Medical Assistance

Background Conditional cash transfers (CCT) provide monetary transfers to households on the condition that they comply with some pre-defined requirements. CCT programmes have been justified on the grounds that demand-side subsidies are necessary to address ...

Hispanic immigrants are increasingly residing in rural communities, including in the midwestern United States. Limitations in the ability of rural Hispanics to access and utilize health care contribute to patterns of poor health and health disparity. A conceptual model of "vulnerability" guides this community-based participatory assessment project designed to explore rural Hispanics' perceived barriers to accessing and utilizing health care. Findings from a series of 19 focus groups with 181 participants from three communities in the upper Midwest identified perceived barriers at the individual and health care system levels. The most commonly perceived barriers were the lack of and limitations in health insurance coverage, high costs of health care services, communication issues involving patients and providers, legal status/discrimination, and transportation concerns. Findings imply that these barriers could be addressed using multiple educational and health service d...

This analysis is the fi rst to use state-level data to estimate public expenditure on births resulting from unintended pregnancy, as well as the contribution of public insurance programs in providing essential care to pregnant women and infants.

Background: In many developing countries, the maternal mortality ratio remains high with huge poor-rich inequalities. Programmes aimed at improving maternal health and preventing maternal mortality often fail to reach poor women. Vouchers in health and Health Equity Funds (HEFs) constitute a financial mechanism to improve access to priority health services for the poor. We assess their effectiveness in improving access to skilled birth attendants for poor women in three rural health districts in Cambodia and draw lessons for further improvement and scaling-up. Methods: Data on utilisation of voucher and HEF schemes and on deliveries in public health facilities between 2006 and 2008 were extracted from the available database, reports and the routine health information system. Qualitative data were collected through focus group discussions and key informant interviews. We examined the trend of facility deliveries between 2006 and 2008 in the three health districts and compared this with the situation in other rural districts without voucher and HEF schemes. An operational analysis of the voucher scheme was carried out to assess its effectiveness at different stages of operation. Results: Facility deliveries increased sharply from 16.3% of the expected number of births in 2006 to 44.9% in 2008 after the introduction of voucher and HEF schemes, not only for voucher and HEF beneficiaries, but also for selfpaid deliveries. The increase was much more substantial than in comparable districts lacking voucher and HEF schemes. In 2008, voucher and HEF beneficiaries accounted for 40.6% of the expected number of births among the poor. We also outline several limitations of the voucher scheme. Conclusions: Vouchers plus HEFs, if carefully designed and implemented, have a strong potential for reducing financial barriers and hence improving access to skilled birth attendants for poor women. To achieve their full potential, vouchers and HEFs require other interventions to ensure the supply of sufficient quality maternity services and to address other non-financial barriers to demand. If these conditions are met, voucher and HEF schemes can be further scaled up under close monitoring and evaluation.

This study aimed at examine the number of planned and acute hospital admissions during 1 year among people 65+ and its relation to municipal care, outpatient care, multimorbidity, age and sex. Four thousand nine hundred and seven individuals having one or more admissions during 2001 were studied. Data were collected from two registers and comparisons were made between those having one, two and three or more hospital stays and between those with and without municipal care and services. Linear regression was used to examine factors predicting number of acute and planned admissions. Fifteen percent of the sample had three or more hospital stays (range 3-15) accounting for 35% of all admissions. This group had significantly more contacts in outpatient care with physician (median number of contacts (md) = 15), compared to those with one (md: 8), or two admissions (md: 11). Main predictors for number of admissions were number of diagnosis groups and number of contacts with physician in outpatient care. Those who are frequently admitted to hospital constitute a small group that consume a great deal of inpatient care and also tend to have frequent contacts in outpatient care. Thus interventions focusing on frequent admissions are needed, and this requires collaboration between outpatient and hospital care. #

Objectives: This study aims to examine the charges and frequency of return visits for treating dental health problems in hospital emergency rooms (ERs) in order to provide a basis for policy discussion concerning cost-effective and appropriate treatment for those without access to private dental services.Methods: Records were abstracted from hospital administrative data systems for dental-related ER visits from five major hospital systems in the Minneapolis-St. Paul metropolitan area during a 1-year period. Data on the number of visits and charges were analyzed by age and type of payor (public or private). Similar data were obtained from records for a commercially insured population from a single large employer.Results: There were over 10,000 visits to ERs for dental-related problems with total charges reaching nearly $5 million in 1 year, mainly charged to public programs and reimbursed at about 50 percent. The frequency of repeat visits suggests that while acute pain and infection were treated by the ER physicians, the underlying dental problem often was not resolved. In contrast, a population with commercial dental insurance rarely used hospital ERs for dental problems.Conclusions: Access to preventive and restorative dental care is a critical public health problem in the United States, particularly for those without insurance and those covered by public programs. Public health policy initiatives such as the use of dental therapists should be expanded to improve access and to provide alternatives that offer more complete and less costly care for oral health problems than do hospital ERs.

Background: Demand-side financing (DSF) interventions, including cash transfers and vouchers, have been introduced to promote maternal and newborn health in a range of low-and middle-income countries. These interventions vary in design but have typically been used to increase health service utilisation by offsetting some financial costs for users, or increasing household income and incentivising 'healthy behaviours'. This article documents experiences and implementation factors associated with use of DSF in maternal and newborn health. Methods: A secondary analysis (using an adapted Supporting the Use of Research Evidence framework-SURE) was performed on studies that had previously been identified in a systematic review of evidence on DSF interventions in maternal and newborn health. Results: The article draws on findings from 49 quantitative and 49 qualitative studies. The studies give insights on difficulties with exclusion of migrants, young and multiparous women, with demands for informal fees at facilities, and with challenges maintaining quality of care under increasing demand. Schemes experienced difficulties if communities faced long distances to reach participating facilities and poor access to transport, and where there was inadequate health infrastructure and human resources, shortages of medicines and problems with corruption. Studies that documented improved care-seeking indicated the importance of adequate programme scope (in terms of programme eligibility, size and timing of payments and voucher entitlements) to address the issue of concern, concurrent investments in supply-side capacity to sustain and/or improve quality of care, and awareness generation using community-based workers, leaders and women's groups. Conclusions: Evaluations spanning more than 15 years of implementation of DSF programmes reveal a complex picture of experiences that reflect the importance of financial and other social, geographical and health systems factors as barriers to accessing care. Careful design of DSF programmes as part of broader maternal and newborn health initiatives would need to take into account these barriers, the behaviours of staff and the quality of care in health facilities. Research is still needed on the policy context for DSF schemes in order to understand how they become sustainable and where they fit, or do not fit, with plans to achieve equitable universal health coverage.

Recent welfare reform policies could fundamentally change the nature of public-sector substance abuse services available to women. This review summarizes what is presently known about substance abuse services and women on welfare, and identifies limitations in our current knowledge about the potential effects of welfare reform. Five crucial areas are examined in which research on services has fallen short: (1) assessing the need for substance abuse services across a broad spectrum of welfare populations, (2) exploring the role that alcohol and drug problems play in welfare dependency, (3) examining how welfare programs can serve as pathways to alcohol and drug treatment, (4) evaluating the effectiveness and costs of innovative welfare-treatment programs, and (5) understanding systems-level adaptations in substance abuse services for women that result from changing welfare policies. We conclude that researchers who study services should take a broad view of these issues-one that considers the unique situation of poor women and single mothers, that views substance abuse within a work impairment or disabilities framework, and one that is attuned to future changes in the effects of welfare reform as the economy and labor markets undergo change.

The American College of Physicians recently highlighted the need to provide increased information comparing the effectiveness of health care interventions to ensure the rational and effective practice of medicine. Comparative effectiveness refers to the evaluation of the relative clinical effectiveness, safety, and cost of 2 or more medical services, drugs, devices, therapies, or procedures used to treat the same condition. The College further recommended the establishment of an adequately funded, trusted national entity that should prioritize, sponsor, or produce both comparative clinical and cost-effectiveness data.

Background: Health systems that deliver prevention of mother to child transmission (PMTCT) services in low and middle income countries continue to underperform, resulting in thousands of unnecessary HIV infections of newborns each year. We used a combination of approaches to health systems strengthening to reduce transmission of HIV from mother to infant in a multi-facility public health system in South Africa.

In 2009, a publicly transparent evidence-informed process responded to the requirement of the Children's Health Insurance Program Reauthorization Act (CHIPRA) legislation to identify an initial core set of recommended children's health care quality measures for voluntary use by Medicaid and the Children's Health Insurance Program, which together cover almost 40 million of America's children and adolescents. Future efforts under CHIPRAwill be used to improve and strengthen the initial core set, develop new measures as needed, and post improved core measure sets annually beginning in January 2013.

Objectives: Demand side financing (DSF) mechanisms transfer purchasing power to specified groups for defined goods and services in order to increase access to specified services. This is an important innovation in health care systems where access remains poor despite substantial subsidies towards the supply side. In Bangladesh, a maternal health DSF pilot in 33 sub-districts was launched in 2007. We report the results of a rapid review of this scheme undertaken during 2008 after 1 year of its setup. Methods: Quantitative data collected by DSF committees, facilities and national information systems were assessed alongside qualitative data, i.e. key informant interviews and focus group discussions with beneficiaries and health service providers on the operation of the scheme in 6 sub-districts. Results: The scheme provides vouchers to women distributed by health workers that entitle mainly poor women to receive skilled care at home or a facility and also provide payments for transport and food. After initial setbacks voucher distribution rose quickly. The data also suggest that the rise in facility based delivery appeared to be more rapid in DSF than in other non-DSF areas, although the methods do not allow for a strict causal attribution as there might be co-founding effects. Fears that the financial incentives for surgical delivery would lead to an over emphasis on Caesarean section appear to be unfounded although the trends need further monitoring.

Literature concur that there is a disparity between epidemiological prevalence and mental health services (MHS) utilization rates for Latino and Asian Americans. This study adapted the behavioral model of health service use to examine factors associated with MHS use among Latino and Asian Americans. The model consists of predisposing, enabling, and need factors. This study used the National Latino and Asian American Study data, including six ethnic groups. The outcome measure for this study was the use of MHS in the past 12 months. Age, sex, and education predicted higher odds of MHS use among Latinos, none of which were significant among Asians. Needs factors were strongly associated with higher odds of MHS use among Latinos and Asians.

Background: This study focused on the 47 Member States of the World Health Organization (WHO) African Region. The specific objectives were to prepare a synthesis on the situation of health systems' components, to analyse the correlation between the interventions related to the health Millennium Development Goals (MDGs) and some health systems' components and to provide overview of four major thrusts for progress towards universal health coverage (UHC).

Improving access to health care and financial protection of the poor is a key concern for policymakers in low-and middle-income countries, but there have been few rigorous program evaluations. The Medical Insurance Program for the Poor in the republic of Georgia provides a free and extensive benefit package and operates through a publicly funded voucher program, enabling beneficiaries to choose their own private insurance company. Eligibility is determined by a proxy means test administered to applicant households. The objective of this study is to evaluate the program's impact on key outcomes including utilization, financial risk protection, and health behavior and management. A dedicated survey of approximately 3500 households around the thresholds was designed to minimize unobserved heterogeneity by sampling clusters with both beneficiary and non-beneficiary households. The research design exploits the sharp discontinuities at two regional eligibility thresholds to estimate local average treatment effects. Results suggest that the program did not affect utilization of health services but decreased mean out-of-pocket expenditures for some groups and reduced the risk of high inpatient expenditures. There are no systematic impacts on health behavior, management of chronic illnesses, and patient satisfaction. Copyright

This paper examines mental health service use among publicly insured white and African-American pregnant and postpartum women who live in a metropolitan area. The study examines the extent to which ethnicity, physical health problems, and behavioral ...

The growing burden of non-communicable diseases in middle-income countries demands models of care that are appropriate to local contexts and acceptable to patients in order to be effective. We describe a multi-method health system appraisal to inform the design of an intervention that will be used in a cluster randomized controlled trial to improve hypertension control in Malaysia. A health systems appraisal was undertaken in the capital, Kuala Lumpur, and poorer-resourced rural sites in Peninsular Malaysia and Sabah. Building on two systematic reviews of barriers to hypertension control, a conceptual framework was developed that guided analysis of survey data, documentary review and semi-structured interviews with key informants, health professionals and patients. The analysis followed the patients as they move through the health system, exploring the main modifiable system-level barriers to effective hypertension management, and seeking to explain obstacles to improved access and ...

Methods-Multivariate regression models were built using data obtained from the 2005 through 2009 California Office of Statewide Health Planning and Development (OSHPD) datasets for all ED visits by injured children younger than 19 years of age.

illions ofAmericans are dependent on what is often called the "safety net." These loosely-organized networks of health M and social service providers serve the many Americans who are uninsured, dependent on public coverage, or for a variety of reasons unable to access other private systems of care.

Background: While oral health is part of general health and well-being, oral health disparities nevertheless persist. Potential mechanisms include socioeconomic factors that may influence access to dental care in the absence of universal dental care insurance coverage. We investigated the evolution, prevalence and determinants (including socioeconomic) of forgoing of dental care for economic reasons in a Swiss region, over the course of six years.

The impact on utilisation of differential public entitlements to free health services is analysed, using data for a large sample of Irish households. GP visiting rates are seen to be significantly higher for those on low incomes whose costs are covered by the State than for those who pay for such care, having controlled for other characteristics including health status. The importance of taking differences in health status into account in attempting to distinguisir the effects of economic incentives is shown both for GP visits and hospital stays.

Background/Purpose: Disparities in access to health care are known to exist for the most vulnerable pediatric population, children with special health care needs. Timely access to surgical care in this population is critical, yet poorly studied. Methods: A national database of pediatric hospitals in the United States was searched for nonsyndromic, healthy patients younger than 24 months who underwent cleft palate repair from 2003 to 2008. A multivariate, linear regression model was constructed to determine the relationship of public payer status and race with age at palatal repair. Results: Age at palate repair was significantly delayed for patients who were publicly insured (1.2 weeks, P = .01), were of nonwhite race/ethnicity (1.5-3.5 weeks, P = .009), and had a diagnosis of cleft lip in addition to cleft palate (3.4 weeks, P = .006) compared to their counterparts in a sample of 2995 patients with cleft palate. Conclusion: There is a small but significant delay in age at repair for patients who are publicly insured or of nonwhite race/ethnicity. These results may herald broader access disparities that could adversely affect clinical outcomes and should be investigated further.

Background: Bariatric surgery is the most effective current treatment for severe obesity. Capacity to perform surgery within Canada's public health system is limited and potential candidates face protracted wait times. A better understanding of the gaps between demand for surgery and the capacity to provide it is required. The purpose of this study was to quantify and characterize the bariatric surgery-eligible population in Canada in comparison to surgery-ineligible subjects and surgical recipients. Methods: Data from adult (age > 20) respondents of the 2007-09 nationally representative Canadian Health Measures Survey (CHMS) were analyzed to estimate the prevalence and characteristics of the surgery-eligible and ineligible populations. Federally mandated administrative healthcare data (2007-08) were used to characterize surgical recipients. Results: In 2007-09, an estimated 1.5 million obese Canadian adults met eligibility criteria for bariatric surgery. 19.2 million were surgery-ineligible (3.4 million obese and 15.8 million non-obese). Surgery-eligible Canadians had a mean BMI of 40.1 kg/m 2 (95% CI 39.3 to 40.9 kg/m 2 ) and, compared to the surgery-ineligible obese population, were more likely to be female (62 vs. 44%), 40-59 years old (55 vs. 48%), less educated (43 vs. 35%), in the lowest socioeconomic tertile (41 vs. 34%), and inactive (73 vs. 59%). Self-rated mental health and quality of life were lower and comorbidity was higher in surgery-eligible respondents compared with the ineligible populations. The annual proportion of Canadians eligible for surgery that actually underwent a publicly funded bariatric surgery between 2007-09 was 0.1%. Surgical recipients (n = 847) had a mean age of 43.6 years (SD 11.1) and 82% were female. With the exception of type 2 diabetes, obesity-related comorbidity prevalence was much lower in surgical recipients compared to those eligible for surgery. Conclusions: The proportion of bariatric surgery-eligible Canadians that undergo publicly funded bariatric surgery is very low. There are notable differences in sociodemographic profiles and prevalence of comorbidities between surgery-eligible subjects and surgical recipients.

Self-rated health is a subjective measure that has been related to indicators such as mortality, morbidity, functional capacity, and the use of health services. In Spain, there are few longitudinal studies associating self-rated health with hospital services use. The purpose of this study is to analyze the association between self-rated health and socioeconomic, demographic, and health variables, and the use of hospital services among the general population in the Region of Valencia, Spain. Longitudinal study of 5,275 adults who were included in the 2005 Region of Valencia Health Survey and linked to the Minimum Hospital Data Set between 2006 and 2009. Logistic regression models were used to calculate the odds ratios between use of hospital services and self-rated health, sex, age, educational level, employment status, income, country of birth, chronic conditions, disability and previous use of hospital services. By the end of a 4-year follow-up period, 1,184 participants (22.4 %) h...

Objectives. The objectives of this study were to assess racial/ethnic trends in surveillance data in four states-California, New York, Florida and Texas, identify structural barriers to and facilitators of access to HIV pharmaceuticals by individuals in Medicaid and the AIDS Drug Assistance Program (ADAP), and identify treatment education and outreach efforts responding to the needs of ethnic minority HIV patients.

This paper studies the impact of regulatory stringency, as measured by the statewide deficiency citation rate over the past year, on the quality of care provided in a national sample of nursing homes from 2000 to 2005. The quality measure used is the proportion of residents who are using antipsychotic medication. Although the changing case-mix of nursing home residents accounts for some of the increase in the use of antipsychotics, we find that reliance on antipsychotics by nursing homes is responsive to state regulatory enforcement. Nursing homes reduce their use of antipsychotics in response to the number and type of deficiencies received by facilities in the state.

The study evaluated the impact of a socioeconomic support intervention-described in Box 1-in 32 contiguous shanty towns in Callao, Peru, the northern, coastal extension of the Objective To evaluate the impact of socioeconomic support on tuberculosis preventive therapy initiation in household contacts of tuberculosis patients and on treatment success in patients. Methods A non-blinded, household-randomized, controlled study was performed between February 2014 and June 2015 in 32 shanty towns in Peru. It included patients being treated for tuberculosis and their household contacts. Households were randomly assigned to either the standard of care provided by Peru's national tuberculosis programme (control arm) or the same standard of care plus socioeconomic support (intervention arm). Socioeconomic support comprised conditional cash transfers up to 230 United States dollars per household, community meetings and household visits. Rates of tuberculosis preventive therapy initiation and treatment success (i.e. cure or treatment completion) were compared in intervention and control arms. Findings Overall, 282 of 312 (90%) households agreed to participate: 135 in the intervention arm and 147 in the control arm. There were 410 contacts younger than 20 years: 43% in the intervention arm initiated tuberculosis preventive therapy versus 25% in the control arm (adjusted odds ratio, aOR: 2.2; 95% confidence interval, CI: 1.1-4.1). An intention-to-treat analysis showed that treatment was successful in 64% (87/135) of patients in the intervention arm versus 53% (78/147) in the control arm (unadjusted OR: 1.6; 95% CI: 1.0-2.6). These improvements were equitable, being independent of household poverty. Conclusion A tuberculosis-specific, socioeconomic support intervention increased uptake of tuberculosis preventive therapy and tuberculosis treatment success and is being evaluated in the Community Randomized Evaluation of a Socioeconomic Intervention to Prevent TB (CRESIPT) project.

Objective To identify predictors of antenatal alcohol consumption among women who usually consume alcohol. Design Prospective cohort study. Setting Australian Longitudinal Study on Women's Health (ALSWH). Population or Sample A total of 1969 women sampled from the ALSWH 1973-78 cohort. Methods Women were included if they were pregnant in 2000, 2003, 2006 or 2009. The relationship between antenatal alcohol consumption and sociodemographics, reproductive health, mental health, physical health, health behaviours, alcohol guidelines and healthcare factors was investigated using a multivariate logistic regression model. Main outcome measures Alcohol use during pregnancy. Results Most (82.0%) women continued to drink alcohol during pregnancy. Women were more likely to drink alcohol during pregnancy if they had consumed alcohol on a weekly basis before pregnancy (odds ratio [OR] 1.47; 95% confidence interval [95% CI] 1.13-1.90), binge drank before pregnancy (OR 2.28; 95% CI 1.76-2.94), or if they were pregnant while alcohol guidelines recommended low alcohol versus abstinence (OR 1.60; 95% CI 1.26-2.03). Drinking during pregnancy was less likely if women had a Health Care Card (OR 0.63; 95% CI 0.45-0.88) or if they had ever had fertility problems (OR 0.64; 95% CI 0.48-0.86).

Objective. To investigate (1) the relative contributions of family and contextual characteristics to observed variation in disenrollment rates from the State Children's Health Insurance Program (SCHIP), and (2) whether context explains observed familylevel patterns. Data Sources. We use secondary data on 24,628 families enrolled in New Jersey's SCHIP program (NJ KidCare), and county-level data from the Area Resource File, the Census, and the NJ FamilyCare provider roster. Study Design. Information on family characteristics, SCHIP plan, and dates of enrollment and disenrollment are taken from NJ KidCare administrative records, which provided surveillance data from January 1998 through April 2000. Data Collection/Analysis. We estimate a multilevel discrete-time-hazards model of SCHIP disenrollment. Findings. Families enrolled in plans involving cost-sharing, blacks, and those with only one enrolled child have higher than average rates of disenrollment. Disenrollment rates for blacks are lower in counties with a high share of black physicians. These characteristics account for part of the intercounty variation in disenrollment rates; remaining intercounty variation is largely explained by physician density or population density. Policy Implications. It may be worthwhile to pay special attention to black families and counties with high disenrollment rates to address the reasons for their lower retention. Addressing cultural differences between physician and client and the geographic distribution of medical providers might reduce disenrollment.

To assess the effect of a restriction on publicly subsidised temazepam 10 mg capsules upon the injection of benzodiazepines by injecting drug users (IDUs). Cross-sectional study of regular IDUs targeting periods before and after the policy change. Analysis of prescription data, including time-series analysis. Drug services in the capital cities of New South Wales, Victoria, Tasmania, Queensland and the Northern Territory. Changes in prescriptions and patterns of benzodiazepine use; harms associated with benzodiazepine use. There was a decrease in temazepam 10 mg capsule prescriptions and a corresponding increase in temazepam 10 mg tablet prescriptions after the policy change. IDU survey data suggested that IDUs continued to inject benzodiazepines and temazepam capsules. The frequency of the injection of capsules after the restriction appeared similar to that before the policy change. There was no change in the frequency of injection of tablets. Most IDUs reported obtaining their ben...

Objective. To identify factors that account for variation in complication rates across hospitals and surgeons performing lumbar spinal fusion surgery. Data Sources. Discharge registry including all nonfederal hospitals in Washington State from 2004 to 2007. Study Design. We identified adults (n = 6,091) undergoing an initial inpatient lumbar fusion for degenerative conditions. We identified whether each patient had a subsequent complication within 90 days. Logistic regression models with hospital and surgeon random effects were used to examine complications, controlling for patient characteristics and comorbidity. Principal Findings. Complications within 90 days of a fusion occurred in 4.8 percent of patients, and 2.2 percent had a reoperation. Hospital effects accounted for 8.8 percent of the total variability, and surgeon effects account for 14.4 percent. Surgeon factors account for 54.5 percent of the variation in hospital reoperation rates, and 47.2 percent of the variation in hospital complication rates. The discretionary use of operative features, such as the inclusion of bone morphogenetic proteins, accounted for 30 and 50 percent of the variation in surgeons' reoperation and complication rates, respectively. Conclusions. To improve the safety of lumbar spinal fusion surgery, quality improvement efforts that focus on surgeons' discretionary use of operative techniques may be more effective than those that target hospitals.

We examine whether adult immigrants in California had the same likelihood of having public health insurance as nonimmigrants with comparable characteristics, using 44,434 non-elderly adult samples of the 2001 California Health Interview Survey public use data. Multinomial logistic regression was used to assess the likelihood of public health insurance relative to private (employment-based or privately purchased) health insurance by generation status, controlling for individual characteristics. The outcome of interest was public health insurance among three health insurance categories: private health insurance, public health insurance, and uninsured. Both first and second generation immigrants were more likely to have public health insurance than were nonimmigrants. However, the difference vanished, when demography, socioeconomic status, health status, employment sector, and English facility were controlled for. The combined effect of lower returns to education and lower employment-based insurance offer

This article focuses on help received by a nationally-representative sample of 2,376 Mexican men age 60+ in 1994. In the month before the interview, about one-half of the men received in-kind or domestic assistance, two-fifths received financial assistance, and about one-fourth received physical assistance. This was so even as almost half the men still worked, and over half (57%) had no discernable functional limitation. Using logistic regression, the study found support for the common assumption that living arrangements are an important predictor of assistance. Other factors are important too however. In fact, many elders received help from non-coresiding relatives. Beside financial remittances, help from non-coresiding relatives included in-kind, domestic, and physical assistance. Research on Mexico suggests that we need to revisit notions of a modified extended family in which non-coresidential ties can be important. Surveys need questions about frequency of contact and geographic distance between elderly people and their kin. *This article is a synthesis of papers presented at the

Background: India leads all nations in numbers of maternal deaths, with poor, rural women contributing disproportionately to the high maternal mortality ratio. In 2005, India launched the world's largest conditional cash transfer scheme, Janani Suraksha Yojana (JSY), to increase poor women's access to institutional delivery, anticipating that facility-based birthing would decrease deaths. Indian states have taken different approaches to implementing JSY. Tamil Nadu adopted JSY with a reorganization of its public health system, and Gujarat augmented JSY with the state-funded Chiranjeevi Yojana (CY) scheme, contracting with private physicians for delivery services. Given scarce evidence of the outcomes of these approaches, especially in states with more optimal health indicators, this cross-sectional study examined the role of JSY/CY and other healthcare system and social factors in predicting poor, rural women's use of maternal health services in Gujarat and Tamil Nadu. Methods: Using the District Level Household Survey (DLHS)-3, the sample included 1584 Gujarati and 601 Tamil rural women in the lowest two wealth quintiles. Multivariate logistic regression analyses examined associations between JSY/CY and other salient health system, socio-demographic, and obstetric factors with three outcomes: adequate antenatal care, institutional delivery, and Cesarean-section. Results: Tamil women reported greater use of maternal healthcare services than Gujarati women. JSY/CY participation predicted institutional delivery in Gujarat (AOR = 3.9), but JSY assistance failed to predict institutional delivery in Tamil Nadu, where mothers received some cash for home births under another scheme. JSY/CY assistance failed to predict adequate antenatal care, which was not incentivized. All-weather road access predicted institutional delivery in both Tamil Nadu (AOR = 3.4) and Gujarat (AOR = 1.4). Women's education predicted institutional delivery and Cesarean-section in Tamil Nadu, while husbands' education predicted institutional delivery in Gujarat. Conclusions: Overall, assistance from health financing schemes, good road access to health facilities, and socio-demographic and obstetric factors were associated with differential use of maternity health services by poor, rural women in the two states. Policymakers and practitioners should promote financing schemes to increase access, including consideration of incentives for antenatal care, and address health system and social factors in designing state-level interventions to promote safe motherhood.

Criticisms of health aid have largely been derived from African and Latin American experiences. It is suggested that such analyses, while valuable, cannot be applied wholesale to India without detailed examination of the patterns of health sector aid which have actually characterized the period since 1947. This article brings together material on the scale and form that this assistance has taken, and demonstrates that its focus has been preventive in emphasis and oriented towards the primary care sector. In some periods it has contributed a substantial share of total public sector expenditures, and in some spheres, it has played a major role, particularly the control of communicable diseases. However, the impact of less substantial sums going to prestige medical colleges or to population control programs should not be ignored; and several of the aid categories have been of dubious origin (PL-480 counterpart funds and U.S. food surpluses as the prime examples). However, the "new" health aid programs do not deserve the ready dismissal they have received in some quarters.

Objective: To examine whether government-funded, low-income vision care programs improve use of eye care services by lowincome individuals in Canada. Design: Cross-sectional survey. Participants: 27,375 white respondents to the Canadian Community Health Survey (CCHS) Healthy Aging 2008/2009. Methods: Government-funded, low-income vision care programs were reviewed. The amount of assistance provided was compared with professional fee schedules for general/routine eye examinations and market prices for eyeglasses. The utilization of eye care providers was derived from the CCHS. Results: To receive low-income vision care assistance, individuals must be in receipt of social assistance. Criteria for receiving social assistance are stringent. The Canadian Financial Capability Survey revealed that 7.9% of Canadians aged 45 to 64 years and 5.5% aged Z65 years received social assistance in 2009. The CCHS found in 2008/2009 that 12.5% of citizens aged 45 to 64 years and 13.2% of those aged Z65 years had difficulty paying for basic expenses such as food. In 5 provinces, low-income vision care assistance fully covers a general/routine eye examination. In the remainder, the assistance provided is insufficient for a general/routine eye examination. The assistance for eyeglasses is inadequate in 5 provinces, requiring out-of-pocket copayments. Among middle-aged whites who self-reported not having glaucoma, cataracts, diabetes, or vision problems not corrected by lenses, utilization of eye care providers was 28.1% among those with financial difficulty versus 41.9% among those without (p o 0.05), giving a prevalence ratio 0.68 (95% CI 0.57-0.80) adjusted for age, sex and education. Conclusions: Despite government assistance, low-income individuals use vision care services less often than wealthy individuals.

Objective: Several interventions have been developed during recent years to support informal caregivers of palliative patients. However, these trials reported low enrollment rates. Employing a newly developed group intervention, existential behavioral therapy (EBT), one study reported that only 13.6% of approached informal caregivers participated. The purpose of our present study was to identify the reasons for this low enrollment rate in order to improve future support designs. Method: All participants in the EBT trial (intervention vs. standard-care control group) as well as those who declined participation during a 4-month recruitment period were studied prospectively over 12 months. Andersen's behavioral model of healthcare service use was employed to identify group differences between acceptors and decliners: predisposing (age, gender, education, family status, relationship), enabling (social support, distance to hospital, caring vs. bereaved), and need factors (psychologic...

China has exploded onto the world economy over the past few decades and is undergoing rapid transformation toward relatively more services. The health sector is an important part of this transition. This article provides a historical account of the development of health care in China since 1949. It also focuses on health insurance and macroeconomic structural adjustment to less saving and more consumption. In particular, the question of how health insurance impacts precautionary savings is considered. Multivariate analysis using data from 1990 to 2012 is employed. The household savings rate is the dependent variable in 3 models segmented for rural and urban populations. Independent variables include out-of-pocket health expenditures, health insurance payouts, housing expenditure, education expenditure, and consumption as a share of gross domestic product (GDP). Out-of-pocket health expenditures were positively correlated with household savings rates. But health insurance remains wea...

Background: Flu vaccination is recommended annually for high risk groups. However, in Ireland, free access to vaccination is not universal for those in high risk groups; the vaccine and consultation are only free for those with a medical card, a means tested scheme. Few private health insurance policies cover the cost of attendance for vaccination in general practice. The aim was to examine the influence of this reimbursement policy on vaccination coverage among older adults. Methods: Cross-sectional wave 1 data from The Irish Longitudinal Study on Ageing (TILDA) were analysed (2009)(2010)(2011). TILDA is a nationally representative prospective cohort study of adults aged ≥50, sampled using multistage stratified clustered sampling. Self-reported entitlement to healthcare was categorised as 1) medical card only 2) private health insurance only, 3) both and 4) neither. The outcome was responses to 'have you ever had a flu shot'. Multivariate logistic regression was used, adjusting for age and need. Results: 68.6% of those defined as clinically high-risk received the flu vaccination in the past (95% CI = 67-71%). Those with a medical card were almost twice as likely to have been vaccinated, controlling for age and chronic illness (OR = 1.9, 95% CI = 1.5-2.5, p = <0.001). Conclusions: Having a medical card increased the likelihood of being vaccinated, independent of age and need. The mismatch between vaccination guidelines and reimbursement policy is creating unequal access to recommended services among high risk groups.