Financial costs of assisted reproductive technology for patients in low- and middle-income countries: a systematic review

STUDY QUESTION

What are the direct costs of assisted reproductive technology (ART), and how affordable is it for patients in low- and middle-income countries (LMICS)?

SUMMARY ANSWER

Direct medical costs paid by patients for infertility treatment are significantly higher than annual average income and GDP per capita, pointing to unaffordability and the risk of catastrophic expenditure for those in need.

WHAT IS KNOWN ALREADY

Infertility treatment is largely inaccessible to many people in LMICs. Our analysis shows that no study in LMICs has previously compared ART medical costs across countries in international dollar terms (US$PPP) or correlated the medical costs with economic indicators, financing mechanisms, and policy regulations. Previous systematic reviews on costs have been limited to high-income countries while those in LMICs have only focussed on descriptive analyses of these costs.

STUDY DESIGN SIZE DURATION

Guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA), we searched PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature, EconLit, PsycINFO, Latin American & Caribbean Health Sciences Literature, and grey literature for studies published in all languages from LMICs between 2001 and 2020.

PARTICIPANTS/MATERIALS SETTING METHODS

The primary outcome of interest was direct medical costs paid by patients for one ART cycle. To gauge ART affordability, direct medical costs were correlated with the GDP per capita or average income of respective countries. ART regulations and public financing mechanisms were analyzed to provide information on the healthcare contexts in the countries. The quality of included studies was assessed using the Integrated Quality Criteria for Review of Multiple Study designs.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 4062 studies identified, 26 studies from 17 countries met the inclusion criteria. There were wide disparities across countries in the direct medical costs paid by patients for ART ranging from USD2109 to USD18 592. Relative ART costs and GDP per capita showed a negative correlation, with the costs in Africa and South-East Asia being on average up to 200% of the GDP per capita. Lower relative costs in the Americas and the Eastern Mediterranean regions were associated with the presence of ART regulations and government financing mechanisms.

LIMITATIONS REASONS FOR CAUTION

Several included studies were not primarily designed to examine the cost of ART and thus lacked comprehensive details of the costs. However, a sensitivity analysis showed that exclusion of studies with below the minimum quality score did not change the conclusions on the outcome of interest.

WIDER IMPLICATIONS OF THE FINDINGS

Governments in LMICs should devise appropriate ART regulatory policies and implement effective mechanisms for public financing of fertility care to improve equity in access. The findings of this review should inform advocacy for ART regulatory frameworks in LMICs and the integration of infertility treatment as an essential service under universal health coverage.

STUDY FUNDING/COMPETING INTERESTS

This work received funding from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO). The authors declare no competing interests.

TRIAL REGISTRATION NUMBER

This review is registered with PROSPERO, CRD42020199312.

Impact of household shocks on access to healthcare services in Kenya: a propensity score matching analysis

OBJECTIVE

This study examines the effects of household shocks on access to healthcare services in Kenya. Shocks are adverse events that lead to loss of household income and/or assets.

DESIGN AND SETTING

The study used data from the Kenya Integrated Household Budget Survey 2015/2016, a nationally representative cross-sectional survey. A propensity score matching approach was applied for the analysis.

PARTICIPANTS

The study sample included 16 297 individuals from households that had experienced shocks (intervention) and those that had not experienced shocks (control) within the last 12 months preceding the survey.

OUTCOME MEASURES

The outcome of interest was access to healthcare services based on an individual's perceived need for health intervention.

RESULTS

The results indicate that shocks reduce access to healthcare services when household members are confronted with an illness. We observed that multiple shocks in a household exacerbate the risk of not accessing healthcare services. Asset shocks had a significant negative effect on access to healthcare services, whereas the effect of income shocks was not statistically significant. This is presumably due to the smoothing out of income shocks through the sale of assets or borrowing. However, considering the time when the shock occurred, we observed mixed results that varied according to the type of shock.

CONCLUSIONS

The findings suggest that shocks can limit the capacity of households to invest in healthcare services, emphasising their vulnerability to risks and inability to cope with the consequences. These results provoke a debate on the causal pathway of household economic shocks and health-seeking behaviour. The results suggest a need for social protection programmes to integrate mechanisms that enable households to build resilience to shocks. A more viable approach would be to expedite universal health insurance to cushion households from forgoing needed healthcare when confronted with unanticipated risks.

Decomposition of changes in socioeconomic inequalities in catastrophic health expenditure in Kenya

BACKGROUND

Catastrophic health expenditure (CHE) is frequently used as an indicator of financial protection. CHE exists when health expenditure exceeds a certain threshold of household consumption. Although CHE is reported to have declined in Kenya, it is still unacceptably high and disproportionately affects the poor. This study examines the socioeconomic factors that contribute to inequalities in CHE as well as the change in these inequalities over time in Kenya.

METHODS

We used data from the Kenya household health expenditure and utilisation (KHHEUS) surveys in 2007 and 2013. The concertation index was used to measure the socioeconomic inequalities in CHE. Using the Wagstaff (2003) approach, we decomposed the concentration index of CHE to assess the relative contribution of its determinants. We applied Oaxaca-type decomposition to assess the change in CHE inequalities over time and the factors that explain it.

RESULTS

The findings show that while there was a decline in the incidence of CHE, inequalities in CHE increased from -0.271 to -0.376 and was disproportionately concentrated amongst the less well-off. Higher wealth quintiles and employed household heads positively contributed to the inequalities in CHE, suggesting that they disadvantaged the poor. The rise in CHE inequalities overtime was explained mainly by the changes in the elasticities of the household wealth status.

CONCLUSION

Inequalities in CHE are persistent in Kenya and are largely driven by the socioeconomic status of the households. This implies that the existing financial risk protection mechanisms have not been sufficient in cushioning the most vulnerable from the financial burden of healthcare payments. Understanding the factors that sustain inequalities in CHE is, therefore, paramount in shaping pro-poor interventions that not only protect the poor from financial hardship but also reduce overall socioeconomic inequalities. This underscores the fundamental need for a multi-sectoral approach to broadly address existing socioeconomic inequalities.

Economic costs of infertility care for patients in low-income and middle-income countries: a systematic review protocol

INTRODUCTION

Infertility, a condition of the reproductive system, affects millions of individuals and couples worldwide. Despite infertility treatment's existence, it is largely unavailable and inaccessible in low/middle-income countries (LMICs) due to the prohibitive costs compounded by an absence of financing. Previous systematic reviews have shown that there is scanty information in LMICs on out-of-pocket (OOP) payments for infertility treatment. This protocol outlines the methodological approach and analytical process to appraise the extent of economic burden due to payments for infertility care services in LMICs.

METHOD AND ANALYSIS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach, we will primarily search for articles indexed in PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature, EconLit and PsycINFO databases. Grey literature from relevant organisations' virtual libraries shall also be searched. Backward and forward searches on the articles selected will also be done. Quantitative studies on infertility treatment costs from LMICs across the world regions within the last 20 years will be considered. The primary outcome of interest shall include OOP payments, catastrophic health expenditure and direct costs for infertility services. Conversely, informal payments and indirect costs related to infertility treatments shall be considered as secondary outcomes. Integrated quality Criteria for Review Of Multiple Study designs will be used to assess the quality of the studies included in the review. Meta-analysis shall be considered if sufficient studies identified are homogenous in characteristics. Also, the review shall analyse the average cost of infertility treatment against the respective countries' economic indicators like gross domestic product per capita if data permit.

ETHICS AND DISSEMINATION

Research and ethics approval will not be required given this will be a review of published articles on the subject. The findings shall be disseminated through publication in a peer-reviewed journal and presentation to the WHO and its partners.

PROSPERO REGISTRATION NUMBER

CRD42020199312.

Cost-related unmet need for healthcare services in Kenya

Background

The assessment of unmet need is one way to gauge inequities in access to healthcare services. While there are multiple reasons for unmet need, financial barriers are a major reason particularly in low- and middle-income countries where healthcare systems do not offer financial protection. Moreover, accessibility and affordability are paramount in achieving universal health coverage. This study examines the extent of unmet need in Kenya due to financial barriers, the associated determinants, and the influence of regional variations.

Methods

We use data from the 2013 Kenya household health expenditure and utilization (KHHEUS) cross sectional survey. Self-reported unmet need due to lack of money and high costs of care is used to compute the outcome of interest. A multilevel regression model is employed to assess the determinants of cost-related unmet need, confounding for the effect of variations at the regional level.

Results

Cost-related barriers are the main cause of unmet need for outpatient and inpatient services, with wide variations across the counties. A positive association between county poverty rates and cost-related unmet is noted. Results reveal a higher intraclass correlation coefficient (ICC) of 0.359(35.9%) for inpatient services relative to 0.091(9.1%) for outpatient services. Overall, differences between counties accounted for 9.4% (ICC ~ 0.094) of the total variance in cost-related unmet need. Factors that positively influence cost-related unmet need include older household heads, inpatient services, and urban residence. Education of household head, good self-rated health, larger household size, insured households, and higher wealth quintiles are negatively associated with cost-related unmet need.

Conclusion

The findings underscore the important role of cost in enabling access to healthcare services. The county level is seen to have a significant influence on cost-related unmet need. The variations noted in cost-related unmet need across the counties signify the existence of wide disparities within and between counties. Scaling up of health financing mechanisms would fundamentally require a multi-layered approach with a focus on the relatively poor counties to address the variations in access. Further segmentation of the population for better targeting of health financing policies is paramount, to address equity in access for the most vulnerable and marginalized populations.

Health promotion policies for elderly-Some comparisons across Germany, Italy, the Netherlands and Poland

OBJECTIVE

The aim of this study is to compare health promotion policies (HPP) for older adults in four European countries: Germany, Italy, the Netherlands and Poland. We focus on the design, regulations and implementation of policies in these countries.

METHOD

As policy relevant information is mostly available in national languages we have approached experts in each country. They filled in a specially designed questionnaire on the design, regulation and implementation of health promotion policies. To analyze the data collected via questionnaires, we use framework analyses. For each subject we define several themes.

RESULTS

Regarding regulations, Poland and Italy have a top-down regulation system for health promotion policy. Germany and Netherlands have a mixed system of regulation. Regarding the scope of the policy, in all four countries both health promotion and prevention are included. Activities include promotion of a healthy life style and social inclusion measures. In Poland and Italy the implementation plans for policy measures are not clearly defined. Clear implementation plans and budgeting are available in Germany and the Netherlands CONCLUSIONS: In all four countries there is no document that exclusively addresses health promotion policies for older adults. We also found that HPP for older adults appears to be gradually disappearing from the national agenda in all four countries.

Adherence to Electronic Health Tools Among Vulnerable Groups: Systematic Literature Review and Meta-Analysis

Background

Electronic health (eHealth) tools are increasingly being applied in health care. They are expected to improve access to health care, quality of health care, and health outcomes. Although the advantages of using these tools in health care are well described, it is unknown to what extent eHealth tools are effective when used by vulnerable population groups, such as the elderly, people with low socioeconomic status, single parents, minorities, or immigrants.

Objective

This study aimed to examine whether the design and implementation characteristics of eHealth tools contribute to better use of these tools among vulnerable groups.

Methods

In this systematic review, we assessed the design and implementation characteristics of eHealth tools that are used by vulnerable groups. In the meta-analysis, we used the adherence rate as an effect size measure. The adherence rate is defined as the number of people who are repetitive users (ie, use the eHealth tool more than once). We also performed a meta-regression analysis to examine how different design and implementation characteristics influenced the adherence rate.

Results

Currently, eHealth tools are continuously used by vulnerable groups but to a small extent. eHealth tools that use multimodal content (such as videos) and have the possibility for direct communication with providers show improved adherence among vulnerable groups.

Conclusions

eHealth tools that use multimodal content and provide the possibility for direct communication with providers have a higher adherence among vulnerable groups. However, most of the eHealth tools are not embedded within the health care system. They are usually focused on specific problems, such as diabetes or obesity. Hence, they do not provide comprehensive services for patients. This limits the use of eHealth tools as a replacement for existing health care services.

Understanding variations in catastrophic health expenditure, its underlying determinants and impoverishment in Sub-Saharan African countries: a scoping review

BACKGROUND

To assess the financial burden due to out of pocket (OOP) payments, two mutually exclusive approaches have been used: catastrophic health expenditure (CHE) and impoverishment. Sub-Saharan African (SSA) countries primarily rely on OOP and are thus challenged with providing financial protection to the populations. To understand the variations in CHE and impoverishment in SSA, and the underlying determinants of CHE, a scoping review of the existing evidence was conducted.

METHODS

This review is guided by Arksey and O'Malley scoping review framework. A search was conducted in several databases including PubMed, EBSCO (EconLit, PsychoInfo, CINAHL), Web of Science, Jstor and virtual libraries of the World Health Organizations (WHO) and the World Bank. The primary outcome of interest was catastrophic health expenditure/impoverishment, while the secondary outcome was the associated risk factors.

RESULTS

Thirty-four (34) studies that met the inclusion criteria were fully assessed. CHE was higher amongst West African countries and amongst patients receiving treatment for HIV/ART, TB, malaria and chronic illnesses. Risk factors associated with CHE included household economic status, type of health provider, socio-demographic characteristics of household members, type of illness, social insurance schemes, geographical location and household size/composition. The proportion of households that are impoverished has increased over time across countries and also within the countries.

CONCLUSION

This review demonstrated that CHE/impoverishment is pervasive in SSA, and the magnitude varies across and within countries and over time. Socio-economic factors are seen to drive CHE with the poor being the most affected, and they vary across countries. This calls for intensifying health policies and financing structures in SSA, to provide equitable access to all populations especially the most poor and vulnerable. There is a need to innovate and draw lessons from the 'informal' social networks/schemes as they are reported to be more effective in cushioning the financial burden.

Does household help prevent loneliness among the elderly? An evaluation of a policy reform in the Netherlands

BACKGROUND

Household help is a community intervention in the Netherlands. Its primary goal is to provide professional help in doing domestic work. A secondary goal of the intervention is to alleviate loneliness. In 2007, a major health care reform and budget cut changed household help. After the reform alleviating loneliness is no longer an aim of the intervention. In this study we evaluate the effects of the policy change in household help on loneliness among older adults in the Netherlands.

METHODS

We use SHARE data collected during the period 2004-2013 to compare levels of loneliness among older adults in the Netherlands and those in 9 other European countries (Austria, Belgium, Germany, Denmark, Italy, France, Sweden, Spain and Switzerland). We use a synthetic control method (SCM) based on aggregate data. To check the robustness of our results we also apply a difference-in-differences (DiD) estimator that allows us to estimate the effects of policy changes using individual level data.

RESULTS

In 2004, the prevalence of loneliness ranged between 6.5% in the Netherlands and 15.4% in Italy. Loneliness increased with time for all observed countries. The increase between 2004 and 2013 was highest in France - 30.2%, Italy - 33. 4% and Belgium - 25.0%. The level of loneliness among older adults in the Netherlands increased after 2011. However, it is still lower than in other countries. There was no statistical significant difference in age between waves (67.36 ± 13.7 before 2011 to 68.55 ± 9.24 after 2011, p = 0.01). Based on the DiD estimator, there is no statistically significant difference in the incidence of loneliness between older adults in the Netherlands and those in the control countries.

CONCLUSION

Our results do not suggest that the policy change and budget cut in 2007 on household help has had an effect on loneliness. In absolute numbers, the prevalence of loneliness has increased since 2011, however we find no evidence that this can be attributed to the policy change.

Preanalytical and analytical challenges in gas chromatographic determination of cholesterol synthesis and absorption markers

INTRODUCTION

Cholesterol homeostasis disruption contributes to the development of different pathologies. Non-cholesterol sterols (NCSs) serve as cholesterol synthesis markers (desmosterol and lathosterol), and cholesterol absorption surrogate markers (campesterol, stigmasterol and β-sitosterol). The study aimed to resolve certain new pre-analytical and analytical problems and ensure a reliable and validated method.

MATERIALS AND METHODS

Method optimization, validation and stability studies were executed in human serum and plasma. Freeze-thaw cycles were done with and without antioxidant. Gas chromatography-mass spectrometer (GC-MS) was used for NCSs confirmation and plasticizer identification, while GC-flame ionization detector (GC-FID) was used for NCSs quantitation.

RESULTS

Intra- and inter-assay variabilities for all NCSs were 2.75-9.55% and 5.80-7.75% for plasma and 3.10-5.72% and 3.05-10.92% for serum, respectively. Recovery studies showed satisfactory percentage errors for all NCSs: 93.4-105.7% in plasma and 87.5-106.9 in serum. Derivatized samples were stable up to 7days at -20°C and derivatization yield was affected by presence of plasticizers. Fatty acid amids were identified as interfering plastic leachates. Statistically different NCSs concentrations were observed after the 1st freeze-thaw cycle, in antioxidant-free samples, and after the 4th cycle in antioxidant-enriched samples.

CONCLUSIONS

All of the in-house procedures proved to be useful for minimizing the preanalytical and analytical variations, as proven by the validation results.

Lifestyle differences between older migrants and non-migrants in 14 European countries using propensity score matching method

Objectives

We examine the differences in lifestyle between four groups of migrants—first generation of older migrants originating from one of the EU countries, Africa or the Middle East and second-generation older EU migrants—with non-migrants in their country of destination.

Methods

We use wave 5 of the SHARE data. To control for differences in socio-demographic characteristics, cultural factors and duration of stay in country of destination between migrants and non-migrants, we use propensity matching score analysis.

Results

Older migrants from Southern European countries are more likely to smoke than non-migrants in their country of origin. Older migrants originating from Africa and the Middle East are more likely to smoke than non-migrants in their country of destination. Some groups of second-generation older migrants are more likely to consume alcohol and to have lower levels of physical activity than non-migrants in their country of destination.

Conclusions

Our results show that differences in lifestyle between migrants and non-migrants exist, but they are not solely related to their migrant status. Cultural and socio-demographic characteristics also play a role.

Within the triangle of healthcare legacies: comparing the performance of South-Eastern European health systems

OBJECTIVE

Inter-regional comparison of health-reform outcomes in south-eastern Europe (SEE).

METHODS

Macro-indicators were obtained from the WHO Health for All Database. Inter-regional comparison among post-Semashko, former Yugoslavia, and prior-1989-free-market SEE economies was conducted.

RESULTS

United Nations Development Program Human Development Index growth was strongest among prior-free-market SEE, followed by former Yugoslavia and post-Semashko. Policy cuts to hospital beds and nursing-staff capacities were highest in post-Semashko. Physician density increased the most in prior-free-market SEE. Length of hospital stay was reduced in most countries; frequency of outpatient visits and inpatient discharges doubled in prior-free-market SEE. Fertility rates fell for one third in Post-Semashko and prior-free-market SEE. Crude death rates slightly decreased in prior-free-market-SEE and post-Semashko, while growing in the former Yugoslavia region. Life expectancy increased by 4 years on average in all regions; prior-free-market SEE achieving the highest longevity. Childhood and maternal mortality rates decreased throughout SEE, while post-Semashko countries recorded the most progress.

CONCLUSIONS

Significant differences in healthcare resources and outcomes were observed among three historical health-policy legacies in south-eastern Europe. These different routes towards common goals created a golden opportunity for these economies to learn from each other.

Physical activity on prescription schemes (PARS): do programme characteristics influence effectiveness? Results of a systematic review and meta-analyses

BACKGROUND

Physical activity on prescription schemes (PARS) are health promotion programmes that have been implemented in various countries. The aim of this study was to outline the differences in the design of PARS in different countries. This study also explored the differences in the adherence rate to PARS and the self-reported level of physical activity between PARS users in different countries.

METHOD

A systematic literature review and meta-analyses were conducted. We searched PubMed and EBASCO in July 2015 and updated our search in September 2015. Studies that reported adherence to the programme and self-reported level of physical activity, published in the English language in a peer-reviewed journal since 2000, were included. The difference in the pooled adherence rate after finishing the PARS programme and the adherence rate before or during the PARS programme was 17% (95% CI 9% to 24%). The difference in the pooled physical activity was 0.93 unit score (95 CI -3.57 to 1.71). For the adherence rate, a meta-regression was conducted.

RESULTS

In total, 37 studies conducted in 11 different countries met the inclusion criteria. Among them, 31 reported the adherence rate, while the level of physical activity was reported in 17 studies. Results from meta-analyses show that PARS had an effect on the adherence rate of physical activity, while the results from the meta-regressions show that programme characteristics such as type of chronic disease and the follow-up period influenced the adherence rate.

CONCLUSIONS

The effects of PARS on adherence and self-reported physical activity were influenced by programme characteristics and also by the design of the study. Future studies on the effectiveness of PARS should use a prospective longitudinal design and combine quantitative and qualitative data. Furthermore, future evaluation studies should distinguish between evaluating the adherence rate and the self-reported physical activity among participants with different chronic diseases.

A review of health promotion funding for older adults in Europe: a cross-country comparison

BACKGROUND

Health promotion interventions for older adults are important as they can decrease the onset and evolution of diseases and thus can reduce the medical costs related to those diseases. However, there is no comparative evidence on how those interventions are funded in European countries. The aim of this study is to explore the funding of health promotion interventions in general and health promotion interventions for older adults in particular in European countries.

METHOD

We use desk research to identify relevant sources of information such as official national documents, international databases and scientific articles. Fora descriptive overview on how health promotion is funded, we focus on three dimensions: who is funding health promotion, what are the contribution mechanisms and who are the collecting agents. In addition to general information on funding of health promotion, we explore how programs on health promotion for older population groups are funded.

RESULTS

There is a great diversity in funding of health promotion in European countries. Although public sources (tax and social health insurance revenues) are still most often used, other mechanisms of funding such as private donations or European funds are also common. Furthermore, there is no clear pattern in the funding of health promotion for different population groups. This is of particular importance for health promotion for older adults where information is limited across European countries.

CONCLUSIONS

This study provides an overview of funding of health promotion interventions in European countries. The main obstacles for funding health promotion interventions are lack of information and the fragmentation in the funding of health promotion interventions for older adults.

Financial incentives for a healthy life style and disease prevention among older people: a systematic literature review

Background

To motivate people to lead a healthier life and to engage in disease prevention, explicit financial incentives, such as monetary rewards for attaining health-related targets (e.g. smoking cessation, weight loss or increased physical activity) or disincentives for reverting to unhealthy habits, are applied. A review focused on financial incentives for health promotion among older people is lacking. Attention to this group is necessary because older people may respond differently to financial incentives, e.g. because of differences in opportunity costs and health perceptions. To outline how explicit financial incentives for healthy lifestyle and disease prevention work among older persons, this study reviews the recent evidence on this topic.

Methods

We applied the method of systematic literature review and we searched in PUBMED, ECONLIT and COCHRANE LIBRARY for studies focused on explicit financial incentives targeted at older adults to promote health and stimulate primary prevention as well as screening. The publications selected as relevant were analyzed based on directed (relational) content analysis. The results are presented in a narrative manner complemented with an appendix table that describes the study details. We assessed the design of the studies reported in the publications in a qualitative manner. We also checked the quality of our review using the PRISMA 2009 checklist.

Results

We identified 15 studies on the role of explicit financial incentives in changing health-related behavior of older people. They include both, quantitative studies on the effectiveness of financial rewards as well as qualitative studies on the acceptability of financial incentives. The quantitative studies are characterized by a great diversity of designs and provide mixed results on the effects of explicit financial incentives. The results of the qualitative studies indicate limited trust of older people in the use of explicit financial incentives for health promotion and prevention.

Conclusions

More research is needed on the effects of explicit financial incentives for prevention and promotion among older people before their broader use can be recommended. Overall, the design of the financial incentive system may be a crucial element in their acceptability.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1517-0) contains supplementary material, which is available to authorized users.

Catastrophic Health Care Expenditure among Older People with Chronic Diseases in 15 European Countries

Introduction

It is well-known that the prevalence of chronic diseases is high among older people, especially those who are poor. Moreover, chronic diseases can result in catastrophic health expenditure. The relationship between chronic diseases and their financial burden on households is thus double-sided, as financial difficulties can give rise to, and result from, chronic diseases. Our aim was to examine the levels of catastrophic health expenditure imposed by private out-of-pocket payments among older people diagnosed with diabetes mellitus, cardiovascular diseases and cancer in 15 European countries.

Methods

The SHARE dataset for individuals aged 50+ and their households, collected in 2010–2012 was used. The total number of participants included in this study was N = 51,661. The sample consisted of 43.8% male and 56.2% female participants. The average age was 67 years. We applied an instrumental variable approach for binary instrumented variables known as a treatment-effect model.

Results

We found that being diagnosed with diabetes mellitus and cardiovascular diseases was associated with catastrophic health expenditure among older people even in comparatively wealthy countries with developed risk-pooling mechanisms. When compared to the Netherlands (the country with the lowest share of out-of-pocket payments as a percentage of total health expenditure in our study), older people diagnosed with diabetes mellitus in Portugal, Poland, Denmark, Italy, Switzerland, Belgium, the Czech Republic and Hungary were more likely to experience catastrophic health expenditure. Similar results were observed for diagnosed cardiovascular diseases. In contrast, cancer was not associated with catastrophic health expenditure.

Discussion

Our study shows that older people with diagnosed chronic diseases face catastrophic health expenditure even in some of the wealthiest countries in Europe. The effect differs across chronic diseases and countries. This may be due to different socio-economic contexts, but also due to the specific characteristics of the different health systems. In view of the ageing of European populations, it will be crucial to strengthen the mechanisms for financial protection for older people with chronic diseases.

Shortcomings of maternity care in Serbia

BACKGROUND

Maternity care in Serbia is an integrated part of the centralized health care system inherited from the former Yugoslavia. Childbirth is often perceived as a medical event instead of a physiological process. This paper examines quality and access indicators, and patient payments for maternity care in Serbia.

METHODS

We apply a method of triangulation using data collected through three sources: online questionnaires filled in by mothers who delivered in one of the maternity wards in Serbia in the period 2000-2008, research publications, and official guidelines. To compare the qualitative data from all three sources, we apply framework analysis.

RESULTS

The results show a good network of maternity wards in Serbia. On the other hand, many women who gave birth in maternity wards in Serbia indicate problems with the treatment they received. The existence of informal patient payments and so-called "special connections" make the position of Serbian women in maternity wards vulnerable, especially when they have neither connections nor the ability to pay. Poor communication and bedside manner of medical staff (obstetricians, other physicians, midwives, and nurses) during the birth process are also frequently reported.

DISCUSSION

Actions should be taken to improve bedside manners of medical staff. In addition, the government should consider the involvement of private practitioners paid by the national insurance fund to create competition and decrease the need for informal payments and "connections."