Expansion of health insurance in Moldova and associated improvements in access and reductions in direct payments

Background Moldova is the poorest country in Europe. Economic constraints mean that Moldova faces challenges in protecting individuals from excessive costs, improving population health and securing health system sustainability. The Moldovan government has introduced a state benefit package and expanded health insurance coverage to reduce the burden of healthcare costs for citizens. This study examines the effects of expanded health insurance by examining factors associated with health insurance coverage, likelihood of incurring out-of-pocket (OOP) payments for medicines or services, and the likelihood of forgoing healthcare when unwell. Methods Using publically available databases and the annual Moldova Household Budgetary Survey, we examine trends in health system financing, healthcare utilisation, health insurance coverage, and costs incurred by individuals for the years 2006-2012. We perform logistic regression to assess the likelihood of having health insurance, incurring a cost for healthcare, and forgoing healthcare when ill, controlling for socio-economic and demographic covariates. Findings Private expenditure accounted for 55.5% of total health expenditures in 2012. 83.2% of private health expenditures is OOP payments – especially for medicines. Healthcare utilisation is inline with EU averages of 6.93 outpatient visits per person. Being uninsured is associated with groups of those aged 25-49 years, the self-employed, unpaid family workers, and the unemployed, although we find lower likelihood of being uninsured for some of these groups over time. Overtime, the likelihood of OOP for medicines increased (OR=1.422 in 2012 compared to 2006), but fell for healthcare services (OR=0.873 in 2012 compared to 2006). No insurance and being older and male, was associated with increased likelihood of forgoing healthcare when sick, but we found the likelihood of forgoing healthcare to be increasing over time (OR=1.295 in 2012 compared to 2009). Interpretation Moldova has achieved improvements in health insurance coverage with reductions in OOP for services, which are modest but are eroded by increasing likelihood of OOP for medicines. Insurance coverage was an important determinant for healthcare costs incurred by patients and patients forgoing healthcare. Improvements notwithstanding, there is an unfinished agenda of attaining universal health coverage in Moldova to protect individuals from healthcare costs

How do programs work to improve child nutrition?: Program impact pathways of three nongovernmental organization intervention projects in the Peruvian highlands

This paper examines the program logic of three nongovernmental, community-based programs with different intervention models to reduce childhood stunting. Two programs, Child Nutrition Program (PNI) and Good Start, focused directly on education and behavior change among caregivers, or the short routes to achieve impact, while one program, Sustainable Networks for Food Security (REDESA), focused on upstream factors, such as improving local governance and coordination, improving water and sanitation, and increasing family incomes, or the long routes to achieve impact. We compared the logic of each program as it was explicitly documented to the logic as perceived by the implementers. We elucidated the program impact pathways (PIPs) of key activities by actors at different operational levels in each program to identify congruencies and gaps in the perceptions of causal mechanisms between program activities and their intended outcomes, and analyzed them with the simple program models and logical frameworks to highlight the methodology and utility of PIPs. In a desire to move beyond static input-out models of the three programs, we designed and conducted data collection activities (document review, semi-structured interviews, and observations) with the intention of gaining insights about those aspects of the program that brought causal mechanisms of a given program into clearer focus. We propose that different methods for eliciting PIPs may be necessary at different operational levels. The interview method elicited more complete responses among those who are familiar with programmatic concepts, whereas actors at the local operational level provided sparse and fragmentary responses, even when simple, common language was used during the interviews. Group participatory processes, using visual aids, may be more effective for mapping the perceptions of those who are not accustomed to articulating information about programs. To reduce the length and frequency of interviews with program actors, initial PIPs could also be constructed from program documents, then discussed and revised iteratively with program actors. Although program logic models and the logical frameworks provide a succinct overview of the program (for communication, strategic planning, and management), we found that PIPs provide a better representation of the causal connections between program activities and results, particularly when both upstream and direct intervention activities were part of the same program. PIPs provide a visual tool for tracking how activities were perceived to work and make an impact, bringing into focus the different pathways of the activities and influences along the way. Beyond the logical sequence of program inputs, outputs, and outcomes, the conceptualization of impact pathways is a useful approach for understanding the causal connections required for impact and for identifying where attention and reinforcements may be required within program operation. The utility of this tool warrants its use not only during final evaluation but also during mid-program monitoring and relevant assessments. National- and regional-level program actors had good understanding of the overarching frameworks and principles of their respective programs as well as the program components and activities. They demonstrated a strong coherence to the program documents, provided similar cohesive responses, and were able to articulate the impact pathways. However, program actors at the national level identified fewer facilitators and barriers along the impact pathways than did the local actors, revealing that the practical dimensions of the impact pathways were not as evident to planners and managers farther from the communities. Although program actors at the local level were more apt to provide practical examples of influencing factors or incidents that occur during implementation, they had difficulty fully articulating their perceived PIPs and provided fragmented views of how the activities linked to their outcomes. Similar patterns were found across the three programs. This finding raises the question of desirability of a common understanding of the goals and pathways by which these outcomes are achieved or the acceptability of diversity of perspectives. It is still unclear whether program effectiveness may be improved through greater congruency in the PIPs. Future research should elucidate how congruency of PIPs among program actors across operational levels could be increased, and whether greater congruency would improve program implementation and effectiveness.program impact pathway, program logic model, logical framework, childhood stunting, child nutrition programs,

Magnetic structure of Cd-doped CeCoIn5

The heavy fermion superconductor CeCoIn5 is believed to be close to a magnetic instability, but no static magnetic order has been found. Cadmium doping on the In-site shifts the balance between superconductivity and antiferromagnetism to the latter with an extended concentration range where both types of order coexist at low temperatures. We investigated the magnetic structure of nominally 10% Cd-doped CeCoIn5, being antiferromagnetically ordered below T_N=3 K and superconducting below T_c=1.3 K, by elastic neutron scattering. Magnetic intensity was observed only at the ordering wave vector Q_AF = (1/2,1/2,1/2) commensurate with the crystal lattice. Upon entering the superconducting state the magnetic intensity seems to change only little. The commensurate magnetic ordering in CeCo(In1-xCdx)5 is in contrast to the incommensurate antiferromagnetic ordering observed in the closely related compound CeRhIn5. Our results give new insights in the interplay between superconductivity and magnetism in the family of CeTIn5 (T=Co, Rh, and Ir) based compounds.Comment: 4 pages, 4 figure

Children are full of optimism, but those rose-tinted glasses are fading-Reduced learning from negative outcomes drives hyperoptimism in children

Believing that good things will happen in life is essential to maintain motivation and achieve highly ambitious goals. This optimism bias, the overestimation of positive outcomes, may be particularly important during childhood when motivation must be maintained in the face of negative outcomes. In a learning task, we have thus studied the mechanisms underlying the development of optimism bias. Investigating children (8 to 9 year-olds), early (12 to 13 year-olds), and late adolescents (16 to 17 year-olds), we find a consistent optimism bias across age groups. However, children were particularly hyperoptimistic, with the optimism bias decreasing with age. Using computational modeling, we show that this was driven by a reduced learning from worse-than-expected outcomes, and this reduced learning explains why children are hyperoptimistic. Our findings thus show that insensitivity to bad outcomes in childhood helps to prevent taking on an overly realistic perspective and maintain motivation. (PsycInfo Database Record (c) 2021 APA, all rights reserved)