Jelena Arsenijevic

Measuring the catastrophic and impoverishing effect of household health care spending in Serbia

Out-of-pocket patient payments can impose a catastrophic burden on households. This problem may not only affect poor but also wealthy households who need to use health care frequently. The available literature offers no consensus on how to measure poverty and how to measure the effects of out-of-pocket payments on household budgets. The objective of this paper is to contribute to current research in this area by comparing results across different approaches. In particular, the paper examines the catastrophic and impoverishing effects of health care spending in Serbia applying different types of thresholds used in previous research. The application of various approaches allows us to analyze the robustness and convergent validity of the results. We also include the subjective poverty approach in our examination. We use household data from the Serbian Living Standard Measurement Study (LSMS). The Serbian LSMS data were collected in 2007 and consists of 17,375 participants living in 5557 households (sample representative for Serbia). Our results indicate that irrespective of the approach applied, out-of-pocket patient payments have a catastrophic effect on poor households in Serbia. Moreover, households that are above the absolute, relative and subjective poverty lines respectively, after the subtraction of out-of-pocket payments fall below these poverty lines. The probability of catastrophic out-of-pocket patient payments is higher in rural areas, in larger households, and among chronically sick household members (namely, people with diabetes and mental diseases, as well as cardiology diseases in some instances). Perceived health status also appears to be a significant indicator. Policy in Serbia should aim to protect vulnerable groups, especially chronically sick patients and people from rural areas.

Out-of-pocket payments for public healthcare services by selected exempted groups in Serbia during the period of post-war healthcare reforms

This paper focuses on the exemption mechanism that accompanies patient co-payments for outpatient and inpatient hospital care in Serbia. The objective was to investigate the level and dynamics of out-of-pocket payments for this type of services by exempted groups (older than 65 years, younger than 15 years, unemployed, disabled and individuals with low family income) compared with that by other groups. For this purpose, we use empirical household data collected in the Serbian Living Standards Measurement Study carried out in 2002, 2003 and 2007. These years correspond to the start of the recent reforms in the Serbian healthcare sector and 1 and 5 years after the start of the reform. Our results show that people who belong to exempted groups were paying for healthcare in 2002, 2003 and 2007. They report different types of out-of-pocket payments for outpatient and inpatient hospital care. Thus, despite the ambition of the Ministry of Health in Serbia to promote equity in healthcare as a leading aim of the reforms, the implementation of the exemption mechanism fails to protect the targeted groups. Future exemption mechanism should be pro-poor oriented but should also exempt those whose health status requires a frequent healthcare use.

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

Abstract 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.

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.

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.

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

BackgroundTo 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.MethodsWe 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.ResultsWe 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.ConclusionsMore 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.

Advocated but Sidelined: Health promotion for the elderly in the Netherlands

Health promotion (HP) in the Netherlands is the responsibility of both the national (the Ministry of Health, Welfare and Sport) and local governments. Two government organizations are involved in the development, implementation and monitoring of HP: the Dutch Institute of Public Health (RIVM) and The Netherlands Organization for Health Research and Development (ZonMw). Within RIVM, the Center for Healthy Living (Loketgezondleven.nl) has been established. ZonMw subsidizes the Academic Collaborative Centers (ACC) in eight areas which together cover the whole of the Netherlands. ACC centers are responsible for transferring evidence based scientific knowledge into practical activities. Also, health promotion “thematic” institutes such as the TRIMBOS institute (Institute for mental health) and NISB (Dutch Insitute for Sport and Physical Activity), the GGDs (the municipal institutes for public health), general practitioners and work and health professionals (Arbo-coordinators) are actors in HP. There are two laws that regulate the role of HP namely: The Public Health Law (“Wet publieke gezondheid”) (Wpg), and the Social Support Act (Wmo). Funding for HP comes from the central government, local municipalities, health insurance companies and regional care offices. Health insurance companies are mostly responsible for financing indicated and disease related HP. Evidence from Loketgezondleven.nl shows that only few HP are efficient and effective. Because of this both municipalities and insurance companies are reluctant to invest in HP. HP for elderly are mostly financed by public sources and, basic health insurance premiums but also through patient payments

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

BackgroundHealth 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.MethodWe 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.ResultsThere 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.ConclusionsThis 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.

Social Protection in Health Care and Vulnerable Population Groups in Serbia

Social protection refers to a set of policy measures to protect individuals, especially the critically poor, from financial losses due to high-risk events, such as natural disasters, social risks like unemployment, war or unexpected financial shocks, and political risks like discrimination of minorities in conflict zones (1–3). In terms of health, social protection includes protection against health risks, to ensure good quality of care and financial protection that aims to protect people from unexpected health care shocks (4). One way to assure financial protection in the health care sector is to introduce universal social health insurance (5). However, when universal health insurance cannot provide financial sustainability of the health care system, patient charges are necessary. With patient payments social protection can be achieved by the implementation of an exemption mechanism (5). In this paper, we focus on financial protection in health care in Serbia. Serbia is a middle income country with long-term tradition in social protection related to health, inherited from the period of the former Yugoslavia (6–11). The health care system of Yugoslavia was known as a Swedish model in the Balkan (12). However, during the period 1991–2000, Serbia faced a civil war combined with a severe economic crisis (13). The crisis was followed by impoverishment among the citizens and the collapse of the existing health care system. Impoverishment was not the only consequence of the civil war. Like in many other post-conflict and transitional societies, corruption became a modus vivendi in the public sector in Serbia (14). The widespread corruption had a direct effect on health care consumers as well. Different types of informal (under the table) patient payments become common practice in the health care system (15). After a major political change in 2000, the Serbian government introduced health care reforms. The main objective was to improve efficiency, service quality, and equity in health care (16). As part of the health care reforms, in 2002, the Serbian government introduced official co-payments for services covered by the compulsory health insurance to improve the financial situation of the public health care system. The introduction of official co-payments was accompanied with an exemption mechanism (7, 17).