Health Policy Open最新文献

Price transparency & out-of-pocket payments for medications: Implications of associated delivery fees in the United States 药品价格透明和自付：美国相关配送费用的影响

IF 2.3 Q3 HEALTH CARE SCIENCES & SERVICES

Health Policy Open

Pub Date : 2026-01-26 DOI: 10.1016/j.hpopen.2026.100163

Deborah R. Kaye , Hui-Jie Lee , Daniel J. George , Charles D. Scales , M.Kate Bundorf

Background

Price transparency has been cited as a tool to reduce out-of-pocket (OOP) payments to patients. These tools for prescription drugs often focus on the price to patients for the drug alone. However, costs associated with drug delivery (i.e. infusion center fees, labs, etc) are often unknown and could impact the effectiveness of price transparency tools. Objective: To examine total OOP payments on day of drug receipt (“full day”, i.e. drug + drug administration fees) out-of-pocket (OOP) payments associated with six first-line treatments for metastatic castrate resistant prostate cancer and compare these with payments for drug alone and by insurance type.

Methods

Using the IBM Marketscan databases, we identify male patients who initiated treatment with one of six focus drugs (docetaxel, abiraterone, enzalutamide, sipuleucel-T, cabazitaxel, and radium-223) used to treat mCRPC from 07/01/2013–06/30/2019. We calculated total OOP payments on day of drug receipt (full day OOP payments) by drug type for six first line treatments. We then used a two-part model to assess the association of first-line therapy with OOP payments for the four most frequently prescribed during the study time period.

Results

We find that there is variation in the proportion of payments for drug alone relative to full day payments across first-line treatments. However, regression-adjusted mean full day OOP payments are not statistically different across first-line treatments for mCRPC for the four most frequently prescribed drugs. There are differences in the likelihood that an individual will incur any OOP payment by first-line treatment type and by health plan type.

Conclusion

These analyses suggest that when accounting for additional services required on the day of drug receipt, the amount a patient pays to receive a medication for mCRPC can be very different from the OOP payment for the drug alone; these payments also vary by drug and health plan type. Therefore, price transparency for drug alone may not lead to reduced OOP payments for patients.

价格透明度被认为是减少自费支付给患者的一种工具。这些针对处方药的工具通常只关注药物对患者的价格。然而，与药物输送相关的成本（即输液中心费用、化验室费用等）往往是未知的，可能会影响价格透明工具的有效性。目的：研究转移性去势抵抗性前列腺癌6种一线治疗药物收到当天（“全天”，即药物+药物管理费用）的自付费用总额，并将其与单独用药和按保险类型支付的费用进行比较。方法利用IBM Marketscan数据库，对2013年1月7日至2019年6月30日期间开始使用6种重点药物（多西他赛、阿比特龙、恩杂鲁胺、sipuleucel-T、卡巴他赛和镭-223）治疗mCRPC的男性患者进行分析。我们按药物类型计算了6种一线治疗药物收到当天的总OOP付款（全天OOP付款）。然后，我们使用了一个两部分模型来评估一线治疗与在研究期间最常开处方的四种OOP支付的关系。结果我们发现，相对于一线治疗的全天支付，单药支付的比例存在差异。然而，经回归调整后，对于四种最常用的处方药物，mCRPC一线治疗的全天平均OOP支付在统计学上没有差异。根据一线治疗类型和健康计划类型，个人承担任何OOP付款的可能性存在差异。结论这些分析表明，当考虑到药物收货当天所需的额外服务时，患者为获得mCRPC药物支付的金额可能与单独为药物支付的OOP费用有很大差异；这些付款也因药物和健康计划类型而异。因此，仅靠药品价格透明可能不会导致患者OOP支付的减少。

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引用次数: 0

Association of hospitalization costs with demographic, socioeconomic, and lifestyle characteristics: Population-based study in Sao Paulo city, Brazil, 2003–2015 住院费用与人口、社会经济和生活方式特征的关系：2003-2015年巴西圣保罗市基于人口的研究

IF 2.3 Q3 HEALTH CARE SCIENCES & SERVICES

Health Policy Open

Pub Date : 2026-01-17 DOI: 10.1016/j.hpopen.2026.100162

Lucas Akio Iza Trindade , Jaqueline Lopes Pereira , Marcelo Macedo Rogero , Regina Mara Fisberg , Flavia Mori Sarti

Evidence from studies conducted in high-income countries suggests that lifestyle factors, such as leisure-time physical activity, sedentary habits, and obesity, are associated with a significant socioeconomic burden of disease and the attribution of direct costs to healthcare systems. In Brazil, the occurrence of primary care-sensitive hospitalizations is responsible for a relevant socioeconomic burden. However, there is a scarcity of evidence regarding the association of lifestyle factors on the direct costs of the Brazilian healthcare system. In this context, the present study aims to analyze the association between leisure-time physical activity, sedentary habits, and obesity with hospitalization costs in São Paulo city, Brazil. A quantitative analysis of microdata from the São Paulo Health Survey (ISA-Capital), which is representative for the urban population of São Paulo City, and was conducted in 2003, 2008, and 2015, was employed. Multiple two-part regression models (logit and GLM) and marginal effects (ME) were estimated. The study’s findings suggest that meeting the weekly frequency of leisure-time physical activity recommended by the World Health Organization is associated with lower hospitalization costs in the public (logit β = −0.475, p < 0.05; ME = −31.03, p < 0.05) and private sector (logit β = −0.494, p < 0.01; ME = −37.89, p < 0.01). Sedentary habits (logit β = 0.442, p < 0.05; ME = 40.92, p < 0.01), and obesity (GLM β = 0.385, p < 0.05) were associated with higher costs in the private sector. No associations were observed between sedentary habits and obesity for hospitalization costs in the public sector. The evidence from the present study suggests that policies encouraging the adoption of healthy active lifestyles, such as practicing leisure-time physical activity and reducing sedentary habits, as well as policies for obesity prevention, may be important strategies for minimizing hospitalization costs in urban population contexts in the two-tier of the Brazilian healthcare system. Yet, associations identified in the study should be interpreted with caution due to the impossibility of establishment of causal links between lifestyle factors and healthcare expenditures.

在高收入国家开展的研究证据表明，生活方式因素，如闲暇时间的身体活动、久坐习惯和肥胖，与疾病的重大社会经济负担和医疗保健系统的直接成本相关。在巴西，对初级保健敏感的住院是造成相关社会经济负担的原因。然而，关于生活方式因素与巴西医疗保健系统直接成本之间关系的证据缺乏。在此背景下，本研究旨在分析闲暇时间体育活动、久坐习惯和肥胖与巴西圣保罗市住院费用之间的关系。采用了圣保罗健康调查（ISA-Capital）的微观数据的定量分析，该调查于2003年、2008年和2015年进行，代表了圣保罗市的城市人口。估计了多个两部分回归模型（logit和GLM）和边际效应（ME）。研究结果表明，达到世界卫生组织推荐的每周休闲时间体育活动频率与公共部门（logit β = - 0.475, p < 0.05; ME = - 31.03, p < 0.05）和私营部门（logit β = - 0.494, p < 0.01; ME = - 37.89, p < 0.01）的住院费用降低有关。久坐习惯（logit β = 0.442, p < 0.05; ME = 40.92, p < 0.01）和肥胖（GLM β = 0.385, p < 0.05）与私营部门较高的成本相关。在公共部门，没有观察到久坐习惯和肥胖与住院费用之间的联系。本研究的证据表明，鼓励采用健康积极的生活方式的政策，如在闲暇时间进行体育活动和减少久坐不动的习惯，以及预防肥胖的政策，可能是在巴西双层医疗保健系统中城市人口环境中最大限度地减少住院费用的重要策略。然而，研究中发现的关联应该谨慎解释，因为不可能建立生活方式因素与医疗保健支出之间的因果关系。

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引用次数: 0

Nursing shortages and migration: a two-decade study of Ireland’s dependence on migrant nurses 护理短缺和移民：爱尔兰对移民护士依赖的二十年研究

IF 2.3 Q3 HEALTH CARE SCIENCES & SERVICES

Health Policy Open

Pub Date : 2026-01-07 DOI: 10.1016/j.hpopen.2026.100161

Comfort O. Chima , Vishnu Renjith , Niamh Humphries

Background

There has been global concern about nursing shortages and nurse migration, as nurses move in search of better working conditions. Ireland is one of the countries facing nursing shortages. Ireland, like many other countries, has begun to rely heavily on migrant nurses. This study examines the recent trends in the nursing workforce and possible contributing factors to Ireland’s dependence on international nurse recruitment, drawing insights from existing data and literature.

Methodology

This paper integrates and analyses secondary data obtained from the Nursing and Midwifery Board of Ireland (NMBI) 2003–2022 and data from the Faculty of Nursing and Midwifery, RCSI, registration register (2015–2022). The population data of Ireland was obtained from the Central Statistics Office (CSO).

Result

The data available indicates a heavy reliance on migrant nurses due to a shortage of Irish-trained nurses relative to increased demand for nurses in the period (2003–2022). More than 50% of the Nurses registered in that period were migrant nurses (EU and Non-EU).

Conclusion

There is an urgent need for Ireland to increase the domestic training of nurses and midwives, as well as, a need to develop a robust nurse workforce planning system to improve retention and ensure nursing workforce self-sufficiency.

随着护士为寻求更好的工作条件而迁移，护士短缺和护士移徙一直是全球关注的问题。爱尔兰是面临护士短缺的国家之一。像许多其他国家一样，爱尔兰已经开始严重依赖移民护士。本研究考察了护理人员的最新趋势，以及爱尔兰依赖国际护士招聘的可能因素，并从现有数据和文献中得出了见解。本文整合并分析了爱尔兰护理和助产委员会（NMBI） 2003-2022年的二手数据，以及RCSI护理和助产学院2015-2022年注册登记的数据。爱尔兰的人口数据是从中央统计局获得的。结果现有数据表明，由于2003-2022年期间对护士的需求增加，爱尔兰培训的护士短缺，因此严重依赖移民护士。在此期间，超过50%的注册护士是移民护士（欧盟和非欧盟）。结论爱尔兰迫切需要增加护士和助产士的国内培训，同时需要建立健全的护士劳动力计划系统，以提高保留率并确保护理劳动力的自给自足。

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引用次数: 0

Strengthening global health cooperation-insights from worldwide WHO collaborating centres 加强全球卫生合作——来自世界卫生组织合作中心的见解

IF 2.3 Q3 HEALTH CARE SCIENCES & SERVICES

Health Policy Open

Pub Date : 2025-12-19 DOI: 10.1016/j.hpopen.2025.100158

Sophia Achab , Benedetto Saraceno

Background

WHO Collaborating Centres (WHO CCs) are entities designated to provide scientific or technical support to the World Health Organization (WHO) in specific areas. They play a crucial role in global public health efforts; however, their leadership and sustainability present multiple complex challenges.

Objectives

The aim of this analysis is to identify the strategic and management challenges faced by WHO CCs and to provide expert recommendations to enhance their sustainability. This study focuses on leadership capabilities as a key driver of successful global health cooperation.

Methods

The study employed a three-phase approach: (1) a conceptual framework for strategic management of WHO CCs, (2) empirical testing through qualitative interviews with WHO CCs directors worldwide, and (3) development of actionable recommendations. A flexible sampling strategy was used, including convenience, purposeful, and database-based sampling to ensure diversity across regions, institution types, and health topics.

Results

WHO CCs are manageable organizations but face unique strategic (mission alignment, core values, vision), and management challenges (project management, financial constraints, communication barriers).

Long-lasting WHO CCs were led by directors whose leadership practices aligned with established models of effective leadership (e.g., self-awareness, strategic positioning, clear, and engaging vision). Key threats included a lack of resources, recognition, or project management skills, misaligned strategic vision, and communication gaps with WHO or the host institution.

Conclusion

WHO CCs are vital to global health but require structured strategic management and leadership development. Their strategic management must take into account both the similarities and differences with other organizations. Expert recommendations include securing financial resources, improving WHO- WHO CCs communication, and fostering leadership skills to ensure sustainability and impact.

卫生组织合作中心是指定在特定领域向世界卫生组织（卫生组织）提供科学或技术支助的实体。它们在全球公共卫生努力中发挥着关键作用；然而，它们的领导力和可持续性带来了多重复杂的挑战。本分析的目的是确定世卫组织控制中心面临的战略和管理挑战，并提供专家建议，以加强其可持续性。本研究的重点是领导能力作为成功的全球卫生合作的关键驱动力。方法本研究采用了三个阶段的方法：(1)世卫组织控制中心战略管理的概念框架；(2)通过与世界各地的世卫组织控制中心主任进行定性访谈进行实证检验；(3)制定可操作的建议。采用了灵活的抽样策略，包括方便、有目的和基于数据库的抽样，以确保跨区域、机构类型和健康主题的多样性。世卫组织cc是可管理的组织，但面临独特的战略（使命一致性、核心价值观、愿景）和管理挑战（项目管理、财务约束、沟通障碍）。世卫组织长期的CCs由其领导实践符合既定有效领导模式（例如，自我意识、战略定位、清晰和引人入胜的愿景）的主任领导。主要威胁包括缺乏资源、认可或项目管理技能、战略愿景不一致以及与世卫组织或东道国机构之间的沟通差距。结论世卫组织cc对全球卫生至关重要，但需要有组织的战略管理和领导力发展。他们的战略管理必须考虑到与其他组织的异同。专家建议包括确保财政资源，改善世卫组织与世卫组织的沟通，以及培养领导技能，以确保可持续性和影响力。

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引用次数: 0

Cross-sectional analysis of accuracy versus interpretability in Medicare Advantage risk adjustment 医疗保险优势风险调整的准确性与可解释性的横断面分析

IF 2.3 Q3 HEALTH CARE SCIENCES & SERVICES

Health Policy Open

Pub Date : 2025-12-17 DOI: 10.1016/j.hpopen.2025.100160

Maya Lozinski

Background

Risk adjustment models in Medicare Advantage determine annual payments of over $300 billion in public funds to private companies. Policymakers want risk adjustment models that are both accurate and interpretable to ensure appropriate use of public funds.

Methods

The trade-off between accuracy and interpretability from using standard machine learning (ML) models for risk adjustment was evaluated. A cross-sectional analysis was conducted using 2018–2019 Medicare claims with 3,602,618 beneficiaries. Multiple risk adjustment models were estimated, including traditional and ML-based approaches. Performance was assessed using out-of-sample mean absolute and squared error (MAE and MSE). Interpretability was measured using coefficient count and log-transformed coefficient count of models.

Results

ML models, especially gradient-boosted trees, significantly improved prediction accuracy relative to recent Medicare models, with MAE reductions of − 1,352 (95 % CI: −1,392, −1,316) and MSE reductions of − 5 (95 % CI: −9, −1). However, these improvements increased model complexity by more than 1000x and provided less than 0.1 % of the accuracy improvement per additional coefficient of a previous major model change. Notably, the predictions from gradient-boosted trees responded less to strategic diagnosis coding, reducing incentives to upcode.

Conclusions

Standard ML models can modestly improve predictive accuracy but substantially worsen model interpretability in risk adjustment. Future research is needed to improve accuracy in these models while maintaining the interpretability essential for oversight of public spending.

医疗保险优势中的风险调整模型决定了每年向私营公司支付超过3000亿美元的公共资金。政策制定者希望风险调整模型既准确又可解释，以确保公共资金的适当使用。方法评估使用标准机器学习（ML）模型进行风险调整的准确性和可解释性之间的权衡。对2018-2019年的医疗保险索赔进行了横断面分析，共有3,602,618名受益人。评估了多种风险调整模型，包括传统方法和基于机器学习的方法。使用样本外平均绝对误差和平方误差（MAE和MSE）评估性能。可解释性通过模型的系数计数和对数变换系数计数来衡量。结果sml模型，特别是梯度增强树，与最近的Medicare模型相比，显著提高了预测精度，MAE降低了- 1352 (95% CI: - 1392, - 1316)， MSE降低了- 5 （95% CI: - 9, - 1）。然而，这些改进使模型复杂性增加了1000倍以上，并且在以前主要模型更改的每个附加系数中提供的精度提高不到0.1%。值得注意的是，梯度增强树的预测对策略诊断编码的响应较小，减少了对上编码的激励。结论标准ML模型可以适度提高预测准确性，但在风险调整方面显著降低模型的可解释性。未来的研究需要提高这些模型的准确性，同时保持对公共支出监督至关重要的可解释性。

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引用次数: 0

Good intentions and the costs of inaction: Financial protection in Austria 善意与不作为的代价：奥地利的金融保护

IF 2.3 Q3 HEALTH CARE SCIENCES & SERVICES

Health Policy Open

Pub Date : 2025-12-16 DOI: 10.1016/j.hpopen.2025.100159

Christoph Stegner, Thomas Czypionka

Understanding the financial strain of health care costs borne by households is crucial for assessing the equity and affordability of a health system. Building on an already generous system, Austrian health policy has strived over decades to include more and more people in its Social Health Insurance Schemes and to find ways to lower individual financial burden. Using data from the Austrian household budget survey for the years 2004/05, 2009/10, 2014/15 and 2019/20, this study investigates whether these efforts have been successful. Analyzing expenditures on various health care types, including medicines, medical products, outpatient care, dental care, diagnostic tests and inpatient care, our study aims to determine how the percentage of households experiencing catastrophic health expenditure (CHE) according to WHO definitions has changed over time. Logistic regression analyses were carried out to identify factors associated with CHE. The results reveal an increase in the prevalence of CHE from 2.1 % in 2004/05 to 3.6 % in 2019/20. Across all survey rounds, at least 60% of households experiencing CHE belonged to the poorest consumption quintile. Age, sex, educational attainment and employment status of the head of the household emerged as factors associated with CHE from the regression analysis. The observed rise in CHE is surprising given Austria’s generous health system and the introduction of policies during the study period aimed at expanding the breadth and depth of coverage. It serves as an example for other countries that failing to tackle underlying structural problems in the healthcare system may counteract financial protection policies.

了解家庭承担的卫生保健费用的财务压力对于评估卫生系统的公平性和可负担性至关重要。在一个已经很慷慨的制度基础上，奥地利的卫生政策几十年来一直努力将越来越多的人纳入其社会健康保险计划，并设法降低个人的经济负担。利用2004/05年、2009/10年、2014/15年和2019/20年奥地利家庭预算调查的数据，本研究调查了这些努力是否取得了成功。我们的研究分析了各种卫生保健类型的支出，包括药品、医疗产品、门诊护理、牙科护理、诊断测试和住院护理，旨在确定根据世卫组织的定义经历灾难性卫生支出（CHE）的家庭百分比如何随时间变化。进行逻辑回归分析以确定与CHE相关的因素。结果显示，CHE的患病率从2004/05年度的2.1%上升至2019/20年度的3.6%。在所有的调查中，至少有60%的家庭属于最贫穷的消费五分之一。回归分析显示，户主的年龄、性别、受教育程度和就业状况是与CHE相关的因素。鉴于奥地利慷慨的卫生系统和研究期间旨在扩大覆盖范围和深度的政策，观察到的CHE上升令人惊讶。它为其他国家提供了一个例子，说明未能解决医疗体系中潜在的结构性问题可能会抵消金融保护政策。

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引用次数: 0

Private health insurance in Gulf Cooperation Council countries: A scoping review 海湾合作委员会国家的私人医疗保险：范围审查

IF 2.3 Q3 HEALTH CARE SCIENCES & SERVICES

Health Policy Open

Pub Date : 2025-12-05 DOI: 10.1016/j.hpopen.2025.100157

Husein Reka , Robin van Kessel , Elias Mossialos , Wim Groot , Milena Pavlova

Private Health Insurance (PHI) in Gulf Cooperation Council (GCC) countries has experienced rapid growth over the past two decades, driven by demographic and economic changes. Although various analyses at the country level have been reported, no study has reviewed PHI systems in the GCC through a methodological approach. We provide a conceptual framework to review, describe and document the development of PHI in the GCC, based on literature from the scoping review. As of December 2023, all GCC countries have laws in place or have promulgated laws establishing mandatory PHI schemes. Most of these schemes are designed for expatriate populations residing in these countries, but there is a trend to extend them to nationals working in the private sector. The health system context plays a role in how PHI emerged and is designed in terms of role, eligibility, and coverage. PHI markets in the region are concentrated and dominated by local companies with performance levels that could be further improved. These markets are maturing and subject to more robust technical and prudential regulations as governments seek to enhance competition. Governments in the region must ensure the sustainable growth of these schemes and a more strategic alignment with health system objectives. Lessons learned from more mature markets are critical for future developments.

在人口和经济变化的推动下，海湾合作委员会国家的私人健康保险在过去二十年中经历了快速增长。虽然报告了国家一级的各种分析，但没有研究通过方法学方法审查海湾合作委员会的PHI系统。我们提供了一个概念性框架来回顾、描述和记录GCC中PHI的发展，该框架基于范围审查的文献。截至2023年12月，所有海湾合作委员会国家都制定了法律或颁布了建立强制性PHI计划的法律。这些计划大多数是为居住在这些国家的外籍人口设计的，但有一种趋势是将其扩大到在私营部门工作的国民。卫生系统环境在PHI如何出现以及在角色、资格和覆盖范围方面的设计中发挥着作用。该地区的PHI市场集中并由业绩水平有待进一步提高的当地公司主导。随着各国政府寻求加强竞争，这些市场正在走向成熟，并受到更强有力的技术和审慎监管。该区域各国政府必须确保这些计划的可持续发展，并与卫生系统的目标更加战略性地保持一致。从更成熟的市场吸取的经验教训对未来的发展至关重要。

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引用次数: 0

The NICE experience of designing and utilising severity weights NICE设计和使用严重性权重的经验

IF 2.3 Q3 HEALTH CARE SCIENCES & SERVICES

Health Policy Open

Pub Date : 2025-12-04 DOI: 10.1016/j.hpopen.2025.100156

Allan Wailoo , Helen Bell Gorrod , Lorna Dunning , Juliet Kenny , Emily Leckenby , Koonal Shah

Background

In January 2022, NICE changed from “End of Life” (EoL) to “severity” weights, whereby additional value is applied within cost effectiveness analysis to health benefits arising from health technologies deemed to qualify This study examines the relationship between these concepts, how they relate to patient age, and whether the new system is cost-neutral as intended.

Methods

Data was extracted from 555 NICE Technology Appraisal decisions from 2009 to 2024. Absolute (AS) and proportional shortfall (PS) severity indicators were estimated for pre 2022 decisions. Post 2022 decisions were judged against EoL criteria.

We describe the relationship between severity weights, including the constituent AS and PS elements, age and EoL. Comparisons are made between the distribution of AS, PS and overall severity categories using descriptive statistics and significance tests.

Results

AS and PS have different relationships with patient age. In NICE appraisals, AS reduces with age but the relationship is flat between 40 and 60 years. All decisions in the highest AS category (AS > 18 QALYs) have a starting age below 20 years. PS peaks around 60 years. EoL applies almost exclusively where age exceeds 40 years. 91 % of appraisal decisions meeting EoL would receive a severity weight above 1.

There is no difference in the mean severity weight between pre and post 2022 appraisal decisions (1.116 vs 1.125). Mean AS is lower in post 2022 appraisals.

Conclusions

Severity weights do not correlate precisely with EoL. They have been applied as often as expected. The change from EoL to severity weights has been approximately cost-neutral.

在2022年1月，NICE将“生命终结”（EoL）权重改为“严重程度”权重，因此在成本效益分析中，附加价值被应用于被认为符合条件的卫生技术所产生的健康效益。本研究探讨了这些概念之间的关系，它们与患者年龄的关系，以及新系统是否如预期的那样成本中性。方法从2009年至2024年的555个NICE技术评价决策中提取数据。对2022年前决策的绝对（AS）和比例短缺（PS）严重程度指标进行了估计。2022年后的决定是根据EoL标准来判断的。我们描述了严重性权重之间的关系，包括组成AS和PS元素，年龄和EoL。使用描述性统计和显著性检验对AS、PS和总体严重性类别的分布进行比较。结果as和PS与患者年龄有不同的关系。在NICE的评估中，AS随着年龄的增长而下降，但在40到60岁之间的关系是平缓的。最高AS类别（AS > 18 QALYs）的所有决策的起始年龄都低于20年。PS在60岁左右达到峰值。EoL几乎只适用于年龄超过40岁的人。91%符合EoL的评估决策的严重性权重高于1。2022年前后评估决定的平均严重程度权重没有差异（1.116 vs 1.125）。在2022年后的评估中，平均AS较低。结论严重程度权重与EoL关系不密切。它们像预期的那样经常被应用。从EoL到严重性权重的变化几乎是成本中性的。

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引用次数: 0

Oral health care’s contribution to catastrophic spending in Canada: a descriptive study 口腔保健对加拿大灾难性支出的贡献：一项描述性研究

IF 2.3 Q3 HEALTH CARE SCIENCES & SERVICES

Health Policy Open

Pub Date : 2025-11-20 DOI: 10.1016/j.hpopen.2025.100155

Diego Proaño , Sara Allin , Beverley M. Essue , Sonica Singhal , Carlos Quiñonez

Background

Oral health care (OHC) in Canada is largely financed through employer-sponsored insurance and out-of-pocket (OOP) payments and is generally excluded from its system of universal health coverage, although public financing will increase substantially with the introduction of the Canadian Dental Care Plan (CDCP). We generate estimates of catastrophic health expenditure (CHE) in Canada and assess the contribution of OOP spending in OHC on CHE between 2010 and 2019.

Methods

We examined the Survey of Household Spending from 2010 to 2019 by year and in pooled cross-sections and followed the WHO/Europe methodology to determine CHE. Spending OOP in OHC was compared to medicines, medical products, outpatient care, diagnostic tests, and inpatient care. We assessed CHE and the share of OOP spending annually, nationally, provincially, across income quintiles and presence of private insurance including oral health coverage.

Results

Estimates in CHE dropped from 5 % (2010) to 3.4 % (2019) and was more common among lower income groups, those without private insurance and Québec residents. Oral health care was the second highest contributor to CHE (after medicines) especially among the lowest income groups. Having private insurance yielded a higher share of OOP spending among lower than higher income groups.

Conclusions

From 2010 to 2019, OOP spending in OHC was the second-highest contributor to CHE in Canada. Further monitoring is warranted to ensure financial protection is achieved for OHC after the full implementation of the CDCP.

背景加拿大的口腔卫生保健主要通过雇主赞助的保险和自付费用供资，一般不包括在全民健康保险制度之外，但随着加拿大牙科保健计划的实施，公共资金将大幅增加。我们估算了加拿大的灾难性卫生支出（CHE），并评估了2010年至2019年期间OHC中OOP支出对CHE的贡献。方法：我们按年度和汇总横截面检查了2010年至2019年的家庭支出调查，并遵循世卫组织/欧洲的方法来确定CHE。将面向对象的OHC支出与药品、医疗产品、门诊护理、诊断测试和住院护理进行比较。我们评估了国家、省、收入五分位数和包括口腔健康保险在内的私人保险的存在，每年CHE和OOP支出的份额。结果CHE的估计值从2010年的5%下降到2019年的3.4%，在低收入群体、没有私人保险的人群和曲海居民中更为常见。口腔保健是卫生保健支出的第二大来源（仅次于药品），尤其是在收入最低的群体中。拥有私人保险在低收入群体中所占的OOP支出比例高于高收入群体。结论从2010年到2019年，OHC的OOP支出是加拿大CHE的第二大贡献者。有必要进行进一步监测，以确保在全面实施《疾病预防控制方案》后为OHC提供财政保护。

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引用次数: 0

Structural determinants of HIV inequities in South Africa: Policy analysis of the national strategic plan for HIV 2023–2028 南非艾滋病毒不平等的结构性决定因素：对2023-2028年国家艾滋病毒战略计划的政策分析

IF 2.3 Q3 HEALTH CARE SCIENCES & SERVICES

Health Policy Open

Pub Date : 2025-11-19 DOI: 10.1016/j.hpopen.2025.100154

Aqilah Julaihi

Background

South Africa continues to experience the world’s highest HIV burden despite major progress in antiretroviral therapy (ART) scale-up. Persistent disparities across gender, geography, and socioeconomic status reveal that structural and political inequities shape vulnerability, access, and outcomes. This paper examines inequalities in HIV outcomes and evaluates how social, economic, and political structures influence policy effectiveness despite expanded ART coverage.

Methods

A document-based policy analysis was conducted using Walt and Gilson’s Policy Triangle framework. National strategic plans, government policy documents, and peer-reviewed literature published between 2015 and 2025 were identified through targeted database and grey literature searches. Documents addressing HIV policy, health system reform, or structural determinants were thematically analysed across four domains: policy content, context, actors, and processes.

Results

Structural inequities in HIV incidence, access, and treatment outcomes remain despite expanded services. The 2023–2028 National Strategic Plan adopts a more equity-oriented and multisectoral approach, aligning with Universal Health Coverage and WHO behavioural insights. It includes differentiated service delivery, community-led monitoring, legal reform, and social protection integration. However, implementation is constrained by health system fragmentation, workforce shortages, donor dependency, and weak accountability. The suspension of PEPFAR funding disrupted community-based services, demonstrating the fragility of external financing. International experiences (eg, Thailand, Kenya) show that integrating HIV services within UHC and decentralising delivery can improve retention and equity when supported by domestic investment.

Conclusions

Policy commitments increasingly recognise that equity requires structural transformation rather than solely biomedical solutions. Without stronger domestic investment, clearer implementation mechanisms, and alignment with broader reforms such as National Health Insurance, equity goals risk remaining aspirational. Embedding HIV services within a decentralised, accountable, and people-centred UHC framework offers a credible pathway to sustainability and health equity.

尽管在扩大抗逆转录病毒治疗（ART）方面取得了重大进展，但南非仍然是世界上艾滋病毒负担最重的国家。性别、地域和社会经济地位之间的持续差异表明，结构性和政治上的不平等影响了脆弱性、获取和结果。本文考察了艾滋病毒结果的不平等，并评估了社会、经济和政治结构如何在扩大抗逆转录病毒治疗覆盖面的情况下影响政策有效性。方法采用walter和Gilson的政策三角框架进行基于文献的政策分析。通过有针对性的数据库和灰色文献检索，确定2015年至2025年间发表的国家战略计划、政府政策文件和同行评议文献。涉及艾滋病毒政策、卫生系统改革或结构性决定因素的文件在四个领域进行了主题分析：政策内容、背景、行为者和过程。结果尽管扩大了服务，但艾滋病毒发病率、可及性和治疗结果方面的结构性不平等仍然存在。《2023-2028年国家战略计划》采用了更加注重公平和多部门的方法，与全民健康覆盖和世卫组织的行为见解保持一致。它包括差异化的服务提供、社区主导的监测、法律改革和社会保障一体化。然而，由于卫生系统碎片化、人力短缺、对捐助者的依赖以及问责不力，实施工作受到限制。总统防治艾滋病紧急救援计划资金的暂停中断了社区服务，显示了外部融资的脆弱性。国际经验（如泰国、肯尼亚）表明，在得到国内投资支持的情况下，将艾滋病毒服务纳入全民健康覆盖并下放提供可以改善保留和公平性。政策承诺日益认识到，公平需要结构转型，而不仅仅是生物医学解决方案。如果没有更强有力的国内投资、更清晰的实施机制，以及与国民健康保险（National Health Insurance）等更广泛的改革保持一致，公平目标就有可能仍然遥不可及。将艾滋病毒服务纳入分散、负责任和以人为本的全民健康覆盖框架，为实现可持续性和卫生公平提供了一条可靠的途径。

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