Aleli D. Kraft

The health and cost impact of care delay and the experimental impact of insurance on reducing delays.

OBJECTIVE To examine whether delays in seeking care are associated with worse health outcomes or increased treatment costs in children, and then assess whether insurance coverage reduces these delays. STUDY DESIGN We use data on 4070 children younger than 5 years from the Quality Improvement Demonstration Study, a randomized controlled experiment assessing the effects of increasing insurance coverage. We examined whether delay in care, defined as greater than 2 days between the onset of symptoms and admission to the study district hospitals, is associated with wasting or having positive C-reactive protein levels on discharge, and with total charge for hospital admission; we also evaluated whether increased benefit coverage and enrollment reduced the likelihood of delay. RESULTS Delay is associated with 4.2% and 11.2% percentage point increases in the likelihood of wasting (P = .08) and having positive C-reactive protein levels (P = .03), respectively, at discharge. On average, hospitalization costs were 1.9% higher with delay (P = .04). Insurance intervention results in 5 additional children in 100 not delaying going to the hospital (P = .02). CONCLUSIONS In this population, delayed care is associated with worse health outcomes and higher costs. Access to insurance reduced delays; thus insurance interventions may have positive effects on health outcomes.

Stagnant Neonatal Mortality and Persistent Health Inequality in Middle-Income Countries: A Case Study of the Philippines.

Background The probability of survival through childhood continues to be unequal in middle-income countries. This study uses data from the Philippines to assess trends in the prevalence and distribution of child mortality and to evaluate the country’s socioeconomic-related child health inequality. Methodology Using data from four Demographic and Health Surveys we estimated levels and trends of neonatal, infant, and under-five mortality from 1990 to 2007. Mortality estimates at national and subnational levels were produced using both direct and indirect methods. Concentration indices were computed to measure child health inequality by wealth status. Multivariate regression analyses were used to assess the contribution of interventions and socioeconomic factors to wealth-related inequality. Findings Despite substantial reductions in national under-five and infant mortality rates in the early 1990s, the rates of declines have slowed in recent years and neonatal mortality rates remain stubbornly high. Substantial variations across urban-rural, regional, and wealth equity-markers are evident, and suggest that the gaps between the best and worst performing sub-populations will either be maintained or widen in the future. Of the variables tested, recent wealth-related inequalities are found to be strongly associated with social factors (e.g. maternal education), regional location, and access to health services, such as facility-based delivery. Conclusion The Philippines has achieved substantial progress towards Millennium Development Goal 4, but this success masks substantial inequalities and stagnating neonatal mortality trends. This analysis supports a focus on health interventions of high quality – that is, not just facility-based delivery, but delivery by trained staff at well-functioning facilities and supported by a strong referral system – to re-start the long term decline in neonatal mortality and to reduce persistent within-country inequalities in child health.

Supporting local planning and budgeting for maternal, neonatal and child health in the Philippines.

BackgroundResponsibility for planning and delivery of health services in the Philippines is devolved to the local government level. Given the recognised need to strengthen capacity for local planning and budgeting, we implemented Investment Cases (IC) for Maternal, Neonatal and Child Health (MNCH) in three selected sub-national units: two poor, rural provinces and one highly-urbanised city. The IC combines structured problem-solving by local policymakers and planners to identify key health system constraints and strategies to scale-up critical MNCH interventions with a decision-support model to estimate the cost and impact of different scaling-up scenarios.MethodsWe outline how the initiative was implemented, the aspects that worked well, and the key limitations identified in the sub-national application of this approach.ResultsLocal officials found the structured analysis of health system constraints helpful to identify problems and select locally appropriate strategies. In particular the process was an improvement on standard approaches that focused only on supply-side issues. However, the lack of data available at the local level is a major impediment to planning. While the majority of the strategies recommended by the IC were incorporated into the 2011 plans and budgets in the three study sites, one key strategy in the participating city was subsequently reversed in 2012. Higher level systemic issues are likely to have influenced use of evidence in plans and budgets and implementation of strategies.ConclusionsEfforts should be made to improve locally-representative data through routine information systems for planning and monitoring purposes. Even with sound plans and budgets, evidence is only one factor influencing investments in health. Political considerations at a local level and issues related to decentralisation, influence prioritisation and implementation of plans. In addition to the strengthening of capacity at local level, a parallel process at a higher level of government to relieve fund channelling and coordination issues is critical for any evidence-based planning approach to have a significant impact on health service delivery.

Information, Incentives And Practice Patterns: The Case Of Tb Dots Services And Private Physicians In The Philippines

To explain divergent physician practices, studies focus on either differences in education and training or in financial incentives. The policy challenge is to identify the most cost-effective interventions to encourage adherence to practice guidelines. Utilizing private physician data in major cities in the Philippines, we show the effects of training and financial incentives in physician adoption of the TB DOTS protocol. Training seems to be more important when the new protocol is a significant departure from the old know-how, while financial incentives seem to work better on those who are already clinically competent. These imply that uniform application of information-based and incentive-based interventions may not be cost-effective.

Awareness of health insurance benefits in the Philippines : what do people know and how?

In recent years, the Philippines has seen a rapid expansion of health insurance coverage, especially among the poor. In particular, the implementation of the 2012 Sin Tax Law, which increased tobacco and alcohol excise tax and earmarked most of the incremental revenues for PhilHealth premium subsidies for indigent households, contributed to an increase in the number of families receiving government-subsidized health insurance from 5.2 million to 15.3 million poor families and senior citizens between 2012 and 2015. This paper assesses how people who are eligible for government-subsidized (free) health insurance through Philippines Health Insurance Corporation (PhilHealth) find out about their eligibility and their benefits, and also how well people know the PhilHealth benefits.

Expansion of health insurance in the Philippines : evidence from panel data

In December 2012, the government of the Philippines passed the Sin Tax Law (RA 10351) which restructured and raised tobacco and alcohol taxes, while earmarking 85 percent of the incremental revenues for health. Of this 85 percent, 80 percent was intended to be used to provide free health insurance for poor and near-poor families through the National Health Insurance Program managed by PhilHealth, programs intended to speed progress of the health Millennium Development Goals, and programs to promote health awareness. The remaining 20 percent augments the financing of the Medical Assistance Program of the Department of Health (DOH), which is a hospital-based fund (in the name of mayors, congressmen, and DOH officials) that can be used at the discretion of the facility to cover the medical costs of those who cannot afford to pay, and also the DOH’s Health Facilities Enhancement Program which allows the DOH to supplement the local governments’ investments in health facilities. This reform was important from a health financing perspective.In November 2014, free health insurance coverage was also extended to the elderly. This paper assesses the extent to which the automatic enrollment of a large number of poor and elderly people into health insurance programs, as a result of the Sin Tax Law, has been associated with an increase in self-reported health insurance coverage, especially among the poorest quintiles and households living below the poverty line.