Disability and the achievement of Universal Health Coverage in the Maldives.

OBJECTIVE: To assess access to general and disability-related health care among people with disabilities in the Maldives. METHODS: This study uses data from a case-control study (n = 711) nested within a population-based, nationally representative survey to compare health status and access to general healthcare amongst people with and without disabilities. Cases and controls were matched by gender, location and age. Unmet need for disability-related healthcare is also assessed. Multivariate regression was used for comparisons between people with and without disabilities. RESULTS: People with disabilities had poorer levels of health compared to people without disabilities, including poorer self-rated health, increased likelihood of having a chronic condition and of having had a serious health event in the previous 12 months. Although most people with and without disabilities sought care when needed, people with disabilities were much more likely to report difficulties when routinely accessing healthcare services compared to people without disabilities. Additionally, 24% of people with disabilities reported an unmet need for disability-related healthcare, which was highest amongst people with hearing, communication and cognitive difficulties, as well as amongst older adults and people living in the lowest income per capita quartile. Median healthcare spending in the past month was modest for people with and without disabilities. However, people with disabilities appear to have high episodic healthcare costs, such as for disability-related healthcare and when experiencing a serious health event. CONCLUSIONS: This study found evidence that people with disabilities experience unmet needs for both disability-related and general healthcare. There is therefore evidence that people with disabilities in the Maldives are falling behind in core components relevant to UHC: availability of all services needed, and quality and affordability of healthcare.

Musculoskeletal impairment among Syrian refugees living in Sultanbeyli, Turkey: prevalence, cause, diagnosis and need for related services and assistive products.

BACKGROUND: Epidemiological data on musculoskeletal impairment (MSI) and related service and assistive product (AP) needs for displaced populations are lacking. This study aimed to estimate the prevalence, aetiology, and specific MSI diagnosis and the need for related services and APs among Syrian refugees living in Sultanbeyli, a district in Istanbul, Turkey. METHODS: A population-based survey used probability proportionate to size and compact segment sampling to select 80 clusters ('street') of 50 individuals (aged 2+), for total sample size of approximately 4000 participants. An updated version of the Rapid Assessment of MSI tool (RAM) was used to screen all participants using six questions. Any participant who screened positive underwent a standardised examination by a physiotherapist to assess the presence, aetiology, severity and specific diagnosis of MSI and an assessment of need for related services and APs. RESULTS: The all-age prevalence of MSI was 12.2% (95% CI 10.8-13.7) and this increased significantly with age to 43.8% in people 50 and older. Over half (51%) of MSI was classified as moderate, 30% as mild and 19% as severe. The war in Syria was identified as the direct cause for 8% of people with MSI. The majority (56%) of MSI diagnoses were acquired non-traumatic causes. There was high unmet need for rehabilitation services; for example, 83% of people with MSI could benefit from physiotherapy but were not receiving this service. Overall, 19% of people with MSI had an unmet need for at least one AP. Apart from availability of walking sticks/canes, coverage was low with less than half the people with MSI who needed APs and services had received them. The most common reasons for not seeking services and APs were 'need not felt', lack of service availability and of awareness of services, and financial barriers. CONCLUSIONS: MSI is common among the Syrian refugee population living in Sultanbeyli District, particularly older adults, however less than half have been able to access relevant services and APs. These findings can inform the planning of health services for migrant populations, including the essential integration of rehabilitation and APs, and increase access to these vital services.

Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review.

BACKGROUND: One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC. METHODS: We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care. RESULTS: The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments. CONCLUSION: Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.