Out-of-pocket expenditure, need, utilisation, and private health insurance in the Australian healthcare system.

Despite widespread public service provision, public funding, and private health insurance (PHI), 20% of all healthcare expenditure across the OECD is covered by out-of-pocket expenditure (OOPE). This creates an equity concern for the increasing number of individuals with chronic conditions and greater need, particularly if higher need coincides with lower income. Theoretically, individuals may mitigate OOPE risk by purchasing PHI, replacing variable OOPE with fixed expenditure on premiums. Furthermore, if PHI premiums are not risk-rated, PHI may redistribute some of the financial burden from less healthy PHI holders that have greater need to healthier PHI holders that have less need. We investigate if the burden of OOPE for individuals with greater need increases less strongly for individuals with PHI in the Australian healthcare system. The Australian healthcare system provides public health insurance with full, partial, or limited coverage, depending on the healthcare service used, and no risk rating of PHI premiums. Using data from the Household, Income and Labour Dynamics in Australia survey we find that individuals with PHI spend a greater share of their disposable income on OOPE and that the difference in OOPE share between PHI and non-PHI holders increases with greater need and utilisation, contrary to the prediction that PHI may mitigate OOPE. We also show that OOPE is a greater concern for poorer individuals for whom the difference in OOPE by PHI is the greatest.

Spillover effects of retirement: Does health vulnerability matter?

The current literature investigating the impact of retirement and the associated spousal spillover effects overlooks the unintended effects of retirement on spouses in vulnerable health, namely spouses with long-term health conditions (LTHCs). In this paper, we fill this gap in the literature and investigate the impact of an individual's retirement on their partner's health outcomes when their partner has LTHCs. Given the inherent identification challenges associated with entry into retirement, we use the pension-qualifying age in Australia as an instrument. Based on data from the Household Income and Labour Dynamics in Australia survey, we find that the husband's retirement has a positive impact on the wife's quality-adjusted life years (QALY) and other physical and mental health outcomes. We also identify redistribution of domestic workload as a key transmission mechanism of the spousal spillover effects. Women with LTHCs will see their QALY and health improve only if their husband devotes more time to domestic tasks after retirement.

Will China's Cooperative Medical System fail again? Insight from farmer satisfaction survey.

This paper studied the sustainability of China's New Rural Cooperative Medical System (NCMS) by evaluating the satisfaction rate of its participants-the farmers. The study related the overall satisfaction of the farmers to their satisfaction with the four different aspects of the program. It also identified which personal and program attributes affect the farmers' satisfaction rate. Survey data of 1278 households from 66 counties in Shandong Province of China were collected in 2011 using a multi-stage stratified cluster-sampling method. To overcome the nepotistic barriers in rural China, field surveys in each township were conducted by university students from the same place. Data were analyzed using multiple regressions and structural equation modeling method. The results showed that 86% of the farmers were either satisfied or very satisfied with the NCMS and 82% indicated their intention to continue participating in the program. Aside from its financial benefits, both the publicity and reimbursement procedure of the program were found to be significant factors in influencing the satisfaction of the farmers. Majority of the participants held positive opinions toward the NCMS, contradicting the negative assessments made by many previous studies. Given the high proportion of farmers willing to continue with the program, it is likely to be sustainable in the near future. Greater publicity and education efforts should be made to make the farmers better informed about the program, and measures should be taken to improve its reimbursement procedure and the setting of the premium level.

Relative health performance in BRICS over the past 20 years: the winners and losers.

OBJECTIVE: To determine whether the health performance of Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--has kept in step with their economic development. METHODS: Reductions in age- and sex-specific mortality seen in each BRICS country between 1990 and 2011 were measured. These results were compared with those of the best-performing countries in the world and the best-performing countries with similar income levels. We estimated each country's progress in reducing mortality and compared changes in that country's mortality rates against other countries with similar mean incomes to examine changes in avoidable mortality. FINDINGS: The relative health performance of the five study countries differed markedly over the study period. Brazil demonstrated fairly even improvement in relative health performance across the different age and sex subgroups that we assessed. India's improvement was more modest and more varied across the subgroups. South Africa and the Russian Federation exhibited large declines in health performance as well as large sex-specific inequalities in health. Although China's levels of avoidable mortality decreased in absolute terms, the level of improvement appeared low in the context of China's economic growth. CONCLUSION: When evaluating a country's health performance in terms of avoidable mortality, it is useful to compare that performance against the performance of other countries. Such comparison allows any country-specific improvements to be distinguished from general global improvements.

Identifying covariates of population health using extreme bound analysis.

BACKGROUND: The literature is full of lively discussion on the determinants of population health outcomes. However, different papers focus on small and different sets of variables according to their research agenda. Because many of these variables are measures of different aspects of development and are thus correlated, the results for one variable can be sensitive to the inclusion/exclusion of others. METHOD: We tested for the robustness of potential predictors of population health using the extreme bounds analysis. Population health was measured by life expectancy at birth and infant mortality rate. RESULTS: We found that only about half a dozen variables are robust predictors for life expectancy and infant mortality rate. Among them, adolescent fertility rate, improved water sources, and gender equality are the most robust. All institutional variables and environment variables are systematically non-robust predictors of population health. CONCLUSION: The results highlight the importance of robustness tests in identifying predictors or potential determinants of population health, and cast doubts on the findings of previous studies that fail to do so.

Does donor assistance for HIV respond to media pressure?

HIV/AIDS is a heavily mediatised disease. In this article, we test whether media attention is affecting donors' disbursement of aid for HIV to African countries. We use information available on the number of articles and press documents on HIV issues and other health concerns published in donor countries to construct a proxy of media coverage. This proxy is then included as an explanatory variable in a regression of aid for HIV to Africa. After controlling for several donor characteristics, we find that greater media coverage increases aid disbursement. This may be good news for the HIV campaign but may result in displacement effects to the extent that other diseases that cause greater mortality and morbidity receive less media coverage than HIV and thus less health aid.

Has HIV/AIDS displaced other health funding priorities? Evidence from a new dataset of development aid for health.

In recent times there has been a sense that HIV/AIDS control has been attracting a significantly larger portion of donor health funding to the extent that it crowds out funding for other health concerns. Although there is no doubt that HIV/AIDS has absorbed a large share of development assistance for health (DAH), whether HIV/AIDS is actually diverting funding away from other health concerns has yet to be analyzed fully. To fill this vacuum, this study aims to test if a higher level of HIV/AIDS funding is related to a displacement in funding for other health concerns, and if yes, to quantify the magnitude of the displacement effect. Specifically, we consider whether HIV/AIDS DAH has displaced i) TB, ii) malaria iii) health sector and 'other' DAH in terms of the dollar amount received for aid. We consider this question within a regression framework controlling for time and recipient heterogeneity. We find displacement effects for malaria and health sector funding but not TB. In particular, the displacement effect for malaria is large and worrying.

The income-climate trap of health development: a comparative analysis of African and Non-African countries.

This article conducts a comparative analysis of the interrelationship between climate, life expectancy and income between African and non-African countries. To put the analysis in a broader context of development, the paper develops an income-climate trap model that explains the multi-directional interaction between income, climate and life expectancy. It is suggested that the interaction can give rise to either a virtuous cycle of prosperity or a vicious cycle of poverty. Applying the model to a data set of 158 countries, we find that climate is a more important determinant of life expectancy in African countries than in non-African countries. We provide further empirical evidence that while climate is important in determining both life expectancy and income, income can in turn moderate the adverse effects of climate on life expectancy. In the past two decades, the income level of non-African countries has grown significantly while that of African countries has largely been stagnant, implying that the future development of African countries remains highly vulnerable to adverse climatic conditions. These findings have important implications in the context of climate change, as global warming is likely to create worsening climatic conditions that could see many less developed countries sinking deeper into an income-climate trap of underdevelopment in health.

Measuring health inequality with realization of potential life years (RePLY).

This paper proposes a new method to measure health inequalities that are caused by conditions amenable to policy intervention. The method is built on a technique that can separate avoidable and unavoidable mortality risks, using world mortality data compiled by the World Health Organization for the year 2000. The new method is applied to data from 191 countries. It is found that controlling for unavoidable mortality risks leads to a lower estimate of health inequality than otherwise, especially for developed countries. Furthermore, although countries with a higher life expectancy at birth tend to have lower health inequality, there are significant variations in health inequalities across countries with the same life expectancy. The results therefore support the WHO's plea for using health inequality as a distinct parameter from the average level of health in assessing the performance of health systems.

Avoidable mortality risks and measurement of wellbeing and inequality.

This paper proposes a data envelopment method to separate avoidable and unavoidable mortality risks. As unavoidable mortality is either beyond the control of humanity or likely to be very cost-ineffective to reduce in the short to medium term, avoidable mortality is of much greater practical relevance in measuring wellbeing and inequality. The new method is applied to a dataset consisting of life tables for 191 countries in the year 2000 to obtain a reference distribution of unavoidable mortality risks. The reference distribution is used to improve on the standard age-at-death measure to obtain an age-at-avoidable-death measure. Compared with the standard measure, age-at-avoidable-death provides a very different picture of wellbeing, and more so when it comes to inequality measures.

Measuring health inequalities between genders and age groups with realization of potential life years (RePLY).

OBJECTIVE: We propose a new method to measure health inequalities caused by conditions amenable to policy intervention and use this to identify health differences between sexes and age groups. METHODS: The lowest observed mortality rates are used as a proxy of unavoidable mortality risks to develop a new measure of health outcome - realization of potential life years (RePLY). The RePLY distribution is used to measure avoidable health inequalities between sex and age groups respectively. FINDINGS: Using RePLY we find that even those countries with very high life expectancy at birth can have substantial health inequalities across different age groups. Also, gender inequality is more pronounced among those aged < 30. Among countries with a life expectancy < 60 years, there is a much larger prevalence of gender inequality against females; countries with life expectancy > 60 years have comparable numbers of cases of inequality among females and males. Finally, high avoidable health inequality is associated with low average income, high income inequality and high population fractionalization. CONCLUSION: It is important to distinguish between unavoidable and avoidable mortality when measuring health outcomes and their distribution in society. The proposed new measure (RePLY) enables policy-makers to focus on age-sex groups with low realization of potential life years and thus high avoidable mortality risks.