Search Results (100)

Background: Caesarean section (CS) is a critical intervention, yet stark inequities in access persist across low- and middle-income countries (LMICs). Over the last decade, governments have introduced policies to eliminate or subsidize user fees; however, the collective impact of these initiatives on utilization, equity, and financial protection has not been fully synthesized. Methods: We conducted a systematic review in line with PRISMA 2020 guidelines. Searches were conducted in PubMed, Dimensions, Google Scholar, Scopus, Web of Science, and government portals for studies published between 1 January 2009 and 30 May 2025. Eligible studies evaluated government-initiated financing reforms, including full user-fee exemptions, partial subsidies, vouchers, insurance schemes, and provider-payment restructuring. Two reviewers independently applied the PICOS criteria, extracted data using a 15-item template, and assessed the study quality. Given heterogeneity, results were synthesized narratively. Results: Thirty-seven studies from 28 LMICs were included. Most (70%) evaluated fee exemptions. Mixed-methods and cross-sectional designs predominated, while only six studies employed interrupted time series designs. Twenty-two evaluations (59%) reported increased CS uptake, ranging from a 1.4-fold rise in Senegal to a threefold increase in Kano State, Nigeria. Similar surges were also observed in non-African contexts such as Iran and Georgia, where reforms included incentives for vaginal delivery or punitive tariffs to curb overuse. Fourteen of 26 fee-exemption studies documented pro-rich or pro-urban drift, while catastrophic expenditure persisted for 12–43% of households, despite the implementation of “free” policies. Median out-of-pocket costs ranged from USD 14 in Burkina Faso to nearly USD 300 in Dakar’s slums. Only one study linked reforms to a reduction in neonatal mortality (a 30% decrease in Mali/Benin), while none demonstrated an impact on maternal mortality. Qualitative evidence highlighted hidden costs, delayed reimbursements, and weak accountability. At the same time, China and Bangladesh demonstrated how demographic reforms or voucher schemes could inadvertently lead to CS overuse or expose gaps in service readiness. Conclusions: Government-led financing reforms consistently increased CS volumes but fell short of ensuring equity, financial protection, or sustained quality. Effective initiatives combined fee removal with investments in surgical capacity, timely reimbursement, and transparent accountability. Future CS policies must integrate real-time monitoring of equity and quality and adopt robust quasi-experimental designs to enable mid-course correction. Full article

Breast cancer remains a leading cause of global cancer burden, with marked differences in incidence across countries. While biological risk factors are well established, understanding the broader structural and sociocultural influences has been less comprehensive. In this study, we analyzed harmonized data from 183 countries (2017–2023), encompassing 33 variables and 7 subvariables related to demographics, nutrition, environment, health, and healthcare access, drawn from open-access international databases. Spearman correlation analysis identified strong positive associations between breast cancer incidence and discontinued breastfeeding, high LDL cholesterol, out-of-pocket healthcare expenditure, and educational attainment. Conversely, poor sanitation, lack of handwashing facilities, unsafe water, and certain nutritional deficiencies exhibited robust negative correlations, likely reflecting under detection and reporting limitations in lower-resource settings rather than true protective effects. These findings were further explored using multiple linear regression, which explained approximately 73% of the variance in global breast cancer incidence. The final model highlighted discontinued breastfeeding, prevalence of cocaine use, unsafe sanitation, high out-of-pocket healthcare expenditure, limited handwashing access, and high processed meat consumption as the most influential independent predictors. Receiver operating characteristic (ROC) analysis confirmed strong predictive value for discontinued breastfeeding and out-of-pocket expenditure, with sanitation and hygiene variables showing paradoxical inverse associations. Our results emphasize that breast cancer risk is shaped not only by individual behaviors and genetics, but also by larger-scale structural, socioeconomic, and environmental factors. These patterns suggest that targeted interventions addressing both lifestyle behaviors and systemic inequities—such as promoting breastfeeding, reducing financial barriers to healthcare, and strengthening public health infrastructure—could meaningfully reduce the global burden of breast cancer. In conclusion, this study underscores the importance of multisectoral, equity-focused prevention strategies. It also highlights the value of country-level ecological analyses in uncovering upstream determinants of cancer incidence and calls for further research to disentangle individual and contextual effects in cancer epidemiology. Full article

Background: Human immunodeficiency virus and hypertension increasingly co-occur in South Africa. Despite publicly funded care, patients with multimorbidity face high out-of-pocket costs, yet limited evidence exists from the patient perspective. Purpose: To quantify the economic burden of comorbid HIV and hypertension, assess predictors of monthly out-of-pocket costs, and explore coping mechanisms. Methods: We conducted a cross-sectional analysis using patient-level data from the Mobile Phone Text Messages to Improve Hypertension Medication Adherence in Adults with HIV (MOPHADHIV trial) [Trial number: PACTR201811878799717], a randomized controlled trial evaluating short messages services adherence support for hypertension care in people with HIV. We calculated the monthly direct non-medical, indirect, and coping costs from a patient perspective, valuing indirect costs using both actual income and minimum wage assumptions. Generalized linear models with a gamma distribution and log link were used to identify cost determinants. Catastrophic expenditure thresholds (10–40% of monthly income) were assessed. Results: Among 683 participants, mean monthly total costs were ZAR 105.81 (USD 5.72) using actual income and ZAR 182.3 (USD 9.9) when valuing indirect costs by minimum wage. These time-related productivity losses constituted the largest share of overall expenses. Regression models revealed a strong income gradient: participants in the richest quintile incurred ZAR 131.9 (95% CI: 63.6–200.1) more per month than the poorest. However, this gradient diminished or reversed under standardized wage assumptions, suggesting a heavier proportional burden on middle-income groups. Other socio-demographic factors (gender, employment, education) not significantly associated with total costs, likely reflecting the broad reach of South Africa’s primary health system. Nearly half of the participants also reported resorting to coping mechanisms such as borrowing or asset sales. Conclusions: Comorbid HIV and hypertension impose substantial patient costs, predominantly indirect. Income disparities drive variation, raising equity concerns. Strengthening integrated human immunodeficiency virus—non-communicable diseases care and targeting financial support are key to advancing South Africa’s Universal Health Coverage reforms. Full article

Objectives: This study aims to examine the impact of Diagnosis-Related Group (DRG) payment on medical costs, efficiency, and quality of healthcare services in public hospitals, providing policy recommendations for further health insurance payment reforms in China. Methods: Utilizing inpatient medical insurance settlement data from 2020 to 2023 in the selected city, we constructed a regression discontinuity design (RDD) and an interrupted time series (ITS) model to evaluate the causal effects of the DRG reform. The analysis includes 66,533 inpatient settlement records. Results: Following the reform, the average length of stay (LOS) decreased by 2 days (95% CI: −3.43 to −0.70, p < 0.01), total hospitalization expenditures dropped by 13% (95% CI: −0.26 to −0.00, p < 0.05), and expenditures from the medical insurance fund declined by 25% (95% CI: −0.39 to −0.12, p < 0.01). Additionally, examination and consultation fees were reduced by 23% (95% CI: −0.41 to −0.05, p < 0.05), although patients’ out-of-pocket burden increased by 8% (95% CI: 0.05 to 0.10, p < 0.01). In terms of healthcare quality, the 30-day readmission rate decreased by 1% (95% CI: −0.01 to −0.00, p < 0.01), and the mortality rate among low-risk patients declined by 4% (95% CI: −0.04 to −0.03, p < 0.01). We found no evidence of patient selection or denial of admission. Heterogeneity analysis revealed that the reduction in hospital stay was concentrated among enrollees under the Urban and Rural Resident Basic Medical Insurance and those treated in secondary hospitals. The policy’s effects peaked shortly after implementation but gradually attenuated over time. Conclusions: Our study offers hospital-level evidence indicating that the initial stage of DRG implementation achieved its preliminary goals of optimizing medical resource allocation and improving the efficiency of medical insurance fund utilization. However, the reform still faces several challenges. These findings may offer valuable references for developing countries pursuing reforms in primary healthcare and health insurance payment systems. Full article

Out-of-pocket expenditure (OOPE) comprises 62% of national health expenditure in India. This heavy reliance on direct payments has engendered economic vulnerability and catastrophic financial pressures (typically defined as out-of-pocket spending exceeding a certain threshold of household income, leading to financial hardship) on households in a country where public health spending remains below targeted levels. The onset of the COVID-19 pandemic intensified these financial hardships further, as both total healthcare spending and OOPE experienced significant escalations due to the increased need for emergency care, vaccination efforts, and expanded health infrastructure. A retrospective, single-center study was conducted using data from COVID-19 patients admitted between June 2020 and June 2022. Patient data were collected from the Medical Records, IT, and Finance departments. A validated proforma was used for data extraction. Descriptive statistics were calculated, and the Shapiro–Wilk test was applied to assess normality of billing and OOPE data. Patients were stratified into three groups based on their insurance status, allowing for comparative analysis of OOPE percentages and absolute expenditures. The 2715 COVID-19 patients were categorized into three groups according to their health financing: those covered under AB-PMJAY (42.76%), private health insurance (22.16%), and the uninsured (35%). While the median billing amounts were comparable across these groups (ranging between INR 85,000 and INR 90,000), a substantial disparity was observed in terms of financial burden. All patients covered under AB-PMJAY incurred no OOPE, whereas privately insured patients had a median OOPE that constituted approximately 21% of their total billing amounts, with significant variability among different insurers. The uninsured group represented 35% of the cases and experienced the highest median OOPE, indicating substantial financial risk. The COVID-19 pandemic has revealed critical gaps in India’s health financing framework. This study emphasizes the strong financial protection provided by AB-PMJAY, while also exposing the limitations of private health insurance in shielding patients from substantial healthcare costs. As the country progresses toward universal health coverage, there is a pressing need to expand public health insurance schemes that are inclusive, equitable, and effectively implemented. Additionally, strengthening regulation and accountability in the private insurance sector is essential. The study findings reinforce that AB-PMJAY has been highly successful in reducing OOPE and enhancing financial risk protection. Although private insurance reduced OOPE, patients still faced considerable expenses. The stark difference in OOPE of 100% for uninsured patients, 21.16% for privately insured, and 0% for AB-PMJAY beneficiaries underscores the importance of further expanding AB-PMJAY to reach more vulnerable populations. Full article

This article thoroughly examines the multidimensional consequences of intimate partner violence against women (IPVAW) and estimates the monetary costs associated with this kind of violence in Spain for 2022. Based on the accounting model approach, three alternative scenarios are proposed to quantify the direct tangible costs of IPVAW from a microeconomic perspective. Each scenario considers the out-of-pocket expenditures and the opportunity cost of lost income due to IPVAW, borne by the survivor women, their families and relatives, the public sector, and the private organizations. The study utilizes microdata from the latest Spanish Macro-survey on Violence Against Women, conducted in 2019 by the Government Office against Gender-Based Violence (Spanish Government). Results show the costs ranging from EUR 1.38 billion (the most conservative estimate) to EUR 3.01 billion (the highest estimate). Further research is needed to deepen understanding of the mechanisms by which violence affects the various domains and agents of society. Full article

Specialized mental health services (SMHS) should be accessible to all populations. This study investigated the accessibility of public SMHS for children and adolescent patients, as well as their caregivers, in Mexico. A cross-sectional survey was conducted with 400 patient–caregiver dyads receiving care at two primary SMHS facilities. The survey included indicators within four dimensions of accessibility: (1) organizational entry into SMHS; (2) organizational processes within SMHS; (3) ecological factors; (4) financial aspects. Additionally, six outcome variables were explored, including perceived health conditions and quality of care indicators. A principal component analysis (PCA) was utilized to construct four accessibility indices. Subsequently, multiple linear regression models were applied to examine the relationship between these accessibility indices and the outcome variables. Several indicators yielded notable results. The average emergency ward waiting time was 74.3 min (SD = 95.99), the post-hospitalization wait time was 1.28 weeks (SD = 1.85), and the average medical costs amounted to 962.6 Mexican pesos (SD = 2555.1). Several of the tested relationships between accessibility indices and outcome variables were statistically significant; organizational processes within SMHS and financial indices had a higher number of these significant relationships. These findings highlight the significant challenges in improving accessibility to public SMHS for children and adolescents in Mexico. Full article

In this paper, we utilize the 2019/20 Uganda National Household Survey data to answer three related questions: (i) To what extent did out-of-pocket payments (OOPs) for health care services exceed the threshold for household financial catastrophe amidst COVID-19? (ii) What is the impoverishing effect of OOPs for health care services on household welfare? (iii) What are the socioeconomic and demographic determinants of OOPs for health care services in Uganda? Leveraging three health expenditure thresholds (10%, 25%, and 40%), we run a Tobit model for “left-censored” health expenditures and quantile regressions, and we find that among households which incur any form of health care expense, 37.7%, 33.6%, and 28.7% spend more than 10%, 25%, and 40% of their non-food expenditures on health care, respectively. Their average OOP budget share exceeds the respective thresholds by 82.9, 78.0, and 75.8 percentage points. While, on average, household expenditures on medicine increased amidst the COVID-19 pandemic, expenditures on consultations, transport, traditional doctors’ medicines, and other unbroken hospital charges were reduced during the same period. We find that the comparatively low incidence and intensity of catastrophic health expenditures (CHEs) in the pandemic period was not necessarily due to low household health spending, but due to foregone and substituted care. Precisely, considering the entire weighted sample, about 22% of Ugandans did not seek medical care during the pandemic due to a lack of funds, compared to 18.6% in the pre-pandemic period. More Ugandans substituted medical care from health facilities with herbs and home remedies. We further find that a 10% increase in OOPs reduces household food consumption expenditures by 2.6%. This modality of health care financing, where households incur CHEs, keeps people in chronic poverty. Full article

The modern world is confronting interconnected challenges, such as achieving sustainable health system financing for poverty reduction, amid limited guidance for stakeholders. Adhering to SDG-3 guidelines for good health and well-being could aid in accomplishing SDG-1 for eradicating poverty. This roadmap requires scientific validation. Therefore, this study aims to investigate the effect of out-of-pocket health expenditure (OOPHE) and government health expenditure (GHE) on poverty in sub-Saharan Africa (SSA) using Fully Modified Ordinary Least Squares (FMOLS) from 1990 to 2022. The results reveal that OOPHE increases poverty in the long run. In addition, the results also show that GHE augments poverty in the long run. Moreover, it is observed that GHE reinforces the positive impact of OOPHE on poverty in the long run. Additionally, the study’s empirical results support the conclusion that policymakers should advocate for the effective management of government health expenditure. Full article

This study aims to analyze the impact of government and external health spending on OOPHE across 30 SSA countries from 1995 to 2021. Using advanced econometric techniques, including the cross-sectionally augmented autoregressive distributed Lags (CS-ARDL) model and the dynamic common correlated effects (DCCE) approach, the study examined both short-term and long-term effects. Findings reveal that in the long term, government health expenditure (GHE) has a more significant impact on reducing OOPHE compared to external health expenditure (EHE). However, in the short term, GHE initially increases OOPHE, while EHE directly reduces it. This suggests that increasing GHE is more effective for long-term progress towards SDG 3. In contrast, EHE can provide immediate relief in the short term. To achieve SDG 3, policymakers should focus on increasing GHE for sustained improvements while leveraging EHE to address short-term challenges. Combining both strategies can optimize progress toward ensuring universal health coverage and well-being for all. Full article

In this study, we provide the first estimates of the effect of COVID-19 (COVID-19 legal restrictions) on catastrophic medical expenditure and forgone medical care in Africa. Data for this study were drawn from the 2018/19 Nigeria General Household Survey (NGHS) panel and the 2020/21 Nigeria COVID-19 National Longitudinal Phone Survey panel (COVID-19 NLPS). The 2020/21 COVID-19 panel survey sample was drawn from the 2018/19 NGHS panel sample monitoring the same households. Hence, we leveraged a rich set of pre-COVID-19 and COVID-19 panel household surveys that can be merged to track the effect of the pandemic on welfare outcomes. We found that the COVID-19 legal restrictions decreased catastrophic medical expenditure (measured by out-of-pocket (OOP) expenditures exceeding 10% of total household expenditure). However, the COVID-19 legal restrictions increased the incidences of forgone medical care. The results showed a consistent positive effect on forgone medical care across waves one and two, corresponding to full and partial implementation of COVID-19 legal restrictions, respectively. However, the negative effect on catastrophic medical spending was only observed when the COVID-19 legal restrictions were fully in force, but the sign reversed when the restriction enforcement became partial. Moreover, our panel regression analyses revealed that having health insurance is associated with a reduced probability of incurring CHE and forgoing medical care relative to having no health insurance. We suggest that better policy design in terms of expanding the depth and coverage of health insurance will broaden access to quality healthcare services during and beyond the pandemic periods. Full article

The empirical findings of this study suggest a significant long-term relationship between the probability of mortality due to non-communicable diseases (NCDs) among individuals aged 30–70 in Azerbaijan and key economic and social indicators, including Gross Domestic Product per Capita, Waged Employment, Human Development Index, and out-of-pocket health expenditures. The Error Correction Model coefficient (−0.724701) implies that the system adjusts back to equilibrium at a rate of 72.47% per period, highlighting a strong corrective mechanism. Additionally, in the short run, GDP, HDI, wage employment, and out-of-pocket health expenditures significantly influence mortality rates. The model’s statistical diagnostics confirm its robustness, and the results align with economic theory, reinforcing their validity and policy relevance. According to the conclusion of this research, we suggest the enhancement of the HDI and Employment, control out-of-pocket expenditures, and increase Government Healthcare Spending to significantly reduce mortality rates. This study emphasizes that enhancing social determinants like the HDI, Waged Employment, and accessible healthcare services is crucial for reducing mortality rates of NCDs. While Azerbaijan’s economic growth has improved living standards, further efforts are necessary to improve healthcare investments and reduce inequalities in health outcomes. Full article

Background: This systematic review assesses the role of the Cooperative Health Insurance System (CHIS) in achieving Universal Health Coverage (UHC) in Saudi Arabia’s evolving healthcare system by consolidating and analyzing findings from diverse studies to provide a comprehensive overview of CHIS’s impact and also identifies contextual challenges and practical insights that can inform similar reforms globally. Methods: We report results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following six databases were searched for relevant studies: PubMed, Scopus, CINAHL, Business Source Complete, APA PsycINFO, and SocIndex. The review protocol was registered with PROSPERO. Inclusion criteria focused on studies examining the impact of CHIS on the UHC dimensions based on the following themes: population covered, affordability, quality, efficiency, access, services covered, and financial coverage. The initial search identified 1316 publications. Results: A total of 30 studies met the inclusion criteria. Our synthesis indicates that CHIS has significantly improved healthcare access and quality, particularly in the private sector. CHIS was also associated with increased healthcare efficiency through standardized benefit packages and reduced out-of-pocket expenditures. However, these studies noted challenges such as rising insurance premiums, infrastructural deficiencies, and cultural barriers. Conclusions: CHIS is integral to Saudi Arabia’s healthcare reform, substantially contributing to UHC’s objectives. Despite notable advances, continuous efforts are needed to address existing challenges and expand coverage. The findings suggest that enhanced government support and public awareness are crucial for advancing UHC goals in Saudi Arabia. Full article

Background/Objectives: The Brazilian health system provides healthcare financed by the public and private sector, being the first designed to encompass universal healthcare coverage delivered to the population without charge to patients (Sistema Único de Saúde, SUS), whilst the second refers to healthcare coverage delivered for individuals with the capacity to pay for assistance through health insurance or out-of-pocket disbursements. Health insurance companies with beneficiaries receiving publicly financed healthcare from the SUS are required to provide the reimbursement of healthcare expenditures to the government, considering that the health insurance beneficiaries obtain deductions of income taxes designed to fund the SUS. Therefore, the study investigated patterns of healthcare utilization and public expenditure due to the use of public healthcare by beneficiaries of health insurance between 2003 and 2019. Methods: Datasets including annual information on healthcare utilization by beneficiaries of health insurance from the National Agency of Supplementary Health (Agência Nacional de Saúde Suplementar, ANS) were organized into a single database to allow for the identification of patterns of interest to inform public policies of health. The empirical strategy adopted included the estimation of regression models and agglomerative hierarchical cluster analysis to identify factors associated with public sector expenditure. Results: The regression results indicated lower expenditure with female patients, particularly children and adolescents under 20 years old, receiving treatment in public sector facilities linked to the federal government. The cluster analysis showed five types of health insurance beneficiaries with a higher level of healthcare utilization, being three clusters referring to medium complexity procedures with lower public expenditures, and two clusters with higher public expenditures, one cluster that refers to high complexity procedures, and one cluster referring to health insurance schemes without hospitalization. Conclusions: The findings of the study highlight the existence of patterns of healthcare utilization by health insurance beneficiaries that may compromise the sustainability of public funding within the Brazilian health system. Full article

Background/Objectives: There is a lack of empirical studies of out-of-pocket health expenditures associated with dyslipidemias, which are major cardiovascular risk factors, especially in underrepresented admixed populations. The study investigates associations of health costs with lipid traits, GWAS-derived genetic risk scores (GRSs), and other cardiometabolic risk factors. Methods: Data from the observational cross-sectional 2015 ISA-Nutrition comprised lifestyle, environmental factors, socioeconomic and demographic variables, and biochemical and genetic markers related to the occurrence of cardiometabolic diseases. GWAS-derived genetic risk scores were estimated from SNPs previously associated with lipid traits. There was phenotypic and genetic information available for 490 independent individuals, which was used as inputs for random forests and logistic regression to explain private quantitative and categorical health costs. Results: There were significant correlations between GRSs and their respective lipid phenotypes. The main relevant variables across techniques and outcome variables comprised income per capita, principal components of ancestry, diet quality, global physical activity, inflammatory and lipid markers, and LDL-c GRS and non-HDL-c GRS. The area under the ROC curve (AUC) of quartile-based categorical health expenditure without GRSs was 0.76. GRSs were not significant for this categorical outcome. Conclusions: We present an original contribution to the investigation of determinants of private health expenditures in a highly admixed population, providing insights on associations between genetic and socioeconomic dimensions of health in Brazil. Ancestry information was also among the main factors contributing to health expenses, providing a novel view of the role of genetic ancestry on cardiometabolic risk factors and its potential impact on health costs. Full article