sections related to patient demographics, insurance enrollment details, utilisation patterns, and satisfaction with insurance coverage. ResultsResponses were collected from 385 patients undergoing treatment at tertiary care hospitals. The most utilised plans were health cards 107 (29.8%), private schemes 99 (27.6%), Central Government schemes 66 (18.4%), followed by trust 50 (13.9%), society schemes 30 (8.4%), and state schemes 7 (1.9%). The most common Central Government insurance scheme was Employee State Insurance, with 63 (17.5%) of patients enrolled, followed by Ex-servicemen Contributory Health Scheme 2 (0.6%) and Central Government Health Scheme 1 (0.3%). Among those with State Insurance, the Chief Minister Relief Fund Government of Karnataka 3 (0.8%), followed by the Arogya Bhagya Scheme 1 (0.3%). ConclusionsThe utilisation rates of insurance benefits were relatively high among hemodialysis patients, demonstrating the significance of insurance coverage in facilitating their healthcare needs.

The Implementation of Diagnostic Assessment in Breast Lump Cases: A Cross-Sectional Study in Sragen, Indonesia.

Introduction Triple assessment, consisting of clinical breast examination, breast imaging, and fine-needle aspiration biopsy (FNAB), is the gold standard for breast lump diagnosis to avoid diagnostic errors. However, current diagnostic practices for breast lump cases in Indonesia are widely variable and evidence for triple assessment implementation is lacking. We aimed to explore the implementation of diagnostic assessments in breast lump cases, its influencing factors, and its association with diagnostic error. Methods This cross-sectional study consecutively recruited 364 females with breast lumps who underwent surgery in Soehadi Prijonegoro Public Hospital, Sragen, Indonesia. Data were retrospectively collected from patient's medical records. Diagnostic assessments were classified as single assessment with clinical breast examination, double assessment with clinical breast examination and breast ultrasonography (USG) or fine-needle aspiration biopsy (FNAB), and triple assessment. Diagnostic error was defined as a discrepancy between pre- and post-surgery diagnosis or repeated surgery without neoadjuvant chemotherapy. Factors associated with diagnostic assessment implementation, diagnostic error, and repeated surgery were analyzed using the chi-square test. Results The choice of diagnostic assessment was influenced by patients' age and health insurance (p<0.001). Triple assessment was only implemented in 21 (5.8%) breast lump cases. It was more frequently applied in patients ≥40 years (57.1%) and patients with contributory health insurance (76.2%). Diagnostic errors were observed in 84 cases (23.1%) and 47 patients out of them (47%) experienced repeated surgery. The implementation of diagnostic assessments was not associated with diagnostic error (p=0.257)but was significantly associated with repeated surgery in breast cancer (p<0.001). Repeated surgery rates were significantly lowered in cases receiving double assessment with FNAB (p<0.001). Conclusions The implementation of triple assessment in the local setting was very low. The choice of diagnostic assessment was influenced by patients' age and health insurance. Further, double assessment applying clinical breast examination and FNAB significantly decreased repeated surgery rates and thus may serve as an alternative to triple assessment in the limited resource setting.

The lifetime risk of developing type II diabetes in an urban community in Mumbai: findings from a ten-year retrospective cohort study

BackgroundIncidence and prevalence do not capture the risk of developing diabetes during a defined period and only limited evidence exists on the lifetime risk of diabetes based on longer and continuous follow-up studies in India. Lacunae in evidence on lifetime risk can be attributed primarily to the absence of comprehensive and reliable information on diabetes incidence, mortality rates and lack of longitudinal studies in India. In light of the scarcity of evidence in India, the objective of this study was to estimate the incidence of diabetes and its lifetime risk in an urban community of Mumbai.MethodsThe research study utilized data which is extracted from the electronic medical records of beneficiaries covered under the Contributory Health Service Scheme in Mumbai. The dataset included information on 1652 beneficiaries aged 40 years and above who were non-diabetic in 2011–2012, capturing their visit dates to medical center and corresponding laboratory test results over a span ten years from January, 2012- December, 2021. Survival analysis techniques are applied to estimate the incidence of diabetes. Subsequently, the remaining life years from the life table were utilized to estimate the lifetime risk of diabetes for each gender, stratified by age group.ResultsA total of 546 beneficiaries developed diabetes in ten years, yielding an unadjusted incidence rate of 5.3 cases per 1000 person-years (95% CI: 4.9- 5.8 cases/ 1000 person years). The age-adjusted lifetime risk of developing type II diabetes in this urban community is estimated to be 40.3%. Notably, males aged 40 years and above had 41.5% chances of developing diabetes in their lifetime as compared to females with a risk of 39.4%. Moreover, the remaining lifetime risk of diabetes decreased with advancing age, ranging from 26.4% among 40–44 years old to 4.2% among those age 70 years and above.ConclusionThe findings stress the significance of recognizing age specific lifetime risk and implementing early interventions to prevent or delay diabetes onset and to focus on diabetes management programs in India.

Health insurance and contraceptive use, Indonesian Family Planning Census 2021.

To assess the association between health insurance coverage and sociodemographic characteristics, and the use of modern contraception in Indonesia. We used data from the 2021 Indonesian family planning census which included 38 408 597 couples. Contraception is covered by the national health insurance scheme: members are non-contributory (for poor families who do not make any monetary contribution) or contributory (for better-off families who pay for the insurance). We used regression analyses to examine the correlation between each type of health insurance (non-contributory, contributory, private or none) and contraceptive use and type of contraceptive used. The prevalence of the use of modern contraceptives in Indonesia was 57.0% (21 897 319/38 408 597). Compared with not having health insurance, having health insurance was associated with a greater likelihood of contraceptive use, odds ratio (OR): 1.14 (95% confidence intervals, CI: 1.13-1.14) and OR: 1.01 (95% CI: 1.01-1.01) for women with non-contributory and contributory health insurance, respectively. Having private health insurance was associated with lower use of modern contraceptives (OR: 0.94; 95% CI: 0.94-0.94). Intrauterine devices, lactational amenorrhoea and tubal ligation were the most common forms of contraceptive used by women. The prevalence of modern contraceptive use in Indonesia is lower than the 75% target of the 2030 sustainable development goals. As national health insurance positively correlated with modern contraceptive use, extending its coverage on remote Indonesian islands is recommended to increase the use of such contraceptive methods in those areas.

Experience of a TelEmergency program in Colombia South America: descriptive observational study between 2019 and 2021

IntroductionColombia has 50,912,429 inhabitants, but only 50–70% of the population can effectively access health care services. The emergency room (ER) is a main contributor to the in-hospital care system since up to half of the admissions come through it. Telemedicine has become a tool to facilitate effective access to health care services, improve the timeliness of care, reduce diagnostic variability, and reduce costs associated with health. The aim of this study is to describe the experience of a Distance Emergency Care Program through Telemedicine (TelEmergency) to improve specialist access for patients at the Emergency Room (ER) in low- and medium-level care hospitals in Colombia.MethodsAn observational descriptive study of a cohort including 1,544 patients during the program’s first two years was conducted. Descriptive statistics were used to analyze the available data. The data are presented with summarized statistics of sociodemographic, clinical, and patient-care variables.ResultsThe study included a total of 1,544 patients, and the majority were adults between 60 and 79 years of age (n = 491, 32%). More than half were men (n = 832, 54%), and 68% (n = 1,057) belonged to the contributory health care regime. The service was requested from 346 municipalities, 70% (n = 1,076) from intermediate and rural settings. The most common diagnoses were related to COVID-19 (n = 356, 22%), respiratory diseases (n = 217, 14%), and cardiovascular diseases (n = 162, 10%). We observed 44% (n = 681) of local admissions either under observation (n = 53, 3%) or hospitalization (n = 380, 24%), limiting the need for hospital transfers.Program operation data revealed that 50% (n = 799) of requests were answered within two hours by the medical staff. The initial diagnosis was modified in 7% (n = 119) of the patients after being evaluated by specialists at the TelEmergency program.ConclusionsThis study shows the operational data collected during the first two years after the implementation of the TelEmergency program in Colombia, the first of its kind in the country. Its implementation offered specialized timely management of patients at the ER in low- and medium-level care hospitals, where there is no availability of specialized doctors.

Fragmentation of Care and Its Association With Survival and Costs for Patients With Breast Cancer in Colombia

Breast cancer care requires a multimodal approach and a multidisciplinary team who must work together to obtain good clinical results. The fragmentation of care can affect the breast cancer care; however, it has not been measured in a low-resource setting. The aim of this study was to identify fragmentation of care, the geographic variation of this and its association with 4-year overall survival (OS), and costs of care for patients with breast cancer enrolled in Colombia's contributory health care system. A retrospective cohort study was conducted using administrative databases. Women with breast cancer who were treated from January 1, 2013, to December 31, 2015, were included. Fragmentation of care was the exposure, which was measured by the number of different health care provider institutions (HCPIs) that treated a patient during the first year after diagnosis. Crude mortality rates were estimated, survival functions were calculated using the nonparametric Kaplan-Meier approach, and adjusted hazard ratios (HRs) were estimated using multivariate Cox regression model to identify the association of fragmentation with 4-year OS. The association between fragmentation and costs of care was assessed using a multivariate linear regression model. A total of 10,999 patients with breast cancer were identified, and 1,332 deaths were observed. The 4-year crude mortality rate was 31.97 (95% CI, 30.25 to 33.69) per 1,000 person-years for the whole cohort, and the highest rate was in the cohort defined for the fourth quartile of the fragmentation measurement (eight or more HCPIs), 40.94 (95% CI, 36.49 to 45.39). The adjusted HR for 4-year OS was 1.04 (95% CI, 1.01 to 1.07) for each HCPI additional. The cost of care is increased for each additional HCPIs (cost ratio, 1.25; 95% CI, 1.23 to 1.26). Fragmentation of care decreases overall 4-year OS and increases the costs of care in women with breast cancer for Colombia.

Is contributory health insurance indeed an addiction to a bad idea? A comment on its relevance for low- and middle-income countries

Financing of health systems is an enduring concern world wide. Yazbeck and colleagues in their paper make an important point that when there is a choice between financing in which contributions from citizens take place in the form of generalised taxes versus those in which they are in the form of insurance premiums, the overwhelming evidence suggests that tax-based financing is unambiguously superior even in low- and middle-income countries. Despite the strength of their case against contributory insurance, we suggest that the path forward may be more complex than they envisage for a number of reasons. The problem of a high proportion of informal sector workers that they argue impacts contributory approaches is also an issue with taxes because of the very low numbers of people who file returns. Taxes in most developing countries are in fact largely derived from highly regressive indirect taxes which the poor are forced to pay. Additionally, in most developing countries, including large ones like India and Nigeria, the only choice on offer is continued dependence on out-of-pocket expenditures. In such a situation exploring alternatives which are superior to out-of-pocket expenditures becomes imperative. Asking citizens to wait interminably for additional tax resources to be made available would be a grave disservice to them.

Examining The Efficiency And Effectiveness Of Ex-Servicemen Contributory Health Scheme (Echs0 Implementation In Maharashtra: A Critical Analysis Of Healthcare Services For Ex-Servicemen

Examining The Efficiency And Effectiveness Of Ex-Servicemen Contributory Health Scheme (Echs0 Implementation In Maharashtra: A Critical Analysis Of Healthcare Services For Ex-Servicemen

Addiction to a bad idea, especially in low- and middle-income countries: Contributory health insurance

Despite limited evidence of successful development and implementation of contributory health insurance and low and middle income countries, many countries are in the process implementing such schemes. This commentary summarizes all available evidence on the limitations of contributory health insurance including the lack of good theoretical underpinning and the considerable evidence of inequity and fragmentation created by such schemes. Moreover, the initiation of a contributory health insurance scheme has not been found to increase revenues to the health sector or help health countries achieve universal health coverage. Low and middle income countries can improve equity and efficiency of the health sector by replacing out-of-pocket spending with pre-paid pooling mechanisms, but that is best done through budget transfers and not by contributory insurance that links payment to sub-population entitlements.

Addiction to a bad idea, contributory health systems – A comment

Addiction to a bad idea, contributory health systems – A comment