The effect of old-age pensions on health care utilization patterns and insurance uptake in Mexico

Current and Projected Mortality and Hospitalization Rates Associated With Conditional Cash Transfer, Social Pension, and Primary Health Care Programs in Brazil, 2000-2030

Importance

The health outcomes of increased poverty and inequalities in low- and middle-income countries (LMICs) have been substantially amplified as a consequence of converging multiple crises. Brazil has some of the world's largest conditional cash transfer (Programa Bolsa Família [PBF]), social pension (Beneficio de Prestacão Continuada [BPC]), and primary health care (Estratégia de Saúde da Família [ESF]) programs that could act as mitigating interventions during the current polycrisis era of increasing poverty, slow or contracting economic growth, and conflicts.

Objective

To evaluate the combined association of the Brazilian conditional cash transfer, social pension, and primary health care programs with the reduction of morbidity and mortality over the last 2 decades and forecast their potential mitigation of the current global polycrisis and beyond.

Design, Setting, and Participants

This cohort study used a longitudinal ecological design with multivariable negative binomial regression models (adjusted for relevant socioeconomic, demographic, and health care variables) integrating the retrospective analysis from 2000 to 2019, with dynamic microsimulation models to forecast potential child mortality scenarios up to 2030. Participants included a cohort of 2548 Brazilian municipalities from 2004 to 2019, projected from 2020 to 2030. Data analysis was performed from September 2022 to February 2023.

Exposure

PBF coverage of the target population (those who were poorest) was categorized into 4 levels: low (0%-29.9%), intermediate (30.0%-69.9%), high (70.0%-99.9%), and consolidated (≥100%). ESF coverage was categorized as null (0), low (0.1%-29.9%), intermediate (30.0%-69.9%), and consolidated (70.0%-100%). BPC coverage was categorized by terciles.

Main outcomes and measures

Age-standardized, all-cause mortality and hospitalization rates calculated for the entire population and by age group (<5 years, 5-29 years, 30-69 years, and ≥70 years).

Results

Among the 2548 Brazilian municipalities studied from 2004 to 2019, the mean (SD) age-standardized mortality rate decreased by 16.64% (from 6.73 [1.14] to 5.61 [0.94] deaths per 1000 population). Consolidated coverages of social welfare programs studied were all associated with reductions in overall mortality rates (PBF: rate ratio [RR], 0.95 [95% CI, 0.94-0.96]; ESF: RR, 0.93 [95% CI, 0.93-0.94]; BPC: RR, 0.91 [95% CI, 0.91-0.92]), having all together prevented an estimated 1 462 626 (95% CI, 1 332 128-1 596 924) deaths over the period 2004 to 2019. The results were higher on mortality for the group younger than age 5 years (PBF: RR, 0.87 [95% CI, 0.85-0.90]; ESF: RR, 0.89 [95% CI, 0.87-0.93]; BPC: RR, 0.84 [95% CI, 0.82-0.86]), on mortality for the group aged 70 years and older, and on hospitalizations. Considering a shorter scenario of economic crisis, a mitigation strategy that will increase the coverage of PBF, BPC, and ESF to proportionally cover the newly poor and at-risk individuals was projected to avert 1 305 359 (95% CI, 1 163 659-1 449 256) deaths and 6 593 224 (95% CI, 5 534 591-7 651 327) hospitalizations up to 2030, compared with fiscal austerity scenarios that would reduce the coverage of these interventions.

Conclusions and relevance

This cohort study's results suggest that combined expansion of conditional cash transfers, social pensions, and primary health care should be considered a viable strategy to mitigate the adverse health outcomes of the current global polycrisis in LMICs, whereas the implementation of fiscal austerity measures could result in large numbers of preventable deaths.

The impact of a randomized cash transfer intervention on mortality of adult household members in rural South Africa, 2011-2022

BACKGROUND

Increasing socioeconomic resources through cash transfer payments could help promote healthy longevity. However, research in this area is limited due to endogeneity in cash transfer exposures and limited geographic representation.

METHODS

We leveraged the HPTN 068 randomized cash transfer trial, conducted from 2011 to 2015 in a rural setting in South Africa. We assessed long-term mortality follow-up (until March 2022) on older adult members (n = 3568) of households enrolled in the trial from the complete Agincourt Health and socio-Demographic Surveillance System census of the underlying source population. The trial intervention was a monthly cash payment of 300 Rand conditional on school enrollment of index young women. The payments were split between the young woman (1/3) and their caregiver (2/3). Young women and their households were randomized 1:1 to intervention vs. control. We used Cox PH models to compare mortality rates in older adults living in intervention vs. control households.

FINDINGS

The cash transfer intervention did not significantly impact mortality in the full sample [HR (95% CI): 0.94 (0.80, 1.10)]. However, we observed strong protective effects of the cash transfer intervention among those with above-median household assets [HR (95% CI): 0.66 (0.50, 0.86)] and higher educational attainment [HR (95% CI): 0.37 (0.15, 0.93)].

INTERPRETATION

Our findings indicate that short-term cash transfers can lead to reduced mortality in certain subgroups of older adults with higher baseline socioeconomic status. Future work should focus on understanding the optimal timing, structure, and targets to maximize the benefits of cash transfer programs in promoting healthy aging and longevity.

Physical activity's impact on rural older adult health: The multiple mediating effects of education, income, and psychological capital

Introduction

This study aims to explore the influence mechanism of rural older adult health. By examining the mediating roles of education, income, and psychological capital in physical activity's impact on health, this study provides a reference for lifestyle interventions to improve the health level of rural older adults.

Methods

The analysis was conducted on a sample of 1778 rural older adults from CGSS2017, and data were analyzed using PROCESS V4.2 for multiple mediating effects.

Results

The findings indicate that physical activity impacts rural older adult health through multiple mediating pathways. The mediating role includes seven paths, comprising the independent effects of three mediating variables of income, education, and psychological capital, and the chain mediating effects generated together.

Discussion

Based on the influence mechanism of health on rural older adults, optimizing policy focus and developing a precise, interconnected, and sustainable health security system for older adults is necessary. These research results are of practical significance for advancing healthy aging in rural areas.

Health improvements of older adults based on benefit duration: Lessons from Korean social pension policies

The social pension, introduced in 2008 in Korea, has now become the most prominent old age income for most older adults. As of May 2022, it paid a monthly benefit of around USD 275 for 6.0 million older persons aged 65 and over who belong to the bottom 70% of the income and asset distribution. Although social pension's objectives focus on alleviating old age poverty and increasing income levels, it also encompasses a clear implication on health: social pension benefit can be spent on items or activities that improve the beneficiary's health. Using the Korean Longitudinal Study on Ageing data, between 2006 and 2018, and the Propensity Score Matching combined with Generalized Difference-In-Differences based on event study design, this study investigates the effects of receiving the social pension on objective measures of health that are representative of health and well-being in old age, by benefit duration. Study results showed that continually receiving social pension significantly improved beneficiaries' grip strength and cognitive ability. Grip strength was improved by 2.3-kg in the fifth year of receiving social pension. Additionally, the cognitive ability (K-MMSE score) was improved by 1.309 points in the first year. Results of descriptive analysis suggested that the social pension may have benefitted the health of the beneficiaries by improving their nutrition, health care utilization, and physical activities, and reducing financial strain and associated stress level. To the best of our knowledge, this is the first study to investigate the cumulative effects of nation-wide social pension programs on older adults' objective health measures by benefit duration up to five years, in a high-income country setting where old age income security systems are under-developed.

Configurations of the driving factors promoting China's commercial health insurance: A comparative qualitative analysis based on the technology–organization–environment framework

With the nation's remarkable improvement in living standards, China's health insurance system cannot satisfy people's higher demands; therefore, it is necessary to promote the supply of commercial health insurance (CHI) in China. Based on the technology–organization–environment (TOE) framework, this study constructs a novel analysis framework to investigate the driving path of China's CHI. Employing the data of 31 provincial regions of China in 2018, a fuzzy-set qualitative comparative analysis is conducted to analyze configurations. We also adopt a necessary condition analysis in the robustness check to examine the necessary conditions, determining that no necessary relationship exists between possible conditions and the performance of CHI. More particularly, three sufficient configurations, TOE strategy, government attention (GA)–environment adaptability (EA)–citizen demand (CD) strategy, and dual EA–CD strategy are demonstrated to achieve high performance, and the other three configurations of technological management capability (TMC)–EA-CD strategy, technological infrastructure (TI)–EA strategy, and combined TI–TMC–EA strategy do not result in high performance. In addition, technological conditions (TI and TMC) and EA are relatively more important than the other configurations. Notably, government departments' financial expenditure is found to have a negative effect on CHI promotion.

Does social pension buy improved mental health and mortality outcomes for senior citizens? Evidence from South Africa's 2008 pension reform

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The 2008 pension reform in South Africa improved access to healthcare.

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The 2008 pension reform improved mental health and 60-year-old deaths.

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The impact of the 2008 pension reform in averting 60-year-old deaths is higher in urban regions than rural regions.

In South Africa, men were traditionally eligible to receive government pensions at 65 years. However, that eligibility criterion was changed in 2008 to allow men to receive a pension payout at 60 years. This study is designed to quantify the impact of the 2008 pension reform on mental health outcomes (depression and traumatic stress) and deaths among 60-year-old men from disadvantaged households without advanced education. This analysis used secondary data issued by Statistic South Africa- General Household Survey. Men who reported earning a pension at 60 years from 2008 to 2014 were exposed to the 2008 pension reform and thus were classified as the treatment group. The 60-year-old men during 2002–2007 were ineligible to earn the pension, therefore considered the control group. We then used a Two-stage Least Squared Model (2SLS) to quantify the impact of the 2008 pension reform on healthcare utilization, depression cases, traumatic stress cases, and deaths among 60-year-old men. The model shows that the 2008 pension reform improved healthcare utilization by 3 % in the cohorts of men who benefitted from the 2008 reform. The 2008 pension reform averted depression cases, traumatic stress cases, and deaths among 60-year-old men by 3 %, 4 %, and 5 %, respectively. The impact of the 2008 pension reform in averting deaths among 60-year-old men was higher in urban regions than rural regions. We concluded that the 2008 pension reform successfully bought improved mental health outcomes and prevented depression, traumatic stress, and deaths among 60-year-old men.

Pension exposure and health: Evidence from a longitudinal study in South Africa

Social protection schemes have been expanding around the world with the objective of protecting older persons during retirement. While theoretically they have been seen as tools to improve individual wellbeing, there are few studies that evaluate whether social pensions can improve health. In this study, we exploit the change in eligibility criteria for the South African Old Age grant to estimate the association between pension exposure eligibility and health of older persons. For this, we use data from the Health and Aging in Africa: A longitudinal Study of an INDEPTH Community in South Africa (HAALSI) and model pension exposure in terms of its cumulative effect. Our results show that pension exposure is associated with better health as measured by a set of health indices. Disentangling these effects, we find that pension exposure is most likely to improve health through the delayed onset of physical disabilities in the elderly population. Our study highlights the relevance of social protection schemes as a mechanism to protect older persons physical health.

Effect of Health Insurance Policy on the Health Outcomes of the Middle-Aged and Elderly: Progress Toward Universal Health Coverage

This population-based study aims to explore the effect of the integration of the Urban and Rural Residents' Basic Medical Insurance (URRBMI) policy on the health outcomes of the middle-aged and elderly. A total of 13,360 participants in 2011 and 15,082 participants in 2018 were drawn from the China Health and Retirement Longitudinal Study. Health outcomes were evaluated using the prevalence of chronic diseases. A generalized linear mixed model was used to analyze the effect of the URRBMI policy on the prevalence of chronic disease. Prior to the introduction of the URRBMI policy, 67.09% of the rural participants and 73.00% of the urban participants had chronic diseases; after the policy's implementation, 43.66% of the rural participants and 45.48% of the urban participants had chronic diseases. When adjusting for the confounding factors, the generalized linear mixed model showed that the risk of having a chronic disease decreased by 81% [odds ratio (OR) = 0.19; 95% confidence interval (CI): 0.16, 0.23] after the introduction of the policy in the urban participants; in the rural participants, the risk of having a chronic disease was 30% lower (OR = 0.70; 95% CI: 0.60, 0.82) than the risk in the urban participants before the policy and 84% lower (OR = 0.16; 95% CI: 0.14, 0.19) after the implementation of the policy; the differences in the ORs decreased from 0.30 prior to the policy to 0.03 after the policy had been introduced between rural and urban participants when adjusting for the influence of socioeconomic factors on chronic diseases. This study provides evidence of the positive effects of the URRBMI policy on improving the rural population's health outcomes and reducing the gap in health outcomes between rural and urban populations, indicating that the implementation of the URRBMI policy has promoted the coverage of universal health.

Predictors of Healthcare Utilization Among Older Adults with Moderate to Severe Cognitive Limitations in Ghana: A Cross-Sectional Analysis of the WHO Study on Global Ageing and Adult Health (SAGE) Wave 1

BACKGROUND

As the number of older adults in Ghana keeps increasing, so does the prevalence of aging-related diseases and conditions that tend to lead to cognitive decline. However, knowledge on the predicting factors of healthcare utilization among older adults with cognitive limitations is still scarce.

OBJECTIVE

This study examines the predictive factors of healthcare-seeking behavior among older adults with moderate-to-severe cognitive limitations in Ghana.

METHODS

Based on Andersen's behavioral model of health service utilization, the study analyzed data from 3106 older adults with moderate to severe cognitive limitations in Ghana aged 50+ using Bivariate Probit Regression and the Heckman Selection Model.

RESULTS

Results showed that individuals who were aged 75+, living in urban settlements, educated, higher income levels and parents who had some level of education, pension benefits, and both mandatory and voluntary health insurance were more likely to seek inpatient care. Enabling resources such as the national health insurance scheme and other types of medical insurance, household income, pension benefits, and predisposition factors like education influenced outpatient and inpatient healthcare consumption for older adults with moderate to severe cognitive limitations but had little influence on the choice of healthcare facility except for health insurance.

CONCLUSION

Since the healthcare-seeking behavior of older adults with moderate-to-severe cognitive limitations is driven by an amalgamation of several internal and external factors, there is a need for policy change to understand and cautiously incorporate these factors into the decision to improve equitable access to healthcare services for these individuals, as not all sizes fit all in providing quality care for them.

Lifetime socioeconomic determinants of health trajectories among older adults

Drawing on life course theory and research, we explored how socioeconomic circumstances during childhood and adulthood shape self-reported health trajectories among older Mexican adults. We used data from the Mexican Health and Aging Study panel survey (2001-2015) and used sequence analysis to estimate types of self-reported health trajectories in older adulthood. We then explored the association between those health trajectories and socioeconomic determinants at different life stages, including education, occupation, employment, economic status, parental education, and adverse living conditions and illnesses during childhood. Our contributions are threefold. First, we identified four types of health trajectories for men and eight for women, representing a more nuanced longitudinal health status profile than previously shown. Second, we found that childhood and adult socioeconomic circumstances influence self-reported health trajectories at older age. Third, our results suggest there is no simple monotonic relationship between life course circumstances and self-reported health trajectories.

Measurement and Evaluation of the Operating Efficiency of China's Basic Pension Insurance: Based on Three-Stage DEA Model

Purpose

This paper aims to measure the operating efficiency of China’s basic pension insurance from 2014 to 2019 in 31 provinces.

Methods

The three-stage DEA model was used to evaluate the operating efficiency of basic pension insurance in 31 provinces.

Results

On the whole, the operating efficiency of China’s basic pension insurance was at a high level, but there was still room for improvement. GDP, urbanization level and scale of government public expenditure had a positive impact on the operating efficiency of regional basic pension insurance. In contrast, the old-age dependency ratio had a significant negative effect. There were noticeable regional differences in the operating efficiency of China’s basic pension insurance, which showed a pattern of Central (0.742) >Eastern (0.689) >Western (0.505) after removing the influence of environmental variables.

Conclusion

This study systematically analyzes the impact of external environmental regulations on China’s basic pension insurance’s operating efficiency and provides decision-making references for further improving the operating efficiency of China’s basic pension insurance. In order to further optimize the allocation of basic endowment insurance, this paper proposes the following countermeasures and suggestions: (1) broaden investment channels and improve the investment efficiency; (2) increase supervision of social security departments and strengthen information disclosure; (3) unify the management of social basic pension insurance.

Association Between Social Pensions With Depression, Social, and Health Behaviors Among Poor Older Individuals in Colombia

OBJECTIVES

Many low- and middle-income countries have introduced social pensions to alleviate extreme poverty and improve the well-being of older individuals. However, evidence remains inconclusive about the potential effects of such programs on mental health, social, and health behaviors.

METHODS

Data for individuals aged 60 or older came from the nationally representative Encuesta Nacional de Salud, Bienestar y Envejeciamiento survey in Colombia 2015 (N = 9,456). We used propensity score matching to estimate the association between the country's social pension program (Colombia Mayor) with depression, self-rated health, food insecurity, alcohol consumption, social participation, and labor force participation.

RESULTS

Results show that receiving the program does not significantly affect the likelihood of suffering from depression or self-rated health among either men or women. However, receiving the program is associated with significant reductions in the likelihood of experiencing food insecurity and significant increases in the likelihood of participating socially. Among women, receiving the program is associated with significant reduction in the likelihood of participating in the labor force.

DISCUSSION

The absence of a measurable effect on depression and self-rated health may be explained, at least partly, by the program's comparatively small cash benefit and the sharing of resources with other family members. Policymakers should assess possibilities to maximize the health and social benefits of social pensions.

The relation between social pensions and health among poor older individuals in Colombia: a qualitative study

We assessed the relation between social pension benefits and health among poor older individuals in Colombia based on a qualitative case study (N = 51) using in-depth semi-structured interviews. Participants were beneficiaries of the Colombia Mayor social pension programme, recruited through snowball sampling in one rural and one urban area. Participants reported using cash benefits mainly for purchasing essential foods and medicines, as well as for paying for household utilities and satisfying personal needs. Beneficiaries of the programme view the latter as being positively associated with their health as it not only satisfies material needs but also increases their sense of autonomy, emotional wellbeing and also promotes a positive and cheerful attitude. Despite most beneficiaries perceiving the programme as positively associated with their health and wellbeing, results also highlight the importance of the various individual- as well as contextual-level factors in determining the relation between social pensions and health.

Supplemental income program design: A cluster-randomized controlled trial to examine the health and wellbeing effects on older adults by gender, duration, and payment frequency

BACKGROUND

We documented results from a cluster-randomized controlled trial we designed to supplement incomes in poor towns among adults 70 or older. We analyzed effects on health by gender, persistence over time, and variation by payment frequency.

METHODS

We compared supplemental income effects over an 18-month period for two towns in Yucatan, Mexico: Valladolid, where eligible individuals received a monthly income supplement over the entire analysis period, and Motul, a demographically matched control town, where eligible individuals received a bimonthly income supplement over the last 12 months of the analysis period. While differing in frequency of payment, supplements provided similar levels of income. We conducted three surveys of recipients: (1) at baseline, (2) six months after baseline, and (3) 18 months after baseline.

RESULTS

The primary outcomes we examined were peak expiratory flow, hemoglobin level, and verbal recall. The secondary outcomes were health care use and food availability. We found health benefits persisted for at least eighteen months for the monthly income supplement, with both males and females benefiting. Bimonthly income supplements had smaller health benefits.

CONCLUSIONS

Older people in the developing world who lack social security benefits and health care may benefit most from monthly income programs. The greater payment frequency of monthly programs may influence how household resources are allocated. Supplemental income programs are common in low- and middle-income countries; hence, our results have implications for program design in many nations.