Health services utilization and out-of-pocket (OOP) expenditures in public and private facilities in Pakistan: An empirical analysis of the 2013-14 OOP health expenditure survey

Background: As low- and middle-income countries progress toward Universal Health Coverage, there is an increasing focus on measuring out-of-pocket (OOP) expenditure and health services utilization within countries. While there have been several reforms to improve health services coverage and financial protection in Pakistan, there is limited empirical research comparing OOP expenditure and health services utilization between public and private facilities and exploring their determinants, a knowledge gap addressed in this study.Methods: We used data from 2013 to 14 OOP Health Expenditure Survey, a population-based household survey carried out for Pakistan\u27s National Health Accounts. The analysis included 7969 encounters from 4293 households. We conducted bivariate analyses to describe patterns of care utilization, estimated annualized expenditures by type and sector of care, and assessed expenditure composition. We used multivariable logistic regression modeling to identify factors associated with sector of care and generalized linear model (GLM) with log link and gamma distribution to identify determinants of OOP expenditures stratified by type of care (inpatient and outpatient).Results: Most encounters (82.5%) were in the private sector and were for outpatient visits (85%). Several public-private differences were observed in annualized expenditures and expenditure components. Logistic regression results indicate males, wealthier individuals, Punjab and Sindh residents, and those in smaller households were more likely to access private outpatient care. In the inpatient model, rural residents were more likely to use a private provider, while Khyber Pakhtunkhwa residents were less likely to use private care. GLM results indicate private sector inpatient expenditures were approximately PKR 6660 (USD 61.8) higher than public sector expenditures, but no public-private differences were observed for outpatient expenditures. Several demographic factors were significantly associated with outpatient and inpatient expenditures. Of note, expenditures increased with increasing wealth, decreased with increasing household size, and differed by province and region.Conclusions: This is the first study comprehensively investigating how healthcare utilization and OOP expenditures vary by sector, type of care, and socio-economic characteristics in Pakistan. The findings are expected to be particularly useful for the next phase of social health protection programs and supply side reforms, as they highlight sub-populations with higher OOP and private sector utilization

Vegetation Dynamics at the Upper Reaches of a Tropical Montane Forest are Driven by Disturbance Over the Past 7300 Years

We assessed tropical montane cloud forest (TMCF) sensitivity to natural disturbance by drought, fire, and dieback with a 7300-year-long paleorecord. We analyzed pollen assemblages, charcoal accumulation rates, and higher plant biomarker compounds (average chain length [ACL] of n-alkanes) in sediments from Wai'ānapanapa, a small lake near the upper forest limit and the mean trade wind inversion (TWI) in Hawai‘i. The paleorecord of ACL suggests increased drought frequency and a lower TWI elevation from 2555–1323 cal yr B.P. and 606–334 cal yr B.P. Charcoal began to accumulate and a novel fire regime was initiated ca. 880 cal yr B.P., followed by a decreased fire return interval at ca. 550 cal yr B.P. Diebacks occurred at 2931, 2161, 1162, and 306 cal yr B.P., and two of these were independent of drought or fire. Pollen assemblages indicate that on average species composition changed only 2.8% per decade. These dynamics, though slight, were significantly associated with disturbance. The direction of species composition change varied with disturbance type. Drought was associated with significantly more vines and lianas; fire was associated with an increase in the tree fern Sadleria and indicators of open, disturbed landscapes at the expense of epiphytic ferns; whereas stand-scale dieback was associated with an increase in the tree fern Cibotium. Though this cloud forest was dynamic in response to past disturbance, it has recovered, suggesting a resilient TMCF with no evidence of state change in vegetation type (e.g., grassland or shrubland)

A Field Range Bound for General Single-Field Inflation

We explore the consequences of a detection of primordial tensor fluctuations for general single-field models of inflation. Using the effective theory of inflation, we propose a generalization of the Lyth bound. Our bound applies to all single-field models with two-derivative kinetic terms for the scalar fluctuations and is always stronger than the corresponding bound for slow-roll models. This shows that non-trivial dynamics can't evade the Lyth bound. We also present a weaker, but completely universal bound that holds whenever the Null Energy Condition (NEC) is satisfied at horizon crossing.Comment: 16 page

An experimental evaluation of a loop versus a reference design for two-channel microarrays

Motivation: Despite theoretical arguments that socalled "loop designs" of two-channel DNA microarray experiments are more efficient, biologists keep on using "reference designs". We describe two sets of microarray experiments with RNA from two different biological systems (TPA-stimulated mammalian cells and Streptomyces coelicor). In each case, both a loop and a reference design were performed using the same RNA preparations with the aim to study their relative efficiency. Results: The results of these experiments show that (1) the loop design attains a much higher precision than the reference design, (2) multiplicative spot effects are a large source of variability, and if they are not accounted for in the mathematical model, for example by taking log-ratios or including spot-effects, then the model will perform poorly. The first result is reinforced by a simulation study. Practical recommendations are given on how simple loop designs can be extended to more realistic experimental designs and how standard statistical methods allow the experimentalist to use and interpret the results from loop designs in practice

A quantitative analysis of attitudes and behaviours concerning sustainable parasite control practices from Scottish sheep farmers

Nematode control in sheep, by strategic use of anthelmintics, is threatened by the emergence of roundworms populations that are resistant to one or more of the currently available drugs. In response to growing concerns of Anthelmintic Resistance (AR) development in UK sheep flocks, the Sustainable Control of Parasites in Sheep (SCOPS) initiative was set up in 2003 in order to promote practical guidelines for producers and advisors. To facilitate the uptake of ‘best practice’ approaches to nematode management, a comprehensive understanding of the various factors influencing sheep farmers’ adoption of the SCOPS principles is required. A telephone survey of 400 Scottish sheep farmers was conducted to elicit attitudes regarding roundworm control, AR and ‘best practice’ recommendations. A quantitative statistical analysis approach using structural equation modelling was chosen to test the relationships between both observed and latent variables relating to general roundworm control beliefs. A model framework was developed to test the influence of socio-psychological factors on the uptake of sustainable (SCOPS) and known unsustainable (AR selective) roundworm control practices. The analysis identified eleven factors with significant influences on the adoption of SCOPS recommended practices and AR selective practices. Two models established a good fit with the observed data with each model explaining 54% and 47% of the variance in SCOPS and AR selective behaviours, respectively. The key influences toward the adoption of best practice parasite management, as well as demonstrating negative influences on employing AR selective practices were farmer’s base line understanding about roundworm control and confirmation about lack of anthelmintic efficacy in a flock. The findings suggest that improving farmers’ acceptance and uptake of diagnostic testing and improving underlying knowledge and awareness about nematode control may influence adoption of best practice behaviour

3,4-O-Isopropyl­idene-2-C-methyl-d-galactonolactone

X-ray crystallography unequivocally confirmed the stereochemistry of the 2-C-methyl group in the title mol­ecule, C10H16O6, in which the 1,5-lactone ring exists in a boat conformation. The use of d-galactose in the synthesis determined the absolute stereochemistry. The crystal exists as O—H⋯O hydrogen-bonded layers in the ab plane, with each mol­ecule acting as a donor and acceptor for two hydrogen bonds