Pediatric discharge against medical advice in Bouake Cote d'Ivoire, 1980-1992.
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Discharge information was obtained from pediatric ward logbooks of the Centre Hospitalier Regional de Bouake from 1982 to 1992. While number of children admitted per month and discharge diagnosis remained relatively stable throughout the period, the proportion of children who left the hospital against medical advice increased by nearly 5 times during the 11-year period to over 12% of all pediatric admissions. The proportion of discharges against medical advice decreased to 10% of all pediatric admissions after institution of a programme to provide essential drugs at cost to patients (previously only available from private pharmacies). Most children who were taken from the hospital left within the first two days of hospitalization. The admission diagnoses of these children suggest that most had serious, life-threatening illness and that they left the hospital prior to having received adequate treatment. The increase in pediatric ward discharge against medical advice occurred simultaneously with serious budgetary shortfalls in the hospital resulting in inadequacy of medicines and basic equipment. Hospital staff suspected that most of the discharges against medical advice were caused by families being unable to afford the purchase of medicines and supplies necessary for inpatient treatment. It is suggested that widespread policies of decreasing funding for basic curative services in public hospitals may be associated with a substantial increase in preventable child mortality. (+info)
The impact of alternative cost recovery schemes on access and equity in Niger.
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The authors examine accessibility and the sustainability of quality health care in a rural setting under two alternative cost recovery methods, a fee-for-service method and a type of social financing (risk-sharing) strategy based on an annual tax+fee-for-service. Both methods were accompanied by similar interventions aimed at improving the quality of primary health services. Based on pilot tests of cost recovery in the non-hospital sector in Niger, the article presents results from baseline and final survey data, as well as from facility utilization, cost, and revenue data collected in two test districts and a control district. Cost recovery accompanied by quality improvements increases equity and access to health care and the type of cost recovery method used can make a difference. In Niger, higher access for women, children, and the poor resulted from the tax+fee method, than from the pure fee-for-service method. Moreover, revenue generation per capita under the tax+fee method was two times higher than under the fee-for-service method, suggesting that the prospects of sustainability were better under the social financing strategy. However, sustainability under cost recovery and improved quality depends as much on policy measures aimed at cost containment, particularly for drugs, as on specific cost recovery methods. (+info)
Enhancing health programme efficiency: a Cambodian case study.
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In 1995, the Cambodian Urban Health Care Association (CUHCA) was set up as facilitator between private health care providers and patients, guaranteeing good quality health care and fair pricing to patients and providing training and logistic support to providers. Providers were engaged on a fee-for-service basis and competition encouraged. CUHCA's objectives followed the same line of thought as the 1993 World Development Report, aiming at influencing the unregulated private health care market through competition mechanisms. But soon after the start of the project the basic problem was recognized to be not the absence of effective government regulation but rather that consumers lack the requisite knowledge to make good choices in the market for health services. CUHCA had not adequately addressed the demand for health services. The original supply-side strategy of improving health services by increasing competition was a failure. In order to improve CUHCA's health programme efficiency the association's objectives were subsequently redefined and its functioning reorganized. CUHCA now tries to educate consumers and provides good quality services so that consumers will be able to act on the basis of their newly acquired knowledge. CUHCA's health centres serve as model clinics for first-line health care. Community educators organize information, education and communication (IEC) activities. Staff help school teachers to improve formal health education in schools and CUHCA assists local leaders in sanitation development. Only full-time personnel are employed, encouraging team spirit and communication with the target population. Salaries are based on team performance. The CUHCA programme demonstrates that, depending on the market situation, health programme models need to address both the supply and the demand for services in order to be efficient. Where consumers lack essential knowledge to make appropriate choices in the health service market, interventions should focus on health education and social marketing and provide models of quality care catering to informed consumer choice. (+info)
Access to care for the uninsured: is access to a physician enough?
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OBJECTIVES: This study examined a private-sector, statewide program (Kentucky Physicians Care) of care for uninsured indigent persons regarding provision of preventive services. METHODS: A survey was conducted of a stratified random sample of 2509 Kentucky adults (811 with private insurance, 849 Medicaid recipients, 849 Kentucky Physicians Care recipients). RESULTS: The Kentucky Physicians Care group had significantly lower rates of receipt of preventive services. Of the individuals in this group, 52% cited cost as the primary reason for not receiving mammography, and 38% had not filled prescribed medicines in the previous year. CONCLUSIONS: Providing free access to physicians fills important needs but is not sufficient for many uninsured patients to receive necessary preventive services. (+info)
Income levels of bad-debt and free-care patients in Massachusetts hospitals.
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This study disputes the common notion that many hospitalized patients whose expenses are written off to bad debt are able to pay their bills. By matching 1996 state tax returns to more than 350,000 bad-debt and free-care claims at seven Massachusetts hospitals, we found that most patients involved had incomes below the federal poverty level and thus were presumably eligible for either public programs or hospital-based free care. This suggests that hospitals and public officials need to investigate further why low-income, uninsured patients are not receiving benefits for which they are eligible. Our results also suggest that measurements of indigent care levels in hospitals for purposes of research or regulation should include some portion of bad debt. (+info)
Preferences for sites of care among urban homeless and housed poor adults.
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OBJECTIVE: To describe sources of health care used by homeless and housed poor adults. DESIGN: In a cross-sectional survey, face-to-face interviews were conducted to assess source of usual care, preferred site of care for specific problems, perceived need for health insurance at different sites of care, and satisfaction with care received. Polychotomous logistic regression analysis was used to identify the factors associated with selecting non-ambulatory-care sites for usual care. SETTING: Twenty-four community-based sites (i.e., soup kitchens, drop-in centers, and emergency shelters) frequented by the homeless and housed poor in Allegheny County, Pa. PARTICIPANTS: Of the 388 survey respondents, 85.6% were male, 78.1% African American, 76.9% between 30 and 49 years of age, 59.3% were homeless less than 1 year, and 70.6% had health insurance. MAIN RESULTS: Overall, 350 (90.2%) of the respondents were able to identify a source of usual medical care. Of those, 51.3% identified traditional ambulatory care sites (i.e., hospital-based clinics, community and VA clinics, and private physicians offices); 28.9% chose emergency departments; 8.0%, clinics based in shelters or drop-in centers; and 2.1%, other sites. Factors associated with identifying nonambulatory sites for usual care included lack of health insurance (relative risk range for all sites [RR] = 3.1-4.0), homelessness for more than 2 years (RR = 1. 4-3.0), receiving no medical care in the previous 6 months (RR = 1. 6-7.5), nonveteran status (RR = 1.0-2.5), being unmarried (RR = 1. 2-3.1), and white race (RR = 1.0-3.3). CONCLUSIONS: Having no health insurance or need for care in the past 6 months increased the use of a non-ambulatory-care site as a place for usual care. Programs designed to decrease emergency department use may need to be directed at those not currently accessing any care. (+info)
Health insurance coverage after welfare.
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This DataWatch examines the health insurance coverage of former welfare recipients who left welfare between January 1995 and mid-1997, using data from the 1997 National Survey of America's Families. Although the majority of women who left welfare were working, only 33 percent of these women obtained health coverage through their jobs. Rates of uninsurance increase with the number of months since leaving welfare and with declines in Medicaid coverage. A year or more after leaving welfare, 49 percent of women and 30 percent of children were uninsured. (+info)
Utilization of health care services among adults attending a health fair in South Los Angeles County.
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A bilingual survey was developed to collect information regarding socio-demographics, access to medical and dental care, health insurance coverage, perceived health status, and use of folk medicine providers from 70 adults presenting to a health fair in South Los Angeles County. Ninety-seven percent of respondents were foreign-born. Seventy-nine percent reported having no health insurance during the year prior to survey. Of the uninsured, 61 percent lacked a doctor visit and 76 percent lacked a dental visit during the previous year. The high cost of care was the most frequently cited barrier to seeking medical (58 percent) and dental (67 percent) care even when respondents felt it was necessary. Respondents who felt they needed medical attention but did not seek it had a lower perceived health status (7.0 +/- 2.2) than those who did (8.0 +/-2.0). Among respondents perceiving themselves in poor health, only 17 percent were insured. Relatively few respondents (7.2 percent) reported seeing a folk healer during the past year. Our results support the argument that the medically indigent in some localities face serious financial, as well as less salient, barriers to access. These local conditions reflect inadequate enforcement by local governments in correcting the difficult problems indigent populations face in accessing medical and dental care. (+info)