Impoverishing Effect Research Articles

Crowding out and impoverishing effect of tobacco in Mexico

IntroductionTobacco is one of the world’s largest preventable causes of premature death, accounting for more than 8 million deaths and costing the global economy US$1.4 trillion each year. Smoking is...

The Impoverishing Effect of Tobacco Use in Indonesia.

Smoking households in Indonesia diverted a significant share of their budget to tobacco. Tobacco expenditure is deemed unproductive, as it crowds out resources from essential commodities and increases health care expenditure driven by tobacco-induced diseases. Therefore, despite having adequate resources, some smoking families in Indonesia may spend less on basic needs, which inadvertently puts their standard of living below the poverty line. Employing data from 2021 (March) Indonesia's Socioeconomic Survey (SUSENAS), this research aims to quantify the impoverishing effect of tobacco consumption in Indonesia, considering spending on tobacco and tobacco-attributable health care costs as unproductive expenditure. The de facto headcount poverty rate and poverty gap index are calculated by removing tobacco expenditures and tobacco-attributable health care expenditures from the household's total spending. Accounting for unproductive spending related to tobacco use, Indonesia's headcount poverty ratio in March 2021 would rise by 3.22 percentage points, equivalent to an additional 8.75 million people living below the poverty line. In addition, the poverty gap index would increase by 0.77 percentage points. The impoverishment effect of tobacco is larger among rural populations than their urban counterparts. Moreover, the impoverishment is mainly driven by direct tobacco spending rather than tobacco-attributable health care expenditure. Significant portions of Indonesia's population are exposed to secondary poverty due to tobacco use. A high level of cigarette spending among smoking households is the major source of the impoverishing effect of tobacco use. The study provides quantitative evidence of the true cost of smoking in Indonesia, where the de facto number of the poor population after accounting for tobacco-related spending is higher than what is published in the official statistics. The findings of this study support tobacco control policies in Indonesia, particularly to effectively reduce tobacco use and mitigate the impoverishing impact of tobacco use on low-income households.

Catastrophic Health Expenditure and Impoverishment Amongst Hepatitis B Patients in a Resource-Poor Setting

Introduction: The economic burden of managing hepatitis B has become a concern because viral hepatitis disease is a global public health problem that resulted in more deaths in 2016 than HIV and AIDs, Tuberculosis and Malaria individually. This study aimed at estimating the catastrophic health expenditure associated with managing hepatitis B, the predictors of the same and the impoverishing effect that management of hepatitis B has on affected households.
 Methods: A facility-based cross-sectional survey involving 135 hepatitis B patients selected through a two-stage sampling. Data was collected using a structured interviewer administered questionnaire and analyzed using SPSS version 25.
 Results: The average age of the respondents is 41, 60% male, 40% female. About 71% were married, and nearly two-thirds had tertiary education. Most (90.9%) paid for treatment out-of-pocket, only 7.6% had health insurance, and 1.5% were employer-covered. 71.1% of households spent over 10% of total expenditure on hepatitis B treatment, leading to financial catastrophe. Prevalence of Catastrophic health expenditure (CHE) was 71.1%, with a 20% overshoot and a mean positive overshoot of 28.1%. Being employed was protective against CHE. (OR=0.71; 95%CI=1.12 – 1.97) Post-treatment, 25.2% fell into poverty, and 21.5% into extreme poverty.
 Conclusion: Majority of hepatitis B patients pay out-of-pocket for healthcare. A major proportion of them are in financial catastrophe as a result of paying for treatment. The heavy reliance on out-of-pocket payment exposes the households of hepatitis B patients to catastrophic health expenditure and treatment of the condition impoverishes the affected households.

Impoverishing effect of tobacco use in Vietnam

BackgroundTobacco consumption places a significant economic burden on households, which is particularly severe in developing countries like Vietnam. In a country where the social insurance system is weak and healthcare...

Spatial disparities in impoverishing effects of out-of-pocket health payments in Malawi

ABSTRACT Background Out-of-pocket health payments as a means of financing health services are a cause of concern among households in low and middle-income countries. They prevent households from accessing health care services, can disrupt households’ living standards by reducing consumption of other basic needs and push households into poverty. Previous studies have reported geographical variations in impoverishing effects of out-of-pocket health payments. Yet, we know relatively little about spatial effects on impoverishing effects of health payments. Objective This paper assesses the factors associated with impoverishing effects of health payments and quantifies the role of districts spatial effects on impoverishment in Malawi. Methods The paper uses a cross sectional integrated household survey data collected from April 2016 to April 2017 among 12447 households in Malawi. Impoverishing effect of out-of-pocket health payments was calculated as the difference between poverty head count ratio before and after subtracting health payments from total household consumption expenditures. We assessed the factors associated with impoverishment and quantified the role of spatial effects using a spatial multilevel model. Results About 1.6% and 1.2% of the Malawian population were pushed below the national and international poverty line of US$1.90 respectively due health payments. We found significant spatial variations in impoverishment across districts with higher spatial residual effects clustering in central region districts. Higher socio-economic status (AOR=0.34, 95% CI=0.22-0.52) decreased the risk of impoverishment whereas hospitalizations (AOR=3.63, 95% CI 2.54-5.15), chronic illness (AOR=1.56, 95% CI=1.10-1.22), residency in rural area (AOR=2.03, 95% CI=1.07-4.26) increased the risk of impoverishment. Conclusions Our study suggests the need to plan financial protection programs according to district specific needs and target the poor, residents of rural areas and those with chronic illnesses. Policy makers need to pay attention to the importance of spatial and neighborhood effects when designing financial protection programs and policies.

Developing Malawi's Universal Health Coverage Index.

The inclusion of Universal Health Coverage (UHC) in the Sustainable Development Goals (target 3.8) cemented its position as a key global health priority and highlighted the need to measure it, and to track progress over time. In this study, we aimed to develop a summary measure of UHC for Malawi which will act as a baseline for tracking UHC index between 2020 and 2030. We developed a summary index for UHC by computing the geometric mean of indicators for the two dimensions of UHC; service coverage (SC) and financial risk protection (FRP). The indicators included for both the SC and FRP were based on the Government of Malawi's essential health package (EHP) and data availability. The SC indicator was computed as the geometric mean of preventive and treatment indicators, whereas the FRP indicator was computed as a geometric mean of the incidence of catastrophic healthcare expenditure, and the impoverishing effect of healthcare payments indicators. Data were obtained from various sources including the 2015/2016 Malawi Demographic and Health Survey (MDHS); the 2016/2017 fourth integrated household survey (IHS4); 2018/2019 Malawi Harmonized Health Facility Assessment (HHFA); the MoH HIV and TB data, and the WHO. We also conducted various combinations of input indicators and weights as part of sensitivity analysis to validate the results. The overall summary measure of UHC index was 69.68% after adjusting for inequality and unadjusted measure was 75.03%. As regards the two UHC components, the inequality adjusted summary indicator for SC was estimated to be 51.59% and unadjusted measure was 57.77%, whereas the inequality adjusted summary indicator for FRP was 94.10% and unweighted 97.45%. Overall, with the UHC index of 69.68%, Malawi is doing relatively well in comparison to other low income countries, however, significant gaps and inequalities still exist in Malawi's quest to achieve UHC especially in the SC indicators. It is imperative that targeted health financing and other health sector reforms are made to achieve this goal. Such reforms should be focused on both SC and FRP rather than on only either, of the dimensions of UHC.

Financial Risk Protection and Unmet Healthcare Need in Russia.

Achieving universal health coverage (UHC) includes financial risk protection. To date, catastrophic healthcare expenditure (CHE), the impoverishing effect of out-of-pocket (OOP) healthcare payments, and unmet healthcare need are the most widely used indicators for assessing the financial risk protection of a healthcare system. This study aimed to estimate the Russian healthcare system's financial risk protection by focusing on CHE, OOP and unmet healthcare need. The study used eight waves of the Russia Longitudinal Monitoring Survey (RLMS) (2010-2017) to analyze the financial risk protection of the Russian healthcare system. Commonly used indicators - CHE, both incidence and intensity, the impoverishing effect of CHE and unmet need -were used. We found low incidence and intensity of CHE in the Russian Federation. Our results are robust to various definitions of CHE (eg, as a share of total household expenditure or total household income). Furthermore, the impoverishing effect of OOP healthcare payments remains limited, despite the most recent economic slowdown (2014- 2016). This could be explained by a noticeable reduction in CHE during the crisis years, as postponing healthcare was adopted as a coping mechanism, particularly among households heavily affected by the crisis. As stressed by the UHC framework, our findings suggest that CHE only partly captures inefficiencies and inequities in coverage, because one tenth of households forwent medical care for medicines and certain services. As spending on medicines and dental care are the main drivers of CHE, policy interventions should focus on extending coverage for pharmaceutical and dental care and target financial barriers to seeking care, particularly for the poor and vulnerable.

Age class of alien tree stands retained for mammal protection have differential effects on flower‐visiting insect assemblages

Abstract Limited sunlight reduces plant productivity and foraging activities of pollinators, such as when alien trees shade out native flowering plants. The conservation management response is to remove the impoverishing effect of the alien tree canopy. However, alien trees can provide benefit for certain species when they provide significant scarce resources. We assess how flower‐visiting insects respond to shading from young, small‐sized, open canopy vs. mature, tall, closed‐canopy alien pine trees retained specifically as refuges for certain rare mammals. We sampled flower–visitor species diversity and interactions at various distances from pine stands of both sizes in a matrix of low sclerophyllous natural vegetation. We sampled flower–visitors using coloured pan traps and estimated flower–visitor interactions and flower diversity. Reduction in percentage light reaching the understorey significantly reduced flower abundance, with zero flowers in tall pine understorey. Flower–visitor species composition differed across sampling locations with increasing distance from tall pine understorey. Although pine tree size led to a decline in flower–visitor interaction frequency and network specialisation in all pine tree stands, some bee species that are mostly tree nesters, were observed in unique interactions in association with tall pines only. We show that alien pines, especially tall trees, have an impoverishing effect on flowering plants and flower–visitors. However, these trees also confer benefit to specialised groups such as tree‐nesting bees. While active alien pine removal is encouraged where the trees are actively invading, maintaining well‐contained small stands is of value for two different taxa of conservation concern.

The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018

IntroductionProgress towards effective service coverage and financial protection—the two dimensions of Universal Health Coverage (UHC)—has been limited in Kenya in the last decade. The government of Kenya has embarked on...

Impoverishing effect of household healthcare expenditure in semi-rural communities in Yenagoa, Nigeria

Inequity in the payment mechanism for healthcare systematically affects poorer households more than the rich. This article examines the impoverishing effect of healthcare expenditure on households in Yenagoa. Data was obtained from a crosssectional survey of households in 2 communities in Yenagoa selected by simple random sampling. A pretested, structured, interviewer-administered questionnaire was used to obtain information on household (HH) income, general expenditures and financing for healthcare. Two international poverty lines designed by World Bank were employed to classify households as poor, extremely poor and to determine the impoverishing effects of households’ healthcare expenditures. Responses were received from 525 HHs with 9.2% of HHs falling below poverty line, another 9% pushed deeper into poverty after healthcare spending. A 12.3% and 16% increase in the poverty and extreme poverty gaps respectively were attributable to health payment. A significant percentage of households who were non-poor were pushed into poverty after healthcare spending. There is need for increased public spending and implementation of innovative pre-payment mechanisms and social insurance that assures financialrisk protection and equity in health financing in Yenagoa.

Financial protection analysis in eight countries in the WHO South-East Asia Region.

ObjectiveTo document the financial protection status of eight countries of the South-East Asian region and to investigate the main components of out-of-pocket expenditure on health care.MethodsWe calculated two financial protection indicators using data from living standards surveys or household income and expenditure surveys in Bangladesh, Bhutan, India, Maldives, Nepal, Sri Lanka, Thailand and Timor-Leste. First, we calculated the incidence of catastrophic health expenditure, defined as the proportion of the population spending more than 10% or 25% of their total household expenditure on health. Second, using World Bank poverty lines, we determined the impoverishing effect of health-care spending by households. We also conducted an analysis of the main components of out-of-pocket expenditure.ResultsAcross countries in this study, 242.7 million people experienced catastrophic health expenditure at the 10% threshold, and 56.4 million at the 25% threshold. We calculated that 58.2 million people were pushed below the extreme poverty line of 1.90 United States dollars (US$) and 64.2 million people below US$ 3.10 (per capita per day values in 2011 purchasing power parity), due to out-of-pocket spending on health. Spending on medicines was the main component of out-of-pocket spending in most of the countries.ConclusionA substantial number of people in South-East Asia experienced financial hardship due to out-of-pocket spending on health. Several countries have introduced policies to make medicines more available, but the finding that out-of-pocket expenditure on medicines remains high indicates that further action is needed to support progress towards universal health coverage.

Evaluation of affordability and impoverishment effect of cardiovascular medicines in Iran

Cardiovascular disease is one of the most important causes of death in the world. There are variety of plans and strategies to treatment and prevention of CVD. Medicines have significant role to reach the goals. Ensuring Affordability of medicines is very crucial to success in these programs. The impoverishment method which focuses on the impoverishing effect of the purchasing of medicines is one the most popular methods to quantifying affordability of medicines. We applied this method to measure affordability of cardiovascular medicines in Iran. We used two poverty lines 1.25 USD and 2 USD per day which are recommended by World Bank to access the affordability of medicines. Mono therapy with one anti platelet, beta blocker, ACE inhibitor and statin as well as combination therapy have been determined. Our study highlighted that the poorest households in Iran would be at risk of pushing under poverty line because of price of the medicines.

Evaluation of public subsidy for medical travel: does it protect against household impoverishment?

BackgroundIn resource-constrained health systems medical travel is a common alternative to seeking unavailable health services. This paper was motivated by the need to understand better the impact of such travel on households and health systems.MethodsWe used primary data from 344 subsidized and 471 non-subsidized inbound medical travellers during June to December 2013 drawn from the North, Centre and South regions of the Maldives where three international airports are located. Using a researcher-administered questionnaire to acquire data, we calculated annual out-of-pocket (OOP) spending on health, food and non-food items among households where at least one member had travelled to another country for medical care within the last year and estimated the poverty head count using household income as a living standard measure.ResultsMost of the socio demographic indicators, and costs of treatment abroad among Maldivian medical travellers were similar across different household income levels with no statistical difference between subsidized and non-subsidized travellers (p value: 0.499). The government subsidy across income quintiles was also similar indicating that the Maldivian health financing structure supports equality rather than being equity-sensitive. There was no statistical difference in OOP expenditure on medical care abroad and annual OOP expenditure on healthcare was similar across income quintiles. Diseases of the circulatory system, eye and musculoskeletal system had the most impoverishing effect – diseases for which half of the patients, or less, did not receive the public subsidy. Annually, 6 and 14% of the medical travellers in the Maldives fell into poverty ($2 per day) before and after making OOP payments to health care.ConclusionEvidence of a strong association between predominant public financing of medical travel and equality was found. With universal eligibility to the government subsidy for medical travel, utilization of treatment abroad, medical expenditures abroad and OOP expenditures on health among Maldivian medical travellers were similar between the poor and the rich. However, we conclude mixed evidence on the linkages between public financing of medical travel and impoverishment which needs to be further explored with comparison of impoverishment levels between households with and without medical travel.

Out-of-pocket health spending and equity implications in Tunisia

Using data from 2000, 2005 and 2010 national household budget and consumption surveys, this paper examines the scope of catastrophic out-of-pocket (OOP) health expenditures in Tunisia and their distribution. It analyses their evolution since 2000 in relation to policy reforms in Tunisia especially since a new national health insurance fund (Caisse Nationale d’Assurance Maladie (CNAM)) became effective in 2007. The paper assesses the catastrophic dimension of OOP payments by calculating their incidence and their intensity at several thresholds and by analyzing their distribution throughout concentration indices. Estimating a probit model, the paper explores the determinants of catastrophic payments and identifies the characteristics of households coping with higher risk of catastrophic health expenditures. Finally, questioning whether the catastrophic payments have impoverishing effects on households, the paper estimates the percentage of households who move below the poverty line when accounting for OOP health payments. The paper concludes that the lasting importance of health OOP expenditures in Tunisia, their catastrophic dimension and their impoverishing effect make it necessary to look for a better allocation of the existing resources through more efficient financing mechanisms and better institutional arrangements.

Assessing catastrophic and impoverishing effects of health care payments in Uganda.

BackgroundDirect out-of-pocket payments for health care are recognised as limiting access to health care services and also endangering the welfare of households. In Uganda, such payments comprise a large portion of total health financing. This study assesses the catastrophic and impoverishing impact of paying for health care out-of-pocket in Uganda.MethodsUsing data from the Uganda National Household Surveys 2009/10, the catastrophic impact of out-of-pocket health care payments is defined using thresholds that vary with household income. The impoverishing effect of out-of-pocket health care payments is assessed using the Ugandan national poverty line and the World Bank poverty line ($1.25/day).ResultsA high level and intensity of both financial catastrophe and impoverishment due to out-of-pocket payments are recorded. Using an initial threshold of 10% of household income, about 23% of Ugandan households face financial ruin. Based on both the $1.25/day and the Ugandan poverty lines, about 4% of the population are further impoverished by such payments. This represents a relative increase in poverty head count of 17.1% and 18.1% respectively.ConclusionThe absence of financial protection in Uganda’s health system calls for concerted action. Currently, out-of-pocket payments account for a large share of total health financing and there is no pooled prepayment system available. There is therefore a need to move towards mandatory prepayment. In this way, people could access the needed health services without any associated financial consequence.

Disability and food insufficiency in the Palestinian refugee population in Lebanon: a household survey

Background According to the available data, Palestinian refugees in Lebanon have higher disability rates (4·4% in 2010) than do the Lebanese population (2·0% in 2004), and the Palestinian population in the occupied Palestinian territory (2·7% in 2011). However, the sociodemographic characteristics of the Palestinian refugees with disabilities are still not known. In this study, we describe their sociodemographic profile by type and cause of disability, and quantify the risk of disability associated with food insufficiency. Methods Data for 2631 households, including their socioeconomic and demographic characteristics, health, disability, food consumption, and food security, were from the 2010 Socio-Economic Survey of Palestine Refugees in Lebanon. Missing data for individual variables resulted in reduced sample sizes in bivariate analyses. We did not impute missing values and report findings with available data. Using Stata (version 10.0), we regressed household food consumption on disability, controlling for geographical region, household size, age composition, wealth, expenditures, sex and education of the head of the household, chronic illnesses, and participation in social assistance programmes. We also undertook multinomial logistic regression of disability by cause—food insufficiency and food security. Food security was assessed with a six-item food security scale adapted from the US Household Food Security Survey Module and the Yemen National Food Insecurity and Vulnerability Information and Mapping Systems Survey, and modified to the context of refugees living in Lebanon. Food insufficiency was defined as a positive response to a threshold question from the food security scale: food that we bought did not last and we didn't have money to buy more? We regarded most of the time and sometimes as a positive response. The household survey was approved by the institutional review board of the American University of Beirut, Beirut, Lebanon. We obtained verbal informed consent from the household proxy respondent who responded to the questionnaire. Findings 402 (15%) of 2631 Palestinian households had a member with a disability. 302 (64%) of 475 individuals with a disability were men ( vs 4810 [46%] of 10 458 able-bodied individuals), and 260 (55%) of 470 with a disability had a chronic illness ( vs 3096 [30%] of 10 418 individuals without a disability). 92 (29%) of 320 cases of disability were due to birth defects, 66 (21%) to accidents, 56 (18%) to war, 27 (8%) to work, and 79 (25%) to other causes. The sex distribution in the 24% of individuals with a disability due to other causes was less skewed than in those with a disability due to birth defects, accidents, or work (41 [53%] of 77 were men vs 175 [73%] of 241, respectively). The prevalence of chronic illnesses was higher in people with a disability caused by disease who were younger than 65 years than in those older than 65 years (35 [78%] of 45 vs 121 [50%] of 242). Regression analysis showed that disability of any cause was significantly associated with food insufficiency (p=0·023) and insecurity (p=0·008). However, food insufficiency was associated with a significantly higher risk of disability only when the disability was due to disease (p=0·05). Interpretation Our findings confirm the impoverishing effect of disability irrespective of the cause. Food insufficiency was associated with disability only when the disability was caused by disease. Interventions to ensure food sufficiency and adequate nutrition can play a part in the prevention of disability in the Palestinian refugee population and break the cycle of poverty, poor nutrition, and poor health. Funding UN Relief and Works Agency for Palestine Refugees in the Near East.

Measuring the catastrophic and impoverishing effect of household health care spending in Serbia

Out-of-pocket patient payments can impose a catastrophic burden on households. This problem may not only affect poor but also wealthy households who need to use health care frequently. The available literature offers no consensus on how to measure poverty and how to measure the effects of out-of-pocket payments on household budgets. The objective of this paper is to contribute to current research in this area by comparing results across different approaches. In particular, the paper examines the catastrophic and impoverishing effects of health care spending in Serbia applying different types of thresholds used in previous research. The application of various approaches allows us to analyze the robustness and convergent validity of the results. We also include the subjective poverty approach in our examination.We use household data from the Serbian Living Standard Measurement Study (LSMS). The Serbian LSMS data were collected in 2007 and consists of 17,375 participants living in 5557 households (sample representative for Serbia). Our results indicate that irrespective of the approach applied, out-of-pocket patient payments have a catastrophic effect on poor households in Serbia. Moreover, households that are above the absolute, relative and subjective poverty lines respectively, after the subtraction of out-of-pocket payments fall below these poverty lines. The probability of catastrophic out-of-pocket patient payments is higher in rural areas, in larger households, and among chronically sick household members (namely, people with diabetes and mental diseases, as well as cardiology diseases in some instances). Perceived health status also appears to be a significant indicator. Policy in Serbia should aim to protect vulnerable groups, especially chronically sick patients and people from rural areas.

Dissecting the Perivascular Stem-Cell Niche

Cancer stem-like cells (CSCs) may be the long sought answer to the questions puzzling scientists for over 50 years: recurrence and treatment resistance in glioblastoma multiforme (GBM). The endothelium might be the exponential player in the complex cellular milieu that regulates tumor behavior and growth. Going deeper into the perivascular stem cell niche and understanding the molecular mechanisms underlying the crosstalk between different components, may uncover innovative and more efficient therapeutic options. Eradicating the cancer stem-like cells, not only directly but also by targeting the endothelial niche, seems to be a topic of high interest in cancer research today. Recent work published by Zhu et al (Cancer Research, September 2011) tackles the problem of NOTCH ligands (DLL1, DLL4 and JAG1) of endothelial origin as the juxtacrine driving mechanism for CSC self-renewal, similar to the one seen in the normal neural stem cells of the subventricular zone. Interestingly, differentiated tumor cells seem to also contribute by providing additional NOTCH ligands, specifically JAG1. One of the three quintessential stem cell properties, self-renewal, is viewed by the authors as the main cause of tumor growth and relapse. The paper shows that the ligands directly promote neurosphere growth in vitro in a dose dependent manner by maintaining this intrinsic self-renewal capacity. Authors also conclude that these ligands do not increase the overall culture proliferation rate, as assessed by PCNA and Ki-67 levels, when mediated by the endothelium (see Figure, hBMCs–human brain microvascular endothelial cells). Ligand knockdown studies further show their diminishing growth capacity as intracranial xenografts and the impoverishing effect on CSC markers such as CD133.Figure: Human brain microvascular endothelial cells.By using the putative glioblastoma stem cell marker NESTIN, authors first demonstrate that NOTCH1 receptors are predominantly localized on CSCs and that JAG1/DLL expressing cells are placed in the vicinity of NOTCH activated cells. Having solved the problem of proximity they move on to elucidate the nature of NOTCH ligand expressing cells. DLL4 seems to be primarily linked to CD31 positive endothelial cells within the GBM. On the other hand, DLL1 is much more characteristic for tumor cells, being a marker for well differentiated GBM cells with reduced CD133 levels and reduced proliferation. By losing stemness and NOTCH activity, these later more mature cells seem to be having more of a supportive and structural role as part of the niche, with a much lower capacity to induce tumors in vivo when compared to fully functional CSCs. Blockage of the NOTCH pathway seemingly has a dual effect: depletion of the CSC pool in vitro and inhibition of tumor progression in vivo, which are probably interrelated phenomena. The authors postulate that CD 133 positive stem cells induce VEGF that further leads to DLL4 production, thereby closing a CSC-endothelium loop. The promising results seen with angiogenesis inhibitors such as bevacizumab in recurrent GBMs might therefore also be explained through this mechanistic loop, although more refined studies on the molecular effects of bevacizumab are deemed necessary. Granted that other molecules looming around the niche are also involved in CSC self-renewal, such as NO and HIF2α, and more targeted and specific antibody inhibition of each pathway might be more efficient, further studies are warranted to clearly identify all crosstalk channels of the stem cell niche and to decide upon the best mode of action to completely eradicate cancer stem cells.

Catastrophic Healthcare Payments and Impoverishment in the Occupied Palestinian Territory

Financial protection from the risks of ill health has globally recognized importance as a principal performance goal of any health system. This type of financial protection involves minimizing catastrophic payments for healthcare and their associated impoverishing effects. Realization of this performance goal is heavily influenced by factors related to the overall policy environment and sociopolitical context in each country. To examine the incidence and intensity of catastrophic and impoverishing healthcare payments borne by Palestinian households between 1998 and 2007. The incidence and intensity of these effects are examined within the historically unique policy and socioeconomic context of the occupied Palestinian territory. A healthcare payment was considered catastrophic if it exceeded 10% of household resources, or 40% of resources net of food expenditures. The impoverishing effect of healthcare was examined by comparing poverty incidence and intensity before and after healthcare payments. The data source was a series of annual expenditure and consumption surveys covering 1998 and 2004-7, and including representative samples of Palestinian households (n = 1231-3098, per year). Total household expenditure was used as a proxy for household level of resources; and the sum of household expenses on a comprehensive list of medical goods and services was used to estimate healthcare payments. While only around 1% of the surveyed households spent ≥40% of their total household expenditures (net of food expenses) on healthcare in 1998, the percentage was almost doubled in 2007. In terms of impoverishing effect, while 11.8% of surveyed households fell into deep poverty in 1998 due to healthcare payments, 12.5% of households entered deep poverty for the same reason in 2006. Over the same period, the monthly amount by which poor households failed to reach the deep poverty line due to healthcare payments increased from $US9.4 to $US12.9. The inability of the Palestinian healthcare system to protect against the financial risks of ill health could be attributed to the prevailing sociopolitical conditions of the occupied Palestinian territory, and to some intrinsic system characteristics. It is recommended that pro-poor financing schemes be pursued to mitigate the negative impact of the recurrent health shocks affecting Palestinian households.

Quantifying the Impoverishing Effects of Purchasing Medicines: A Cross-Country Comparison of the Affordability of Medicines in the Developing World

Increasing attention is being paid to the affordability of medicines in low- and middle-income countries (LICs and MICs) where medicines are often highly priced in relation to income levels. The impoverishing effect of medicine purchases can be estimated by determining pre- and postpayment incomes, which are then compared to a poverty line. Here we estimate the impoverishing effects of four medicines in 16 LICs and MICs using the impoverishment method as a metric of affordability. Affordability was assessed in terms of the proportion of the population being pushed below US$1.25 or US$2 per day poverty levels because of the purchase of medicines. The prices of salbutamol 100 mcg/dose inhaler, glibenclamide 5 mg cap/tab, atenolol 50 mg cap/tab, and amoxicillin 250 mg cap/tab were obtained from facility-based surveys undertaken using a standard measurement methodology. The World Bank's World Development Indicators provided household expenditure data and information on income distributions. In the countries studied, purchasing these medicines would impoverish large portions of the population (up to 86%). Originator brand products were less affordable than the lowest-priced generic equivalents. In the Philippines, for example, originator brand atenolol would push an additional 22% of the population below US$1.25 per day, whereas for the lowest priced generic equivalent this demographic shift is 7%. Given related prevalence figures, substantial numbers of people are affected by the unaffordability of medicines. Comparing medicine prices to available income in LICs and MICs shows that medicine purchases by individuals in those countries could lead to the impoverishment of large numbers of people. Action is needed to improve medicine affordability, such as promoting the use of quality assured, low-priced generics, and establishing health insurance systems. Please see later in the article for the Editors' Summary.