Evidence of a causal link between health outcomes, insurance coverage, and a policy to expand access: experimental data from children in the Philippines. Eliciting public preference for health-care resource allocation in South Korea. Health insurance and health-seeking behavior: evidence from a randomized community-based insurance rollout in rural Burkina Faso. Does health insurance improve health?: Evidence from a randomized community-based insurance rollout in rural Burkina Faso. Feasibility, acceptability and preliminary effectiveness of patient advocates for improving asthma outcomes in adults Promoting Employee Health by Integrating Health Protection, Health Promotion, and Continuous Improvement: A Longitudinal Quasi-Experimental Intervention Study Public views on determinants of health, interventions to improve health, and priorities for government. Tensions in public health policy: patient engagement, evidence-based public health and health inequalities Time preferences for health gains: an empirical investigation. Improving the reporting of public health intervention research: advancing TREND and CONSORT. Supporting Goal-Oriented Primary Health Care for Seniors with Complex Care Needs Using Mobile Technology: Evaluation and Implementation of the Health System Performance Research Network, Bridgepoint Electronic Patient Reported Outcome Tool Healthy public policy A conceptual cognitive framework. Goal Setting and Health Risk Reduction Citizen Participation in Patient Prioritization Policy Decisions: An Empirical and Experimental Study on Patients' Characteristics Does the financial protection of health insurance vary across providers? Vietnam's experience. 'The public is too subjective': public involvement at different levels of health-care decision making. 'More research needed': plugging gaps in the evidence base on health inequalities.
In this paper , we present evidence on the health effects of a health insurance intervention targeted to poor children using data from a r and omized policy experiment known as the Quality Improvement Demonstration Study . Among study participants , using a difference-in-difference regression model , we estimated a 9 - 12 and 4 - 9 percentage point reduction in the likelihood of wasting and having an infection , respectively , as measured by a common biomarker C-reactive Protein . Interestingly , these benefits were not apparent at the time of discharge ; the beneficial health effects were manifest several weeks after release from the hospital OBJECTIVES To identify the principles the public considers important and the trade-offs between different values in health-care re source allocation practice s. METHODS This study approached the issue in both qualitative and quantitative ways . In a qualitative study , two focus groups discussed the issues of re source allocation in health care . To facilitate the discussion , a simple ranking task and a series of pairwise choice practice s were implemented . A discrete choice experiment survey question naire was also administered to a sample of the general population . Attributes and levels were determined through literature review s and the results from the focus group interview . We used a r and om-effect probit model to assess the effects of each attribute . RESULTS Through the focus group interviews , we found strong public support for the principle of equal opportunity . The participants thought that the severity of disease was the most important criterion when setting priorities . The majority supported the idea that the most disadvantaged should have the highest priority even when their health gains are less than those of others . The discrete choice experiment results showed that the severity of disease , health gains , and patients ' socioeconomic status significantly influence their choices , with each parameter having an expected sign . CONCLUSION The results showed that Koreans support not only health maximization but also equal opportunity , fair re source allocation , and e quality In 2004 , a community-based health insurance ( CBI ) scheme was introduced in Nouna district , Burkina Faso , with the primary objective of improving access to facility-based health services . In order to overcome self- selection issues in the analysis of the behavioral effects of insurance , we combine four waves of the Nouna Health District Household Survey into a panel data set , and use the r and omized timing of insurance rollout to estimate the causal effect of insurance coverage on health-seeking behavior . While we find a generally positive association between CBI affiliation and treatment seeking , we can not reject the null that the introduction of health insurance does not have any effect on treatment seeking in general , and utilization of facility-based professional care , in particular . Low levels of health care provider satisfaction , poor perceived quality of care by enrollees , and ambiguity in the coverage level of the CBI benefit package appear to have contributed to these weak results . Our findings imply that the basic notion of insurance mechanically increasing facility-based professional care is not necessarily true empirically , and likely contingent on a large number of context ual factors affecting health-seeking behavior within households and communities From 2004 to 2006 , a  community-based health insurance ( CBI ) scheme was rolled out in Nouna District , Burkina Faso , with the objective of improving access to health services and population health . We explore the r and om timing of the insurance rollout generated by the stepped wedge cluster-r and omized design to evaluate the welfare and health impact of the insurance program . Our results suggest that the insurance had limited effects on average out-of-pocket expenditures in the target areas , but substantially reduced the likelihood of catastrophic health expenditure . The introduction of the insurance scheme did not have any effect on health outcomes for children and young adults , but appears to have increased mortality among individuals aged 65 and older . The negative health effects of the program appear to be primarily driven by the adverse provider incentives generated by the scheme and the result ing decline in the quality of care received by patients Abstract Background : Asthmatic adults from low-income urban neighborhoods have inferior health outcomes which in part may be due to barriers accessing care and with patient-provider communication . We adapted a patient advocate ( PA ) intervention to overcome these barriers . Objective : To conduct a pilot study to assess feasibility , acceptability and preliminary evidence of effectiveness . Methods : A prospect i ve r and omized design was employed with mixed methods evaluation . Adults with moderate or severe asthma were r and omized to 16 weeks of  PA  or a minimal intervention ( MI ) comparison condition . The PA , a non-professional , modeled preparations for a medical visit , attended the visit and confirmed underst and ing . The PA facilitated scheduling , obtaining insurance coverage and overcoming barriers to implementing medical advice . Outcomes included electronically-monitored inhaled corticosteroid ( ICS ) adherence , asthma control , quality of life , FEV1 , emergency department ( ED ) visits and hospitalizations . Mixed-effects models guided an intention-to-treat analysis . Results : 100 adults participated : age 47 ± 14 years , 75 % female , 71 % African – American , 16 % white , baseline FEV1 69 % ± 18 % , 36 % experiencing hospitalizations and 56 % ED visits for asthma in the prior year . Ninety-three subjects completed all visits ; 36 of 53 PA-assigned had a PA  visit . Adherence declined significantly in the control ( p = 0.001 ) but not significantly in the PA group ( p = 0.30 ) . Both PA and MI groups demonstrated improved asthma control ( p = 0.01 in both ) and quality of life ( p = 0.001 , p = 0.004 ) . Hospitalizations and ED visits for asthma did not differ between groups . The observed changes over time tended to favor the PA group , but this study was underpowered to detect differences between groups . Conclusion : The PA intervention was feasible and acceptable and demonstrated potential for improving asthma control and quality of life Objective : To test the effects of integrating health protection and health promotion with a continuous improvement system ( Kaizen ) on proximal employee outcomes ( health promotion , integration , and Kaizen ) and distal outcomes ( workability , productivity , self-rated health and self-rated sickness absence ) . Methods : Twelve units in a county hospital in Sweden were r and omized to control or intervention groups using a quasiexperimental study design . All staff ( approximately 500 ) provided self-ratings in question naires at baseline , and a 12- and 24-month follow-up ( response rate , 79 % to 87.5 % ) . Result : There was a significant increase in the proximal outcomes over time in the intervention group compared with the control group , and a trend toward improvement in the distal outcomes workability and productivity . Conclusions : Integration seems to promote staff engagement in health protection and promotion , as well as to improve their underst and ing of the link between work and health OBJECTIVE There is increasing evidence about the importance of factors that impact health beyond health care and individual behavior , yet there is little public and policy discourse about these things in the United States . We surveyed Wisconsin adults to see what they think are the most important factors that affect health . We also examined which interventions they believe would improve health , and whether government should prioritize such interventions . METHODS A phone survey of a r and om sample of 1459 Wisconsin adults was conducted between September 2006 and February 2007 . RESULTS The Wisconsin public believes that health practice s , access to health care , and health insurance are the most important factors affecting health , and that health insurance is a high government priority . Other broader social and economic determinants of health , such as employment , social support , income , housing , and neighborhood factors are seen as less important to health . Although respondents believe that health practice s are important to health , they are less likely to suggest that government prioritize improving individual health practice s. Although the public believes the government should prioritize access to health care and health insurance , they are not as likely to support government implementing social or economic policies in order to improve health . CONCLUSION In light of research demonstrating the importance of social and economic determinants of health , and of ongoing public forums meant to raise awareness of these determinants of health , it will be important to track whether public opinion of Wisconsin adults changes over time to increase attention to the social and economic determinants of health and related policy initiatives This paper examines the proposition that there are considerable tensions between key strategies in health policy — namely , evidence -based approaches to population health improvement , reduction of health inequalities , and public and patient engagement — using ( 1 ) a critical analysis of the intersection of evidence -based public health , patient and public engagement , and health inequalities policies from a social constructionist perspective and ( 2 ) mathematical modelling of paternalistic and shared decision making in the management of hypertension in a r and om age and sex stratified community sample of residents of south east Northumberl and , UK . It is concluded that there may be unintended effects on population health of incongruities in major components of public health policy . Greater public and patient engagement may militate against the disease prevention goals of evidence -based policy , and may better engage sections of the population who already benefit from greater access and better health associated with social status and opportunity , serving to increase inequalities by further marginalising those already suffering from relative exclusion The purpose of this study was to elicit the implied discount rates to be used in economic evaluations of health care programmes . The paper presents results from two Norwegian surveys in which a r and om sample of the population and a sample of health planners were asked to prioritise between alternative health care programmes , and make trade-offs between future health gains and more immediate gains . The question naire had four hypothetical choice situations ; two for life saving and two for health improvement BACKGROUND Evidence -based public health decision-making depends on high quality and transparent accounts of what interventions are effective , for whom , how and at what cost . Improving the quality of reporting of r and omized and non-r and omized study design s through the CONSORT and TREND statements has had a marked impact on the quality of study design s. However , public health users of systematic review s have been concerned with the paucity of synthesized information on context , development and rationale , implementation processes and sustainability factors . METHODS This paper examines the existing reporting frameworks for research against information sought by users of systematic review s of public health interventions and suggests additional items that should be considered in future recommendations on the reporting of public health interventions . RESULTS Intervention model , theoretical and ethical considerations , study design choice , integrity of intervention/process evaluation , context , differential effects and inequalities and sustainability are often overlooked in reports of public health interventions . CONCLUSION Population health policy makers need synthesized , detailed and high quality a priori accounts of effective interventions in order to make better progress in tackling population morbidities and inequalities . Adding simple criteria to reporting st and ards will significantly improve the quality and usefulness of published evidence and increase its impact on public health program planning Background Older adults experiencing multiple chronic illnesses are at high risk of hospitalization and health decline if they are unable to manage the significant challenges posed by their health conditions . Goal -oriented care approaches can provide better care for these complex patients , but clinicians find the process of ascertaining goals “ too complex and too-time consuming , ” and goals are often not agreed upon between complex patients and their providers . The electronic patient reported outcomes ( ePRO ) mobile app and portal offers an innovative approach to creating and monitoring goal -oriented patient-care plans to improve patient self-management and shared decision-making between patients and health care providers . The ePRO tool also supports proactive patient monitoring by the patient , caregiver(s ) , and health care provider . It was developed with and for older adults with complex care needs as a means to improve their quality of life . Objective Our proposed project will evaluate the use , effectiveness , and value for money of the  ePRO tool  in a 12-month multicenter , r and omized controlled trial in Ontario ; targeting individuals 65 or over with two or more chronic conditions that require frequent health care visits to manage their health conditions . Methods Intervention groups using the ePRO tool will be compared with control groups on measures of quality of life , patient experience , and cost-effectiveness . We will also evaluate the implementation of the tool . Results The proposed project presented in this paper will be funded through the Canadian Institute for Health Research ( CIHR ) eHealth Innovation Partnerships Program ( eHIPP ) program ( CIHR–143559 ) . The expected completion date of the study is November , 2019 . Conclusions We anticipate our program of work will support improved quality of life and patient self-management , improved patient-centered primary care delivery , and will encourage the adoption of goal -oriented care approaches across primary health care systems . We have partnered with family health teams and quality improvement organizations in Ontario to ensure that our research is practical and that findings are shared widely . We will work with our established international network to develop an implementation framework to support continued adaptation and adoption across Canada and internationally More than three decades ago , the report A New Perspective on the Health of Canadians ( 1974 ) highlighted the significance of other determinants than the healthcare system . The adoption of healthy public policy was identified in the Ottawa Charter ( 1986 ) as one of five strategies aim ing to promote health . It must now be acknowledged that even if we have a better underst and ing of health determinants , the latter are not necessarily taken into consideration when developing public policies . The purpose of this paper is to help foster a better underst and ing of the healthy public policies by presenting a conceptual framework that is inspired by the Advocacy Coalition Framework developed by Sabatier and Jenkins-Smith ( 1999 ) . On the one h and , this paper intends to show the relevance of the notion of subsystem of public policies in healthy public policy process . On the other , it aims to convince that it is necessary to channel the analysis around the decision-making process , the prospect i ve evaluation of public policies and the knowledge transfer and appropriation process . Finally , the purpose of this paper is to contribute to the ongoing debate about the role of knowledge , values or beliefs in the formulation and adoption of public policies . After briefly summarizing the theoretical developments in studies on public policies , the logic and components of the ACF are introduced . The main criticisms regarding the ACF are then examined , followed by an introduction of the conceptual framework that is adapted to the reality of healthy public policies . The notions of the subsystem of public policy(ies ) , of process and of learning process are central to this framework The effectiveness of client participation in goal selection aim ed at health risk reduction was compared with the effectiveness of provider-selected goals and of no goal setting . No difference in goal attainment was found between the two groups with goals . However , analyses of covariance for selected sub sample s of individuals at risk revealed a significant difference between goal - setting groups for weight reduction , with the collaborative goal - setting group being more effective . Covariance analyses for other sub sample s at risk showed significant differences between the goal - setting groups for current health age and potential for life expectancy increase ; the provider goal - setting group proved to be more effective . Paired t tests within groups revealed that the provider goal - setting group made significant change in alcohol intake , seat belt use , and exercise as well as in global measures of current health age , estimated life expectancy , and potential for life expectancy increase . For the collaborative goal - setting group , significant change was found in weight reduction , exercise levels , and the global measures of estimated life expectancy and potential for life expectancy increase . The control group made a significant change in exercise , but not in any of the global measures of risk reduction Health systems worldwide are grappling with the need to control costs to maintain system viability . With the combination of worsening economic conditions , an aging population and reductions in tax revenues , the pressures to make structural changes are expected to continue growing . Common cost control mechanisms , e.g. curtailment of patient access and treatment prioritization , are likely to be adversely viewed by citizens . It seems therefore wise to include them in the decision making processes that lead up to policy changes . In the context of a multilevel iterative mixed- method design a quantitative survey representative of the German population ( N = 2031 ) was conducted to probe the acceptance of priority setting in medicine and to explore the practicability of direct public involvement . Here we focus on preferences for patients ' characteristics ( medical aspects , lifestyle and socio-economic status ) as possible criteria for prioritizing medical services . A question naire with closed response options was fielded to gain insight into attitudes toward broad prioritization criteria of patient groups . Furthermore , a discrete choice experiment was used as a rigorous approach to investigate citizens ' preferences toward specific criteria level in context of other criteria . Both the question naire and the discrete choice experiment were performed with the same sample . The citizens ' own health and social situation are included as explanatory variables . Data were evaluated using corresponding analysis , contingency analysis , logistic regression and a multinomial exploded logit model . The results show that some medical criteria are highly accepted for prioritizing patients whereas socio-economic criteria are rejected Using household panel data from Vietnam , this paper compares out-of-pocket health expenditures on outpatient care at a health facility between insured and uninsured patients as well as across various providers . In the r and om effects model , the estimated coefficient of the insurance status variable suggests that insurance reduces out-of-pocket spending by 24 % for those with the compulsory and voluntary coverage and by about 15 % for those with the health insurance for the poor coverage . However , the modest financial protection of the compulsory and voluntary schemes disappears once we control for time-invariant unobserved individual effects using the fixed effects model . Additional analysis of the interaction terms involving the type of insurance and health facility suggests that the overall insignificant reduction in out-of-pocket expenditures as a result of the insurance schemes masks wide variations in the reduction in out-of-pocket sending across various providers . Insurance reduces out-of-pocket expenditures more for those enrollees using district and higher level public health facilities than those using commune health centers . Compared to the uninsured patients using district hospitals , compulsory and voluntary insurance schemes reduce out-of-pocket expenditures by 40 and 32 % , respectively . However , for contacts at the commune health centers , both the compulsory health scheme and the voluntary health insurance scheme schemes have little influence on out-of-pocket spending while the health insurance scheme for the poor reduces out-of-pocket spending by about 15 % There are a number of impulses towards public participation in health care decision making including instrumentalist , communitarian , educative and expressive impulses and the desire for increased accountability . There has , however , been little research looking systematic ally at the public 's preferences for being involved in particular types of rationing decisions , nor indeed , has there been a critical examination of the degree of involvement desired by the public . The research reported here uses findings from focus groups and in-depth interviews to explore these questions . Eight focus groups were conducted with a total of 57 informants , four amongst r and omly selected members of the public and four with informants from health and non-health related organisations . Nineteen interviews were conducted to allow the elaboration of focus group comments , to probe views more deeply and to pursue emerging themes . The findings show variations in the willingness of members of the public to be involved in health care decisions and consistency across the different forms of the public as represented by the focus groups with r and omly selected citizens and pre-existing organisations . There was a strong desire in all the groups for the public to be involved both at the system and programme levels , with much less willingness to be involved at the individual level . At the system and programme levels informants generally favoured consultation , without responsibility for decisions , but with the guarantee that their contribution would be heard and that decisions taken following consultation would be explained . At the patient level informants felt that the public should participate only by setting criteria for deciding between potential beneficiaries of treatment . The public has much to contribute , particularly at the system and programme levels , to supplement the inputs of health care professionals Policymakers and public health research ers have dem and ed better evidence of the effects of interventions on public health and health inequalities and have pointed to the relative absence of rigorous outcome evaluations in this area . While most of these commentators agree that health inequalities are a problem , the means of tackling them often seems to rest on poor evidential foundations . This is no longer surprising , as the problem has been well-documented and the solution probably seems clear : if there is not enough evidence , then obviously we need more ; and if the evidence is ‘ weak ’ , well , then , it just needs to be ‘ stronger ’ in future . The funding environment in the UK , at least , is supportive of the production of this new , stronger evidence , with several new funding initiatives which are aim ing to foster the production of new evaluations of public health interventions . However , it might be useful to consider further what ‘ more evidence ’ might look like ( that is , what sort of evidence is needed ) and how might it be ‘ stronger ’ than in the past and also to consider what additional challenges collecting this new evidence might bring . It is clear that evidence on the effectiveness and cost-effectiveness of public health interventions is often missing . Sometimes this is because policies are insufficiently subjected to outcome evaluation , perhaps because it is assumed that they are mostly beneficial and any positive outcomes can be taken as read . R and omized controlled trials of policies are particularly uncommon and there are a variety of real and perceived barriers to trials . This means that the public are frequently ‘ enrolled ’ in real-life policy ‘ experiments ’ without giving their explicit consent , or indeed without any real prospect of anyone learning anything substantial about the effects of those interventions . Although the experimental nature of most policies is generally unacknowledged , this is not always the
INTERPRETATION Increased health insurance coverage generally appears to increase access to health care facilities , improve financial protection and improve health status , although findings are not totally consistent .
BACKGROUND Exp and ing public health insurance seeks to attain several desirable objectives , including increasing access to healthcare services , reducing the risk of catastrophic healthcare expenditures , and improving health outcomes .
The extent to which these objectives are met in a real-world policy context remains an empirical question of increasing research and policy interest in recent years .