Action to address the household economic burden of non-communicable diseases

Determinants of outpatient healthcare-seeking behaviors among the rural poor affected by chronic conditions in India: a population-based cross-sectional study in seven states

BACKGROUND

A rising burden of chronic non-communicable diseases (CNCDs) increases demand for outpatient healthcare. Yet, evidence on preferences and barriers to healthcare services for India's most disadvantaged population, the target of India's largest public health insurance scheme (PM-JAY), is lacking.

OBJECTIVE

We explore determinants of outpatient healthcare-seeking behavior among PM-JAY eligible individuals with CNCDs in rural areas of seven states.

METHODS

Using cross-sectional data from a household survey (conducted between November 2019 and March 2020), we employed multilevel multinomial logistic regression to identify factors associated with seeking care from informal (home treatment, pharmacies, traditional healers), formal public, or formal private providers, compared with no care. Anderson's behavioral model informed the selection of independent variables.

RESULTS

Of 51,820 individuals, 5,061 (9.8%) reported a chronic condition. Despite their disease, 1,168 (23.1%) reported not using regular outpatient care. Another 2,421 individuals (48.0%) used formal private, 922 (18.3%) used formal public, and 535 (10.6%) used informal care. Predictors of formal private care were higher socioeconomic status (RRR = 2.441, 95% CI [1.61, 3.70]) and health insurance coverage (RRR = 1.478, 95% CI [1.12, 1.95]). Residents of Tamil Nadu, Kerala, and Gujarat were more likely to use formal public care (RRR = 23.915, 95% CI [9.01, 63.44]). Suffering from Major CNCDs or experiencing limitations in daily activities increased the probability of using healthcare across all options.

CONCLUSION

Future research should explore the reasons for non-utilization of chronic care and the preference for private providers. Policies to enhance public healthcare utilization and expand insurance for outpatient care could improve access and reduce health inequities.

Role of artificial intelligence in early identification and risk evaluation of non-communicable diseases: a bibliometric analysis of global research trends

OBJECTIVE

This study aims to shed light on the transformative potential of artificial intelligence (AI) in the early detection and risk assessment of non-communicable diseases (NCDs).

STUDY DESIGN

Bibliometric analysis.

SETTING

Articles related to AI in early identification and risk evaluation of NCDs from 2000 to 2024 were retrieved from the Scopus database.

METHODS

This comprehensive bibliometric study focuses on a single database, Scopus and employs narrative synthesis for concise yet informative summaries. Microsoft Excel V.365 and VOSviewer software (V.1.6.20) were used to summarise bibliometric features.

RESULTS

The study retrieved 1745 relevant articles, with a notable surge in research activity in recent years. Core journals included Scientific Reports and IEEE Access, and core institutions included the Harvard Medical School and the Ministry of Education of the People's Republic of China, while core countries comprised China, the USA, India, the UK and Saudi Arabia. Citation trends indicated substantial growth and recognition of AI's impact on NCDs management. Frequent author keywords identified key research hotspots, including specific NCDs like Alzheimer's disease and diabetes. Risk assessment studies demonstrated improved predictions for heart failure, cardiovascular risk, breast cancer, diabetes and inflammatory bowel disease.

CONCLUSION

Our findings highlight the increasing role of AI in early detection and risk prediction of NCDs, emphasising its widening research impact and future clinical potential.

Quality of Life in Patients with CKD With Catastrophic Health Care Expenditures: A National Study From Thailand

Rationale & Objective

Despite universal health coverage, patients with chronic kidney disease (CKD) in middle-income nations still face financial hardship. Catastrophic health care expenditures (CHEs) serve as a valuable index of patient-derived financial hardship, but few studies have explored the connection of CHE with clinical correlates, especially in patients with CKD. This study aimed to assess the association between CHE and health-related quality of life (HRQoL) in a spectrum of patients with CKD in Thailand.

Study Design

A multicenter, nationwide cross-sectional study.

Setting & Population

Patients with CKD (stages 3-5 and dialysis) from 11 centers across Thailand.

Exposures

Catastrophic health expenditures.

Outcomes

Health-related quality of life.

Analytical Approach

Data on clinical, socioeconomic status, and out-of-pocket expenses were acquired via interviews. The CHE was defined as health care expenditures of at least 40% of the household's capacity to pay. The HRQoL was assessed using the EuroQol-5 Dimensions (EQ5DL) questionnaire. Fractional and multivariable logistic regression models were used to determine the CHE's effect on EQ5DL composite utility scores and each HRQoL dimension.

Results

Of 1,224 patients with CKD, 20% experienced CHE. EuroQol-5 Dimensions utility scores were notably lower in those with CHE (CHE, 0.76 vs No CHE, 0.82, P < 0.001) after adjustments for confounding factors. Differences between CHE and non-CHE appeared in mobility, self-care, and usual activity, with multivariable analysis showing more severe mobility and activity issues in CHE. (adjusted OR [95% CI] in CHE vs non-CHE: mobility: 1.89 [1.23-2.91], P = 0.004; usual activity: 1.82 [1.10-3.02], P = 0.020].

Limitations

Cross-sectional design prevents causal inferences.

Conclusions

Despite health coverage, patients with CKD with financial strain experience reduced quality of life, with pronounced effects on mobility and daily activity. Integrating the assessment of patient-derived financial burden is an essential step into CKD care plans in middle-income countries.

Health poverty reduction effect of medical insurance in China's middle-aged and elderly populations: a cross-sectional study

OBJECTIVES

In the context of demographic structure and disease spectrum changes: to study the role of the medical insurance system in providing protection and risk resilience for middle-aged and elderly vulnerable groups who are prone to impoverishment by medical expenses (IME), identify the vulnerable points and propose recommendations for improving the medical insurance system.

SETTING

The research used data from the 2018 China Health and Retirement Longitudinal Study.

PARTICIPANTS

9184 households were included in the research ultimately.

PRIMARY AND SECONDARY OUTCOME MEASURES

We use the WHO's recommended composite measure of disease-related poverty and algorithm to determine the occurrence of IME in households. Instrumental variable probit regression model was used to target the characteristics of vulnerable groups and the influencing factors with strong correlation with IME.

RESULTS

The overall incidence of IME is 8.25% and the high incidence is concentrated in rural populations (9.79%). The risk of IME from stroke (13.17%) has been higher than cancer (7.38%). The incidence of IME is higher in families with five types of non-communicable diseases enrolled in Urban-Rural Integrated Medical Insurance (URRMI) (min 10.00%-max 14.29%) and New Rural Cooperative Medical Insurance Scheme (NRCMS) (min 8.97%-max 15.24%) health insurance than the overall IME incidence (8.25%).

CONCLUSIONS

The medical insurance system has achieved the inclusive economic protection function for most people, but the risk resistance function for the middle-aged and older adults with multiple vulnerabilities still needs to be strengthened.,the.Finally, to address the benefit gap of the NRCMS, the next stage of medical insurance development should focus on improving the top-level design of the reimbursement framework for urban and rural resident medical insurance.

National and province-level primary health care policies for the prevention and control of non-communicable diseases in China from 2009 to 2023: a scoping review

OBJECTIVES

This study systematically characterises policies related to the prevention and control of non-communicable diseases (NCDs) at the provincial primary healthcare (PHC) level, identifying key characteristics and potential gaps compared with national policies.

STUDY DESIGN

Policy review and thematic content analysis.

METHODS

Policy documents from Guangdong and Heilongjiang provinces (2009-2023) were analysed using the WHO's six building blocks framework. A total of 135 eligible documents were included, with thematic analysis conducted to categorise policies as 'extension' or 'reduction' based on their alignment with national directives.

RESULTS

12 major policy initiatives were identified, with most themes reflecting provincial adaptations ('extension') of national strategies. Leadership and governance, medicines and technologies and service delivery received robust policy support, while health information systems lagged. Provincial policies demonstrated significant multisectoral collaboration, though gaps in health financing and workforce capacity persisted.

CONCLUSIONS

To strengthen PHC-based NCD control, future reforms must prioritise multisectoral collaboration, interoperable digital health systems and tailored health education. Addressing regional disparities in policy implementation is critical for equitable outcomes.

Amyotrophic lateral sclerosis in Argentina: unveiling the burden of treatment through patient and caregiver perspectives

PURPOSE

To examine the burden of treatment (BoT) experienced by people with Amyotrophic Lateral Sclerosis (ALS) in Argentina.

METHODS

Qualitative methodological design based on semi-structured interviews. Nineteen semi-structured interviews were conducted (PwALS = 7, informal caregivers= 12). The interview guides were designed based on the literature and BoT theory. Data were analysed following a framework analysis approach.

RESULTS

The research highlighted the arduous journey toward obtaining a diagnosis, marked by delays influenced by healthcare system inefficiencies, lack of disease awareness and pandemic-related anxiety. Receiving the diagnosis was a destabilising experience, triggering the need to reframe self-identity, a new reality. As the disease progressed, patients encountered significant challenges in their daily activities and basic tasks, affecting their ability to work, communicate, and manage personal care. The burden extended beyond the patients to their primary caregivers. Access to specialised care, bureaucratic complexities in securing treatment, and the financial impact of managing the disease posed substantial challenges.

CONCLUSION

The findings offer valuable insights into the experiences of PwALS and their caregivers in Argentina. They underscore the need for increased disease awareness, improved access to specialised care, and enhanced support networks to alleviate the burdens PwALS and their families face.

3-D Sustained-Release Culture Carrier Alleviates Rat Intervertebral Disc Degeneration by Targeting STING in Transplanted Skeletal Stem Cells

The hypoxic and high-pressure microenvironment of the intervertebral discs poses a major challenge to the survival and therapeutic efficiency of exogenous stem cells. Therefore, improving the utilization efficiency and therapeutic effect of exogenous stem cells to delay intervertebral disc degeneration (IVDD) is of great importance. Here, hypoxic induction studies are conducted in vivo and in vitro using rat costal cartilage-derived skeletal stem cells (SSCs) and find that hypoxia activates the cyclic guanosine monophosphate-adenosine monophosphate synthase (cGAS)/stimulator of interferon genes (STING) signaling pathway and increased reactive oxygen species (ROS) accumulation, triggering ferroptosis in SSCs through hypoxia-inducible factor-1 alpha-dependent mitophagy. Progressive hypoxia preconditioning reduce STING expression and ROS accumulation, inducing SSCs differentiation into nucleus pulposus-like cells via the Wnt signaling pathway. Considering this, a 3-D sustained-release culture carrier is generated by mixing SSCs with methacrylated hyaluronic acid and polydopamine nanoparticles coated with the STING inhibitor C-176 and evaluated its inhibitory effect on IVDD. This carrier is demonstrated to inhibit the cGAS/STING pathway and prevent ROS accumulation by continuously releasing C-176-coated polydopamine nanoparticles, thereby reducing ferroptosis, promoting differentiation, and ultimately attenuating IVDD, suggesting its potential as a novel treatment strategy.

Risk factors for non-communicable diseases among Bangladeshi adults: an application of generalised linear mixed model on multilevel demographic and health survey data

OBJECTIVE

This study examines the risk factors associated with non-communicable diseases (NCDs), specifically diabetes mellitus (DM) and hypertension (HTN), among adults in Bangladesh, a lower-middle-income country. Given the rising prevalence of DM and HTN and their significant public health burden, this research aims to identify key socioeconomic, demographic and lifestyle-related determinants to inform targeted interventions.

DESIGN

The study used nationally representative cross-sectional data extracted from the Bangladesh Demographic and Health Survey conducted in 2017-2018.

SETTING

Bangladesh.

PARTICIPANTS

The study included 8013 women and 6691 men aged 18 and older who were eligible for blood pressure and blood glucose measurements.

PRIMARY OUTCOMES

Type 2 DM, HTN.

RESULTS

HTN was significantly associated with higher odds of diabetes (adjusted OR (AOR)=1.28, 95% CI: 1.14 to 1.43), while diabetes was associated with increased odds of HTN (AOR=1.24, 95% CI: 1.11 to 1.39). Individuals aged 40 years and older had 74.8% higher odds of diabetes (AOR=1.748, 95% CI: 1.58 to 1.993) and were 3.21 times more likely to have HTN (AOR=4.208, 95% CI: 3.781 to 4.685). Overweight individuals had 2.15 times higher odds of HTN compared with those with normal weight (AOR=2.154, 95% CI: 1.98 to 2.34). Wealthier individuals also showed significantly higher odds of both DM and HTN.

CONCLUSIONS

This study highlights the strong association between DM and HTN and identifies age, overweight status and higher socioeconomic class as key risk factors. These findings underscore the need for integrated public health strategies targeting NCD prevention and management in Bangladesh. Further research should explore longitudinal trends and the impact of targeted interventions on reducing the burden of NCDs.

Out-of-pocket payments & catastrophic healthcare expenditure for non-communicable diseases: Results of a State-wide STEPS survey in north India

Background & objectives Non-communicable diseases have been designated as 'public health priority' globally, and they are accountable for debility, morbidity, and mortality. Thus, the present study aims to estimate the out-of-pocket payment, catastrophic healthcare expenditures and household wage loss. Methods Field research was conducted with an adapted survey questionnaire. Data from 576 individuals from various healthcare facilities in Punjab were collected using a convenience sampling approach. The out-of-pocket and catastrophic healthcare expenditures (CHE) were estimated using descriptive statistics and indices, viz., headcount overshoot and mean positive overshoot. Lastly, logistic regression models were applied to identify determinants of catastrophic health expenditure. Results The study findings showed that most respondents incurred a high out-of-pocket payment for inpatient care. Further, at any threshold level, the incidence of catastrophic health was highest among diabetic patients. The intensity of catastrophic healthcare expenditure with diabetes and hypertension exceeded the five per cent threshold bracket. Logistic regression results revealed that the odds of incurring catastrophic healthcare expenditure were highest among respondents diagnosed with diabetes, chronic obstructive pulmonary disease (COPD), and stroke. Interpretation & conclusions The study recommends that the government health insurance scheme 'Ayushman Bharat-Mukh Mantri Sehat Bima Yojana (AB-MMSBY)' must include outpatient and pre- and post-diagnostic costs incurred by respondents diagnosed with cardiovascular disease (CVD), COPD, and diabetes in Punjab. Therefore, respondents with diabetes mellitus (i.e., specifically type-1 patients) must be covered under health insurance benefits.

Dissecting the rising tide of inflammatory bowel disease among youth in a changing world: insights from GBD 2021

OBJECTIVES

This study investigates the alarming epidemiological trends of inflammatory bowel disease (IBD) among children and young adults, highlighting the associated disease burden on global health.

MATERIALS AND METHODS

Utilizing data from the Global Burden of Disease (GBD) study 2021, we conducted a comprehensive analysis of age-standardized incidence rates (ASIR), age-standardized mortality rates (ASMR), disability-adjusted life years (DALYs), and estimated annual percentage changes (EAPC). Future trends were forecasted using the Bayesian age-period-cohort model.

RESULTS

From 1990 to 2021, IBD incidence and DALY rates remained persistently high, with a concerning upward trend noted among children and young adults. While men experienced a decline in DALY rates, women faced increasing burdens. In 2021, high-income regions, particularly North America, reported the highest incidence and DALY rates, contrasting sharply with Central Latin America, which exhibited the lowest ASIR. Southeast Asia presented the most favorable DALY rates. A notable negative correlation was identified between DALY rates and socio-demographic index (SDI) at the national level, with high and high-middle SDI countries continuing to bear a substantial burden, while low and middle SDI nations faced rising challenges.

CONCLUSIONS

The persistent high burden of IBD in children and young adults signifies a critical public health concern. The marked geographical and gender disparities underscore the urgent need for tailored regional and population-based strategies aimed at primary prevention and effective management. This study illuminates the pressing necessity for policy interventions to address the growing epidemic of IBD among vulnerable populations.

Trends in Socioeconomic Inequalities in the Prevalence of Chronic Non-Communicable Diseases in China: Evidence from Shaanxi Province During 2003-2013

Background: The link between chronic non-communicable diseases (NCDs) and poverty in underdeveloped countries is debated. This study aims to examine socioeconomic inequalities related to NCDs and assess the contributing factors to these disparities. Methods: The study utilized data from the National Health Services Survey in Shaanxi Province for 2003, 2008, and 2013, having 71,766 respondents. The concentration index (CI) was employed to rigorously quantify the degree of socioeconomic inequality in the prevalence of non-communicable diseases (NCDs). The CI decomposition identified the contribution of each variable, while the horizontal inequity (HI) index was calculated annually to assess changes in inequality. Additionally, a Probit model was employed to examine the significant determinants contributing to the occurrence of NCDs. Results: The results show a significant increase in NCD prevalence with age, particularly for individuals aged 60 and above, who experienced a 286.55% rise from 2003 to 2013. Higher education levels are associated with decreased NCD prevalence, as evidenced by a 74.13% reduction for those with high school education or above. Additionally, wealthier individuals had a 15.31% lower prevalence of NCDs, indicating that higher socioeconomic status correlates with a reduced likelihood of chronic diseases. Conclusions: The study finds that NCD prevalence significantly increases with age, while higher education levels and greater wealth are associated with reduced prevalence. These findings highlight the need to target older populations and lower socioeconomic groups for effective NCD prevention and management. Policies should focus on improving educational opportunities and socioeconomic conditions to reduce the burden of NCDs, particularly among older and economically disadvantaged groups.

Seeking and receiving hypertension and diabetes mellitus care in Tanzania

The rapid increase in chronic non-communicable diseases (NCDs) poses a major challenge to already strained health systems in sub-Saharan Africa. This study investigates the factors associated with seeking and receiving NCD services in Tanzania, using a household survey and client exit interview data from Kilombero and Same districts. Both districts are predominantly rural, with one semi-urban area called Ifakara town and Same town. Of the 784 household survey respondents, 317 (40.4%), 37 (4.7%), and 20 (2.5%) were diagnosed with hypertension, diabetes mellitus, and other NCDs, respectively, of whom 69% had sought care in the past six months. After controlling for covariates, those enrolled in the National Health Insurance Fund (NHIF) and those who received a user fees waiver were more likely to use health services. However, even when NCD patients managed to access the care they needed, they were likely to receive incomplete services. The main reason for not receiving all services at the health facility visited on the day of the survey was drug stock-outs. Among health care users, those registered with the improved Community Health Funds (iCHF) were less likely to receive all prescribed services at the health facility visited than uninsured patients. The findings of this study highlight the need to strengthen both primary care and social health protection systems to improve access to needed care for NCD patients.

Non-communicable diseases in the world over the past century: a secondary data analysis

Introduction

We analyzed the changes in the top 10 non-communicable diseases (NCDs) over the past century across the World Health Organization (WHO) regions.

Materials and methods

The data were extracted from the Global Burden of Disease (GBD) studies. After we accessed this source, all NCDs were sorted according to their prevalence in 2019, and the 10 most common NCDs were selected. Then, the incidence, prevalence, and mortality rates of these 10 NCDs were compared to the rates in 2000.

Results

Diabetes and kidney disease had the highest increase in incidence (49.4%) and prevalence (28%) in the Eastern Mediterranean region. Substance use disorders had a huge increase (138%) in the mortality rates among women in the Americas region. On the other hand, women in Southeast Asia experienced the greatest decrease in incidence (-19.8%), prevalence (-15.8%), and mortality rates (-66%).

Conclusion

In recent years, nearly all NCDs have shown an increase, yet mortality rates have declined across all regions. Lifestyle can be a major cause of this increase, but advancements in health and medical services, such as screening and treatment, have played a crucial role in improving survival rates.

The financial burden of noncommunicable diseases from out-of-pocket expenditure in sub-Saharan Africa: a scoping review

The growing financial burden of noncommunicable diseases (NCDs) in sub-Saharan Africa (SSA) hinders the attainment of the sustainable development goals. However, there has been no updated synthesis of evidence in this regard. Therefore, our study summarizes the current evidence in the literature and identifies the gaps. We systematically search relevant databases (PubMed, Scopus, ProQuest) between 2015 and 2023, focusing on empirical studies on NCDs and their financial burden indicators, namely, catastrophic health expenditure (CHE), impoverishment, coping strategies, crowding-out effects and unmet needs for financial reasons (UNFRs) in SSA. We examined the distribution of the indicators, their magnitudes, methodological approaches and the depth of analysis. The 71 included studies mostly came from single-country (n = 64), facility-based (n = 52) research in low-income (n = 22), lower-middle-income (n = 47) and upper-middle-income (n = 10) countries in SSA. Approximately 50% of the countries lacked studies (n = 25), with 46% coming from West Africa. Cancer, cardiovascular disease (CVD) and diabetes were the most commonly studied NCDs, with cancer and CVD causing the most financial burden. The review revealed methodological deficiencies related to lack of depth, equity analysis and robustness. CHE was high (up to 95.2%) in lower-middle-income countries but low in low-income and upper-middle-income countries. UNFR was almost 100% in both low-income and lower-middle-income countries. The use of extreme coping strategies was most common in low-income countries. There are no studies on crowding-out effect and pandemic-related UNFR. This study underscores the importance of expanded research that refines the methodological estimation of the financial burden of NCDs in SSA for equity implications and policy recommendations.

Non-communicable comorbidities in pulmonary tuberculosis and healthcare utilization: a cross-sectional study of 2021 Indonesian national health insurance data

BACKGROUND

Limited research exists on the comorbidity of pulmonary tuberculosis with non-communicable diseases (NCDs) and its implications for healthcare utilization in Indonesia. The lack of investigation into NCD comorbidity among pulmonary tuberculosis patients could adversely affect both the healthcare system and the national health insurance scheme. Understanding the NCD comorbidity among pulmonary tuberculosis patients, associated factors, and healthcare utilization is crucial for ensuring the effective and efficient delivery of health services.

METHOD

This study utilized an observational cross-sectional design based on anonymized sample data from tuberculosis cases covered by Indonesia's National Health Insurance in 2021. Chi-square tests were employed to analyze dependent and independent variables, while unadjusted and adjusted logistic regressions were used to explore further associations.

RESULTS

The prevalence of NCD comorbidity in tuberculosis patients was 11.81%. Aged over 60 (aOR 5.16; [CI] 4.23-6.3), married (aOR 1.19; [CI] 1.05-1.34), and unemployed (aOR 1.27; [CI] 1.08-1.49) were associated with the NCD comorbidity in pulmonary tuberculosis patients. Factors associated with increased inpatient service utilization among pulmonary tuberculosis patients included aged over 60 (aOR 5.69; [CI] 4.81-6.74), male (aOR 1.32; [CI] 1.23-1.40), self-employment (aOR 1.42; [CI] 1.29-1.56), having insurance subsidized by central government (aOR 1.89; [CI] 1.73-2.08) or local government funds (aOR 1.75; [CI] 1.58-1.93), and having comorbidity non-communicable diseases (aOR 1.80; [CI] 1.66-1.96).

CONCLUSION

Pulmonary tuberculosis patients exhibit a significant prevalence of NCD comorbidity, which substantially impacts healthcare utilization. Early detection and management of these conditions are critical to mitigate burdens on both the healthcare system and the financial sustainability of the national health insurance scheme. Integrating health services for tuberculosis and NCDs through bidirectional screening is essential for comprehensive patient care.

Catastrophic out-of-pocket payments related to non-communicable disease multimorbidity and associated factors, evidence from a public referral hospital in Addis Ababa Ethiopia

BACKGROUND

In low and middle-income countries (LMICs), non-communicable diseases (NCDs) are on the rise and have become a significant cause of mortality. Unfortunately, accessing affordable healthcare services can prove to be challenging for individuals who are unable to bear the expenses out of their pockets. For NCDs, the treatment costs are already high, and being multimorbid further amplifies the economic burden on patients and their families. The present study seeks to bridge the gap in knowledge regarding the financial risks that come with NCD multimorbidity. It accomplishes this by examining the catastrophic out-of-pocket (OOP) expenditure levels and the factors that contribute to it at Tikur Anbesa Specialized Hospital, Addis Ababa, Ethiopia.

METHODS

A facility-based cross-sectional study was conducted at Tikur Anbesa Specialized Hospital between May 18 and July 22, 2020 and 392 multimorbid patients participated. The study participants were selected from the hospital's four NCD clinics using systematic random sampling. Patients' direct medical and non-medical out-of-pocket (OOP) expenditures were recorded, and the catastrophic OOP health expenditure for NCD care was estimated using various thresholds as cutoff points (5%, 10%, 15%, 20%, 25%, and 40% of both total household consumption expenditure and non-food expenditure). The collected data was entered into Epi Data version 3.1 and analyzed using STATA V 14. Descriptive statistics were utilized to present the study's findings, while logistic regression was used to examine the associations between variables.

RESULTS

A study was conducted on a sample of 392 patients who exhibited a range of socio-demographic and economic backgrounds. The annual out-of-pocket spending for the treatment of non-communicable disease multimorbidity was found to be $499.7 (95% CI: $440.9, $558.6) per patient. The majority of these expenses were allocated towards medical costs such as medication, diagnosis, and hospital beds. It was found that as the threshold for spending increased from 5 to 40% of total household consumption expenditure, the percentage of households facing catastrophic health expenditures (CHE) decreased from 77.55 to 10.46%. Similarly, the proportion of CHE as a percentage of non-food household expenditure decreased from 91.84 to 28.32% as the threshold increased from 5 to 40%. The study also revealed that patients who traveled to Addis Ababa for healthcare services (AOR = 7.45, 95% CI: 3.41-16.27), who were not enrolled in an insurance scheme (AOR = 4.97, 95% CI: 2.37, 10.4), who had more non-communicable diseases (AOR = 2.05, 95% CI: 1.40, 3.01), or who had more outpatient visits (AOR = 1.46, 95%CI: 1.31, 1.63) had a higher likelihood of incurring catastrophic out-of-pocket health expenditures at the 40% threshold.

CONCLUSION AND RECOMMENDATION

This study has revealed that patients with multiple non-communicable diseases (NCDs) frequently face substantial out-of-pocket health expenditures (CHE) due to both medical and non-medical costs. Various factors, including absence from an insurance scheme, medical follow-ups necessitating travel to Addis Ababa, multiple NCDs and outpatient visits, and utilization of both public and private facilities, increase the likelihood of incurring CHE. To mitigate the incidence of CHE for individuals with NCD multimorbidity, an integrated NCD care service delivery approach, access to affordable medications and diagnostic services in public facilities, expanded insurance coverage, and fee waiver or service exemption systems should be explored.

Association of Depression With the Progression of Multimorbidity in Older Adults: A Population-Based Cohort Study

BACKGROUND

The relationship between depression and the risk of multimorbidity progression has rarely been studied in older adults. This study was aimed to determine whether depression is associated with progression in the severity and complexity of multimorbidity, considering the influence of depression's severity and subtype.

METHODS

As a part of the Korean Longitudinal Study on Cognitive Aging and Dementia, this population-based cohort study followed a random sample of community-dwelling Koreans aged 60 and older for 8 years at 2-year intervals starting in 2010. Participants included those who completed mood and multimorbidity assessments and did not exhibit complex multimorbidity at the study's outset. Depression was assessed using the Geriatric Depression Scale, while multimorbidity was evaluated using the Cumulative Illness Rating Scale. The study quantified multimorbidity complexity by counting affected body systems and measured multimorbidity severity by averaging scores across 14 body systems.

FINDINGS

The 2,486 participants (age = 69.1 ± 6.5 years, 57.6% women) were followed for 5.9 ± 2.4 years. Linear mixed models revealed that participants with depression had a faster increase in multimorbidity complexity score (β = .065, SE = 0.019, p = 0.001) than those without depression, but a comparable increase in multimorbidity severity score (β = .001, SE = .009, p = 0.870) to those without depression. Cox proportional hazard models revealed that depression was associated with the risk of developing highly complex multimorbidity affecting five or more body systems, particularly in severe or anhedonic depression.

INTERPRETATION

Depression was associated with the worsening of multimorbidity in Korean older adults, particularly when severe or anhedonic. Early screening and management of depression may help to reduce the burden of multimorbidity in older adults.

Epidemiological trend of lung cancer burden caused by residential radon exposure in China from 1990 to 2019

OBJECTIVE

This study employed time series data to assess long-term changes in the burden of lung cancer (LC) caused by residential radon exposure, an important environmental risk factor, so as to develop evidence-based strategies for future public health management.

METHODS

Based on the open data from the Global Burden of Disease (GBD 2019) database, we conducted an analysis of the residential radon exposure-caused LC mortality, disability-adjusted life years (DALYs), and corresponding crude rates and age-standardized rates (ASRs) for various age groups. We employed the employed age-period-cohort (APC) model to investigate the age, period, and cohort effects of the data, allowing us to discern the trends in LC disease burden attributable to radon exposure in residential settings over time.

RESULTS

From 1990 to 2019, age-standardized mortality rates (ASMR) and age-standardized DALYs rates of LC caused by residential radon exposure in China demonstrated an overall increasing trend, with males higher than females. The CMR and crude DALYs rate for males were higher than those for females across all age groups. The APC analysis revealed that the local drift of LC death and DALYs rates in males and females showed a decreasing trend before 60 and an increasing trend after 60.

CONCLUSION

The persistent presence of residential radon exposure as a crucial risk factor for LC underscores the need for public health authorities and policymakers to take more proactive measures to reduce radon exposure. Particularly, attention should be paid on the elderly population and male patients.

Exploring experiences of HIV care to optimize patient-centred care in Conakry, Guinea: a qualitative study

Introduction

Studies on the organisation of care and the power dynamic between providers and patients with HIV in sub-Saharan Africa are rare. This study aims to describe the patient-provider relationship and explore the challenges to optimal and patient-centred care for HIV patients.

Methods

This was a qualitative exploratory descriptive study using in-depth individual interviews and focus group discussions. In total, 17 individual interviews and 5 focus group discussions were conducted. This was conducted in four urban health facilities in Conakry, the capital of Guinea. Three group of participants were included in this study namely patients with HIV; health providers including facilities and services managers; and psychosocial counsellors. Psychosocial counsellors provide emotional and psychosocial support to HIV patients. Their role in the organization care in Guinea is new and they contribute to strengthening adherence of patients with HIV to ARV treatment.

Results

Patients with HIV, health providers, and psychosocial counsellors have a positive perception of the patient-provider relationship. This relationship was characterized essentially by maintaining confidentiality of HIV status disclosure, caring attitudes towards patients (being available, adjusting locations for accessing ART, based on patients' preferences), and participating in HIV patient's social life. However, scolding and miscommunication about the interpretation of viral load tests were reported. The shortage of human resources, low salaries of health staff, poor infrastructure, and the financial burden borne by patients with HIV impede the implementation of optimal patient-centred care.

Conclusion

Integrating psychosocial counsellors in HIV care organization, improving access to ARV, infrastructure, increasing human resources, and removing the financial burden for HIV patients are needed to optimal patient-centred care in Guinea.

Cross-sectional study of the burden and determinants of non-medical and opportunity costs of accessing chronic disease care in rural Tanzania

OBJECTIVES

Countries in sub-Saharan Africa are seeking to improve access to healthcare through health insurance. However, patients still bear non-medical costs and opportunity costs in terms of lost work days. The burden of these costs is particularly high for people with chronic diseases (CDs) who require regular healthcare. This study quantified the non-medical and opportunity costs faced by patients with CD in Tanzania and identified factors that drive these costs.

METHODS

From November 2020 to January 2021, we conducted a cross-sectional patient survey at 35 healthcare facilities in rural Tanzania. Using the human capital approach to value the non-medical cost of seeking healthcare, we employed multilevel linear regression to analyse the impact of CDs and health insurance on non-medical costs and negative binomial regression to investigate the factors associated with opportunity costs of illness among patients with CDs.

RESULTS

Among 1748 patients surveyed, 534 had at least one CD, 20% of which had comorbidities. Patients with CDs incurred significantly higher non-medical costs than other patients, with an average of US$2.79 (SD: 3.36) compared with US$2.03 (SD: 2.82). In addition, they incur a monthly illness-related opportunity cost of US$10.19 (US$0-59.34). Factors associated with higher non-medical costs included multimorbidities, hypertension, health insurance and seeking care at hospitals rather than other facilities. Patients seeking hypertension care at hospitals experienced 35% higher costs compared with those visiting other facilities. Additionally, patients with comorbidities, older age, less education and those requiring medication more frequently lost workdays.

CONCLUSION

Outpatient care in Tanzania imposes considerable non-medical costs, particularly for people with CDs, besides illness-related opportunity costs. Despite having health insurance, patients with CDs who seek outpatient care in hospitals face higher financial burdens than other patients. Policies to improve the availability and quality of CD care in dispensaries and health centres could reduce these costs.

Deep learning-assisted ultrasonic diagnosis of cervical lymph node metastasis of thyroid cancer: a retrospective study of 3059 patients

Objective

This study aimed to develop a deep learning system to identify and differentiate the metastatic cervical lymph nodes (CLNs) of thyroid cancer.

Methods

From January 2014 to December 2020, 3059 consecutive patients with suspected with metastatic CLNs of thyroid cancer were retrospectively enrolled in this study. All CLNs were confirmed by fine needle aspiration. The patients were randomly divided into the training (1228 benign and 1284 metastatic CLNs) and test (307 benign and 240 metastatic CLNs) groups. Grayscale ultrasonic images were used to develop and test the performance of the Y-Net deep learning model. We used the Y-Net network model to segment and differentiate the lymph nodes. The Dice coefficient was used to evaluate the segmentation efficiency. Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were used to evaluate the classification efficiency.

Results

In the test set, the median Dice coefficient was 0.832. The sensitivity, specificity, accuracy, PPV, and NPV were 57.25%, 87.08%, 72.03%, 81.87%, and 66.67%, respectively. We also used the Y-Net classified branch to evaluate the classification efficiency of the LNs ultrasonic images. The classification branch model had sensitivity, specificity, accuracy, PPV, and NPV of 84.78%, 80.23%, 82.45%, 79.35%, and 85.61%, respectively. For the original ultrasonic reports, the sensitivity, specificity, accuracy, PPV, and NPV were 95.14%, 34.3%, 64.66%, 59.02%, 87.71%, respectively. The Y-Net model yielded better accuracy than the original ultrasonic reports.

Conclusion

The Y-Net model can be useful in assisting sonographers to improve the accuracy of the classification of ultrasound images of metastatic CLNs.

Hypertension care cascades and reducing inequities in cardiovascular disease in low- and middle-income countries

Improving hypertension control in low- and middle-income countries has uncertain implications across socioeconomic groups. In this study, we simulated improvements in the hypertension care cascade and evaluated the distributional benefits across wealth quintiles in 44 low- and middle-income countries using individual-level data from nationally representative, cross-sectional surveys. We raised diagnosis (diagnosis scenario) and treatment (treatment scenario) levels for all wealth quintiles to match the best-performing country quintile and estimated the change in 10-year cardiovascular disease (CVD) risk of individuals initiated on treatment. We observed greater health benefits among bottom wealth quintiles in middle-income countries and in countries with larger baseline disparities in hypertension management. Lower-middle-income countries would see the greatest absolute benefits among the bottom quintiles under the treatment scenario (29.1 CVD cases averted per 1,000 people living with hypertension in the bottom quintile (Q1) versus 17.2 in the top quintile (Q5)), and the proportion of total CVD cases averted would be largest among the lowest quintiles in upper-middle-income countries under both diagnosis (32.0% of averted cases in Q1 versus 11.9% in Q5) and treatment (29.7% of averted cases in Q1 versus 14.0% in Q5) scenarios. Targeted improvements in hypertension diagnosis and treatment could substantially reduce socioeconomic-based inequalities in CVD burden in low- and middle-income countries.

Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: a systematic review

BACKGROUND

Globally, non-communicable diseases (NCDs) are the leading cause of mortality and morbidity placing a huge burden on individuals, families and health systems, especially in low- and middle-income countries (LMICs). This rising disease burden calls for policy responses that engage the entire health care system. This study aims to synthesize evidence on how people with NCDs choose their healthcare providers in LMICs, and the outcomes of these choices, with a focus on private sector delivery.

METHODS

A systematic search for literature following PRISMA guidelines was conducted. We extracted and synthesised data on the determinants and outcomes of private health care utilisation for NCDs in LMICs. A quality and risk of bias assessment was performed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

We identified 115 studies for inclusion. Findings on determinants and outcomes were heterogenous, often based on a particular country context, disease, and provider. The most reported determinants of seeking private NCD care were patients having a higher socioeconomic status; greater availability of services, staff and medicines; convenience including proximity and opening hours; shorter waiting times and perceived quality. Transitioning between public and private facilities is common. Costs to patients were usually far higher in the private sector for both inpatient and outpatient settings. The quality of NCD care seems mixed depending on the disease, facility size and location, as well as the aspect of quality assessed.

CONCLUSION

Given the limited, mixed and context specific evidence currently available, adapting health service delivery models to respond to NCDs remains a challenge in LMICs. More robust research on health seeking behaviours and outcomes, especially through large multi-country surveys, is needed to inform the effective design of mixed health care systems that effectively engage both public and private providers.

TRIAL REGISTRATION

PROSPERO registration number CRD42022340059 .

Environmental inequalities and multimorbidity: Insights from the Southwest China Multi-Ethnic Cohort Study

Multimorbidity is an increasingly significant public health challenge worldwide. Although the association between environmental factors and the morbidity and mortality of individual chronic diseases is well-established, the relationship between environmental inequalities and multimorbidity, as well as the patterns of multimorbidity across different areas and ethnic groups, remains unclear. We first focus on analyzing the differences in environmental exposures and patterns of multimorbidity across diverse areas and ethnic groups. The results show that individuals of Han ethnicity residing in Chongqing and Sichuan are exposure to higher levels of air pollutants such as PM2.5, PM10, and NO2. Conversely, Tibetans in Tibet and Yi people in Yunnan face elevated concentrations of O3. Furthermore, the Dong, Miao, Buyi ethnicities in Guizhou and Bai in Yunnan have greater access to green spaces. The key multimorbidity patterns observed in Southwest China are related to metabolic abnormalities combined with digestive system diseases. However, significant differences in multimorbidity patterns exist among different regions and ethnic groups. Further utilizing the logistic regression model, the analysis demonstrates that increased exposure to environmental pollutants (PM2.5, PM10, NO2, O3) is significantly associated with higher odds ratios of multimorbidity. Conversely, a greater presence of green spaces (NDVI 250, NDVI 500, NDVI 1000) significantly reduces the risk of multimorbidity. This large-scale epidemiological study provides some evidence of a significant association between environmental inequalities and multimorbidity. By addressing these environmental inequalities and promoting healthy environments for all, we can work towards reducing the prevalence of multimorbidity and improving overall population health.

Unravelling the nexus of microfinance and women's non-communicable disease (NCD) health outcomes in Sri Lanka: An exploratory study

ABSTRACTNon-communicable diseases (NCDs) are a major contributor to the global burden of disease, increasingly impacting low-income and marginalised populations in low- and middle-income countries such as Sri Lanka. Microfinance could be a potential approach to target NCDs. Using an ethnographic approach with thematic analysis, this study explored the nexus between microfinance and NCD outcomes. In-depth interviews were conducted with 29 micro-loan borrowing women across 15 field sites within Puttalam district in Sri Lanka. The findings revealed that perceived increases in income from microfinance loans contributed to enhanced household health savings ability, enabling the purchase of medicines bought out-of-pocket and from privately owned pharmacies, and spending for NCD-relevant health emergencies and health-related transportation. Additionally, perceived income increases also influenced the behavioural risks, including the spending and consumption of food, and physical activity levels, both positively and negatively. The microfinance networks also influenced women's perceived social support, psychological stress and coping mechanisms, and health information transmission, positively and negatively. The findings from this study provide important insights on how financial inclusion programs such as microfinance influence the health determinants and outcomes relevant to NCDs. This can help address ways to target both NCDs and inequities of socioeconomically disadvantaged and marginalised populations, particularly women.

Equity and Quality of Global Chronic Kidney Disease Care: What Are We Waiting for?

BACKGROUND

Chronic kidney disease (CKD) is an important but insufficiently recognized public health problem. Unprecedented advances in delaying progression of CKD and reducing kidney failure and death have been made in recent years, with the addition of the sodium-glucose cotransporter 2 inhibitors and other newer medication to the established standard of care with inhibitors of the renin-angiotensin system. Despite knowledge of these effective therapies, their prescription and use remain suboptimal globally, and more specially in low resource settings. Many challenges contribute to this gap between knowledge and translation into clinical care, which is even wider in lower resource settings across the globe. Implementation of guideline-directed care is hampered by lack of disease awareness, late or missed diagnosis, clinical inertia, poor quality care, cost of therapy, systemic biases, and lack of patient empowerment. All of these are exacerbated by the social determinants of health and global inequities.

SUMMARY

CKD is a highly manageable condition but requires equitable and sustainable access to quality care supported by health policies, health financing, patient and health care worker education, and affordability of medications and diagnostics.

KEY MESSAGES

The gap between the knowledge and tools to treat CKD and the implementation of optimal quality kidney care should no longer be tolerated. Advocacy, research and action are required to improve equitable access to sustainable quality care for CKD everywhere.

Global, regional, and national burdens of hypertensive heart disease from 1990 to 2019 ：A multilevel analysis based on the global burden of Disease Study 2019

Aim

This study aimed to describe the prevalence, deaths, and disability-adjusted life-years (DALYs) of hypertensive heart disease (HHD) at the global, regional, and national levels and analyze epidemiological trends.

Method

We extracted global estimates of prevalence, deaths, and DALYs related to HHD in 204 countries and regions from the 2019 Global Burden of Diseases Study. Average annual percent change (AAPC) was calculated to represent temporal trends. Joinpoint regression models were used to analyze time trends from 1990 to 2019. Finally, the decomposition analysis showed the driving factors of burden changes.

Results

From 1990 to 2019, the global prevalence of HHD cases increased by 138 %, reaching 18,598,025 cases (95 % uncertainty interval [UI]: 13,544,365-24,898,411). DALYs also rose by 154 %, reaching 21,508,002 (95 % UI, 16,400,051-23,899,879). The death rate increased to 14.95 (95 % UI, 11.11-16.52) per 100,000 people. Of the five sociodemographic index (SDI) regions, the prevalence rate related to HHD was the highest in the high-middle SDI region. In contrast, the death and DALY rate related to HHD were the highest in the middle SDI region. In other regions, the prevalence rate was the highest in East Asia (548.87 per 100,000 people; 95 % UI, 395.40-747.83), and the death rate was the highest in Central Europe (42.64 per 100,000 people; 95 % UI, 30.58-49.38). At the national level, the Cook Islands had the highest prevalence rate for HHD (703.08 per 100,000 people; 95 % UI, 532.87-920.72), Bulgaria had the highest death rate (75.08 per 100,000 people; 95 % UI, 46.38-92.81), and Afghanistan had the highest DALY rate (1374.12 per 100,000 people; 95 % UI, 467.17-2020.70). High body mass index, a diet high in sodium, alcohol use, lead exposure, high temperature, and low temperature were identified as risk factors for death and DALYs related to HHD in 2019. Aging and population growth were the major drivers of prevalence, death, and DALYs. Finally, over the past 30 years, the global age-standardized prevalence rate (ASPR) of HHD has significantly risen (AAPC = 0.21 %, 95 % confidence interval [CI]: 0.17-0.24; P < 0.001), while the age-standardized deaths rate (ASDR) has shown significant declining trends (AAPC = -0.86 %, 95 % CI: 1.00 to -0.71; P < 0.001), and age-standardized DALY rates (AAPC = -1.08 %, 95 % CI: 1.23 to -0.93; P < 0.001).

Conclusion

Despite a significant decline in the global ASDR and age-standardized DALY rate of HHD over the past 30 years, the ASPR continues to rise. The burden of HHD is more heavily skewed towards non-high-income economies. Active prevention, control of risk factors, and improvement of medical protection levels to address the disease burden caused by population growth and aging are needed.

Realigning noncommunicable disease monitoring with health systems priorities in the Africa region

The African region of the World Health Organization (WHO) recently adopted a strategy aimed at more comprehensive care for noncommunicable diseases (NCDs) in the region. The WHO's World Health Assembly has also newly approved several ambitious disease-specific targets that raise the expectations of chronic care and plans to revise and update the NCD-Global Action Plan. These actions provide a critically needed opportunity for reflection and course correction in the global health response to NCDs. In this paper, we highlight the status of the indicators that are currently used to monitor progress towards global goals for chronic care. We argue that weak health systems and lack of access to basic NCD medicines and technologies have prevented many countries from achieving the level of progress required by the NCD epidemic, and current targets do little to address this reality. We identify gaps in existing metrics and explore opportunities to realign the targets with the pressing priorities facing today's health systems.

Onion supplementation and health metabolic parameters: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Functional foods, such as onions, have been the center of many recent investigations. In this systematic-review and meta-analysis, we aimed to gather up the existing information with regard to the impact of onion supplementation on anthropometric measurements/indices, lipid profile, indices of glycemic control and hepatic health, systolic and diastolic blood pressures (SBP and DBP), and adiponectin and leptin.

METHODS

All major online datasets (PubMed, Web of Science, Cochrane, and Scopus) were thoroughly searched from inception up to October 2022. Relevant randomized controlled trials (RCTs) were obtained using the eligibility criteria. Weighted mean differences (WMDs) were calculated and reported. Statistical significance was set as p-values <0.05.

RESULTS

Among all the retrieved data, 14 RCTs were eligible to be included. The results of the crude analysis showed that onion supplementation significantly improved body fat percentage (BFP), low-density lipoprotein-cholesterol (LDL-c), total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-c), systolic blood pressure, adiponectin, and aspartate aminotransferase (AST). Subgroup analysis revealed that interventions lasting more than 12 weeks can significantly alter weight, waist circumference (WC), body mass index (BMI), BFP, LDL-c, TC, SBP, and DBP. Moreover, the intake of dosages of >300 mg/day of onion supplementation could significantly improve weight, WC, BMI, BFP, LDL-c, HDL-C, TC, AST, ALT, SBP and DBP.

CONCLUSION

It seems that the intake of onion supplementation can improve health metabolic parameters. We observed that with either longer follow-up periods or higher dosages of onion supplementation, improvements in cardio-metabolic parameters could be expected.

Health taxes in Indonesia: a review of policy debates on the tobacco, alcoholic beverages and sugar-sweetened beverage taxes in the media

INTRODUCTION

One of the WHO's 'best buys' in controlling non-communicable diseases and their risk factors is to impose health taxes. While the Indonesian political process inhibits the implementation of health tax policy, studies to discuss the issue remain limited.

METHODS

We employed media analysis to document health tax policy dynamics, for example, the changes in policy timeline and key actors' statements. We conducted an article search in the Open-Source Intelligence database using appropriate terminology on three commodities, for example, tobacco, alcoholic beverages and sugar-sweetened beverages (SSB).

RESULTS

Throughout the 15 years of implementation (2007-2022), tobacco has received the most policy attention compared with the other two commodities. This is mainly related to the increasing tariff and reforming the tax structure. As Indonesia is a Muslim-majority country, alcohol consumption is low, and a tax on alcoholic beverages was nearly unchanging and lacked media coverage. Ministry of Finance (MoF) officials are key opinion leaders often cited in the media for health taxes. MoF's support for health taxes is important to pass and implement health taxes. While SSB taxation is emerging, key opinion leaders' media statements imply policy contestation, leading to delayed implementation. The policy debates on tobacco taxation implied election years as a major challenge for health tax passages. During the political years, anti-health tax arguments emerged from politicians. While the political contestation on SSB concluded that accentuating the health tax arguments in favour of public health generates the strongest opposition against taxation from the industry.

CONCLUSIONS

Politics of tobacco tax implementation are complex-compared with the other two commodities. The political context drives the divided views among policy-makers. Policy recommendations include generating public allies with key religious opinion leaders, continuing capacity building for politicians and Ministry of Health, and generating evidence-based arguments in favour of public health for MoF.

Financial hardship associated with catastrophic out-of-pocket spending tied to primary care services in low- and lower-middle-income countries: findings from a modeling study

BACKGROUND

Financial risk protection (FRP) is a key component of universal health coverage (UHC): all individuals must be able to obtain the health services they need without experiencing financial hardship. In many low-income and lower-middle-income countries, however, the health system fails to provide sufficient protection against high out-of-pocket (OOP) spending on health services. In 2018, OOP health spending comprised approximately 40% of current health expenditures in low-income and lower-middle-income countries.

METHODS

We model the household risk of catastrophic health expenditures (CHE), conditional on having a given disease or condition-defined as OOP health spending that exceeds a threshold percentage (10, 25, or 40%) of annual income-for 29 health services across 13 disease categories (e.g., diarrheal diseases, cardiovascular diseases) in 34 low-income and lower-middle-income countries. Health services were included in the analysis if delivered at the primary care level and part of the Disease Control Priorities, 3rd edition "highest priority package." Data were compiled from several publicly available sources, including national health accounts, household surveys, and the published literature. A risk of CHE, conditional on having disease, was modeled as depending on usage, captured through utilization indicators; affordability, captured via the level of public financing and OOP health service unit costs; and income.

RESULTS

Across all countries, diseases, and health services, the risk of CHE (conditional on having a disease) would be concentrated among poorer quintiles (6.8% risk in quintile 1 vs. 1.3% in quintile 5 using a 10% CHE threshold). The risk of CHE would be higher for a few disease areas, including cardiovascular disease and mental/behavioral disorders (7.8% and 9.8% using a 10% CHE threshold), while lower risks of CHE were observed for lower cost services.

CONCLUSIONS

Insufficient FRP stands as a major barrier to achieving UHC, and risk of CHE is a major problem for health systems in low-income and lower-middle-income countries. Beyond its threat to the financial stability of households, CHE may also lead to worse health outcomes, especially among the poorest for whom both ill health and financial risk are most severe. Modeling the risk of CHE associated with specific disease areas and services can help policymakers set progressive health sector priorities. Decision-makers could explicitly include FRP as a criterion for consideration when assessing the health interventions for inclusion in national essential benefit packages.

Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: protocol for a systematic review

INTRODUCTION

The burden of non-communicable diseases (NCDs) has increased substantially in low- and middle-income countries (LMICs), and adapting health service delivery models to address this remains a challenge. Many patients with NCD seek private care at different points in their encounters with the health system, but the determinants and outcomes of these choices are insufficiently understood. The proposed systematic review will help inform the governance of mixed health systems towards achieving the goal of universal health coverage. This protocol details our intended methodological and analytical approaches, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

METHODS AND ANALYSIS

Following the PRISMA approach, this systematic review will develop a descriptive synthesis of the determinants and outcomes of private healthcare utilisation for NCDs in LMICs. The databases Embase, Medline, Web of Science Core Collection, EconLit, Global Index Medicus and Google Scholar will be searched for relevant studies published in English between period 1 January 2010 and 30 June 2022 with additional searching of reference lists. The study selection process will involve a title-abstract and full-text review, guided by clearly defined inclusion and exclusion criteria. A quality and risk of bias assessment will be done for each study using the Mixed Methods Appraisal Tool.

ETHICS AND DISSEMINATION

Ethical approval is not required because this review is based on data collected from publicly available materials. The results will be published in a peer-reviewed journal and presented at related scientific events.

PROSPERO REGISTRATION NUMBER

CRD42022340059.

Temporal trends in inequalities of the burden of cardiovascular disease across 186 countries and territories

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality globally. The extent to which CVD affects the population's health varies across countries. Moreover, quantitative estimates of the trend of inequalities in CVD burden remain unclear. The objective of our study was to assess the socioeconomic inequalities and temporal trends of CVD burden across 186 countries and territories from 2000 to 2019.

METHODS

We extracted data from the Global Burden of Disease, Injuries, and Risk Factors Study (GBD) 2019, and conducted a cross-national time-series analysis. Age-standardized disability-adjusted life-year (DALY) rates were used to measure the burden of CVDs, and gross national income (GNI) per capita was used to approximate the socioeconomic development. Concentration curves and concentration indexes (CIs) were generated to evaluate the cross-national socioeconomic inequality of CVD burden. A joinpoint regression analysis was used to quantify the changes in trends in socioeconomic inequality of CVD burden from 2000 to 2019.

RESULTS

The age-standardized DALY rates of CVDs decreased in 170 (91%) of 186 countries from 2000 to 2019. The concentration curves of the age-standardized DALY rates of CVDs were above the equality line from 2000 to 2019, indicating a disproportional distribution of CVD burden in low-income countries. The CIs declined from - 0.091 (95% CI: -0.128 to - 0.054) in 2000 to - 0.151 (95% CI: -0.190 to - 0.112) in 2019, indicating worsened pro-poor inequality distributions of CVD burden worldwide. A four-phase trend of changes in the CIs of age-standardized DALY rates for CVD was observed from 2000 to 2019, with an average annual percentage change (AAPC) of - 2.7% (95% CI: -3.0 to - 2.4). Decreasing trends in CIs were observed in all CVD subcategories but endocarditis, with AAPC ranging from - 6.6% (95% CI: -7.3 to - 5.9) for ischemic heart disease to - 0.2% (95% CI: -0.4 to - 0.1) for hypertensive heart disease.

CONCLUSIONS

Globally, the burden of CVD has decreased in more than 90% of countries over the past two decades, accompanied by an increasing trend of cross-country inequalities. Moreover, the overall burden of CVD continues to fall primarily on low-income countries.

Economic burden of non-communicable diseases on households in Nigeria: evidence from the Nigeria living standard survey 2018-19

BACKGROUND

The importance of non-communicable diseases (NCDs) in Nigeria is reflected in their growing burden that is fast overtaking that of infectious diseases. As most NCD care is paid for through out-of-pocket (OOP) expenses, and NCDs tend to cause substantial income losses through chronic disabilities, the rising NCD-related health burden may also be economically detrimental. Given the lack of updated national-level evidence on the economic burden of NCDs in Nigeria, this study aims to produce new evidence on the extent of financial hardship experienced by households with NCDs in Nigeria due to OOP expenditure and productivity loss.

METHODS

This study analysed cross-sectional data from the most recent round (2018-19) of the Nigeria Living Standard Survey (NLSS). Household-level health and consumption data were used to estimate catastrophic health expenditure (CHE) and impoverishing effects due to OOP health spending, using a more equitable method recently developed by the World Health Organization European region in 2018. The productivity loss by individuals with NCDs was also estimated from income and work-time loss data, applying the input-based human capital approach.

RESULTS

On average, a household with NCDs spent ₦ 122,313.60 or $ 398.52 per year on NCD care, representing 24% of household food expenditure. The study found that OOP on cancer treatment, mental problems, and renal diseases significantly contribute to the cost of NCD care. The OOP expenditure led to catastrophic and impoverishing outcomes for households. The estimations showed that about 30% of households with NCDs experienced CHE in 2018, using the WHO Europe method at the 40% threshold. The study also found that the cost of NCD medications was a significant driver of CHE among NCD-affected households. The results showed heterogeneity in CHE and impoverishment across states and geographical regions in Nigeria, with a higher concentration in rural and North East geopolitical locations. The study also found that 20% of NCD-affected households were impoverished or further impoverished by OOP payment, and another 10% were on the verge of impoverishment. The results showed a negligible rate of unmet needs among households with NCDs.

CONCLUSIONS

The study highlights the significant effect of NCDs on Nigerian households and the need for effective policy interventions to address this challenge, particularly among the poor and vulnerable.

Building an action plan to tackle palliative care inequality through multi-stakeholder platforms

Background

To achieve universal care and overcome existing barriers, the most effective strategy is to devise an action plan that incorporates palliative care into primary health care (PHC), as recommended by the World Health Organization's (WHO) Astana Declaration. In Colombia, a country with an upper-middle-income status, about 128,000 individuals experience severe health-related suffering (SHS) that necessitates palliative care. Although the country's healthcare system has made steady strides in the integration and development of palliative care, there is still no national plan in place for palliative care.

Objective

Build up Colombia's palliative care plan through stakeholder consensus.

Method

Based on the participatory action research method and the multi-stakeholder platforms model, this study convened 142 stakeholders from different levels of the health system (patient representatives, journalists, health professionals, government entities, insurance companies, universities, and drug regulatory authorities).

Results

The national plan aims to achieve its objectives through a series of strategic actions. These include integrating and diversifying palliative care services, improving access to opioids, increasing palliative care education, promoting community-based palliative care programs, securing funding, and implementing a regulatory framework for palliative care by public policymakers.

Conclusions

The national palliative care is an alliance that aims to reduce palliative care inequity in Colombia by 2026 by empowering stakeholders nationwide to collaborate around specific goals and objectives.

Patterns of Non-Communicable Disease, Multimorbidity, and Population Awareness in Bahir Dar, Northwest Ethiopia: A Cross-Sectional Study

Objective

Ethiopia, like other developing countries, is going through an epidemiological transition, and high rates of non-communicable diseases (NCDs) are having a significant impact on the health system; however, there is limited evidence about community level NCD prevalence, multimorbidity, and population awareness that could inform targeted interventions and policy responses. This study aimed to identify factors associated with NCD prevalence, multimorbidity, and population awareness of NCDs in Bahir Dar, Northwest Ethiopia.

Methods

A community-based cross-sectional survey was conducted with 417 randomly sampled adults. We performed descriptive and logistic regression analyses to evaluate associations between NCD prevalence (cardiovascular diseases, diabetes, cancer, chronic respiratory diseases, chronic kidney disease, and hypertension) multimorbidity (2 or more NCDs) and demographic, socioeconomic, individual risk factors, anthropometrics, knowledge, and attitude.

Results

This study reveals that 24% of participating adults have an NCD, and 8% have multimorbidity. One-third (34.5%) have some NCD knowledge, and 75% consider NCDs more dangerous than communicable diseases. We find low NCD prevalence in participants: younger than 40 years of age (AOR 0.17, 95% CI 0.07 to 0.39); with normal body mass index (AOR 0.27, 0.10 to 0.77) and; with a family history of NCD (AOR 7.7, 4.2 to 14.1). Multimorbidity is lower in young adults (AOR 0.08, 0.03 to 0.26). NCD knowledge is higher in men (AOR 1.76, 1.06 to 2.93) and employed adults (AOR 2.91, 1.52 to 5.57), and NCD attitude in normal-weight adults (AOR 3.23, 1.42 to 7.39).

Conclusion

This study reveals a high prevalence of NCD and overall low NCD awareness in the population. Age above 40 years, family history of NCD, and weight in the obese category are significant predictors of NCD prevalence. These findings can help health professionals, health offices, and concerned stakeholders to plan targeted health interventions to reduce NCDs in the population.

Main drivers of diabetes pharmaceuticals expenditures: evidence from OECD countries and Iran

Purpose

This study aimed to identify the impact of prominent drivers on drug expenditure for diabetes.

Method

Following the examination of previous studies, this study identified possible factors contributing to diabetes pharmaceutical expenditures. The explanatory variables for the study were the median population age, access to innovative drugs, GDP per capita, prevalence, price, and consumption of diabetes drugs. Then, to estimate the per capita expenditure among diabetic patients, this study developed the panel data model and two time-series regression models for OECD countries and Iran, respectively.

Results

In the panel data regression model, R2 was 0.43. The influence of the age, prevalence, consumption volume and GDP per capita coefficients were + 1.79, + 0.704, + 3.86057, + 0.00054, respectively. Also, the probability level of all variables was less than 0.05. In Iran's comparative time-series regression model, R2 was 0.9, and the only significant influence coefficient was the age (β=+0.91). In the another model for Iran, R2 was 0.99, the influence coefficient of age was + 0.249, the prevalence was + 0.131, innovation was + 0.029, and the price was + 0.00054; all the probability levels were less than 0.05.

Conclusion

Pharmaceutical per capita expenditure is affected by several factors. These factors are not the same in various counties. Passing a judgment on drug utilization only based on pharmaceutical per capita expenditure cannot be perfect. Also, judging whether the per capita drug expenditure in one country is desirable without attention to the affecting factors and only relying on the value of utilized medicines is defective.

Evaluating the effectiveness of the National Health Insurance Fund in providing financial protection to households with hypertension and diabetes patients in Kenya

BACKGROUND

Non-communicable diseases (NCDs) can impose a substantial financial burden to households in the absence of an effective financial risk protection mechanism. The national health insurance fund (NHIF) has included NCD services in its national scheme. We evaluated the effectiveness of NHIF in providing financial risk protection to households with persons living with hypertension and/or diabetes in Kenya.

METHODS

We carried out a prospective cohort study, following 888 households with at least one individual living with hypertension and/or diabetes for 12 months. The exposure arm comprised households that are enrolled in the NHIF national scheme, while the control arm comprised households that were not enrolled in the NHIF. Study participants were drawn from two counties in Kenya. We used the incidence of catastrophic health expenditure (CHE) as the outcome of interest. We used coarsened exact matching and a conditional logistic regression model to analyse the odds of CHE among households enrolled in the NHIF compared with unenrolled households. Socioeconomic inequality in CHE was examined using concentration curves and indices.

RESULTS

We found strong evidence that NHIF-enrolled households spent a lower share (12.4%) of their household budget on healthcare compared with unenrolled households (23.2%) (p = 0.004). While households that were enrolled in NHIF were less likely to incur CHE, we did not find strong evidence that they are better protected from CHE compared with households without NHIF (OR = 0.67; p = 0.47). The concentration index (CI) for CHE showed a pro-poor distribution (CI: -0.190, p < 0.001). Almost half (46.9%) of households reported active NHIF enrolment at baseline but this reduced to 10.9% after one year, indicating an NHIF attrition rate of 76.7%. The depth of NHIF cover (i.e., the share of out-of-pocket healthcare costs paid by NHIF) among households with active NHIF was 29.6%.

CONCLUSION

We did not find strong evidence that the NHIF national scheme is effective in providing financial risk protection to households with individuals living with hypertension and/diabetes in Kenya. This could partly be explained by the low depth of cover of the NHIF national scheme, and the high attrition rate. To enhance NHIF effectiveness, there is a need to revise the NHIF benefit package to include essential hypertension and/diabetes services, review existing provider payment mechanisms to explicitly reimburse these services, and extend the existing insurance subsidy programme to include individuals in the informal labour market.

New pattern of individualized management of chronic diseases: focusing on inflammatory bowel diseases and looking to the future

Non-infectious chronic diseases, especially inflammatory bowel diseases (IBDs), hypertension, and diabetes mellitus, are characterized by a prolonged and multisystemic course, and their incidence increases annually, usually causing serious economic burden and psychological stress for patients. Therefore, these diseases deserve scientific and consistent disease management. In addition, the lack of a comprehensive "early disease clues tracking-personalized treatment system-follow-up" model in hospitals also exacerbates this dilemma. Based on these facts, we propose an individualized prediction management system for IBDs based on chronic diseases, focusing on the established IBDs-related prediction models and summarizing their advantages and disadvantages. We call on researchers to pay attention to the integration of models with clinical practice and the continuous correction of models to achieve truly individualized medical treatment for chronic diseases, thus providing substantial value for the rapid diagnosis and adequate treatment of chronic diseases such as IBDs, which follow the "relapse-remission" disease model, and realizing long-term drug use and precise disease management for patients. The goal is to achieve a new level of chronic disease management by scientifically improving long-term medication, precise disease management, and individualized medical treatment, effectively prolonging the remission period and reducing morbidity and disability rates.

Chronic Kidney Disease Burden in Low-Resource Settings: Regional Perspectives

The burden of chronic kidney disease (CKD) has increased exponentially worldwide but more so in low- and middle-income countries. Specific risk factors in these regions expose their populations to an increased risk of CKD, such as genetic risk with APOL1 among populations of West African heritage or farmers with CKD of unknown etiology that spans various countries across several continents to immigrant/indigenous populations in both low- and high-income countries. Low- and middle-income economies also have the double burden of communicable and noncommunicable diseases, both contributing to the high prevalence of CKD. The economies are characterized by low health expenditure, sparse or nonexistent health insurance and welfare programs, and predominant out-of-pocket spending for medical care. This review highlights the challenges in populations with CKD from low-resource settings globally and explores how health systems can help ameliorate the CKD burden.

Sociodemographic and geographic inequalities in diagnosis and treatment of older adults' chronic conditions in India: a nationally representative population-based study

CONTEXT

Expeditious diagnosis and treatment of chronic conditions are critical to control the burden of non-communicable disease in low- and middle-income countries. We aimed to estimate sociodemographic and geographic inequalities in diagnosis and treatment of chronic conditions among adults aged 45 + in India.

METHODS

We used 2017-18 nationally representative data to estimate prevalence of chronic conditions (hypertension, diabetes, lung disease, heart disease, stroke, arthritis, cholesterol, and neurological) reported as diagnosed and percentages of diagnosed conditions that were untreated by sociodemographic characteristics and state. We used concentration indices to measure socioeconomic inequalities in diagnosis and lack of treatment. Fully adjusted inequalities were estimated with multivariable probit and fractional regression models.

FINDINGS

About 46.1% (95% CI: 44.9 to 47.3) of adults aged 45 + reported a diagnosis of at least one chronic condition and 27.5% (95% CI: 26.2 to 28.7) of the reported conditions were untreated. The percentage untreated was highest for neurological conditions (53.2%; 95% CI: 50.1 to 59.6) and lowest for diabetes (10.1%; 95% CI: 8.4 to 11.5). Age- and sex-adjusted prevalence of any diagnosed condition was highest in the richest quartile (55.3%; 95% CI: 53.3 to 57.3) and lowest in the poorest (37.7%: 95% CI: 36.1 to 39.3). Conditional on reported diagnosis, the percentage of conditions untreated was highest in the poorest quartile (34.4%: 95% CI: 32.3 to 36.5) and lowest in the richest (21.1%: 95% CI: 19.2 to 23.1). Concentration indices confirmed these patterns. Multivariable models showed that the percentage of untreated conditions was 6.0 points higher (95% CI: 3.3 to 8.6) in the poorest quartile than in the richest. Between state variations in the prevalence of diagnosed conditions and their treatment were large.

CONCLUSIONS

Ensuring more equitable treatment of chronic conditions in India requires improved access for poorer, less educated, and rural older people who often remain untreated even once diagnosed.

Equitable Prioritization of Health Interventions by Incorporating Financial Risk Protection Weights Into Economic Evaluations

OBJECTIVES

Financial risk protection (FRP), or the prevention of medical impoverishment, is a major objective of health systems, particularly in low- and middle-income countries where the extent of out-of-pocket (OOP) health expenditures can be substantial. We sought to develop a method that allows decision makers to explicitly integrate FRP outcomes into their priority-setting activities.

METHODS

We used literature review to identify 31 interventions in low- and middle-income countries, each of which provided measures of health outcomes, costs, OOP health expenditures averted, and FRP (proxied by OOP health expenditures averted as a percentage of income), all disaggregated by income quintile. We developed weights drawn from the Z-score of each quintile-intervention pair based on the distribution of FRP of all quintile-intervention pairs. We next ranked the interventions by unweighted and weighted health outcomes for each income quintile. We also evaluated how pro-poor they were by, first, ordering the interventions by cost-effectiveness for each quintile and, next, calculating the proportion of interventions each income quintile would be targeted for a given random budget. A ranking was said to be pro-poor if each quintile received the same or higher proportion of interventions than richer quintiles.

RESULTS

Using FRP weights produced a more pro-poor priority setting than unweighted outcomes. Most of the reordering produced by the inclusion of FRP weights occurred in interventions of moderate cost-effectiveness, suggesting that these weights would be most useful as a way of distinguishing moderately cost-effective interventions with relatively high potential FRP.

CONCLUSIONS

This preliminary method of integrating FRP into priority-setting would likely be most suitable to deciding between health interventions with intermediate cost-effectiveness.

Social inequalities in all-cause mortality among adults with multimorbidity: a 10-year prospective study of 0.5 million Chinese adults

BACKGROUND

Chinese individuals face an increase in multimorbidity, but little is known about the mortality gradients of multimorbid people in different socio-economic groups. This study measures relative and absolute socio-economic inequality in mortality among multimorbid Chinese.

METHODS

For this study, the prospective China Kadoorie Biobank (CKB) enrolled 512 712 participants ages 30-79 y from 10 areas of China between 25 June 2004 and 15 July 2008. All-cause mortality was accessed with a mean follow-up period of 10 y (to 31 December 2016). Associations between multimorbidity and mortality were assessed using Cox proportional hazards models, with the relative index of inequality (RII) and slope index of inequality (SII) in mortality calculated to measure disparities.

RESULTS

Mortality risk was highest for those who had not attended formal school and with four or more long-term conditions (LTCs) (hazard ratio 3.11 [95% confidence interval {CI} 2.75 to 3.51]). Relative educational inequality was lower in participants with four or more LTCs (RII 1.92 [95% CI 1.60 to 2.30]), especially in rural areas. Absolute disparities were greater in adults with more LTCs (SII 0.18 [95% CI 0.14 to 0.21] for rural participants with three LTCs).

CONCLUSIONS

Whereas the relative inequality in all-cause mortality was lower among multimorbid people, absolute inequality was greater among multimorbid men, especially in rural areas.

Providing paediatric surgery in low-resource countries

Successful health systems comprise good outcomes, accessibility and availability. Surgery is the service that cuts across many treatment scenarios, yet in low- and middle-income countries 90% of people cannot access it. Estimates using most recent population data suggest that 1.75 billion children lack access to surgical care. Additionally, 30% of the global burden of disease is treatable with surgery, yet in LMICs as much as 87% of the surgical need remains unmet. Paediatric surgical services are not at the level they need to be, highlighting an increasing surgical burden on children’s health globally with a human cost of morbidity and mortality. Achieving Universal Health Coverage and the Sustainable Development Goals will fail if surgical systems are not strengthened in low resource settings.

In 2018, global health charity Kids Operating Room was founded with a goal of ensuring every child has access to the surgery they need. The charity has a four-pillar approach to its work: provision of infrastructure and equipment, paediatric surgical workforce training, database development and research capacity strengthening, and advocating on behalf of children denied access to safe surgery. To ensure that paediatric surgical interventions produce real impact on service delivery, contextual understanding and needs assessment are key. The building of paediatric surgical capacity should align to countries’ priorities and wishes. Investing in local health workforce is essential to delivering quality services, supporting resilient health systems and provides integrated, people-centred health services. A competent surgical information system gives the local surgical workforce the tools needed to action evidence-driven decisions.

Strengthening surgical services in a manner aligned to the WHO’s fundamental health system building blocks, allows for sustainable and long-lasting change. Confronting bottlenecks that exist in surgical services and establishing multi-faceted development, will allow global, national and local surgical targets to be met.

Economic barriers and gaps to reach the desirable consumption of salt, sugar, and fat in Iran: a qualitative study

BACKGROUND

Non-communicable diseases (NCDs), also known as chronic diseases, specifically cardiovascular diseases (CVD), cancers, respiratory diseases, and diabetes are the main reason for more than two-thirds of global deaths, in which the unhealthy diet is one of the primary risk factors. The golden solution to reducing obesity and CVD linked to an unhealthy diet is to reduce calories, salt, sugar, and fat intake. Besides, activities highlighting lifestyles that contain healthy diets usually focus on reducing salt, sugar, and saturated fat consumption. As a result, the researchers aimed to study the gaps and economic barriers to recommended consumption of salt, sugar, and fat in Iran, based on WHO recommendations.

METHODS

This is a qualitative study. We conducted semi-structured and in-depth interviews with 30 stakeholders, including academics, experts, and key informants in different sectors from December 2018 until August 2019 in Tehran, Iran. We used a purposeful and snowball sampling method to select participants. All interviews were transcribed verbatim and thematically analyzed using MAXQDA 11.

RESULTS

Economic problems and inflation in Iran caused people to eat more unhealthy foods, while a healthy diet consumption was reduced due to higher prices. Unfair political sanctions imposed on the country caused economic pressure and adversely affected family nutrition. Worse still, despite legal bans, advertising unhealthy foods via media, mainly to generate revenue, encouraged more consumption of unhealthy food. The lack of targeted subsidies and failure in tax legislation and implementation related to the unhealthy products deteriorated the conditions.

CONCLUSION

Some economic barriers have hampered plans to reduce salt, fat, and sugar consumption in Iran. Fundamental reforms in the tax and subsidy system are required to improve people's eating habits. In particular, citizens' income that has been continuously shrinking due to economic conditions, imposed sanctions, and the inevitably high inflation needs to be addressed urgently. Unless the government of Iran deals with the economic barriers to healthy nutrition, the pathway for implementing the national action plan for prevention and control of NCDs toward a 30% mortality reduction due to NCDs by 2030 looks unlikely to reach.

Temporal trend of population structure, burden of diseases, healthcare resources and expenditure in China, 2000-2019

OBJECTIVES

To explore the evolutionary trend of population structure, disease burden, healthcare resources and expenditure in China, and to identify key domains that are most in need of intervention.

DESIGN

A cross-sectional and longitudinal analysis.

DATA SOURCE

Population and healthcare data from China Statistical Yearbook, and disease burden attributable to causes and risk factors from the Global Burden of Diseases between 2000 and 2019.

MEASURES AND METHODS

We used the Joinpoint Regression Program to measure trends in population composition, population change, dependency ratio, healthcare institution, personnel, expenditure and disease burden from 2000 to 2019.

RESULTS

Regarding the population in China between 2000 and 2019, a decreasing trend was observed among youth aged 0-14 years (average annual percent change (AAPC): -1.17), a slow rising trend was observed among individuals aged 15-64 years (AAPC: 1.10) and a rapidly increasing trend was observed among individuals older than 65 years (AAPC: 3.67). Astonishing increasing trends in healthcare institutions (AAPC: 3.97), medical personnel (AAPC: 3.26) and healthcare expenditures (AAPC: 15.28) were also observed. Among individuals younger than 70 years, neoplasms (AAPC: 0.54) and cardiovascular diseases (AAPC: 0.67) remained among the top three causes, while tobacco (AAPC: 0.22) remained a top three risk factor. However, while musculoskeletal disorders (AAPC: 1.88) were not a top three cause in 2000, they are a top three cause in 2019.

CONCLUSION

Comprehensive age/cause/risk factor-specific strategies are key to reconcile the tension among the triad of population ageing, disease burden and healthcare expenditure. The disease burden from cardiometabolic diseases, neoplasms and musculoskeletal disorders was identified as key domains that require intervention to reduce an increasing disease burden among individuals currently older than 70 years, as well as those approaching this age group.

The importance of wage loss in the financial burden of illness: Longitudinal evidence from India

BACKGROUND

A key aim of Universal Health Coverage (UHC) is to protect individuals and households against the financial risk of illness, and large-scale health insurance expansions are a central focus of the UHC agenda. Importantly, however, health insurance does not protect against a key dimension of financial risk associated with illness: forgone wage income. In this paper, we quantify the economic burden of illness in India attributable - separately - to wage loss and to medical care spending, as well as differences in them across the socio-economic distribution.

METHODS

We use data from two longitudinal Indian household surveys: (i) the Village Dynamics in South Asia (VDSA) survey (1300 households surveyed every month for 60 months between 2010 and 2015) and (ii) the Indian Human Development Survey (IHDS) (more than 40,000 households surveyed in 2005 and again in 2011). Our regression models include a series of fixed effects that account for time-invariant household- (or individual-) level and time-varying unobservables common across households.

FINDINGS

We find that, in the VDSA sample, wage loss accounts for more than 80% of the total economic burden of illness among the poorest households, but only about 20% of the economic burden of illness among the most affluent. Estimates from the IHDS sample confirm that this socio-economic gradient is present in the Indian population generally.

CONCLUSIONS

Wage loss accounts for a substantial share of the total economic burden of illness in India - and disproportionately so among the poorest households. Our findings imply that if UHC is to achieve its objective of protecting households against the financial risk of illness - particularly poor households, the inclusion of wage loss insurance or another illness-related income replacement benefit is needed.

Feasibility of the International Wealth Index and the Gapminder tool as instruments to assess household income and estimate catastrophic expenditure: A prospective patient-level cohort study in India

BACKGROUND

Patient income assessment is required to assess healthcare catastrophic expenditure (Sustainable Development Goal) but self-reported income has several biases. This study aimed to assess the feasibility of the International Wealth Index (IWI) and the Gapminder tool as indirect instruments to assess household income.

METHODS

Prospective cohort study of colorectal cancer patients in five tertiary care hospitals in India (Dec 2020-August 2021). Patient self-reported household income was compared to income estimated from the IWI (twelve questions about household goods) and the Gapminder tool (five pictures of household assets). Agreement between instruments was explored with Bland-Altman methods. Cancer care expenditure from the same cohort was used to illustrate the impact of these tools in catastrophic expenditure rates.

RESULTS

From the 226 patients included, 99.5% completed the IWI and the Gapminder tool. Overall, self-reported incomes were lower than the estimated from the IWI and Gapminder tools (median incomes: 17350₹ for self-reported, 37491₹ for IWI and 51520₹ for Gapminder). The IWI showed better agreement with the self-reported income than the Gapminder tool. For both instruments, the agreement was better for low income earning households. Illustrative catastrophic expenditure rates range from 71% to 56% to 43% when using self-reported, IWI and Gapminder incomes respectively.

DISCUSSION

It is feasible to use the IWI and the Gapminder tools to estimate household income although they might overestimate income, with an impact on catastrophic expenditure rates. Further refinement of these tools could enable global monitoring and modelling of catastrophic expenditure from real-world data, at low burden for patients.

Short and longer-term impacts of health insurance on catastrophic health expenditures in Kwara State, Nigeria

BACKGROUND

Out- of-pocket health expenditures (OOPs) constitute a significant proportion of total health expenditures in many low- and middle-income countries (LMICs), leading to an increased likelihood of exposure to financial catastrophe in the event of illness. Health insurance has the potential to reduce catastrophic health expenditures (CHE), but rigorous evidence of its sustained impact is limited, especially in LMICs. This study examined the short- and longer-term effects of a health insurance program in Kwara State, Nigeria on CHE.

METHODS

The analysis is based on a panel dataset consisting of 3 waves of household surveys in program and comparison areas. The balanced data consists of 1,039 households and 3,450 individuals. We employed a difference-in-differences (DiD) regression approach to estimate intention-to-treat effects, and then computed average treatment effects on the treated by combining DiD with propensity score weighting and an instrumental variables analysis. CHE was measured as OOPs exceeding 10% of household consumption and 40% of capacity-to-pay (CTP).

RESULTS

Using 10% of consumption as a CHE measure, we found that living in the program area was associated with a 4.3 percentage point (pp) decrease in CHE occurrence (p < 0.05), while the effect on insured households was 5.7 pp (p < 0.05). The longer-term impact four years after program introduction was not significant. Heterogeneity analyses show a reduction in CHE of 7.2 pp (p < 0.01) in the short-term for the poorest tercile. No significant effects were found for the middle and richest terciles, nor in the longer-term. Households with a chronically ill member experienced a reduction in CHE of 9.4 pp (p < 0.01) in the short-term, but not in the longer-term. Most estimates based on the 40% of CTP measure were not statistically significant.

CONCLUSION

These findings highlight the critical role of health insurance in reducing the likelihood of catastrophic health expenditures, especially for vulnerable populations such as the poor and the chronically ill, and by extension in achieving universal health coverage. They also show that the beneficial impacts of health insurance may attenuate over time, as households potentially adjust their health-seeking behavior to the new scheme.