Healthcare Fees Research Articles

Seven Years Analysis of Postpartum Death in Selangor, Malaysia: A Lesson Learnt

Information on determinants of postpartum death enhances understanding of the fundamental causes of mortality. Studies on postpartum death in Malaysia are limited despite increasing trends of postpartum mortality. This study aimed to ascertain the determinants of postpartum death in Selangor, Malaysia. A case control was conducted using data from the Maternal Death Registry, Selangor State Health Department, Malaysia. A total of 144 postpartum death cases were included for analysis after the removal of fortuitous and unknown death. Controls were mothers who survived six weeks after childbirth and were selected via simple random sampling. The odds of postpartum death among multiparous was almost two times higher (aOR; 1.76 95% CI 1.10,2.82). The presence of pre-existing medical or surgical problems were associated with a three-folds increase in the odds of postpartum death (aOR 3.23; 95% CI 1.91,5.47). The odds of postpartum death were ten times higher for those who gave birth in non-health facilities (aOR 10.62; 95% CI 2.64,42.74). Women who underwent caesarean section had almost three times more odds (aOR 2.50; 95% CI 1.60,3.91) for death. Women who received antenatal care in government health facilities had low odds (aOR 0.34; 95% CI 0.19,0.60) for postpartum death. The determinants showed significant association with postpartum death in Selangor, Malaysia which included the presence of pre-existing medical or surgical illness, place of birth, mode of birth, place of antenatal care and Malaysian ethnicity-citizenship. In the future, health programmes should not only aim to reduce postpartum deaths by emphasising maternal education and empowerment, but should also enhance pre-pregnancy care, provide continual obstetric emergency skill training to healthcare providers, collaborate with several agencies and underwrite migrants’ maternal healthcare fees.

Care cascades for hypertension and diabetes: Cross-sectional evaluation of rural districts in Tanzania.

Noncommunicable diseases (NCDs), especially hypertension and diabetes, are rapidly rising in sub-Saharan Africa, necessitating health systems transformations. In Tanzania, current policies aim to improve control of hypertension and diabetes, but information is still needed to assess the gaps in treatment. We conducted a cross-sectional household survey of 784 adults in two districts in Tanzania from December 2020 to January 2021, capturing the cascade-of-care for hypertension and diabetes. The ages of the respondents ranged from 18 to 89 years. Of those screened positive for these conditions, we measured the proportion in each step of the cascades: awareness, care engagement, treatment, and control. We conducted multivariable logistic regression analyses for all four steps along the hypertension care cascade with the independent variables of social health protection schemes, and prior diagnosis of comorbid diabetes, and demographic information. In our sample, of the 771 who had their blood pressure measured, 41% (95% confidence interval (CI): 38% to 44%) were screened positive for hypertension, and of the 707 who had their blood sugar measured, 6% (95% CI: 4% to 8%) were screened positive for diabetes. Of those with hypertension, 43% (95% CI: 38% to 49%) had a prior diagnosis, 25% (95% CI: 21% to 31%) were engaged in care, 21% (95% CI: 3% to 25%) were on treatment, and 11% (95% CI: 8% to 15%) were controlled. Of the 42 respondents with diabetes, 80% (95% CI: 69% to 93%) had a prior diagnosis. The diabetes care cascade had much less drop-off, so 66% of those with diabetes (95% CI: 52% to 82%) were engaged in care and on treatment, and 48% (95% CI: 32% to 63%) had their diabetes controlled at the point of testing. Healthcare fee exemptions were independently associated with higher odds of being previously diagnosed (OR 5.81; 95% CI [1.98 to 17.10] p < 0.005), engaged in care (OR 4.71; 95% CI [1.59 to 13.90] p 0.005), and retained in treatment (OR 2.93; 95% CI [1.03 to 8.35] p < 0.05). Prior diagnosis of comorbid diabetes was highly associated with higher odds of being engaged in care for hypertension (OR 3.26; 95% CI [1.39 to 7.63] p < 0.005). The two primary limitations of this study were reliance on screening at a single time point only of people available at the village at the time of the sample and dependence on self-report for to inform the three cascade steps of prior diagnosis, healthcare visits for engagement in care, and treatment use. The high burden of hypertension and low levels of control in our study underscores the importance of improving the awareness and treatment of hypertension. The differences in the care cascades for hypertension and diabetes demonstrates that chronic NCD treatment is possible in this setting, but efforts will be needed across the entire care cascade to improve hypertension control.

Administration of radium-223 and the prognosis in Japanese bone metastatic castration-resistant prostate cancer patients: A large database study.

BackgroundThe ALSYMPCA trial revealed radium‐223 (Ra‐223) to be a life‐prolonging agent for bone metastatic castration‐resistant prostate cancer (CRPC). However, only 2.8% of enrolled patients in that clinical trial were Asian, and no Japanese patients were enrolled. Several retrospective studies have been published concerning Japanese bone metastatic CRPC patients receiving Ra‐223. However, no study has yet reported the correlation between Ra‐223 induction and the survival in Japanese bone metastatic CRPC patients. This study investigated the effect of Ra‐223 as a life‐prolonging agent in a large Japanese healthcare fee database.MethodsA total of around 410 000 prostate cancer patients were extracted from this database, and 25 934 were diagnosed with CRPC. In these patients, the age, date of the CRPC diagnosis, date of Ra‐223 induction, and prognosis were analyzed.ResultsA total of 1628 patients received Ra‐223, and 6693 patients were diagnosed with bone metastasis CRPC, with the remaining 17 613 patients diagnosed with CRPC without bone metastasis. The patients who completed six courses of Ra‐223 showed a significantly more favorable overall and cancer‐specific survival than those who received ≤5 courses (p < 0.0001 and p < 0.0001, respectively). For time from CRPC diagnosis date to death, the Ra‐223 induction group showed a significantly more favorable prognosis with regard to both the overall and cancer‐specific survival than the bone metastatic CRPC patients without Ra‐223 (p < 0.0001 and p < 0.0001, respectively).ConclusionsBone metastatic CRPC patients who received Ra‐223 showed a significantly better prognosis than bone metastatic CPRC patients who did not receive Ra‐223.

Experience and Perception of Patients and Healthcare Professionals on Acute Leukemia in Rwanda: A Qualitative Study.

PurposeTo explore challenges associated with the timely diagnosis, therapy, and prognosis of acute leukemia in Rwanda.MethodsThis is a qualitative study using a phenomenological approach that involved patients, patients’ guardians, and healthcare professionals such as physicians from district hospitals and specialists from referral hospitals, as well as healthcare administrators. The primary data were collected from district and referral hospitals and central healthcare administration in Rwanda. The data were collected between July and October 2019. In-depth interviews were conducted, and thematic analysis was employed to interpret the results.ResultsWe identified barriers to seeking healthcare such as (i) insufficient knowledge within the population may lead patients and their guardians to consult traditional healers before seeking qualified medical care, and (ii) financial constraints that preclude payment of healthcare fees or other out-of-pocket cost related to diagnosis and treatment. We also observed that the referral system is tedious and primary healthcare facilities lack the competence and resources for the necessary diagnostic practices. Both may further delay diagnosis and therapy. Accordingly, healthcare professionals at the referral hospitals stated that most patients were seen at an advanced stage of the disease. For the treatment of acute lymphoblastic leukemia (ALL), only chemotherapy is utilized in Rwanda, while bone marrow (BM) transplantation is not available. Palliation is the only available treatment for the vast majority of Rwandan acute myeloid leukemia (AML) patients.ConclusionALL and AML are likely under-reported in Rwanda and diagnosis may be delayed, which may be explained by patient-related factors (lack of knowledge, financial constraints), a tedious referral system, and suboptimal diagnostic resources.

Status of antimicrobial stewardship programmes in Korean hospitals including small to medium-sized hospitals and the awareness and demands of physicians: a nationwide survey in 2020

This study aimed to identify the status of antimicrobial stewardship programmes (ASPs) in small to medium-sized Korean hospitals as well as the awareness and demands about ASPs of physicians. A questionnaire was designed based on a questionnaire from a previous nationwide survey in 2018 targeting large hospitals in Korea and modified to reflect the results of in-depth interviews with non-infectious diseases (IDs) physicians at secondary care hospitals. The survey targeted all hospitals with ≥150 beds in South Korea and was performed in May-June 2020. Only one ASP-associated physician per hospital participated in the survey. The survey response rate was 31.9% (217/680). ID specialists comprised the majority of medical personnel participating in ASPs in tertiary care hospitals. Conversely, in secondary and primary care hospitals there was no predominant medical personnel for ASPs and the median full-time equivalent was 0 for all types of medical personnel. Tertiary care hospitals, more than secondary and primary care hospitals, tended to perform ASP activities more actively. 'Workforce for ASPs', 'Establishment of healthcare fees for ASPs' and 'Development of tools for ASPs' were the most important required support for ASP improvement. The level of ASP establishment was more limited in primary care hospitals than in secondary and tertiary care hospitals in Korea. To improve ASPs in Korean hospitals, a supporting workforce and the establishment of a healthcare fee for ASPs appear to be necessary.

Socioeconomic inequalities in curative healthcare-seeking for children under five before and after the free healthcare initiative in Sierra Leone: analysis of population-based survey data

BackgroundSocioeconomic inequalities between and within countries lead to disparities in the use of health services. These disparities could lead to child mortality in children under 5 years by depriving them of healthcare. Therefore, initiatives to remove healthcare fees such as the Free Healthcare Initiative (FHCI) adopted in Sierra Leone can contribute to reducing these inequities in healthcare-seeking for children. This study aimed to assess the socioeconomic inequalities in healthcare-seeking for children under 5 years of age before and after the implementation of the FHCI.MethodsData were included on 1207, 2815, 1633, and 1476 children under 5 years of age with fever from the 2008, 2013, 2016, and 2019 nationwide surveys, respectively. Concentration curves were drawn for the period before (2008) and after (2013–2019) the implementation of the FHCI to assess socioeconomic inequalities in healthcare-seeking. Finally, Erreyger’s corrected concentration indices were calculated to understand the magnitude of these inequalities.ResultsBefore the implementation of the FHCI, there were inequalities in healthcare-seeking for children under five (Erreyger’s corrected concentration index (CI) = 0.168, standard error (SE) = 0.049; p < 0.001) in favor of the wealthy households. These inequalities decreased after the implementation of the FHCI (CI = 0.061, SE = 0.033; p = 0.06 in 2013, CI = 0.039, SE = 0.04; p = 0.32 in 2016, and CI = − 0.0005, SE = 0.362; p = 0.98 in 2019). Furthermore, before the implementation of the FHCI, a significant pro-rich inequality in the districts of Kenema (CI = 0.117, SE = 0.168, p = 0.021), Kono (CI = 0.175, SE = 0.078, p = 0.028) and Western Area Urban (CI = 0.070, SE = 0.032, p = 0.031) has been observed. After the implementation of the FHCI in 2019, these disparities were reduced, 11 of the 14 districts had a CI around the value of equality, and only in 2 districts the pro-rich inequality were significant (Western Area Urban (CI = 0.035, SE = 0.016, p = 0.039) and Western Area Rural (CI = 0.066, SE = 0.030, p = 0.027)).ConclusionThe results of this study demonstrated that socio-economic inequalities in healthcare-seeking for children have been considerably reduced after the FHCI in Sierra Leone. To further reduce these inequalities, policy actions can focus on the increase of availability of health services in the districts where the healthcare-seeking remained pro-rich.

РОЗВИТОК ОСОБИСТОГО СТРАХУВАННЯ В УКРАЇНІ В УМОВАХ COVID-19

The article examined the theoretical foundations of personal insurance, the basic types of personal insurance and comparison of social and personal insurance and their insurance risks. Including the current state and development of personal insurance in Ukraine in conditions of Covid-19. Analyzed the main statistical indicators of personal insurance, in particular the dynamics of life insurance companies, set of insurance premiums and insurance payments of medical and personal voluntary insurance. Rankings of life insurance companies from Covid-19 are built during the onset of the pandemic. Health care funding that provides health care fees between different groups of the population is carried out through medical insurance. World experience shows that the insurance market contributes not only to the development of the economy, but also to the solution of social problems. This reduces the effect on the expenditure part of the budget is reduced and state spending on social security of citizens, thereby opening up the possibility of solving problems of protection of the most disadvantaged groups. However, world best practices in combating pandemic Covid-19. In particular, the experience of China was considered, which showed that health insurance coverage should be provided to all to segments of the population, which greatly affected the fight against the pandemic during the fight against it. The experience of Italy showed that the country was not ready for fight against a coronavirus pandemic. The country has taken urgent measures that are aimed at supporting the most affected, both citizens and industries economics. Italian insurers offer their customers a reprieve for motor insurance, life insurance and insurance contracts entrepreneurial risks. The US experience showed that the country spends on Healthcare 11.5% of gross profit, that’s more than any country in the world. At the same time, more than 15% of citizens do not have financial protection from high costs, for medical care due to lack of insurance health policies due to high prices. The article highlights the main shortcomings and proposes certain recommendations for solving problems of personal insurance in Ukraine using certain elements of foreign experience.

Healthcare financing and social protection policies for migrant workers in Malaysia.

For Malaysia, a nation highly dependent on migrant labour, the large non-citizen workforce presents a unique health system challenge. Although documented migrant workers are covered by mandatory healthcare insurance (SPIKPA), financial constraints remain a major barrier for non-citizen healthcare access. Malaysia recently extended protection for migrant workers under the national social security scheme (SOCSO), previously exclusive to citizens. This study aims to evaluate healthcare financing and social security policies for migrant workers to identify policy gaps and opportunities for intervention. A total of 37 in-depth interviews were conducted of 44 stakeholders from July 2018 to July 2019. A mixed-methods analysis combining major themes from qualitative interviews with policy document reviews was conducted. Descriptive analysis of publicly available secondary data, namely revenues collected at government healthcare facilities, was conducted to contextualise the policy review and qualitative findings. We found that migrant workers and employers were unaware of SPIKPA enrolment and entitlements. Higher fees for non-citizens result in delayed care-seeking. While the Malaysian government nearly doubled non-citizen healthcare fees revenues from RM 104 to 182 million (USD 26 to 45 million) between 2014 to 2018, outstanding revenues tripled from RM 16 to 50 million (USD 4 to 12 million) in the same period. SPIKPA coverage is likely inadequate in providing financial risk protection to migrant workers, especially with increased non-citizens fees at public hospitals. Undocumented workers and other migrant populations excluded from SPIKPA contribution to unpaid fees revenues are unknown. Problems described with the previous Foreign Workers Compensation Scheme (FWCS), could be partially addressed by SOCSO, in theory. Nevertheless, questions remain on the feasibility of implementing elements of SOCSO, such as recurring payments to workers and next-of-kin overseas. Malaysia is moving towards migrant inclusion with the provision of SOCSO for documented migrant workers, but more needs to be done. Here we suggest the expansion of the SPIKPA insurance scheme to include all migrant populations, while broadening its scope towards more comprehensive coverage, including essential primary care.

Why not see a doctor when ill? Evidence from the Chinese elderly

BackgroundElder people aged ≥45 years often have more healthcare needs than the younger. But the Chinese elderly are less likely to see a doctor when ill. In this article, this phenomenon is abbreviated as “not see a doctor”. This study aimed to describe the reason distribution of“not see a doctor” among the Chinese elderly. Specifically,we examined the reasons why“not see a doctor” happened to the Chinese elderly with different characteristics.MethodsIn order to explore the associations between various predisposing, enabling and need factors and “not see a doctor” in China, this cross-sectional study used the data from the 2015 wave 4 of the China Health and Retirement Longitudinal Study (CHARLS). Using multivariate analyses, associations between “not see a doctor” and factors were accessed. Models were estimated using a binary model with negative log-log link function (cases versus controls) and multinomial logit analysis (reasons for “not see a doctor”).ResultsAdjusted by individual weight, the analysis included 16,277 people aged ≥45 years, of whom 11% reported “not see a doctor”. Overall, those with older age, other marital status (except married) and poorer health status were more likely to report “not see a doctor”. No significant associations were found between income and “not see a doctor”. The majority of cases report “no need” as the reason for their “not see a doctor”. Except reason “no need”, factor associated with the healthcare system—cost—accounted for the most case of “not see a doctor”. Those without health insurance are more likely not to see a doctor due to affordability issues.ConclusionsThis quantitative study suggests that “not see a doctor” is more likely to happen due to age and marital status issues, especially affordability issues. For China, it is important to enforce the policy of reducing of healthcare fees and increasing health insurance coverage.

Incidence of varicella in children in Jeju-do, Korea, 2005-2016: age-period-cohort analysis.

OBJECTIVESAlthough the nationwide inoculation rate of varicella vaccine was approximately 95% in Korean children recently, the number of notified varicella cases is unexpectedly continuously increasing till now. To suggest some hypotheses regarding this discrepancy, an age-period-cohort (APC) analysis as a descriptive epidemiology study was conducted for children residing in Jeju-do, Korea.METHODSThe raw data were obtained from the nationwide database for insurance claim of healthcare fee provided by the National Health Insurance Service, Korea. The selection criteria were children aged 2-13 years who visited any healthcare center due to varicella from 2005 to 2016 while residing in Jeju-do. After calculating the birth cohort-specific crude incidence rates by age and year, the intrinsic estimator method was used to perform the APC analysis.RESULTSAs the annual crude incidence rates decreased with increasing age between 2005 and 2016, the age and period effects also decreased. The intrinsic estimator coefficients suggesting the cohort effect shifted from positive to negative in 2011, the starting year of free varicella vaccine program in Jeju-do.CONCLUSIONSThe results suggested that inoculated varicella vaccines have preventive effects. However, further studies to evaluate waning immunity would be needed.

The Economic Burden of Metastatic Castration Resistant Prostate Cancer and Skeletal Related Events in Japanese University Hospitals

Objective:Although androgen deprivation therapy (ADT) has improved the survival and quality of life of patients with prostate cancer, resistance to treatment inevitably results in transition to a castration resistant state (CRPC) and, in advanced cases, bone metastasis, leading to skeletal related events (SRE). In order to understand the current burden on patients in Japan, there is a need to estimate the healthcare costs of CRPC treatment in current clinical practice.Methods:This retrospective observational cohort study utilized claims data from 13 national university hospitals through the Platform for Clinical Information Statistical Analysis database. Extracted data included the use of diagnostic tests, the frequency and cost of hospitalizations and outpatient visits, and medication costs, using values from the Healthcare Fee System and the National Health Insurance Drug Price List relative to each observed year.Results:Data were collected from 4001 patients with CRPC, 97% of whom had undergone ADT. Between 2005 and 2016, the mean annualized direct medical cost per patient was ¥739,147 (US$7060), of which 91% was related to medication, 4.8% to laboratory and imaging, 4.1% to radiotherapy, and 0.1% to surgery. A total of 771 (19%) of the 4001 CRPC patients experienced an SRE. Resource utilization was significantly higher (p<0.0001) in patients with SRE than in those without, with mean annualized medication costs per patient of ¥1,074,885 and ¥659,006, respectively, and ¥108,807 and ¥71,392, respectively, for laboratory and imaging. The occurrence of even one SRE led to a significant increase in costs and the use of analgesics, compared to the prior period.Conclusions:A diagnosis of CRPC is associated with considerable healthcare resource utilization and increased economic burden on patients, which are significantly higher in those with SREs. Treatments that can prevent or delay SREs may help ease this burden, thereby providing cost savings across Japanese healthcare systems.

Free versus subsidised healthcare: options for fee exemptions, access to care for vulnerable groups and effects on the health system in Burkina Faso

BackgroundThe many forms of healthcare fee exemptions implemented in Burkina Faso since the 2000s have varied between total exemption (free) and cost subsidisation. This article examines both options, their contextual variations and the ways in which they affect access to healthcare for vulnerable people as well as the operation of the health system. This research is part of an interdisciplinary regional program on the elimination of user fees for health services in West Africa (Burkina Faso, Mali and Niger).MethodA conceptual framework and a chronological review of policy interventions are used as references to summarise the results of the three qualitative studies presented. Historical reference points are used to describe the emergence of healthcare fee exemption policies in Burkina Faso and the events that influenced their adoption. The joint analysis of opinions on options for fee exemption focuses on the different types of repercussions on access to healthcare and the operation of the health system.ResultsIn conjunction with the twists and turns of the gradual development of a national health policy and in response to international recommendations, healthcare fee exemptions have evolved since colonisation. The limitations of the changes introduced with cost recovery and the barriers to healthcare access for the poorest people led to the adoption of the current sectorial fee exemptions. The results provide information on the reasons for the changes that have occurred over time. The nuanced perspectives of different categories of people surveyed about fee exemption options show that, beyond the perceived effects on healthcare access and the health system, the issue is one of more equitable governance.ConclusionsIn principle, the fee exemption measures are intended to provide improved healthcare access for vulnerable groups. In practice, the negative effects on the operation of the health system advocate for reforms to harmonise the changes to multifaceted fee exemptions and the actual needs to promote effectiveness and sustainability.

Exemption from Health Care Fees Influences Indications of Caesarean Section in a Urban Health District Hospital in Benin

Exemption from Health Care Fees Influences Indications of Caesarean Section in a Urban Health District Hospital in Benin

Improving equity by removing healthcare fees for children in Burkina Faso

BackgroundThis study evaluated the effects on healthcare access inequities of an intervention exempting children under 5 years from user fees in Burkina Faso.MethodsThe design consisted of two complementary studies. The...

노인보건의료의 현황과 법 제도적 개선방안

As the population is getting older, medical expenses amount of the whole is keep increasing. So, the pressure of the finances, Health Insurance, Medical Care Assistance Act and etc, is getting higher. The share of healthcare-expense is increasing due to elderly illness. And it became a social problem; we analysed present state of senior healthcare in South Korea-looked into current laws and policies, and found problems. We tried to suggest improvements that drew from the current state of foreign country senior healthcare of those problems. For the result, we found the problem in relevant-law system of senior healthcare guarantee. In this study, we proposed the ways to qualitatively upgrade of medical standard that considered on elderly` features: the strengthened guarantee for healthcare, financial secure for long-term convalescence benefit, linking and functional reinforcement for elderly welfare and long-term convalescence insurance, the solution for overlapped laws about convalescence in long-term convalescence insurance and elderly welfare, a betterment of grading, and a home service consolidation. We need to secure right amount of emergency medical service budget, and effective management system for the improved level of senior severely emergency medical service. Furthermore, we suggested that South Korea needs to legislate [The Law for Senior Medical Secure] to respond to rapidly increasing senior healthcare fee.

Health policy for the new government

The new presidential administration of the Republic of Korea will be launched in February 2013. We hope that the Government effectively administers national affairs as well as health care affairs under the new paradigm. In this paper, I make three proposals for the new administration. First, the new government must overcome the wave of aging, the low birth rate, and low economic growth rate. The aging society increases health care demands, but the low birth rate and low economic growth rate decrease the capability to financially underwrite these demands. Furthermore, Korea faces the unification issue as the mission of the era. The economic burden of unification would be bigger than that faced by Germany. The government must prepare rapidly with a step-by-step plan for this approaching situation. Second, the new administration must solve the top-priority policy problems that are derived not only from the existing problems of the "garbage can model," but also from priority setting with an overall and systematic view. These top-priority health policy problems are the high suicide rate, over-utilization of doctors' visits and length of hospital stay, and high out-of-pocket health care fees. The extreme phenomenon of high out-of-pocket costs affects a high percentage of households with catastrophic medical costs, which is about 3%, the highest level among the Organization for Economic Cooperation and Development countries. Third, the policy approach of the new administration must be not unilateral, but bilateral: efficiency and equity of policies, support and regulation of policy tool, demand-side and supply-side management of healthcare utilization, and service benefits and monetary benefits of Health Insurance. In the past, the main approach of healthcare policy has depended on regulation, supply-side control, and service benefits. The administration should pursue a balance of left and right approaches, regardless of which political party wins. I hope that the new government will overcome these challenges in a turbulent era, solve top-priority problems first, and approach all of this with a new paradigm as new wine must be poured into new wineskins.

Utilization and perceptions of neonatal healthcare providers in rural Uttar Pradesh, India

To describe the utilization and perceptions of existing neonatal health services in rural Uttar Pradesh, India. A prospective observational study. The study was located in Shivgarh, a rural block of Uttar Pradesh, India. One hundred and fifty-three households that utilized a healthcare provider for their sick neonates. None. Perceived neonatal health improvement after utilization of neonatal health services; satisfaction with aspects of neonatal health services: 'overall care', 'interaction with provider', 'waiting time' and 'explanations of immediate care and follow-up care'. Unqualified allopathically oriented providers (UAOPs) were utilized by 110 households (71.8%), while qualified allopathically oriented providers (QAOPs) by 43 households (28.2%). The odds of perceived neonatal health improvement were significantly higher among households utilizing UAOPs (n = 88/110, 80.0%) than those using QAOPs (n = 23/43, 53.5%) [adjusted odds ratio (OR): 3.3, 95% confidence interval (CI): 1.5-7.5]. The median healthcare fee charged was higher for UAOPs (Rs. 25) than those for QAOPs (Rs. 1). Household satisfaction with 'overall care' of neonatal health service was significantly higher among households that utilized UAOPs compared with those that used QAOPs (OR: 2.4, 95% CI: 1.2-5.0). Households that utilized UAOPs reported better perceived neonatal health outcomes and higher satisfaction levels than those that used QAOPs, despite higher costs for the former. Future research should assess what dimensions of neonatal care are important to households and identify incentive structures that promote healthcare providers to deliver better perceived care in high-mortality settings such as rural Uttar Pradesh, India.

The interface between health systems and vertical programmes in Francophone Africa: the managers’ perceptions

To explores the interface between vertical programmes (VPs) and general health services (GHS) in sub-Saharan Africa. Using semi-structured interviews, we analysed the perceptions of a selection of experienced mid-level managers of health systems and of VP originating in francophone Africa on the nature and quality of this interface. The respondents acknowledged that VPs lead to both positive and negative effects on the functioning of GHS. The overall result, however, cannot be viewed as a simple summation of the positive effects possibly compensating for the negative ones. Indeed, some of the negative effects have a profound impact on the management and operation of the health care delivery system and may undermine the long-term institutional capacity of the general health systems. The quality and the nature of the interface between VP and GHS strongly vary in time, between settings and programmes. We argue for more systematic monitoring of the interface between VP and GHS, so as to identify and address, in a timely manner, significant disruptive effects and deficiencies in a perspective of systemic capacity building of health systems.

Czech health two decades on from the Velvet Revolution

20 years ago, half a million citizens took to the streets of Prague to protest against the increasingly oppressive Communist Government. After a week of peaceful demonstrations and strikes, the 40-year regime ended and democracy returned to the Czech people. Today, the citizens are protesting once again—not against oppression, but against health-care copayments. The controversy is the latest chapter in the Czech health-care system’s unique 20-year transformation from an ineffective command-controlled system to one of the most successful and respected in the world. Since the introduction of fees for health-care services in January, 2008, the Czech Social Democratic Party has represented the large portion of the population that opposes this controversial change. For many, it is not the payment of 30 Czech crowns (US$1·60) for a visit to the doctor or for a prescription, the 60 crowns ($3·20) for each day of hospitalisation, nor the 90 crowns ($4·79) for an emergency room visit. It is the principle that health care has always been free. However, the latest attempt by the Social Democrats to abolish the fees was rejected by the Czech Senate.1 The June 18 ruling was well received by the Ministry of Health, which has defended the fees to ensure the financial stability of the health system. Because nearly 80% of health-care expenditure is financed by income-based payments, the Czech system is particularly vulnerable during an economic downturn: this year, the insurance system is projected to lose as much as 13 billion crowns ($692 million) in revenue. This loss could be as high as 20 billion crowns ($1·07 billion) without the health-care fees.2 Furthermore, preserving the fees might discourage the overuse of health-care resources, for which the country has an unusually high demand. In 2007, Czech citizens had an average of 14·6 outpatient contacts with medical personnel per person—the highest in Europe. Similarly, the numbers of acute-care admissions, inpatient admissions, and average lengths of hospital stays have all been higher than the European Union (EU) average since 2000.3 Yet financially, the Czech health-care system is remarkably efficient. Expenditure per capita is among the lowest in the world, at $1490 per person in 2006 (about 20% of 2006 US expenditure). Similarly, only 6·8% of the country’s total gross domestic product was spent on health care in 2006, a remarkably low proportion when compared internationally (figure).4 Figure Health expenditure and life expectancy for selected developed countries and Czech Republic, 1990 versus 2006 Despite the apparent contradiction between the health-care system’s high use and low expenditure, the health of the population has improved dramatically in the past 20 years. Life expectancies increased 5·4 years in men and 4·6 years in women, compared with average increases of 4·4 and 3·2 years, respectively, in richer countries.4 Over this period, the infant mortality rate has dropped to a quarter of what it was, to 3·14 deaths per 1000 livebirths—well below the EU average and among the lowest in the world.3 Mortality rates are typical of developed countries, with diseases of the circulatory system, cerebrovascular diseases, and cancers accounting for three-quarters of all deaths in 2007.7 Investments in prevention and containment have led to rates of communicable disease that are among the lowest in the EU. The prevalence of tuberculosis is low for the region, and similar patterns are seen for viral hepatitis, scarlet fever, and viral encephalitis.4,7 HIV has also been well contained throughout the country—there were only 147 new cases in 2008.8 Despite effective disease control, there is still great concern over the country’s high rates of obesity and tobacco use, especially in young people. Clearly, the Czech health-care system is not without its share of challenges. Besides the overuse of health-care resources and the ongoing controversy over copayments, the country has also faced human capital loss since the opening of EU borders, as many physicians have explored higher-paying opportunities in neighbouring countries. However, the accomplishments have certainly out weighed the difficulties. In 20 years, an effective health-care system has replaced that left by the country’s Communist rule. As one of the most successful overhauls of a health-care system in history continues, modern challenges must be properly dealt with in the next 20 years and beyond.

Investigation in psychological state and it's correlation factors of family members of dderly cancerpatients

Objective To investigate the psychological state and its correlation factors of family members of elderly cancer patients. Methods A total of 76 family members of elderly cancer patients were investigated with questionnaires with Zung's self-rating anxiety scale (SAS) and self-rating depression scale (SDS). Their psychological state and its correlation factors were analyzed. Results Incidence rate of anxiety of elderly cancer patients' family members was 52.63%, and incidence rate of depression was 46.05%. The mean standard score of SAS and SDS of elderly cancer patients' family members were both significantly higher than domestic norm. Difference of family member's gender, ways to pay health care fee, pain degree and disease condition led to different SAS and SDS score. Conclusions Family members of elderly cancer patients possessed different degree of psychological obstacle which related with multiple factors. Medical staff should not only think highly of patients' psychological state, but also their family members'. And meanwhile they should take corresponding strategy to reduce the incidence rate of anxiety and depression state in those family members. Key words: Elderly; Cancer; Family membor; Psychological state