Evolving Health Expenditure Landscape of the BRICS Nations and Projections to 2025

Organizational measures aiming to combat COVID-19 in the Russian Federation: the first experience

BACKGROUND

Coronavirus infection (COVID-19) spreading took place in the Russian Federation in recent 10 months. Russia has a reliable and effective governmental public health infrastructure that worked at an advanced level to control the situation since the first day of receiving reports about pneumonia ofunknown etiology cases in December 2019 and the registration of the first COVID-19 cases in Wuhan, China, in January 2020. Several measures were applied (administrative, organizational, technical, sanitary, and hygiene), nevertheless, creating an adequate response to the COVID-19 pandemic was 15 a challenge for the Russian national public health authorities.

AREAS COVERED

We used official information of the Ministry of Health of the Russian Federation, Service for Surveillance on Consumer Rights Protection and Human Wellbeing (Rospotrebnadzor), the Russian Federation Government, and Moscow Government, and the official World Health Organization (WHO);the analysis was conducted between 1 December 2019 and 31 March 2020.

EXPERT OPINION

Rospotrebnadzor implemented a set of measures which comprised of three stages: 1. Stage 1 Preventive and sanitary measures; 2. Stage 2 Organizational and technical measures; 3. Stage 3 Organizational and preventive measures.

Assessing Productivity Development of Public Hospitals: A Case Study of Shanghai, China

As the main provider of medical services for the general public, the productivity changes of public hospitals directly reflect the development of the healthcare system and the implementation effect of medical reform policies. Using the dataset of 126 public hospitals in China from 2013 to 2018, this paper improves the existing literature in both index selection and model formulation, and examines public hospitals' total factor productivity (TFP) growth. Empirical results not only demonstrate the trend of productivity development but also point out the directions in how to improve the current running status. Our study demonstrates that there were no obvious productivity fluctuations in public hospitals during the recent observing years, indicating that the performance of China's public health system was generally acceptable in coping with fast-growing medical demand. However, the effect of public hospital reform has not been remarkably shown; thus, no significant productivity improvement was observed in most hospitals. Tertiary hospitals witnessed a slight declining trend in TFP, while secondary hospitals showed signs of rising TFP. To effectively enhance the overall performance of public hospitals in China, practical suggestions are proposed from the government and hospital levels to further promote the graded medical treatment system.

Gross Domestic Product and Health Expenditure Growth in Balkan and East European Countries-Three-Decade Horizon

Background: Dynamics of health care has changed over time along with development of the countries themselves. The aim of the study is to compare macroeconomic and health expenditure indicators of interest, such as total health expenditure (THE) as percentage of global domestic product, global domestic product per capita in US$, and private households' out-of-pocket payments of Balkan and Eastern European countries on health, as well as to assess their progress over the observed period. Methods: This research report represents a descriptive data analysis of indicators extracted from the European Health for All database. The data were analyzed using a linear trend and regression analysis to estimate the timeline changes. Results: Greece and Slovenia have the largest median values of global domestic product per capita throughout the whole period, and the largest increment trend was in Lithuania. Median value in out-of-pocket payment of THE was the highest in Albania and Ukraine, while the largest decrease in trend was noticed in Albania and Bosnia and Herzegovina. Bosnia and Herzegovina and Greece had the largest median value of THE as percentage of Gross Domestic Product (GDP) in the observed period, while regression trend analysis showed that Serbia had the largest increase. Most of the countries showed a significant correlation between observed indicators. Conclusion: Trends in the economy must be constantly monitored due to the fact that the population is aging and non-communicable diseases are multiplying, which requires innovations in medical treatment and pharmaceutical development.

Prevalence of depressive symptoms in patients with Heart Failure in China: a meta-analysis of comparative studies and epidemiological surveys

BACKGROUND

Although depressive symptoms is a frequent psychiatric comorbidity in people with Heart Failure (HF) in China, its prevalence was not estimated. This is a meta-analysis of studies examining depressive symptoms in HF patients in China.

METHODS

The following databases including PubMed, the Cochrace Library, Embase, China National Knowledge Infrastructure (CNKI), WanFang and VIP were independently and systematically searched from inception until March 31, 2019. Statistical analyses were performed using the Stata 13.0 software. The pooled prevalence of depressive symptoms was performed using a random-effects model. In addition, subgroup analysis was conducted based on the New York Heart Association (NYHA) functional class, the assessment tools of depression and gender.

RESULTS

Altogether 53 studies (10649 participants) met the inclusion criteria for the analysis. The point prevalence of depressive symptoms in HF was 43%. In subgroup analyses, the prevalence of depressive symptoms was higher in females than in males (46% vs 34%, respectively), and the prevalence of depressive symptoms positively correlated with New York Heart Association functional classes (II 28%, III 46%, IV 52%) . Rates of depression were highest when measured using BDI scale (62%), and lowest when measured using the CES-D (31%).

CONCLUSIONS

This meta-analysis confirmed that the prevalence of depressive symptoms was common in HF patients in China and it is related to the severity of heart failure, gender and the diversity of assessment tools. Appropriate strategies for prevention and treatment of depressive symptoms in this population need greater attention.

Evaluation of quality of pharmacoeconomic studies involved in traditional Chinese medicine in China

OBJECTIVES

The pharmacoeconomic studies of traditional Chinese medicine (TCM) are still in its infancy. Assessing the quality of pharmacoeconomic studies of TCM to improve the efficiency of health resource allocation and guide the rational use of medicine.

METHODS

Four databases were searched from inception to January 2018. The Consolidated Health Economic Evaluation Reporting Standards statement (CHEERS) and the Quality of Health Economic Studies (QHES) were used to assess the reporting quality and methodological quality. STATA 12.0 and Meta analyst 3.13 were used to analyze the related data.

RESULTS

A total of 178 studies were included. The methodological evaluation of the study found that the total score of QHES was 47.85 ± 8.09. The report quality evaluation results found that many studies did not report comprehensive information, such as lack of detailed reports on abstracts, study perspectives, time frames, discount rates, model selection, but the titles, study background and location, and health results, resource and cost estimates, analysis methods, and heterogeneity analysis are reported in more detail. Six of the ten stratification factors have statistically significant differences.

CONCLUSION

The overall quality of pharmacoeconomic studies of TCM is low, and further standardization and improvement are needed to obtain reliable study results.

Real GDP growth rates and healthcare spending - comparison between the G7 and the EM7 countries

BACKGROUND

Accelerated globalisation has substantially contributed to the rise of emerging markets worldwide. The G7 and Emerging Markets Seven (EM7) behaved in significantly different macroeconomic ways before, during, and after the 2008 Global Crisis. Average real GDP growth rates remained substantially higher among the EM7, while unemployment rates changed their patterns after the crisis. Since 2017, however, approximately one half of the worldwide economic growth is attributable to the EM7, and only a quarter to the G7. This paper aims to analyse the association between the health spending and real GDP growth in the G7 and the EM7 countries.

RESULTS

In terms of GDP growth, the EM7 exhibited a higher degree of resilience during the 2008 crisis, compared to the G7. Unemployment in the G7 nations was rising significantly, compared to pre-recession levels, but, in the EM7, it remained traditionally high. In the G7, the austerity (measured as a percentage of GDP) significantly decreased the public health expenditure, even more so than in the EM7. Out-of-pocket health expenditure grew at a far more concerning pace in the EM7 compared to the G7 during the crisis, exposing the vulnerability of households living close to the poverty line. Regression analysis demonstrated that, in the G7, real GDP growth had a positive impact on out-of-pocket expenditure, measured as a percentage of current health expenditure, expressed as a percentage of GDP (CHE). In the EM7, it negatively affected CHE, CHE per capita, and out-of-pocket expenditure per capita.

CONCLUSION

The EM7 countries demonstrated stronger endurance, withstanding the consequences of the crisis as compared to the G7 economies. Evidence of this was most visible in real growth and unemployment rates, before, during and after the crisis. It influenced health spending patterns in both groups, although they tended to diverge instead of converge in several important areas.

Health systems efficiency in Eastern Mediterranean Region: a data envelopment analysis

BACKGROUND

One of the most important issues in public policy and welfare state is health care. Poor management leads to the waste of resources, including money, human resources, facilities, and equipment.

AIMS

This paper seeks to answer the question of which eastern Mediterranean countries are more effective in allocating their health resources, and does Iran, in relation to those countries, have an effective health system.

METHODS

This study examined technical efficiency among eastern Mediterranean countries in 2018. Data were extracted from Global Health Observatory data World Health Organization. We applied input-oriented Data Envelopment Analysis (DEA) models to estimate efficiency scores. Inputs are Physicians density per 10,000 populations, Total hospital beds per 10,000 populations, Current expenditure on health, % of gross domestic product and outputs are infant survival rate and Life expectancy.

RESULTS

The most efficient health systems in the eastern Mediterranean were Bahrain, Egypt, Iran, Lebanon, Morocco, Oman, Pakistan, Qatar, Tunisia and the United Arab Emirates. The inefficient countries are Iraq, Jordan, Kuwait, Libya, Palestine and Saudi Arabia.

CONCLUSIONS

Among the efficient countries, one category of high-entry countries such as Bahrain and Qatar with high input especially in health expenditure had higher output. The second group of countries with lower inputs such as Iran and Morocco has been able to produce similar output with other countries. Also, inefficiency in countries such as Saudi Arabia can be attributed to this with higher input such as health expenditure has lower output such life expectancy and infant survival rate.

Promises and Hurdles of Medical Tourism Development in the Russian Federation

Background: Development of medical tourism improves access to healthcare in countries where the necessary medical procedures are not available or accessible to its citizens. In the country of destination, medical tourism stimulates economic development and raises the quality of healthcare provided. There are both microeconomic and macroeconomic factors affecting the development of medical tourism. Microeconomic factors relate to the receivers and providers of healthcare. Macroeconomic factors relate to the government policy being implemented to support the development of medical tourism. This study aims to identify factors affecting the development of medical tourism in Russia.

Methodology: An expert survey of 36 heads of medical organizations in Russia was conducted to assess the problems that impede the development of the medical care system to foreign patients in Russia, as well as propose possible solutions. The degree of covariation among experts was calculated using the Kendall concordance coefficient.

Results: The experts gave consistent evaluation to numerous sets of problems that impede the development and proposed concrete measures for the development of inbound medical tourism in Russia. These measures ranged from microeconomic to macroeconomic approaches and were directed toward a holistic and coordinated development of medical tourism within Russia.

Conclusion: Based on the results, Russia has several micro- and macroeconomic competitive advantages and disadvantages in facilitating medical tourism. The study yielded a set of measures for the development of inbound medical tourism and the promotion of the export of medical services in the Russian Federation, which can be extended to other countries or parties who are seeking to develop medical tourism.

Does COVID-2019 have an Impact on the Purchase Intention of Commercial Long-Term Care Insurance among the Elderly in China?

PURPOSE

As an important measure to alleviate long-term care (LTC) costs for the disabled due to the aging of the population, long-term care insurance (LTCI) system has been paid more attention in China. In addition to the government-led public LTCI system that has been piloted in cities such as Qingdao, Chongqing and Shanghai, health insurers such as the China Life Insurance Company are also experimenting with various types of commercial LTCI in the private market. However, the commercial LTCI market is developing very slowly due to public awareness and other reasons. On the other hand, COVID-2019 has had an impact on the cognition of the importance of long-term care for the elderly due to the fact that the death cases of COVID-2019 have been mainly concentrated in the elderly population with chronic diseases such as hypertension. Therefore, the purpose of this study is to explore the differences in the purchase intention of commercial LTCI among the elderly in two different periods: before and after the outbreak of COVID-2019.

METHODS

By using the Andersen behavioral model and two investigations in two different periods before and after the outbreak of COVID-2019, this study explores the impacts of COVID-2019 on the purchase intention of commercial LTCI.

RESULTS

Some significant discoveries were found. For example, 25.8% of interviewees showed purchase intention in LTCI in the time before the COVID-2019 outbreak, while this proportion increased to 37.6% after the COVID-2019 outbreak. People who were younger (OR = 2.128, before COVID-2019; OR = 1.875, after COVID-2019) or who had more education (OR = 1.502, before COVID-2019; OR = 2.218, after COVID-2019) were more interested in commercial LTCI.

CONCLUSION

This study shows that COVID-2019 has had an obvious impact on the purchase intention of commercial LTCI, which provides some enlightenment for China to improve the LTCI system in the future, especially to accelerate the development of commercial LTCI. For example, it is essential to promote the importance of long-term care among the elderly in a focused and targeted way. In terms of the key target audience, it can be developed gradually from the groups with higher education levels and the middle elderly aged 45-64 years old.

Productivity Growth in Chinese Medical Institutions during 2009–2018

China is the most populous nation and considerations of economic efficiency in the social sectors is important for maintaining the wellbeing of such a large population. This is especially true when gauging the performance of the healthcare sector treating the population. In this paper, we examine the total factor productivity (TFP) growth in Chinese medical institutions during the period 2009–2018, which experienced a systemic healthcare reform. In order to identify the contribution from each component of TFP indicators and from each provincial or regional medical institutions, a generalized decomposition of productivity gains is applied to analyze hospital operations based on an aggregate directional distance function (DDF). The results show that the annual average TFP growth rate in Chinese medical institutions is 1.87% that is mainly driven by technological progress (0.75%, per annum), while less contributed by technical efficiency change (0.65%, p.a.) and scale efficiency change (0.47%, p.a.). Disparities of provincial hospital performances are observed that may provide policy implications for decision makers.

Cost-effectiveness and resource allocation (CERA) 18 years of evolution: maturity of adulthood and promise beyond tomorrow

Since its inception in 2003, Cost Effectiveness and Resource Allocation journal has come a long way over the past 18 years. Possibly much longer than many of its contemporaries in the blossoming science of health economics might have anticipated. Today, entering 2020 it celebrates the Age of Maturity. We believe that in the third decade of XXI century the interdisciplinary science of health economics, will rejuvenate and come back to us younger than ever from its early historical roots almost a century ago. The spreading of economic globalization in several distinctive ways, either led by multinational business corporations or newly emerged Asian leadership, or both, is likely to make challenges for contemporary health systems far more serious. The fourth industrial revolution (cyber physical systems and artificial intelligence technology) and accelerated innovation in the field of E-Health and digital health, will probably change the workflow in medical and health care, and inevitably transform the labour market in the upcoming decades. So, let us be up to the task. Let us provide academic centres, industry-sponsored pharmaceutical and medical device innovation hubs, and governing authorities alike, with a powerful forum for debate on cost-effective resource allocation in the years to come.

Health System Outcomes in BRICS Countries and Their Association With the Economic Context

The aim of the article is to compare health system outcomes in the BRICS countries, assess the trends of their changes in 2000−2017, and verify whether they are in any way correlated with the economic context. The indicators considered were: nominal and per capita current health expenditure, government health expenditure, gross domestic product (GDP) per capita, GDP growth, unemployment, inflation, and composition of GDP. The study covered five countries of the BRICS group over a period of 18 years. We decided to characterize countries covered with a dataset of selected indicators describing population health status, namely: life expectancy at birth, level of immunization, infant mortality rate, maternal mortality ratio, and tuberculosis case detection rate. We constructed a unified synthetic measure depicting the performance of individual health systems in terms of their outcomes with a single numerical value. Descriptive statistical analysis of quantitative traits consisted of the arithmetic mean (xsr), standard deviation (SD), and, where needed, the median. The normality of the distribution of variables was tested with the Shapiro–Wilk test. Spearman's rho and Kendall tau rank coefficients were used for correlation analysis between measures. The correlation analyses have been supplemented with factor analysis. We found that the best results in terms of health care system performance were recorded in Russia, China, and Brazil. India and South Africa are noticeably worse. However, the entire group performs visibly worse than the developed countries. The health system outcomes appeared to correlate on a statistically significant scale with health expenditures per capita, governments involvement in health expenditures, GDP per capita, and industry share in GDP; however, these correlations are relatively weak, with the highest strength in the case of government's involvement in health expenditures and GDP per capita. Due to weak correlation with economic background, other factors may play a role in determining health system outcomes in BRICS countries. More research should be recommended to find them and determine to what extent and how exactly they affect health system outcomes.

The Emulation and Adaptation of a Global Model of Clinical Practice Guidelines on Chronic Heart Failure in BRICS Countries: A Comparative Study

Whilst knowledge about diseases is universal, access to health care is not equally distributed. During the last decade, the countries of BRICS (Brazil, Russia, India, China, South Africa) have become important actors on the global health scene, pushing for universal, affordable, and more equal access to health care. Although non-communicable diseases place a significant burden on all populations and health systems, low- and middle-income countries (LMIC), such as BRICS, have been affected particularly hard. Approximately 80 percent of worldwide deaths from non-communicable diseases occur in LMIC. We examined if guidelines concerning chronic heart failure from BRICS countries are influenced by global scripts and if these guidelines have converged or diverged in an inter-state context. Our analysis shows that guidelines on heart failure published in BRICS predominantly rely on models initially formulated by European or American cardiological organisations. Guidelines from BRICS deviate from these models to some extent, in particular with regard to specific epidemiological conditions. Except for the Indian guideline, they do not, however, extensively engage with BRICS-specific aspects of costs, access to and affordability of health care services. We interpret these results through the lens of sociological theories on globalisation. Consistent with neoinstitutionalism, recommendations for clinical practice guidelines have spread in BRICS countries in a rather isomorphic fashion. Notwithstanding, some local medical traditions have also been included into these guidelines through localised adaptation and variation.

Marketing and Pricing Strategies of Blockbuster Drugs in the South Korean Market: A 15-Year Retrospective Cohort Study for Choline Alfoscerate

INTRODUCTION

Understanding marketing strategies and price competition among manufacturers is essential to manage health care expenditures, particularly those related to blockbuster drugs.

OBJECTIVES

To assess marketing and pricing strategies of blockbuster drugs in South Korea.

METHODS

Baseline information on manufacturers who were granted marketing approval for choline alfoscerate in various forms was retrieved. Accumulation of manufacturers in the market was also identified, and manufacturers were categorized into first movers and latecomers based on their marketing time. Then, an event history analysis and a regression analysis were applied to estimate the duration of marketing and their price competition.

RESULTS

Currently, 109, 83, and 26 manufacturers produce choline alfoscerate in capsule, tablet, or syrup form, respectively, indicating that many manufacturers have marketed generics and the majority of the generics are categorized as latecomers. The size of the manufacturer was a significant factor in marketing new medicines, while the variable was not related to the marketing of modified drugs. Furthermore, price competition in the market was rare and only a few major firms initiated price competition.

CONCLUSION

The Korean market appears to be an example of perfect competition when we focus on the number of manufacturers. However, the market is near-monopolistic when examining the price of generic drugs. While product competition between different forms of drugs is effective in lowering price, product competition within the same form of a drug does not exist in the market.

The Relative Effects of Economic Growth, Environmental Pollution and Non-Communicable Diseases on Health Expenditures in European Union Countries

National and global health policies are increasingly recognizing the key role of the environment in human health development, which is related to its economic and social determinants, such as income level, technical progress, education, quality of jobs, inequality, education or lifestyle. Research has shown that the increase of GDP (Gross Domestic Product) per capita can provide additional funds for health but also for environmental protection. However, often, economic growth is associated with the accelerated degradation of the environment, and this in turn will result in an exponential increase in harmful emissions and will implicitly determine the increasing occurrence of non-communicable diseases (NCDs), mainly cardiovascular diseases, cancers and respiratory diseases. In this paper, we investigate the role and effects of economic growth, environmental pollution and non-communicable diseases on health expenditures, for the case of EU (European Union) countries during 2000–2014. In order to investigate the long-term and the short-term relationship between them, we have employed the Panel Autoregressive Distributed Lag (ARDL) method. Using the Pedroni-Johansen cointegration methods, we found that the variables are cointegrated. The findings of this study show that economic growth is one of the most important factors influencing the health expenditures both in the long- and short-run in all the 28 EU countries. With regards to the influence of CO₂ emissions on health expenditure, we have found a negative impact in the short-run and a positive impact on the long-run. We have also introduced an interaction between NCDs and environmental expenditure as independent variable, a product variable. Finally, we have found that in all the three estimated models, the variation in environmental expenditure produces changes in NCDs’ effect on health expenditure.

Dynamics of Health Care Financing and Spending in Serbia in the XXI Century

Serbia is an upper-middle income Eastern European economy. It has inherited system of health provision and financing, which is a mixture of Soviet Semashko and German Bismarck models. So far, literature evidence on long-term trends in health spending remains scarce on this region. Observational descriptive approach was utilized relying on nationwide aggregate data reported by the Republic Health Insurance Fund (RHIF) and the Government of Serbia to the WHO office. Consecutively, the WHO Global Health Expenditure Database was used. Long-term trends were extrapolated on existing data and underlying differences were analyzed and explained. The insight was provided across two distinctively different periods within 2000-2016. The first period lasted from 2000 till 2008 (the beginning of global recession triggered by Lehman Brothers' bankruptcy). This was a period of strong upward growth in ability to invest in health care. Spending grew significantly in terms of GDP share, national and per capita reported expenditures. During the second period (2009-2016), after the beginning of worldwide economic crisis, Serbia was affected in a way that its health expenditure growth in PPP terms slowed down effectively fluctuating around plateau values from 2014 to 2016. Serbia health spending showed promising signs of steady growth in its ability to invest in health care. Consolidation marked most of the past decade with certain growth rates in recent years (2017-2019), which were not captured in these official records. The future national strategy should be devised to take into account accelerated population aging as major driver of health spending.

Patient-based cost-effectiveness analysis of FOLFIRI versus FOLFOX7 for advanced gastric adenocarcinoma in China: A 4-year prospective randomised phase II study

BACKGROUND

Using data from the 4-year follow-up results of an open, randomised, phase II study, this patient-based cost-effectiveness analysis compares mFOLFIRI (irinotecan, 5-fluorouracil and leucovorin, the IRI arm) with mFOLFOX7 (oxaliplatin, 5-fluorouracil and leucovorin, the OXA arm) as first-line treatments in patients with locally advanced gastric adenocarcinoma (GC).

METHODS

A Markov model was created based on previous results reported at the 2016 Gastrointestinal Cancers Symposium to evaluate mFOLFIRI and mFOLFOX7 for advanced GC quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were examined as the primary outcomes.

RESULTS

For the evaluable 128 patients, treatment efficacy was 0.59 QALYs for the IRI arm and 0.70 QALYs for the OXA arm, with a total cost of $13,861.34 for the IRI arm and $14,127.30 for the OXA arm. Hence, the ICER was $2,417.82 per QALY the OXA arm, which was below the threshold of 3 × per capita GDP of China. For subgroup analysis of those receiving mFOLFIRI followed by mFOLFOX7 (the IRI arm) and the reverse (the OXA arm), the OXA arm gained 0.44 more QALYs than the IRI arm with a total cost of $28,890.09 for the IRI arm and $31,147.30 for the OXA arm. However, the cost per QALY was also lower for the OXA arm than for the IRI arm, and the cost per QALY gained was $5,129.55 (below the Chinese WTP).

CONCLUSION

mFOLFOX7 is a very high cost-effective alternative as the first-line treatment for those patients with advanced GC compared with mFOLFIRI.

The impact of health expenditures on public health in BRICS nations

•Experiencing a rapid economic growth, Brazil, Russia, India, China, and South Africa (BRICS nations) are now confronting a growing aging population and an increasing prevalence of noncommunicable diseases.•The health care spending share of the economy in the BRICS nations is growing and constitutes an important part of governmental efforts to address population health and health care systems.•Even with the growth in health expenditures, there remains a significant challenge in balancing the need for promoting public health, controlling noncommunicable diseases, and improving population health in these emerging economies.•BRICS nations have a great potential for embracing a public health agenda aimed at promoting physical activity and healthy lifestyles as part of the BRICS public health policies in order to improve population health and reduce the burden of noncommunicable diseases.

Budgetary Impact of Medicinal Therapies for Rare Diseases in Bulgaria

BACKGROUND

Rare diseases have been continually outlined as one of the causes for the National Health Insurance Fund's (NHIF) deficit spending in Bulgaria.

AIM

To estimate the budgetary impact of rare disease medicinal therapies from NHIF perspective for 2014 and 2016.

MATERIALS AND METHODS

Budgetary impact of rare diseases is calculated as a percentage of NHIF total pharmaceutical spending. Total expenditure per ICD-10 code, mean annual number of patients reimbursed and mean annual cost per patient are analysed.

RESULTS

Budgetary impact of rare diseases reached a plateau of about 9% of NHIF total pharmaceutical spending for 2014-2016. Mean number of patients reimbursed and mean annual cost per patient increased by median rates of 4.27% and 2.54%, respectively. Glycogen storage disease, neuropathic heredofamilial amyloidosis and C1 esterase inhibitor deficiency stood out, as they had the second, fourth and fifth most expensive medicinal treatment cost. While accounting for only 92 patients in 2016, these three conditions contributed for 22.89% of NHIF total expenditure on rare disease medicinal therapies. For comparison, coagulation defects, with the biggest total cost per indication, had a similar budgetary impact - 24.88%, but for 277 patients reimbursed.

CONCLUSIONS

Our study does not support the concerns about uncontrolled growth of expenditures for rare disease medicinal therapies. Nevertheless, there is a need for enhanced post-marketing surveillance and performance-based payment of these treatments. Development, collection and analysis of local real-world data have been increasingly applied as a tool to advance these health policy goals.

Underlying Differences in Health Spending Within the World Health Organisation Europe Region-Comparing EU15, EU Post-2004, CIS, EU Candidate, and CARINFONET Countries

This study examined the differences in health spending within the World Health Organization (WHO) Europe region by comparing the EU15, the EU post-2004, CIS, EU Candidate and CARINFONET countries. The WHO European Region (53 countries) has been divided into the following sub-groups: EU15, EU post-2004, CIS, EU Candidate countries and CARINFONET countries. The study period, based on the availability of WHO Global Health expenditure data, was 1995 to 2014. EU15 countries have exhibited the strongest growth in total health spending both in nominal and purchasing power parity terms. The dynamics of CIS members' private sector expenditure growth as a percentage of GDP change has exceeded that of other groups. Private sector expenditure on health as a percentage of total government expenditure, has steadily the highest percentage point share among CARINFONET countries. Furthermore, private households' out-of-pocket payments on health as a percentage of total health expenditure, has been dominated by Central Asian republics for most of the period, although, for the period 2010 to 2014, the latter have tended to converge with those of CIS countries. Western EU15 nations have shown a serious growth of health expenditure far exceeding their pace of real economic growth in the long run. There is concerning growth of private health spending among the CIS and CARINFONET nations. It reflects growing citizen vulnerability in terms of questionable affordability of healthcare. Health care investment capability has grown most substantially in the Russian Federation, Turkey and Poland being the classical examples of emerging markets.

Factors influencing willingness and ability to pay for social health insurance in Nigeria

BACKGROUND

Many low and middle-income countries are increasingly cognisant of the need to offer financial protection to its citizens through pre-payment schemes in order to curb high out of pocket expenditure and catastrophic spending on healthcare. However, there is limited rigorous contextual evidence to make decisions regarding optimal design of such schemes. This study assesses the willingness-to-pay (WTP) for the recently introduced state contributory health insurance scheme (SHIS) in Nigeria.

METHODS

The study took place in 6 local government areas in Kaduna state, North-west Nigeria. Data were collected from a household survey using a three-stage cluster sampling approach, with each household having the same probability of being selected. Interviews were conducted with 4000 individuals in 1020 households. Contingent valuation was used to elicit the willing to pay (WTP) for the household using the bidding game technique. The relationship between socioeconomic status and WTP was also examined using logistic regression models.

FINDINGS

About 82% of the household heads were willing to pay insurance premiums for their households, which came to an average of 513 Naira (1.68 USD) per month per person. The average amount individuals were willing to pay was lower in rural areas (611 Naira) compared to urban areas (463 Naira). These results were influenced by household size, level of education, occupation and household income. In addition, only 65% of the households had the ability to pay the average premium.

CONCLUSION

Socioeconomic factors influence individuals' WTP for contributory health insurance schemes. It is important to create awareness about the benefits of the insurance scheme, especially in rural areas, and in both the formal and informal sectors in Nigeria. WTP information can inform the amount of insurance premiums. However, it is important to consider differences between the WTP and the cost of benefits package to be offered, as the premium amount may need to be subsidized with public financing.

Comparative financing analysis and political economy of noncommunicable diseases

The pandemic of chronic non-communicable diseases (NCDs) poses substantial challenges to the health financing sustainability in high-income and low/middle income countries (LMICs). The aim of this review is to identify the bottle neck inefficiencies in NCDs attributable spending and propose sustainable health financing solutions. The World Health Organization (WHO) introduced the "best buy" concept to scale up the core intervention package against NCDs targeted for LMICs. Population- and individual-based NCD best buy interventions are projected at US$170 billion over 2011-2025. Appropriately designed health financing arrangements can be powerful enablers to scale up the NCD best buys. Rapidly developing emerging nations dominate the landscape of LMICs. Their capability and willingness to invest resources for eradicating NCDs could strengthen WHO outreach efforts in Asia, Africa, and Latin America, much beyond current capacities. There has been a declining trend in international donor aid intended to cope with NCDs over the past decade. There is also a serious misalignment of these resources with the actual needs of recipient countries. Globally, the momentum towards the financing of intersectoral actions is growing, and this presents a cost-effective solution. A budget discrepancy of 10:1 in WHO and multilateral agencies remains in donor aid in favour of communicable diseases compared to NCDs. LMICs are likely to remain a bottleneck of NCDs imposed financing sustainability challenge in the long-run. Catastrophic household health expenditure from out of pocket spending on NCDs could plunge almost 150 million people into poverty worldwide. This epidemiological burden coupled with population ageing presents an exceptionally serious sustainability challenge, even among the richest countries which are members of the Organization for Economic Co-operation and Development (OECD). Strategic and political leadership of WHO and multilateral agencies would likely play essential roles in the struggle that has just begun.

Catastrophic Household Expenditure for Healthcare in Turkey: Clustering Analysis of Categorical Data

The amount of health expenditure at the household level is one of the most basic indicators of development in countries. In many countries, health expenditure increases relative to national income. If out-of-pocket health spending is higher than the income or too high, this indicates an economical alarm that causes a lower life standard, called catastrophic health expenditure. Catastrophic expenditure may be affected by many factors such as household type, property status, smoking and drinking alcohol habits, being active in sports, and having private health insurance. The study aims to investigate households with respect to catastrophic health expenditure by the clustering method. Clustering enables one to see the main similarity and difference between the groups. The results show that there are significant and interesting differences between the five groups. C4 households earn more but spend less money on health problems by the rate of 3.10% because people who do physical exercises regularly have fewer health problems. A household with a family with one adult, landlord and three people in total (mother or father and two children) in the cluster C5 earns much money and spends large amounts for health expenses than other clusters. C1 households with elementary families with three children, and who do not pay rent although they are not landlords have the highest catastrophic health expenditure. Households in C3 have a rate of 3.83% health expenditure rate on average, which is higher than other clusters. Households in the cluster C2 make the most catastrophic health expenditure.

The development and reform of public health in China from 1949 to 2019

BACKGROUND

Public health system plays a vital role in the development of health sector in China and protects the health of Chinese people. However, there are few comprehensive reviews and studies focusing on its evolution and reform. It is worthwhile to pay attention to the public health development in China, given that the history and structure of public health system have their own characteristics in China.

METHODS

The study is a retrospective review of the development public health over seven decades in China. It presents the findings from some national or provincial survey data, interviews with key informants, reviews of relevant published papers and policy contents.

RESULTS

This study identified four key stages that public health experienced in China: the initial stage centering on prevention, the stage of deviation with more attention to treatment but little to prevention, the recovery stage after SARS(Severe Acute Respiratory Syndromes) Crisis, and the new stage to an equitable and people-centered system. In the latest stage, the National Basic Public Health Service Program (NBPHSP) is implemented to respond the threat of noncommunicable diseases (NCDs) and has achieved some initial results, while there are still many challenges including service quality, poor integration among service items and IT system, lack of quality professionals and insufficient intersectoral endeavor.

DISCUSSION

There are unique Chinese wisdom and remarkable achievements as well as twists and turns on the development of China's public health. Prevention-first, flexible structure of the system, multi-agency collaboration and mass mobilization and society participation are the main experience of public health in early stage. Despite twists and turns since 1980s, public health system in China shows substantial resilience which may be from the government's continuous commitment to social development and people's livelihoods and its flexible governance. In 2010s, in order to achieve the well-off society, Chinese government pays unprecedented attention to health sector, which bring a new wave of opportunities to public health such as remaining the NBPHSP for priority. The evolution and reform of China's public health is based on its national condition, accumulates rich experience but also faces many common worldwide challenges. Getting this development and reform right is important to China's social and economic development in future, and China's experience in public health may provide many lessons for other countries.

CONCLUSION

Public health in China needs to focus on prevention, strengthen multi-agency coordination mechanism, improve the quality of public health services in the future.

Priority setting towards achieving under-five mortality target in Africa in context of sustainable development goals: an ordinary least squares (OLS) analysis

Background

Africa reduced its under-5 mortality rate (U5MR) by more than 50% during the MDGs era. However, it still has by far the highest average U5MR in the world – 81 deaths compared to a global average of 43 deaths per 1000 births, with eight of the ten countries in the world with the highest child mortality rates. The primary objective of our study was to examine the socioeconomic, healthcare, and environmental determinants that most account for U5MR disparities between African countries.

Methods

We used a series of ordinary least squares (OLS) regression models to assess the effects of 14 distinct socioeconomic, environmental and healthcare variables that account for the high U5MR differentials that persist between African countries. We conducted our analysis on 43 countries for which data were available. Using a dummy variable, we also emphasized factors that may be accounting for the disparity between the eight worst-performing countries and the remainder of the continent.

Results

Among all the determinants analyzed in our study, the results reveal that the factors that most account for the inequities observed are, in order, expenditure on healthcare (p < 0.01), total fertility rate (p < 0.01), income per capita (p < 0.05), and access to clean water (p < 0.1).

Conclusions

Our results show that the gap between the best and worst performing countries in Africa can be significantly narrowed if government and donor interventions will target downstream factors such as improving education for mothers and sensitising them about birth control since fertility rate differences play a critical role. Improving accessibility to clean water sources to reduce outbreaks of diarrhea diseases is also observed as a critical factor.

Analysis of the Financing of Russian Health Care over the Past 100 Years

The evolution of epidemiological burden in Imperial Russia and, consecutively, the Union of Soviet Socialist Republics (USSR), took place mostly over the duration of the past century [...].

Sources of health financing and health outcomes: A panel data analysis

We study the differential impacts of public and private sources of health spending on health outcomes using a triple difference approach. We find that private health spending has on average a higher health-promoting effect than public health spending. This result is robust with respect to the choice of outcome measure and covariates in the regression and driven primarily by the countries with ineffective governments. Once we restrict our sample to countries with effective governments, private health spending is found to be no better than public health spending in improving the health outcome.

Health care expenditure and health outcome nexus: new evidence from the SAARC-ASEAN region

Background

The total health expenditure (as a percentage of GDP) and health outcomes in the region of South Asian Association for Regional Cooperation (SAARC) and Association for South East Asian Nations (ASEAN) are lower than that of the OECD region and the world. This study investigated the relationship between different types of healthcare expenditures (public, private and total) and three main health status outcomes - life expectancy at birth, crude death rate and infant mortality rate - in the region.

Methodology

Using the World Bank data set for 15 countries over a 20-year period (1995–2014), a panel data analysis was conducted where relevant fixed and random effect models were estimated to determine the effects of healthcare expenditure on health outcomes. The main variables studied were total health expenditure, public health expenditure, private health expenditure, GDP per capita, improved sanitation, life expectancy at birth, crude death rate and infant mortality rate.

Results

Total health expenditure, public health expenditure and private health expenditure significantly reduced infant mortality rates, and, the extent of effect of private health expenditure was greater than that of public health expenditure. Private health expenditure also had a significant role in reducing the crude death rate. Per capita income growth and improved sanitation facilities also had significant positive roles in improving population health in the region.

Conclusions

Health expenditure in the SAARC-ASEAN region should be increased as our results indicated that it improved the health status of the population in the region. Public sector health funds must be appropriately and efficiently used, and accountability and transparency regarding spending of public health funds should be ensured. Finally, government and private institutes should implement appropriate strategies to improve sanitation facilities.

The Influence of Universal Health Coverage on Life Expectancy at Birth (LEAB) and Healthy Life Expectancy (HALE): A Multi-Country Cross-Sectional Study

Background: There are substantial differences in long term health outcomes across countries, particularly in terms of both life expectancy at birth (LEAB) and healthy life expectancy (HALE). Socio-economic status, disease prevention approaches, life style and health financing systems all influence long-term health goals such as life expectancy. Within this context, universal health coverage (UHC) is expected to influence life expectancy as a comprehensive health policy. The aim of the study is to investigate this relationship between Universal Health Coverage (UHC) and life expectancy. Method: A multi-country cross-sectional study was performed drawing on different sources of data (World Health Organization, UNDP-Education and World Bank) from 193 UN member countries, applying administrative record linkage theory. Descriptive statistics, t-tests, Pearson correlations, hierarchical linear regressions were utilized as appropriate. Result: Global average healthy life years was shown to be 61.34 ± 8.40 and life expectancy at birth was 70.00 ± 9.3. Standardized coefficients from regression analysis found UHC (0.34), child vaccination (Diphtheria Pertussis Tetanus-3: 0.17) and sanitation coverage (0.31) were associated with significantly increased life expectancy at birth. In contrast, population growth was associated with a decrease (0.29). Likewise, unit increases in child vaccination (DPT 3), sanitation and UHC would increase healthy life expectancy considerably (0.18, 0.31, and 0.40 respectively), whereas the same for population growth reduces healthy life expectancy by 0.28. Conclusion: Universal Health Coverage (UHC) is a comprehensive health system approach that facilitates a wide range of health services and significantly improves the life expectancy at birth and healthy life expectancy. This study suggests that specific programs to achieve UHC should be considered for countries that have not seen sufficient gains in life expectancy as part of the wider push to achieve the Sustainable Development Goal (SDG).

Cold War Legacy in Public and Private Health Spending in Europe

Cold War Era (1946-1991) was marked by the presence of two distinctively different economic systems, namely the free-market (The Western ones) and central-planned (The Eastern ones) economies. The main goal of this study refers to the exploration of development pathways of Public and Private Health Expenditure in all of the countries of the European WHO Region. Based on the availability of fully comparable data from the National Health Accounts system, we adopted the 1995-2014 time horizon. All countries were divided into two groups: those defined in 1989 as free market economies and those defined as centrally-planned economies. We observed six major health expenditures: Total Health Expenditure (% of GDP), Total Health Expenditure (PPP unit), General government expenditure on health (PPP), Private expenditure on health (PPP), Social security funds (PPP) and Out-of-pocket expenditure (PPP). All of the numerical values used refer exclusively to per capita health spending. In a time-window from the middle of the 1990s towards recent years, total health expenditure was rising fast in both groups of countries. Expenditure on health % of GDP in both group of countries increased over time with the increase in the Free-market economies seen to be more rapid. The steeper level of total expenditure on health for the Free-market as of 1989 market economies, is due mainly to a steep increase in both the government and private expenditure on health relative to spending by centrally-planned economies as of the same date, with the out-of-pocket expenditure and the social security funds in the same market economies category following the same steepness. Variety of governments were leading Eastern European countries into their transitional health care reforms. We may confirm clear presence of obvious divergent upward trends in total governmental and private health expenditures between these two groups of countries over the past two decades. The degree of challenge to the fiscal sustainability of these health systems will have to be judged for each single nation, in line with its own local circumstances and perspectives.

Antibiotic Resistance in Syria: A Local Problem Turns Into a Global Threat

Pharmaceutical sector of Syrian Arab Republic before the war was characterized by bold and successful development since the late 1980s. With the beginning of war in the country back in March 2011, momentum has changed significantly. Traumatism, communicable diseases related to morbidity and mortality as well as wound infections became particularly hot public health concern. This relates not only to the direct victims of military conflict but also to the displaced civilians, refugees, and ordinary citizens alike. Evolving legislative framework in Syria since 1980s tolerated dispensing of antibiotics without appropriate prescription. Such practice led to spreading of antibiotic resistance among the local bacteria frequently causing both community-acquired and nosocomial infections. Laboratory findings of resistant bacteria strains among the Syrian refugees in some European countries serve as evidence of concern spreading far beyond Middle East. Practice of self-diagnosis and self-medication with antibiotics by patients themselves and restraint to pharmacist advice is widespread. A number of recommendations is presented to stakeholders to compact antibiotic resistance after the peace is established in the country. The successful implementation of such recommendations is the way to preserve shrinking golden reserve of highly potent antibiotics as it is the last defense line against resistant bacterial strains causing severe life—threatening infections.

How to apply SHA 2011 at a subnational level in China's practical situation: take children health expenditure as an example

Background

System of Health Accounts 2011 (SHA 2011) is a new health care accounts system, revised from SHA 1.0 by the Organisation for Economic Co-operation and Development (OECD), the World Health Organization (WHO) and Eurostat. It keeps the former tri-axial relationship and develops three analytical interfaces, in order to fix the existing shortcomings and make it more convenient for analysis and comparison across countries. SHA 2011 was introduced in China in 2014, and little about its application in China has been reported. This study takes children as an example to study how to apply SHA 2011 at the subnational level in the practical situation of China’s health system.

Methods

Multistage random sampling method was applied and 3 532 517 samples from 252 institutions were included in the study. Official yearbooks and account reports helped the estimation of provincial data. The formula to calculate Current Health Expenditure (CHE) was introduced step-by-step. STATA 10.0 was used for statistics.

Results

Under the frame of SHA 2011, the CHE for children in Liaoning was calculated as US$ 0.74 billion in 2014; 98.56% of the expenditure was spent in hospital and the allocation to primary health care institutions was insufficient. Infection, maternal and prenatal diseases cost the most in terms of Global Burden of Disease (GBD), and respiratory system diseases took the leading place in terms of International Classification of Disease Tenth Revision (ICD-10). In addition, medical income contributed most to the health financing.

Conclusions

The method to apply SHA 2011 at the subnational level is feasible in China. It makes health accounts more adaptable to rapidly developing health systems and makes the financing data more readily available for analytical use. SHA 2011 is a better health expenditure accounts system to reveal the actual burden on residents and deserves further promotion in China as well as around the world.

High Out-of-Pocket Health Spending in Countries With a Mediterranean Connection

In this study, we analyzed healthcare provision and health expenditure across six Mediterranean countries that adopt the National Health System (Beveridge model) and that form part of the European Union (EU) with the main aim being that of analyzing and comparing out-of-pocket health spending in countries with a European Mediterranean connection. To this end, we considered various economic indicators and statistics to derive commonalities and differences across these countries and also compared trends in these indicators to those observed across the rest of the EU. We then analyzed these findings in light of other data related to the quality of healthcare delivery and the infrastructure of the health system and discussed recent developments in healthcare within each country and the main challenges faced by the respective health systems. The results show that on average, Mediterranean countries spend less on total healthcare expenditure (THE) than the EU average, both as a proportion of GDP, as well as in per capita terms. This is primarily driven by lower-than-EU-average public funding of healthcare. The 2008/2009 macro-economic and financial crisis had a significant impact on the countries under review, and explains the persistent reductions in public health spending as part of the austerity measures put in force across sectors. On the flipside, Mediterranean countries have a higher presence of private health providers in total funding, thereby explaining the higher Out-of-Pocket (OOPs) health expenditures in these countries relative to the EU-average. With regard to the overall health infrastructure in these countries, we observed that although the supply of physicians is largely in line with the rest of the EU, there is under-supply when it comes to hospital beds. This may be symptomatic of lower government funding. Nonetheless, all countries score highly in the evaluation of the quality of health services, as recorded by international rankings like the WHO's 2000 metric, whereas health system performance indicators, namely mortality rates and life expectancy reveal favorable health outcomes in the Mediterranean EU countries. The findings in this paper may be seen in light of the Mediterranean region's lifestyle in terms of diet, health behavior, health beliefs and shared culture. In particular, the higher out-of-pocket expenditure may reflect the tendency for one-to-one relationships with private clinicians and the pursuit of person-centered care (1). Additionally, the Mediterranean people may not be as disciplined as their European counterparts in accessing and using the public health sector. The lower THE also reflects the fact that the Mediterranean countries are less wealthy than the more economically-advanced European countries.

Securitizing HIV/AIDS: a game changer in state-societal relations in China?

BACKGROUND

China has experienced unprecedented economic growth since the 1980s. Despite this impressive economic development, this growth exists side by side with the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and severe acute respiratory syndrome (SARS) crises and the persisting deficiencies in public health provision in China. Acknowledging the prevailing health problems, the Chinese government has encouraged the development of health non-governmental organizations (NGOs) to respond to the health challenges and address the gaps in public health provision of the government. HIV/AIDS-focused NGOs have been perceived as the most outstanding civil society group developed in China. Considering the low priority of health policies since the economic reform, the limitation of the "third sector" activity permitted in authoritarian China, together with the political sensitivity of the HIV/AIDS problem in the country, this article aims to explain the proliferation of HIV/AIDS-focused NGOs in China with the usage of the securitization framework in the field of international relations (IR).

METHODS

The research that underpins this article is based on a desk-based literature review as well as in-depth field interviews with individuals working in HIV/AIDS-focused NGOs in China. Face-to-face interviews for this research were conducted between January and May in 2011, and between December 2016 and January 2017, in China. Discourse analysis was in particular employed in the study of the security-threat framing process (securitization) of HIV/AIDS in China.

RESULTS

This article argues that the proliferation of HIV/AIDS-related NGOs in China is largely attributed to the normative and technical effects of HIV/AIDS securitization ushered in by the United Nations Security Council (UNSC) and supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria (hereinafter Global Fund) observed in China. Despite depicting a positive scenario, the development of HIV/AIDS-focused NGOs in China generated by the international securitization efforts is largely limited. An internal and external factor was identified to verify the argument, namely (1) the reduction of international financial commitments, as well as (2) the fragmentation of HIV/AIDS-focused NGO community in China.

CONCLUSIONS

This article shows that international securitization weakened with the rise of Chinese commitment on HIV/AIDS interventions. In other words, HIV/AIDS-related responses delivered by the national government are no longer checked by the global mechanism of HIV/AIDS; thus it is unclear whether these NGOs would remain of interest as partners for the government. The fragmentation of the HIV/AIDS community would further hinder the development, preventing from NGOs with the same interest forming alliances to call for changes in current political environment. Such restriction on the concerted efforts of HIV/AIDS-related NGOs in China would make achievement of the Sustainable Development Goals (SDGs) to foster stronger partnerships between the government and civil society difficult, which in turn hindering the realization of ending HIV/AIDS in the world by 2030.

Population aging and migration - history and UN forecasts in the EU-28 and its east and south near neighborhood - one century perspective 1950-2050

BACKGROUND

There is a gap in knowledge on long term pace of population aging acceleration and related net-migration rate changes in WHO European Region and its adjacent MENA countries. We decided to compare European Union (EU-28) region with the EU Near Neighborhood Policy Region East and EU Near Neighborhood Policy Region South in terms of these two essential features of third demographic transition. One century long perspective dating back to both historical data and towards reliable future forecasts was observed.

METHODS

United Nation's Department of Economic and Social Affairs estimates on indicators of population aging and migration were observed. Time horizon adopted was 1950-2050. Targeted 44 countries belong to either one of three regions named by EU diplomacy as: European Union or EU-28, EU Near Neighborhood Policy Region East (ENP East) and EU Near Neighborhood Policy Region South (ENP South).

RESULTS

European Union region currently experiences most advanced stage of demographic aging. The latter one is the ENP East region dominated by Slavic nations whose fertility decline continues since the USSR Era back in late 1980s. ENP South region dominated by Arab League nations remains rather young compared to their northern counterparts. However, as the Third Demographic Transition is inevitably coming to these societies they remain the spring of youth and positive net emigration rate. Probably the most prominent change will be the extreme fall of total fertility rate (children per woman) in ENP South countries (dominantly Arab League) from 6.72 back in 1950 to medium-scenario forecasted 2.10 in 2050. In the same time net number of migrants in the EU28 (both sexes combined) will grow from - 91,000 in 1950 to + 394,000 in 2050.

CONCLUSIONS

Long term migration from Eastern Europe westwards and from MENA region northwards is historically present for many decades dating back deep into the Cold War Era. Contemporary large-scale migrations outsourcing from Arab League nations towards rich European Protestant North is probably the peak of an iceberg in long migration routes history. However, in the decades to come acceleration of aging is likely to question sustainability of such movements of people.

Global health worker salary estimates: an econometric analysis of global earnings data

Background

Human resources are consistently cited as a leading contributor to health care costs; however the availability of internationally comparable data on health worker earnings for all countries is a challenge for estimating the costs of health care services. This paper describes an econometric model using cross sectional earnings data from the International Labour Organization (ILO) that the World Health Organizations (WHO)-Choosing Interventions that are Cost-effective programme (CHOICE) has used to prepare estimates of health worker earnings (in 2010 USD) for all WHO member states.

Methods

The ILO data contained 324 observations of earnings data across 4 skill levels for 193 countries. Using this data, along with the assumption that data were missing not at random, we used a Heckman two stage selection model to estimate earning data for each of the 4 skill levels for all WHO member states.

Results

It was possible to develop a prediction model for health worker earnings for all countries for which GDP data was available. Health worker earnings vary both within country due to skill level, as well as across countries. As a multiple of GDP per capita, earnings show a negative correlation with GDP-that is lower income countries pay their health workers relatively more than higher income countries.

Conclusions

Limited data on health worker earnings is a limiting factor in estimating the costs of global health programmes. It is hoped that these estimates will support robust health care intervention costings and projections of resources needs over the Sustainable Development Goal period.

BRIC Health Systems and Big Pharma: A Challenge for Health Policy and Management

BRIC nations – Brazil, Russia, India, and China – represent 40% of the world’s population, including a growing aging population and middle class with an increasing prevalence of chronic disease. Their healthcare systems increasingly rely on prescription drugs, but they differ from most other healthcare systems because healthcare expenditures in BRIC nations have exhibited the highest revenue growth rates for pharmaceutical multinational corporations (MNCs), Big Pharma. The response of BRIC nations to Big Pharma presents contrasting cases of how governments manage the tensions posed by rising public expectations and limited resources to satisfy them. Understanding these tensions represents an emerging area of research and an important challenge for all those who work in the field of health policy and management (HPAM).

Systematic Review of Health Economic Evaluation Studies Developed in Brazil from 1980 to 2013

BACKGROUND

Brazil has sought to use economic evaluation to support healthcare decision-making processes. While a number of health economic evaluations (HEEs) have been conducted, no study has systematically reviewed the quality of Brazilian HEE. The objective of this systematic review was to provide an overview regarding the state of HEE research and to evaluate the number, characteristics, and quality of reporting of published HEE studies conducted in a Brazilian setting.

METHODS

We systematically searched electronic databases (MEDLINE, EMBASE, Latin American, and Caribbean Literature on Health Sciences Database, Scientific Electronic Library Online, NHS Economic Evaluation Database, health technology assessment Database, Bireme, and Biblioteca Virtual em Saúde Economia da Saúde); citation indexes (SCOPUS, Web of Science), and Sistema de Informação da Rede Brasileira de Avaliação de Tecnologia em Saúde. Partial and full HEEs published between 1980 and 2013 that referred to a Brazilian setting were considered for inclusion.

RESULTS

In total, 535 studies were included in the review, 36.8% of these were considered to be full HEE. The category of healthcare technologies more frequently assessed were procedures (34.8%) and drugs (28.8%) which main objective was treatment (72.1%). Forty-four percent of the studies reported their funding source and 36% reported a conflict of interest. Overall, the full HEE quality of reporting was satisfactory. But some items were generally poorly reported and significant improvement is required: (1) methods used to estimate healthcare resource use quantities and unit costs, (2) methods used to estimate utility values, (3) sources of funding, and (4) conflicts of interest.

CONCLUSION

A steady number of HEE have been published in Brazil since 1980. To improve their contribution to inform national healthcare policy efforts need to be made to enhance the quality of reporting of HEEs and promote improvements in the way HEEs are designed, implemented (i.e., using sound methods for HEEs) and reported.

Association between Health-Related Quality of Life and Medication Adherence in Pulmonary Tuberculosis in South Africa

Background: Health-related quality of life (HRQOL) and adherence to treatment are two often inter-related concepts that have implications for patient management and care. Tuberculosis (TB) and its treatment present a major public health concern in South Africa. The study aimed to evaluate the association between HRQOL and adherence in TB patients in South Africa. Methods: Four self-reported HRQOL and one self-reported adherence measures were used in an observational longitudinal multicentre study during 6-month standard TB treatment. These included the generic Short-Form 12 items (SF-12) and European Quality of Life 5 dimensions 5 levels (EQ-5D-5L), the disease-specific St. George's Respiratory Questionnaire (SGRQ) and the condition-specific Hospital Anxiety and Depression Scale (HADS) for HRQOL. Adherence was measured by the Morisky Medication Adherence Scale 8 items (MMAS-8). The relationship between both concepts was examined in 131 patients using Spearman's rho correlations, and linear regression models. Results: HRQOL improved over 6-month TB treatment, whereas adherence mean scores stayed constant with participants attaining a medium average level. Around 76% of patients reported to be high adherers and 24% were reporting a medium or low adherence. Associations between HRQOL and adherence were mainly weak. High adherence at treatment start was positively related to improvements in anxiety and depression after 6-month treatment. The overall improvement in pain and discomfort, and psychosocial health aspects over treatment time was positively, but weakly associated with adherence at 6 months of treatment. Conclusion: A positive relationship exists between adherence and HRQOL in TB in a South African setting, but this relationship was very weak, most likely because HRQOL is affected by a number of different factors and not limited to effects of adherence. Therefore, management of TB patients should, besides adequate drug treatment, address the specific mental and psychosocial needs.

Pharmacoeconomic Analysis of Drugs Used in the Treatment of Pneumonia in Paediatric Population in a Tertiary Care Hospital in India-A Cost-of-Illness Study

AIMS AND OBJECTIVES

The cost of antibiotic therapy for the treatment of pneumonia in the inpatient paediatric population can have a major impact on the healthcare expenditure. We planned to assess the direct and indirect costs of diagnosis and medical treatment of paediatric patients with community acquired pneumonia who are hospitalized in a tertiary care hospital in India.

METHODS

125 children with a diagnosis of pneumonia who were admitted to the inpatient department of a paediatric hospital receiving antibiotic treatment were observed. Data on clinical presentation and resources consumed were collected and the costs of pneumonia treatment were calculated. Descriptive statistics (mean ± standard deviation (SD)) were used to evaluate data regarding demographics, drugs prescribed and cost (direct and indirect cost). Multivariate regression analysis was used to find out predictors of direct and indirect cost.

RESULTS

Among all pneumonia admissions, mild-to-moderate pneumonia constitutes 76.8%, and 23.2% children were admitted with severe pneumonia; 105 children out of 125 (84%) were suffering from associated disorders along with pneumonia. The majority of antibiotics prescribed belonged to beta lactams (52%) followed by aminoglycosides (19%), macrolides (13%) and peptides (11%). Parenteral routes of administration were used in a majority of patients as compared to oral. The average cost per patient in management of pneumonia was 12245 ± 593 INR ($187.34 ± 9.07).

Ongoing Initiatives to Improve the Quality and Efficiency of Medicine Use within the Public Healthcare System in South Africa; A Preliminary Study

Introduction: South Africa has an appreciable burden of both communicable and non-communicable diseases as well as high maternal, neonatal, and child morbidity. In recent years there have been significant strides with improving the public health system, and addressing current inequalities, with the right to health a constitutional provision in South Africa. Initiatives include the introduction of National Health Insurance, programmes to enhance access to medicines for patients with chronic diseases, as well as activities to improve care in hospitals, including improving pharmacovigilance. Consequently, the objective of this paper is to review ongoing initiatives within the public healthcare sector in South Africa and their influence to provide future direction.

Method: Principally a structured review of current and planned activities.

Results: There have been a number of major activities and initiatives surrounding the availability and access to medicines in the public system in recent years in South Africa. This includes a National Surveillance Centre and an innovative early warning system for the supply of medicines as well as the development of a National Health Care Pricing Authority and initiatives to improve contracting. There have also been developments to improve the supply chain including instigating Medicine Procurement Units in the provinces and enhancing forecasting capabilities. Access to medicines is improving though the instigation of stable chronic disease management initiatives to increase the number of external pick-up points for medicines. There are also ongoing programmes to enhance adherence to medicines as well as enhance adherence to the Standard Treatment Guidelines and the Essential Medicines List with their increasing availability. In addition, there is a movement to enhance the role of health technology assessment in future decision making. Hospital initiatives include increased focus on reducing antimicrobial resistance through instigating stewardship programmes as well as improving adverse drug reaction reporting and associated activities.

Conclusion: Overall, there are an appreciable number of ongoing activities within the public healthcare system in South Africa attempting to ensure and sustain universal healthcare. It is too early to assess their impact, which will be the subject of future research.

Growth of Global Publishing Output of Health Economics in the Twenty-First Century: A Bibliographic Insight

Background

Strong growth of interdisciplinary sciences might find exceptional example in academic health economics. We decided to observe the quantitative output in this science since the beginning of the twenty-first century.

Methods

Electronic search of the published literature was conducted in four different databases: one medical database—MEDLINE/PubMed, two general databases—Scopus/Elsevier and Web of Science (WoS), and one specialized health economic database—NHS Economic Evaluation Database (EED). The applied combination of key words was carefully chosen to cover the most commonly used terms in titles of publications dealing with conceptual areas of health economics. All bibliographic units were taken into account.

Results

Within the time horizon from January 1, 2000 to December 31, 2016, without language or limitations on bibliographic unit types, we identified an output ranging approximately from 60,345 to 88,246 records with applied search strategy in MEDLINE/PubMed, Scopus/Elsevier, and WoS. In NHS EED, we detected 14,761 records of economic evaluations of health interventions during the period in which database was maintained and regularly updated. With slightly more than one-third of the identified records, USA clearly dominates in this field. United Kingdom takes a strong second place with about 12% of identified records. Consistently, USA and UK universities are the most frequent among the top 15 affiliations/organizations of the authors of the identified records. Authors from Harvard University contributed to the largest number of the identified records.

Conclusion

There is a clear evidence of both the upward stream of blossoming in health economics publications and its acceleration. Based on this bibliographic data set, it is difficult to distinguish the actual impact growth of this output provided dominantly by academia with modest contribution by pharmaceutical/medicinal device industry and diverse national government-based agencies. Further insight into the citation track record of these individual publications could provide helpful upgrade and a perspective on ongoing development.

Future and potential spending on health 2015-40: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries

BACKGROUND

The amount of resources, particularly prepaid resources, available for health can affect access to health care and health outcomes. Although health spending tends to increase with economic development, tremendous variation exists among health financing systems. Estimates of future spending can be beneficial for policy makers and planners, and can identify financing gaps. In this study, we estimate future gross domestic product (GDP), all-sector government spending, and health spending disaggregated by source, and we compare expected future spending to potential future spending.

METHODS

We extracted GDP, government spending in 184 countries from 1980-2015, and health spend data from 1995-2014. We used a series of ensemble models to estimate future GDP, all-sector government spending, development assistance for health, and government, out-of-pocket, and prepaid private health spending through 2040. We used frontier analyses to identify patterns exhibited by the countries that dedicate the most funding to health, and used these frontiers to estimate potential health spending for each low-income or middle-income country. All estimates are inflation and purchasing power adjusted.

FINDINGS

We estimated that global spending on health will increase from US$9·21 trillion in 2014 to $24·24 trillion (uncertainty interval [UI] 20·47-29·72) in 2040. We expect per capita health spending to increase fastest in upper-middle-income countries, at 5·3% (UI 4·1-6·8) per year. This growth is driven by continued growth in GDP, government spending, and government health spending. Lower-middle income countries are expected to grow at 4·2% (3·8-4·9). High-income countries are expected to grow at 2·1% (UI 1·8-2·4) and low-income countries are expected to grow at 1·8% (1·0-2·8). Despite this growth, health spending per capita in low-income countries is expected to remain low, at $154 (UI 133-181) per capita in 2030 and $195 (157-258) per capita in 2040. Increases in national health spending to reach the level of the countries who spend the most on health, relative to their level of economic development, would mean $321 (157-258) per capita was available for health in 2040 in low-income countries.

INTERPRETATION

Health spending is associated with economic development but past trends and relationships suggest that spending will remain variable, and low in some low-resource settings. Policy change could lead to increased health spending, although for the poorest countries external support might remain essential.

FUNDING

Bill & Melinda Gates Foundation.