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

Spin-Wave Lifetimes Throughout the Brillouin Zone

We use a neutron spin-echo method with $\mu$eV resolution to determine the lifetimes of spin waves in the prototypical antiferromagnet MnF$_2$ over the entire Brillouin zone. A theory based on the interaction of magnons with longitudinal spin fluctuations provides an excellent, parameter-free description of the data, except at the lowest momenta and temperatures. This is surprising, given the prominence of alternative theories based on magnon-magnon interactions in the literature. The results and technique open up a new avenue for the investigation of fundamental concepts in magnetism. The technique also allows measurement of the lifetimes of other elementary excitations (such as lattice vibrations) throughout the Brillouin zone.Comment: 12 pages, 4 figure

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,

Time-dependent correlations in quantum magnets at finite temperature

In this article we investigate the time dependence of the gap mode of copper nitrate at various temperatures. We combine state-of-the-art theoretical calculations with high precision neutron resonance spin-echo measurements to understand the anomalous decoherence effects found previously in this material. It is shown that the time domain offers a complementary view on this phenomenon, which allows us to directly compare experimental data and theoretical predictions without the need of further intensive data analysis, such as (de)convolution.Comment: 6 pages, 5 figure

Energy Gaps and Kohn Anomalies in Elemental Superconductors

The momentum and temperature dependence of the lifetimes of acoustic phonons in the elemental superconductors Pb and Nb was determined by resonant spin-echo spectroscopy with neutrons. In both elements, the superconducting energy gap extracted from these measurements was found to converge with sharp anomalies originating from Fermi-surface nesting (Kohn anomalies) at low temperatures. The results indicate electron many-body correlations beyond the standard theoretical framework for conventional superconductivity. A possible mechanism is the interplay between superconductivity and spin- or charge-density-wave fluctuations, which may induce dynamical nesting of the Fermi surface

External magnetic field effects on a distorted kagome antiferromagnet

We report bulk magnetization, and elastic and inelastic neutron scattering measurements under an external magnetic field, $H$, on the weakly coupled distorted kagome system, Cu_{2}(OD)_3Cl. Our results show that the ordered state below 6.7 K is a canted antiferromagnet and consists of large antiferromagnetic $ac$-components and smaller ferromagnetic $b$-components. By first-principle calculations and linear spin wave analysis, we present a simple spin hamiltonian with non-uniform nearest neighbor exchange interactions resulting in a system of coupled spin trimers with a single-ion anisotropy that can qualitatively reproduce the spin dynamics of Cu_{2}(OD)_3Cl.Comment: 5 figure

Momentum-resolved electron-phonon interaction in lead determined by neutron resonance spin-echo spectroscopy

Neutron resonance spin-echo spectroscopy was used to monitor the temperature evolution of the linewidths of transverse acoustic phonons in lead across the superconducting transition temperature, $T_c$, over an extended range of the Brillouin zone. For phonons with energies below the superconducting energy gap, a linewidth reduction of maximum amplitude $\sim 6 \mu$eV was observed below $T_c$. The electron-phonon contribution to the phonon lifetime extracted from these data is in satisfactory overall agreement with {\it ab-initio} lattice-dynamical calculations, but significant deviations are found