Monitoring progress towards universal health coverage in Europe: a descriptive analysis of financial protection in 40 countries.

Background: Ensuring that access to health care is affordable for everyone-financial protection-is central to universal health coverage (UHC). Financial protection is commonly measured using indicators of financial barriers to access (unmet need for health care) and financial hardship caused by out-of-pocket payments for health care (impoverishing and catastrophic health spending). We aim to assess financial hardship and unmet need in Europe and identify the coverage policy choices that undermine financial protection. Methods: We carry out a cross-sectional study of financial hardship in 40 countries in Europe in 2019 (the latest available year of data before COVID-19) using microdata from national household budget surveys. We define impoverishing health spending as out-of-pocket payments that push households below or further below a relative poverty line and catastrophic health spending as out-of-pocket payments that exceed 40% of a household's capacity to pay for health care. We link these results to survey data on unmet need for health care, dental care, and prescribed medicines and information on two aspects of coverage policy at country level: the main basis for entitlement to publicly financed health care and user charges for covered services. Findings: Out-of-pocket payments for health care lead to financial hardship and unmet need in every country in the study, particularly for people with low incomes. Impoverishing health spending ranges from under 1% of households (in six countries) to 12%, with a median of 3%. Catastrophic health spending ranges from under 1% of households (in two countries) to 20%, with a median of 6%. Catastrophic health spending is consistently concentrated in the poorest fifth of the population and is largely driven by out-of-pocket payments for outpatient medicines, medical products, and dental care-all forms of treatment that should be an essential part of primary care. The median incidence of catastrophic health spending is three times lower in countries that cover over 99% of the population than in countries that cover less than 99%. In 16 out of the 17 countries that cover less than 99% of the population, the basis for entitlement is payment of contributions to a social health insurance (SHI) scheme. Countries that give greater protection from user charges to people with low incomes have lower levels of catastrophic health spending. Interpretation: It is challenging to identify with certainty the coverage policy choices that undermine financial protection due to the complexity of the policies involved and the difficulty of disentangling the effects of different choices. The conclusions we draw are therefore tentative, though plausible. Countries are more likely to move towards UHC if they reduce out-of-pocket payments in a progressive way, decreasing them for people with low incomes first. Coverage policy choices that seem likely to achieve this include de-linking entitlement from payment of SHI contributions; expanding the coverage of outpatient medicines, medical products, and dental care; limiting user charges; and strengthening protection against user charges, particularly for people with low incomes. Funding: The European Union (DG SANTE and DG NEAR) and the Government of the Autonomous Community of Catalonia, Spain.

How resilient is health financing policy in Europe to economic shocks? Evidence from the first year of the COVID-19 pandemic and the 2008 global financial crisis.

The COVID-19 pandemic triggered an economic shock just ten years after the shock of the 2008 global financial crisis. Economic shocks are a challenge for health systems because they reduce government revenue at the same time as they increase the need for publicly financed health care. This article explores the resilience of health financing policy to economic shocks by reviewing policy responses to the financial crisis and COVID-19 in Europe. It finds that some health systems were weakened by responses to the 2008 crisis. Responses to the pandemic show evidence of lessons learnt from the earlier crisis but also reveal weaknesses in health financing policy that limit national preparedness to face economic shocks, particularly in countries with social health insurance schemes. These weaknesses highlight where permanent changes are needed to strengthen resilience in future: countries will have to find ways to reduce cyclicality in coverage policy and revenue-raising; increase the priority given to health in allocating public spending; and ensure that resources are used to meet equity and efficiency goals. Although many health systems are likely to face budgetary pressure in the years ahead, the experience of the 2008 crisis shows that austerity is not an option because it undermines resilience and progress towards universal health coverage.

Могат ли хората да си позволят да плащат за здравни услуги? Нови доказателства за финансовата защита в България

Настоящият обзор е част от серия проучвания по държави за представяне на нови доказателства относно финансовата защита на европейските здравни системи. Финансовата защита заема централно място в универсалното здравно покритие и е ключово измерение за ефективността на здравната система. В България случаите на катастрофални и водещи до обедняване разходи за здравеопазване са много повече в сравнение с другите страни в Европа. Катастрофалните разходи се дължат почти изцяло на преките плащания за лекарства в извънболничната помощ и се увеличават с течение на времето. Най-силна е концентрацията им сред по-бедните домакинства, по-възрастните хора и живеещите в селските райони. Това отразява значителни пропуски в трите измерения на здравното покритие: обхванато население, покритие на услугите и потребителски плащания (доплащания). Въпреки че през последните години публичните разходи за здравеопазване нарастват, те остават ниски по стандартите на Европейския съюз и изостават спрямо ръста на директните плащания или не се използват за посрещане на неудовлетворени потребности и финансови затруднения. За да се намалят неудовлетворените потребности и финансовите затруднения, правителството следва да се съсредоточи върху финансовата достъпност на лекарствата в извънболничната помощ и увеличаване на защитата от директните плащания за по-бедните домакинства и хронично болните. Това може да се постигне като се въведе освобождаване от доплащания за тези две групи хора, разшири се обхвата на годишния лимит на доплащане за болнична помощ с включване на всички видове доплащания и лимитът се свърже с дохода на домакинството, продължи се с подобряване на начина, по който Националната здравноосигурителна каса закупува лекарствата за извънболнично лечение и се намерят начини за разширяване на здравноосигурителното покритие до обхващане на цялото население.

Can people afford to pay for health care? New evidence on financial protection in Bulgaria

This review is part of a series of country-based studies generating new evidence on financial protection in European health systems. Financial protection is central to universal health coverage and a core dimension of health system performance. Bulgaria has a high incidence of impoverishing and catastrophic health spending compared to other countries in Europe. Catastrophic spending is almost entirely driven by out-of-pocket payments for outpatient medicines and has increased over time. It is heavily concentrated among poorer households, older people and people living in rural areas, reflecting significant gaps in all three dimensions of health coverage: population entitlement, service coverage and user charges (co-payments). Although public spending on health has grown in recent years, it remains low by European Union standards and has not kept pace with growth in out-of-pocket payments or been used to target unmet need and financial hardship. To reduce unmet need and financial hardship, the Government should focus on improving the affordability of outpatient medicines and strengthening protection from out-of-pocket payments for poorer households and people with chronic conditions. This can be done by: introducing exemptions from co-payments for these two groups of people; extending the annual cap on co-payments for inpatient care to all co-payments and linking the cap to household income; continuing to improve the way in which the National Health Insurance Fund purchases outpatient medicines; and finding ways to extend health insurance to the whole population.

Inequality in healthcare use among older people in Colombia.

BACKGROUND: Since the early 1990s, Colombia has made great strides in extending healthcare coverage to its population. In order to measure the impact of these efforts, it is important to assess whether the introduction of universal health coverage has translated into equitable access to healthcare in the country, particularly for the elderly. Thus, in this study we assessed the inequality in utilization of health services among elderly patients in Colombia. In addition, we identified the determinants of healthcare utilization. METHODS: We analyzed the 2015 Colombian health, well-being and aging study (SABE). To classify determinants of healthcare use into predisposing, enabling and need factors, we employed the Anderson framework of healthcare utilization. Use of outpatient, inpatient and preventive health services constituted the dependent variables. We performed multivariate logistic regressions, estimated concentration indexes (CI) and performed decomposition analyses of the CIs to determine the contribution of various determinants to inequality of healthcare utilization. RESULTS: The study sample included 23,694 adults over 60-years-old. Wealth quintile, urban dwelling, health insurance type and multimorbidity predicted the utilization of all types of healthcare services except for hospitalization. Aside from inpatient care, pro-rich inequality in utilization of healthcare services was present. Wealth quintile and type of health insurance were the largest contributors to pro-rich inequality in use of preventive services. CONCLUSIONS: While there has been progress in health insurance coverage for the elderly in Colombia, there are still equality challenges in the delivery of healthcare, especially for preventive and outpatient care. These inequalities are driven by individual characteristics such as wealth, urban residence, type of health insurance carried, and presence of multimorbidity. To address this issue, the Colombian health system should extend health insurance coverage to uninsured populations, as well as reduce barriers of access to healthcare services among poorest and the rural population receiving subsidized insurance.

Classical HLA alleles tag SNP in families from Antioquia with type 1 diabetes mellitus

Introduction: The HLA region strongly associates with autoimmune diseases, such as type 1 diabetes. An alternative way to test classical HLA alleles is by using tag SNP. A set of tag SNP for several classical HLA alleles has been reported as associated with susceptibility or resistance to this disease in Europeans. Objective: We aimed at validating the methodology based on tag SNP focused on the inference of classical HLA alleles, and at evaluating their association with type 1 diabetes mellitus in a sample of 200 families from Antioquia. Materials and methods: We studied a sample of 200 families from Antioquia. Each family had one or two children with T1D. We genotyped 13 SNPs using tetra-primer ARMS-PCR or PCRRFLP. In addition, we tested the validity of the tag SNP reported for Europeans in 60 individuals from a population of Colombians living in Medellín (CLM) from the 1000 Genomes Project database. Statistical analyses included the Hardy-Weinberg equilibrium, the transmission disequilibrium and the linkage disequilibrium tests. Results: The linkage disequilibrium was low in reported tag SNP and classical HLA alleles in this CLM population. Association analyses revealed both risk and protection factors to develop type 1 diabetes mellitus. Appropriate tag SNPs for the CLM population were determined by using the genotype information available in the 1000 Genome Project database. Conclusions: Although linkage disequilibrium patterns in this CLM population were different from those reported in Europeans, we did find strong evidence of the role of HLA in the development of type 1 diabetes mellitus in the study population.

Polimorfismos de un solo nucleótido representativos para los alelos clásicos del antígeno leucocitario humano en familias antioqueñas con diabetes mellitus tipo 1 / Classical HLA alleles tag SNP in families from Antioquia with type 1 diabetes mellitus

Resumen Introducción. La región del antígeno leucocitario humano (Human Leukocyte Antigen, HLA) se ha asociado claramente con enfermedades autoinmunitarias, como la diabetes mellitus de tipo 1. Los polimorfismos representativos de un solo nucleótido (tag Single Nucleotide Polymorphism, tag SNP) constituyen una forma alternativa de evaluar los alelos clásicos del HLA. En la población europea se ha reportado un grupo de tag SNP para múltiples alelos clásicos relacionados con la predisposición o la resistencia frente a dicha enfermedad. Objetivo. Validar la metodología basada en los tag SNP enfocada en la inferencia de alelos HLA clásicos, y evaluar su asociación con la diabetes mellitus de tipo 1 en una muestra de familias antioqueñas. Materiales y métodos. Se estudió una muestra de 200 familias antioqueñas con uno a dos hijos afectados por diabetes mellitus de tipo 1. Se genotipificaron 13 SNP mediante el ARMS-PCR (Amplification Refractory Mutation System-Polymerase Chain Reaction) con cuatro iniciadores, o mediante la PCR-RFLP (PCR-Restriction Fragment Length Polymorphism). Además, se evaluó la validez de los tag SNP de 1.000 genomas reportados en europeos en una muestra de 60 individuos de la población colombiana de Medellín. Se hicieron las pruebas de desequilibrio de la transmisión, de desequilibrio de ligamiento y de equilibrio de Hardy-Weinberg. Resultados. En la población de estudio no se encontró suficiente desequilibrio de ligamiento entre los SNP y los alelos clásicos evaluados, por lo cual no fue posible inferir los alelos clásicos del HLA para el conjunto de familias con diabetes mellitus de tipo 1. El estudio de asociación evidenció que esta región aporta factores tanto de riesgo como de protección para el desarrollo de la enfermedad. Los tag SNP apropiados para la muestra de estudio se determinaron usando los SNP ubicados en la región HLA en la base de datos del 1000 Genomes Project en la mencionada población. Conclusiones. Los patrones de desequilibrio de ligamiento en la población estudiada fueron diferentes a los reportados para la población europea. A pesar de esto, se encontró evidencia clara sobre el papel de la región HLA en el riesgo de padecer diabetes mellitus de tipo 1 en la población de estudio.

abstract Introduction: The HLA region strongly associates with autoimmune diseases, such as type 1 diabetes. An alternative way to test classical HLA alleles is by using tag SNP. A set of tag SNP for several classical HLA alleles has been reported as associated with susceptibility or resistance to this disease in Europeans. Objective: We aimed at validating the methodology based on tag SNP focused on the inference of classical HLA alleles, and at evaluating their association with type 1 diabetes mellitus in a sample of 200 families from Antioquia. Materials and methods: We studied a sample of 200 families from Antioquia. Each family had one or two children with T1D. We genotyped 13 SNPs using tetra-primer ARMS-PCR or PCRRFLP. In addition, we tested the validity of the tag SNP reported for Europeans in 60 individuals from a population of Colombians living in Medellín (CLM) from the 1000 Genomes Project database. Statistical analyses included the Hardy-Weinberg equilibrium, the transmission disequilibrium and the linkage disequilibrium tests. Results: The linkage disequilibrium was low in reported tag SNP and classical HLA alleles in this CLM population. Association analyses revealed both risk and protection factors to develop type 1 diabetes mellitus. Appropriate tag SNPs for the CLM population were determined by using the genotype information available in the 1000 Genome Project database. Conclusions: Although linkage disequilibrium patterns in this CLM population were different from those reported in Europeans, we did find strong evidence of the role of HLA in the development of type 1 diabetes mellitus in the study population.

Adaptación transcultural de mensajes de texto para autocuidado en gestantes

El objetivo de este trabajo fue adaptar transculturalmente mensajes de texto dirigidos a gestantes y sus acompañantes para dar herramientas a la academia en los procesos educativos. Se realizó adaptación transcultural en 4 fases: la primera partió de la revisión de textos traducidos al español por los docentes investigadores; luego se procedió a la revisión por parte de expertos; la tercera fase se articuló a partir de grupos focales con gestantes y acompañantes, y finalmente la elaboración de nuevos mensajes de acuerdo con guías y normas de atención en salud. En total, fueron revisados 170 mensajes en la primera fase: los expertos revisaron 107 dirigidos a gestantes, 37 a acompañantes, 18 sobre manejo de recién nacido, sobre estos se hicieron ajustes. El resultado de los grupos focales consolidó el proceso de claridad de los mensajes. El artículo propone una metodología para la adaptación transcultural que permite a la academia obtener mensajes que las gestantes requieren para fortalecer su autocuidado.

The objetive of this work was to adapt Cross-Culturally text messages aimed at pregnant women and their companions to give tools to the academy in educational processes. Cultural adaptation was performed in 4 phases: the first phase was the review of texts translated into Spanish by researchers; then peer review; the third phase was the execution of focus groups with pregnant women and their companions and finally the development of new messages according to guidelines and standards of health care. A total of 170 messages were reviewed in the first phase; the experts reviewed 107 aimed at pregnant women, 37 to companions and 18 related with newborn care. Adjustments were made upon these messages. The result of the focus groups consolidated the process of comprehension of the messages. The article proposes a methodology for cultural adaptation that allows the academy to get messages that pregnant women need to strengthen their self-care.

Objetivo: adaptar transcultural-mente as mensagens de texto para gravidas e seus companheiros para usar uma ferramenta académica nos processos educativos. Realizou-se adaptações transcultural em quatro fases: a primeira partiu na revisão da literatura traduzidos ao idioma espanhol pelos professores pesquisadores, depois a segunda atividade foi o processo de revisão por expertos na área; a terceira fase seleciona por meio de grupos focais com gravidas e companheiros, a última fase a elaboração de novas mensagens de acordo a guias e normas de atenção em saúde. No total, foram revisadas 170 mensagens na primeira fase: os expertos revisarão 107 textos para gravidas, 37 para seus companheiros, 18 sobre o recém-nascido, além disso o grupo focal consolidado o processo com facilidade das mensagens. O artigo propõe uma metodologia para a adaptação transcultural que permite a academia obter as mensagens que as gravides precisam para melhorar seu autocuidado.

Determinantes sociales de la salud y la calidad de vida en población adulta de Manizales, Colombia / Social determinants of health and quality of life of the adult population of Manizales, Colombia

Objetivo: Evaluar la asociación entre los determinantes sociales de la salud y la calidad de vida en una población adulta de la ciudad de Manizales. Métodos: Estudio descriptivo con una fase correlacional en un universo de 18 109 viviendas con una muestra de 440 seleccionadas a través de muestreo estratificado por afijación óptima. Como variable dependiente se midió la calidad de vida a través del formulario WHOQOL-BREF y como variables independientes se midieron los determinantes sociales de la salud estructurales e intermedios. La asociación entre las variables se midió a través de análisis bivariado mediante las pruebas U de Mann Whitney, t de Student, ANOVA y Kruskal Wallis. Resultados: La edad promedio fue de 49 años +/- 17,2 años, los ingresos mensuales mínimos del hogar fueron de 23 dólares y los ingresos máximos de 23 000 dólares, el 88,9 por ciento pertenecía al estrato socioeconómico alto. El 61,6 por ciento calificaron su calidad de vida como bastante buena. El análisis bivariado mostró asociación (p< 0,05) entre la escolaridad y la posición socioeconómica autopercibida con todas los dominios de calidad de vida así como entre los ingresos mensuales del hogar con la salud psicológica, relaciones sociales y el ambiente y la vinculación laboral con todos los dominios excepto las relaciones sociales. Conclusiones: Los determinantes sociales de la salud que se asociaron con la calidad de vida en todos sus dominios fueron la escolaridad y la posición socioeconómica autopercibida(AU)

Objective: To evaluate the association of social determinants of health and quality of life of the population in the city of Manizales, Colombia. Methods: Descriptive correlational study carried out in a sample of 440 households selected through optimal allocation stratified sampling from a universe of 18 109 households. The dependent variable was quality of life measured by using the WHOQOL-BREF and the independent variables were the structural and intermediate social determinants of health. The association of variables was measured though bivariate analysis using Mann-Whitney U, ANOVA, Student´s t and Kruskal Wallis tests. Results: The mean age was 49 ± 17.2 years; the minimum monthly household income was 23 and the maximum income was 23 000 US dollars, and 88.9 percent of the sample was rated as high socio-economic stratum. 61.6 percent rated pretty well their quality of life. The bivariate analysis showed association p< 0.05 between education and self-perceived socioeconomic status in all quality of life domains as well as between monthly household income and psychological health, social relations and working environment and links in all domains except for social relations. Conclusions: The social determinants of health associated with the quality of life in every domain were education and self-perceived socioeconomic status(AU)

Adaptación transcultural de mensajes de texto para autocuidado en gestantes / Cross-cultural adaptation of text messages for self-care in pregnant women / Adaptação transcultural de mensagens de texto para autocuidados em mulheres grávidas

El objetivo de este trabajo fue adaptar transculturalmente mensajes de texto dirigidos a gestantes y sus acompañantes para dar herramientas a la academia en los procesos educativos. Se realizó adaptación transcultural en 4 fases: la primera partió de la revisión de textos traducidos al español por los docentes investigadores; luego se procedió a la revisión por parte de expertos; la tercera fase se articuló a partir de grupos focales con gestantes y acompañantes, y finalmente la elaboración de nuevos mensajes de acuerdo con guías y normas de atención en salud. En total, fueron revisados 170 mensajes en la primera fase: los expertos revisaron 107 dirigidos a gestantes, 37 a acompañantes, 18 sobre manejo de recién nacido, sobre estos se hicieron ajustes. El resultado de los grupos focales consolidó el proceso de claridad de los mensajes. El artículo propone una metodología para la adaptación transcultural que permite a la academia obtener mensajes que las gestantes requieren para fortalecer su autocuidado.

The objective of this work was to cross-culturally adapt text messages addressed to pregnant women and their companions in order to provide tools to the academy in the educational processes. Cross-cultural adaptation was carried out in 4 phases: the first phase was based on the review of texts translated into Spanish by the research teachers; then the review was carried out by experts; the third phase was based on focus groups with pregnant women and their caregivers, and finally the elaboration of new messages in accordance with health care guidelines and norms. In total, 170 messages were reviewed in the first phase: the experts reviewed 107 messages addressed to pregnant women, 37 to those accompanying them, 18 on newborn management, and adjustments were made to these messages. The results of the focus groups consolidated the process of clarifying the messages. The article proposes a methodology for cross-cultural adaptation that allows the academy to obtain messages that pregnant women require to strengthen their self-care.

O objetivo deste trabalho foi adaptar transculturalmente mensagens de texto destinadas a mulheres grávidas e aos seus acompanhantes, a fim de fornecer ferramentas para a academia em processos educativos. A adaptação transcultural foi realizada em 4 fases: a primeira fase baseou-se na revisão dos textos traduzidos para espanhol pelos professores investigadores; em seguida, a revisão foi realizada por peritos; a terceira fase baseou-se em grupos de discussão com mulheres grávidas e seus acompanhantes e, por último, na elaboração de novas mensagens de acordo com as directrizes e normas de cuidados de saúde. No total, foram revistas 170 mensagens na primeira fase: os peritos reviram 107 mensagens dirigidas às mulheres grávidas, 37 aos seus acompanhantes e 18 sobre a gestão dos recém-nascidos, tendo sido efectuados ajustamentos a estas mensagens. Os resultados dos grupos de discussão consolidaram o processo de clarificação das mensagens. O artigo propõe uma metodologia de adaptação transcultural que permite à academia obter as mensagens de que as grávidas necessitam para reforçar o seu autocuidado.

América Latina frente a los determinantes sociales de la salud: Políticas públicas implementadas / Latin-American public policy regarding social determinants of health

RESUMEN El objetivo del presente trabajo fue identificar las políticas públicas que se han desarrollado en los países latinoamericanos frente a la intervención de los Determinantes Sociales de la Salud. Para esto se realizó una revisión temática de artículos científicos a partir de bases de datos y de documentos oficiales de organismos multilaterales y de los Ministerios de Salud de los 22 países latinoamericanos. Se hace un recuento del concepto e historia de los determinantes sociales de la salud de la Organización Mundial de la Salud y del trabajo desarrollado en el ámbito mundial en regiones como Europa, así como en Latinoamérica. Posteriormente se describen como ejemplos los casos de ocho países (Argentina, Brasil, Bolivia, Chile, Colombia, Costa Rica, México y Venezuela) y las políticas públicas desarrolladas en el área de estudio. Se concluye que en Latinoamérica hay un panorama desigual de aplicación de políticas de abordaje hacia los determinantes sociales de la salud así como una intervención segmentada principalmente hacia los determinantes intermedios de la salud, sin tener en cuenta la intervención integral desde diferentes puntos de entrada, según el marco conceptual.

ABSTRACT The study was aimed at identifying Latin-American countries’ public policy which has been related to the social determinants of health. A topic review was thus made of papers kept in the 22 Latin-American countries’ databases and official documents issued by their multilateral organisations and ministries of health. The World Health Organization’s concept of the social determinants of health has been summarised and a history given of the pertinent work developed worldwide in regions such as Europe and Latin-America. Public policy regarding the field of study in Argentina, Brazil, Bolivia, Chile, Colombia, Costa Rica, México and Venezuela has been described. It was concluded that Latin-America provides a panorama of inequality regarding the application of policy concerning the social determinants of health and that there was segmented intervention, mainly regarding intermediate determinants of health, without taking an integrated approach from different entrance points into account, according to the stated conceptual framework.

[Latin-American public policy regarding social determinants of health]. / América Latina frente a los determinantes sociales de la salud: Políticas públicas implementadas.

The study was aimed at identifying Latin-American countries' public policy which has been related to the social determinants of health. A topic review was thus made of papers kept in the 22 Latin-American countries' databases and official documents issued by their multilateral organisations and ministries of health. The World Health Organization's concept of the social determinants of health has been summarised and a history given of the pertinent work developed worldwide in regions such as Europe and Latin-America. Public policy regarding the field of study in Argentina, Brazil, Bolivia, Chile, Colombia, Costa Rica, México and Venezuela has been described. It was concluded that Latin-America provides a panorama of inequality regarding the application of policy concerning the social determinants of health and that there was segmented intervention, mainly regarding intermediate determinants of health, without taking an integrated approach from different entrance points into account, according to the stated conceptual framework.