How effective and fair is user fee removal? Evidence from Zambia using a pooled synthetic control.
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SUBMITTER: Lepine A
PROVIDER: S-EPMC5900920 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundThe impact of user-fee policies on the equity of health care utilization and households' financial burdens has remained largely unexplored in Latin American and the Caribbean, as well as in upper-middle-income countries. This paper assesses the short- and long-term impacts of Jamaica's user-fee-removal for children in 2007.MethodsThis study utilizes 14 rounds of data from the Jamaica Survey of Living Conditions (JSLC) for the periods 1996 to 2012. JSLC is a national household survey, which collects data on health care utilization and among other purposes for planning. Interrupted time series (ITS) analysis was used to examine the immediate impact of the user-fee-removal policy on children's health care utilization and households' financial burdens, as well as the impact in the medium- to long-term.ResultsImmediately following the implementation of user-fee-removal, the odds of seeking for health care if the children fell ill in the past 4 weeks increased by 97% (odds ratio 2.0, 95% confidence interval (CI) 1.1 to 3.5, P = 0.018). In the short-term (2007-2008), health care utilization increased at a faster rate among children not in poverty than children in poverty; while this gap narrowed after 2008. There was minimal difference in health care utilization across wealth groups in the medium- to long-term. The household's financial burden (health expenditure as a share of household's non-food expenditures) reduced by 6 percentage points (95% CI: -11 to -1, P = 0.020) right after the policy was implemented and kept at a low level. The difference in financial burden between children in poverty and children not in poverty shrunk rapidly after 2007 and remained small in subsequent years.ConclusionsUser-fee-removal had a positive impact on promoting health care utilization among children and reducing their household health expenditures in Jamaica. The short-term and the medium- to long-term results have different indications: In the short-term, the policy deteriorated the equity of access to health care for children, while the equity status improved fast in the medium- to long-term.
| S-EPMC5481893 | biostudies-literature
Project description:BackgroundThe Prescription Drug User Fee Act (PDUFA) is due for reauthorization in 2022. Beyond creating the user fee program which now generates a majority of the Food and Drug Administration (FDA) Human Drugs Program budget, PDUFA has made numerous additional changes to FDA policy during its 29-year history. FDA's budgetary dependence on user fees may advantage the industry in negotiating favorable policy changes through PDUFA.MethodsThe full texts of all prior PDUFA reauthorization bills and all submitted public comments and meeting minutes for the 2022 reauthorization were reviewed. Provisions affecting FDA regulatory authority and processes were identified.FindingsPDUFA legislation has instituted a broad range of changes to FDA policy, including evidentiary standards for drug approval, accelerated pathways for approval, industry involvement in FDA decision-making, rules regarding industry information dissemination to providers, and market entry of generic drugs. Negotiations over the 2022 reauthorization suggest that industry priorities include increased application of real-world evidence, regulatory certainty, and increased communication between FDA and industry during the drug application process.ConclusionsThe need for PDUFA reauthorization every 5 years has created a recurring legislative vehicle through which far-ranging changes to FDA have been enacted, reshaping the agency's interactions and relationship with the regulated industry. The majority of policy changes enacted through PDUFA legislation have favored industry through decreasing regulatory standards, shortening approval times, and increasing industry involvement in FDA decision-making. FDA's budgetary dependence on the industry, the urgency of each PDUFA reauthorization's passage to maintain uninterrupted funding, and the industry's required participation in PDUFA negotiations may advantage the industry.
| S-EPMC8917050 | biostudies-literature
Project description:The purpose of this paper is to briefly present a methodological framework that does not require cumbersome investigations for a first assessment of the financial sustainability of policies aiming to remove or reduce healthcare user fees (the so-called free healthcare policy [FHCP]). This paper is organized in two main sections. The first analyzes the various possibilities available to finance an FHCP. Using several scenarios, it includes a special focus devoted to the calculus of what to consider when assessing the sustainability of expanding fiscal space for financing the FHCP. The second section relies on the current FHCP being implemented in Burkina Faso to illustrate a selection of specific issues raised in the methodological framework. The results suggest that sustainable FHCP financing is not outside the range of the government but does represent a significant challenge, as it will require, both currently and in the future, complex and delicate budget trade-offs at the highest governmental levels, regardless of other policy options to be considered.
| S-EPMC7716817 | biostudies-literature
Project description:This study explores the relationship between two health financing initiatives on women's progression through the maternal health continuum in Kenya: a subsidized reproductive health voucher programme (2006-16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the voucher programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the voucher programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P < 0.001) were also positively associated with use of continuous care among ANC users. Among continuous care users, early ANC was associated with increased odds of completing the maternal health pathway as recommended (aOR: 3.80, P < 0.001). Higher parity was negatively associated with all three outcomes, while having health insurance was positively associated with each outcome. The impact of other sociodemographic factors such as maternal age, education, wealth quintile, urban residence, and employment varied by outcome; however, the findings generally suggest that marginalized women faced greater barriers to early ANC initiation and continuity of care. Health financing and women's timing and source of ANC are strongly related to their subsequent progression through the maternal health pathway. To increase continuity of care and improve maternal health outcomes, policymakers must therefore focus on equitably reducing financial and other barriers to care seeking and improving quality of care throughout the continuum.
| S-EPMC6481282 | biostudies-literature
Project description:Global efforts for biodiversity protection and land use-based greenhouse gas mitigation call for increases in the effectiveness and efficiency of environmental conservation. Incentive-based policy instruments are key tools for meeting these goals, yet their effectiveness might be undermined by such factors as social norms regarding whether payments are considered fair. We investigated the causal link between equity and conservation effort with a randomized real-effort experiment in forest conservation with 443 land users near a tropical forest national park in the Vietnamese Central Annamites, a global biodiversity hotspot. The experiment introduced unjustified payment inequality based on luck, in contradiction of local fairness norms that were measured through responses to vignettes. Payment inequality was perceived as less fair than payment equality. In agreement with our preregistered hypotheses, participants who were disadvantaged by unequal payments exerted significantly less conservation effort than other participants receiving the same payment under an equal distribution. No effect was observed for participants advantaged by inequality. Thus, equity effects on effort can have consequences for the effectiveness and efficiency of incentive-based conservation instruments. Furthermore, we show that women exerted substantially more conservation effort than men, and that increasing payment size unexpectedly reduced effort. This emphasizes the need to consider social comparisons, local equity norms, and gender in environmental policies using monetary incentives to motivate behavioral change.
| S-EPMC7321961 | biostudies-literature
Project description:Here, we propose a low-cost, sustainable, and viable adsorbent (pine tree-derived biochar) to remove acid dyes such as acid violet 17 (AV), which is used in the silk dyeing industry. As a case study, the AV removal process was demonstrated using synthetic effluent and further as a proof of concept using real dye effluent produced from the Sirumugai textile unit in India. The pine tree-derived biochar was selected for removal of aqueous AV dye in batch and fixed-bed column studies. The adsorbent material was characterized for crystallinity (XRD), surface area (BET), surface morphology and elemental compositions (SEM-EDX), thermal stability (TGA), weight loss (DGA), and functional groups (FTIR). Batch sorption studies were performed to evaluate (i) adsorption at various pH values (at pH 2 to 7), (ii) isotherms (at 10, 25, and 35 °C) to assess the temperature effect on the sorption efficiency, and (iii) kinetics to reveal the effect of time, adsorbent dose, and initial concentration on the reaction rate. After systematic evaluation, 2 g/L biochar, 25 mg/L AV, pH 3, 40 °C, and 40 and 360 min in a completely mixed batch study resulted in 50 and 90% dye removal, respectively. The isoelectric point at pH 3.7 ± 0.2 results in maximum dye removal, therefore suggesting that monitoring the ratio of different effluent (acid/wash/dye) can improve the colorant removal efficiency. The Langmuir isotherm best fits with the sorption of AV to biochar, provided a maximal dye uptake of 29 mg/g at 40 °C, showing that adsorption was endothermic. Fixed-bed studies were conducted at room temperature with an initial dye concentration of 25 and 50 mg/L. The glass columns were packed with biochar (bed depth 20 cm, pore volume = 14 mL) at an initial pH of 5.0 and a 10 mL/min flow rate for 120 min. Finally, the regeneration of the adsorbent was achieved using desorption studies conducted under the proposed experimental conditions resulted in 90-93% removal of AV even after five cycles of regeneration.
| S-EPMC8757339 | biostudies-literature
Project description:Background Four years prior to the Millenium Development Goals (MDGs) deadline, low- and middle-income countries and international stakeholders are looking for evidence-based policies to improve access to healthcare for the most vulnerable populations. User fee exemption policies are one of the potential solutions. However, the evidence is disparate, and systematic reviews have failed to provide valuable lessons. The authors propose to produce an innovative synthesis of the available evidence on user fee exemption policies in Africa to feed the policy-making process. Methods The authors will carry out a realist review to answer the following research question: what are the outcomes of user fee exemption policies implemented in Africa? why do they produce such outcomes? and what contextual elements come into play? This type of review aims to understand how contextual elements influence the production of outcomes through the activation of specific mechanisms, in the form of context-mechanism-outcome configurations. The review will be conducted in five steps: (1) identifying with key stakeholders the mechanisms underlying user fee exemption policies to develop the analytical framework, (2) searching for and selecting primary data, (3) assessing the quality of evidence using the Mixed-Method Appraisal Tool, (4) extracting the data using the analytical framework and (5) synthesising the data in the form of context-mechanism-outcomes configurations. The output will be a middle-range theory specifying how user fee exemption policies work, for what populations and under what circumstances. Ethics and dissemination The two main target audiences are researchers who are looking for examples to implement a realist review, and policy-makers and international stakeholders looking for lessons learnt on user fee exemption. For the latter, a knowledge-sharing strategy involving local scientific and policy networks will be implemented. The study has been approved by the ethics committee of the CHUM Research Centre (CR-CHUM). It received funding from the Canadian Institutes of Health Research. The funders will not have any role in study design; collection, management, analysis, and interpretation of data; writing of the report and the decision to submit the report for publication, including who will have ultimate authority over each of these activities.
| S-EPMC3269046 | biostudies-literature
Project description:BackgroundThe main policy thrust in many sub-Saharan Africa countries' aim at addressing maternal mortality is the elimination of the user fee for maternal healthcare services. While several studies have documented the effect of the user fee removal policy on the use of maternal health care services, the experiences of women seeking care in facilities offering free obstetrics services, their level of satisfaction and reasons for satisfaction or dissatisfaction are poorly understood.MethodsThis study adopted a mixed study design involving a population survey of 1227 women of reproductive age who gave birth in the last five years preceding the study (2011-2015), 68 in-depth interviews, and six focus group discussions. Simple descriptive statistics were performed on 407 women who benefitted from the user fee removal policy, while the qualitative data were analysed using thematic analysis.ResultsThe overall level of satisfaction with care received was remarkably high (97.1%), with birth outcomes being the central reason for their satisfaction. Participants were also satisfied with both the process aspect of care (which includes health workers' attitude and privacy) and the structural dimension of care (such as, the cleanliness of health care facilities and availability of and access to medicine). From the qualitative analysis, prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space were the main reasons why a few women were dissatisfied with care under free maternal health care.ConclusionThe findings establish a high level of beneficiaries' satisfaction with care under free maternal health policy in Nigeria, raising the need for sustaining the policy in expanding access to maternal health services for the poor. Nevertheless, issues relating to prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space require attention from policymakers.
| S-EPMC6927641 | biostudies-literature
Project description:A new natural adsorbent material, Bathurst burr powder, was used to remove crystal violet dye from synthetic wastewaters. Particle size distribution and SEM and FTIR analyses were performed to characterize it. The effect of the operational adsorption process parameters (pH, ionic strength, initial dye concentration, adsorbent dose, contact time, temperature) onto the adsorption process was evaluated in a batch system. Equilibrium, kinetic, and thermodynamic studies were performed in order to understand the adsorption process. Taguchi method and ANOVA test were used to optimize the dye adsorption conditions and to establish the percentage contribution of each factor, respectively. The accuracy of the Taguchi prediction method was analyzed by correlating the predicted dye removal efficiency with the experimentally determined one. The particle size distribution analysis showed that 82.15% of the adsorbent particles have an average size below 0.5 mm. The adsorption process followed the Langmuir isotherm and pseudo-second order kinetic model. Maximum adsorption capacity value (164.10 mg·g-1) was higher compared to many similar adsorbents. The process was endothermic, spontaneous, and favorably involving a physisorption mechanism. The Taguchi method showed that the most influential controllable factor was pH (65% contribution in adsorption efficiency) and the data analysis indicates a very good accuracy of the experimental design (R2 = 0.994). The obtained results demonstrated that Bathurst burr powder can be used as a cheap and efficient adsorbent for crystal violet dye removal from aqueous solution.
| S-EPMC8510156 | biostudies-literature
Project description:ObjectiveTo assess the differential impact of a copayment exemption compared to a cash incentive on increasing skilled birth attendance (i.e., birth attended by a skilled health worker) in Nepal.Data sources/study settingThis study used data on 8,785 children born between July 2005 and December 2008, obtained from the nationally representative Demographic and Health Surveys, 2006 and 2011.Study designTwenty-five districts received both the policy interventions, and the remaining 50 control districts received only the cash incentive. We employed a difference-in-differences model to compare children born in districts with both interventions to those in districts with conditional cash transfers only. Average marginal effects of the difference-in-difference coefficient on skilled birth attendance measures are estimated.Principal findingsSkilled birth attendance in districts with both interventions was no higher on average than in districts with only the cash incentive. In areas with adequate road networks, however, significantly higher skilled birth attendance was observed in districts with both interventions compared to those with only the cash incentive.ConclusionsThe added incentive of the user-fee exemption did not significantly increase skilled birth attendance relative to the presence of the cash incentive. User-fee exemptions may not be effective in areas with inadequate road infrastructure.
| S-EPMC5517670 | biostudies-literature