Targeting subsidised inpatient services to the poor in a setting with limited state capacity: proxy means testing in Myanmar's hospital equity fund scheme.

OBJECTIVES: Many low- and middle-income countries (LMICs) provide subsidised access to health services for the poor. Proxy means tests (PMTs) for income are typically employed to identify eligible beneficiaries for subsidised services but often result in significant mistargeting of benefits. We assessed the PMT approach used in Myanmar's hospital equity fund (HEF). METHODS: We analysed inclusion/exclusion errors by comparing household eligibility under the PMT used for HEF with household consumption (the gold standard proxy for income in LMICs). We assessed receipt of benefits post-hospitalisation against HEF eligibility rules and household income. Focus groups/interviews were conducted to understand administrative factors that influence targeting. We modelled (linear regression) predictors of household consumption to improve PMT accuracy. RESULTS: We found large targeting errors (86% of households in the bottom consumption quartile would be excluded and 15% of households in the top consumption quartile deemed eligible). HEF scores for PMT held little explanatory power for household income: 93% of individuals meeting the HEF eligibility criteria did not receive benefits post-hospitalisation, while 23% of ineligible individuals received programme support. Re-weighting PMT indicators on electricity access, land ownership and livestock ownership, and assigning weights to home-ownership, households with elderly/disabled members and household head education levels could significantly improve targeting accuracy. Poor programme awareness and uneven adherence to official eligibility determination procedures among staff likely affected targeting. CONCLUSIONS: Re-weighting PMT indicators and increasing training and communication about qualification procedures could improve allocation of limited funds, though accurate targeting may continue to be challenging in contexts of low state capacity.

OBJECTIFS: De nombreux pays à revenu faible ou intermédiaire (PRFI) offrent un accès subventionné aux services de santé pour les pauvres. Les tests des proxys moyens (TPM) de revenus sont généralement utilisés pour identifier les bénéficiaires éligibles pour les services subventionnés, mais aboutissent souvent à un ciblage erroné important des avantages. Nous avons évalué l'approche TPM utilisée dans le fonds d'équité des hôpitaux (FEH) du Myanmar. MÉTHODES: Nous avons analysé les erreurs d'inclusion/exclusion en comparant l'éligibilité d'un ménage selon le TPM utilisé pour le FEH avec la consommation du ménage (indicateur de référence par excellence du revenu dans les PRFI). Nous avons évalué la réception des prestations après l'hospitalisation par rapport aux règles d'éligibilité du FEH et au revenu du ménage. Des discussions de groupes ont été menées pour comprendre les facteurs administratifs qui influencent le ciblage. Nous avons modélisé (régression linéaire) les prédicteurs de la consommation des ménages afin d'améliorer la précision du TPM. RÉSULTATS: Nous avons constaté d'importantes erreurs de ciblage (86% des ménages du quartile de consommation le plus bas seraient exclus et 15% des ménages du quartile de consommation le plus haut jugés éligibles). Les scores FEH du TPM ont peu de pouvoir explicatif sur le revenu du ménage: 93% des personnes répondant aux critères d'éligibilité du FEH ne bénéficiaient pas de prestations post hospitalisation, tandis que 23% des personnes non éligibles recevaient un soutien du programme. La repondération des indicateurs du TPM sur l'accès à l'électricité, la propriété foncière et la propriété du bétail, et l'attribution de pondérations à la propriété du logement, aux ménages composés de personnes âgées/handicapées et au niveau d'éducation des chefs de ménage pourraient améliorer considérablement la précision du ciblage. La faible sensibilisation du programme et le respect inégal des procédures officielles de détermination de l'éligibilité parmi le personnel ont probablement affecté le ciblage. CONCLUSIONS: Une repondération des indicateurs du TPM et une augmentation de la formation et de la communication sur les procédures de qualification pourraient améliorer l'allocation de fonds limités, bien qu'un ciblage précis puisse continuer à être un défi dans des contextes de faible capacité de l'Etat.

Economic burden of chronic conditions among households in Myanmar: the case of angina and asthma.

BACKGROUND: Non-communicable diseases (NCDs) are becoming a major source of the national disease burden in Myanmar with potentially serious economic implications. METHODS: Using data on 5484 households from the World Health Survey (WHS), this study assessed the household-level economic burden of two chronic conditions, angina and asthma, in Myanmar. Propensity score matching (PSM) and coarsened exact matching (CEM) methods were used to compare household out-of-pocket (OOP) spending, catastrophic and impoverishment effects, reliance on borrowing or asset sales to finance OOP healthcare payments and employment among households reporting a member with angina (asthma) to matched households, with and without adjusting for comorbidities. Sensitivity analyses were carried out to assess the impacts of alternative assumptions on common support and potential violations of the assumption of independence of households being angina (asthma) affected and household economic outcomes, conditional on the variables used for matching (conditional independence). RESULTS: Households with angina (asthma) reported greater OOP spending (angina: range I$1.94-I$4.31; asthma: range I$1.53-I$2.01) (I$1 = 125.09 Myanmar Kyats; I$=International Dollar) almost half of which was spending on medicines; higher rates of catastrophic spending based on a 20% threshold ratio of OOP to total household spending (angina: range 6-7%; asthma: range 3-5%); greater reliance on borrowing and sale of assets to finance healthcare (angina: range 12-14%; asthma: range 40-49%); increased medical impoverishment and lower employment rates than matched controls. There were no statistically differences in OOP expenses for inpatient care between angina-affected (asthma-affected) households and matched controls. Our results were generally robust to multiple methods of matching. However, conclusions for medical impoverishment impacts were not robust to potential violations of the conditional independence assumption. CONCLUSIONS: Myanmar is expanding public spending on health and has recently launched an innovative programme for supporting hospital-based care for poor households. Our findings suggest the need for interventions to address OOP expenses associated with outpatient care (including drugs) for chronic conditions in Myanmar's population.

Financial risks from ill health in Myanmar: evidence and policy implications.

The government of Myanmar, with support from international donors, plans to address household financial risks from ill health and expand coverage. But evidence to design policy is limited. WHS (World Health Survey) data for 6045 households were used to investigate the association of out-of-pocket (OOP) health spending, catastrophic expenditures, and household borrowing and asset sales associated with illness with key socioeconomic and demographic correlates in Myanmar. Households with elderly and young children and chronically ill individuals, poor households, and ethnic minorities face higher financial stress from illness. Rural households use less care, suggesting their lower OOP health spending may be at the cost of health. Poorer groups rely more on public sector health services than richer groups. Better targeting, increased budgetary allocations, and more effective use of resources via designing cost-effective benefits packages appear key to sustainably addressing financial risks from ill health in Myanmar.

The relationship between terminal functionalization and molecular weight of a gene delivery polymer and transfection efficacy in mammary epithelial 2-D cultures and 3-D organotypic cultures.

Non-viral gene delivery vectors were developed for efficient gene transfer to hard-to-transfect mouse mammary epithelial cells. Ten modified versions of the same base poly(beta-amino ester), poly(1,4-butanediol diacrylate-co-5-amino-1-pentanol), were tested in both traditional 2-D monolayer and in 3-D organotypic cultures. The polymers self-assembled with plasmid DNA encoding enhanced green fluorescent protein to form nanoparticles (approximately 100 nm) used to transfect the cells. Nanoparticle transfection efficacy was tuned by changes in synthesis and fabrication conditions and the transfection efficacy was analyzed using confocal microscopy and flow cytometry. The best performing polymeric nanoparticles transfected 57 +/- 6% of the cells in 2-D culture and 6 +/- 1% of the cells in 3-D culture. Small modifications to the polymer end-capping molecules and tuning of polymer molecular weight could either significantly enhance the transfection efficacy up to 6-fold or instead abolish efficacy completely. The efficacy of leading polymers was higher than that of the commercial transfection agent FuGENE HD by a factor of 13 in 2-D and 2 in 3-D. These non-viral nanoparticles may be useful as delivery reagents or targeted therapeutics for breast cancer. This gene delivery strategy is also a promising approach for studying the normal development of the mammary gland.