U-Form vs. M-Form: How to Understand Decision Autonomy Under Healthcare Decentralization? Comment on “Decentralisation of Health Services in Fiji: A Decision Space Analysis”

For more than three decades healthcare decentralization has been promoted in developing countries as a way of improving the financing and delivery of public healthcare. Decision autonomy under healthcare decentralization would determine the role and scope of responsibility of local authorities. Jalal Mohammed, Nicola North, and Toni Ashton analyze decision autonomy within decentralized services in Fiji. They conclude that the narrow decision space allowed to local entities might have limited the benefits of decentralization on users and providers. To discuss the costs and benefits of healthcare decentralization this paper uses the U-form and M-form typology to further illustrate the role of decision autonomy under healthcare decentralization. This paper argues that when evaluating healthcare decentralization, it is important to determine whether the benefits from decentralization are greater than its costs. The U-form and M-form framework is proposed as a useful typology to evaluate different types of institutional arrangements under healthcare decentralization. Under this model, the more decentralized organizational form (M-form) is superior if the benefits from flexibility exceed the costs of duplication and the more centralized organizational form (U-form) is superior if the savings from economies of scale outweigh the costly decision-making process from the center to the regions. Budgetary and financial autonomy and effective mechanisms to maintain local governments accountable for their spending behavior are key decision autonomy variables that could sway the cost-benefit analysis of healthcare decentralization

Globalization and medical tourism: the North American experience Comment on “Patient mobility in the global marketplace: a multidisciplinary perspective”

Neil Lunt and Russel Mannion provide an overview of the current state of the medical tourism literature and propose areas for future research in health policy and management. The authors also identify the main unanswered questions in this field ranging from the real size of the medical tourism market to the particular health profiles of transnational patients. In addition, they highlight unexplored areas of research from health economics, ethics, policy and management perspectives. To this very insightful editorial I would add the international trade perspective. While globalization has permeated labor and capital, services such as healthcare are still highly regulated by governments, constrained to regional or national borders and protected by organized interests. Heterogeneity of healthcare regulations and lack of cross-country reciprocity agreements act as barriers to the development of more widespread and dynamic medical tourism markets. To picture these barriers to transnational health services I use evidence from North America, identifying different “pull and push factors” for medical tourist in this region, discussing how economic integration and healthcare reform might shift the incentives to utilize healthcare abroa

Perceived Quality of Care, Receipt of Preventive Care, and Usual Source of Health Care Among Undocumented and Other Latinos

Latinos are the largest minority group in the United States and experience persistent disparities in access to and quality of health care. (1) To determine the relationship between nativity/immigration status and self-reported quality of care and preventive care. (2) To assess the impact of a usual source of health care on receipt of preventive care among Latinos. Using cross-sectional data from the 2007 Pew Hispanic Center/Robert Wood Johnson Foundation Hispanic Healthcare Survey, a nationally representative telephone survey of 4,013 Latino adults, we compared US-born Latinos with foreign-born Latino citizens, foreign-born Latino permanent residents and undocumented Latinos. We estimated odds ratios using separate multivariate ordered logistic models for five outcomes: blood pressure checked in the past 2 years, cholesterol checked in the past 5 years, perceived quality of medical care in the past year, perceived receipt of no health/health-care information from a doctor in the past year, and language concordance. Undocumented Latinos had the lowest percentages of insurance coverage (37% vs 77% US-born, P < 0.001), usual source of care (58% vs 79% US-born, P < 0.001), blood pressure checked (67% vs 87% US-born, P < 0.001), cholesterol checked (56% vs 83% US-born, P < 0.001), and reported excellent/good care in the past year (76% vs 80% US-born, P < 0.05). Undocumented Latinos also reported the highest percentage receiving no health/health-care information from their doctor (40% vs 20% US-born, P < 0.001) in the past year. Adjusted results showed that undocumented status was associated with lower likelihood of blood pressure checked in the previous 2 years (OR = 0.60; 95% CI, 0.43–0.84), cholesterol checked in the past 5 years (OR = 0.62; 95% CI, 0.39–0.99), and perceived receipt of excellent/good care in the past year (OR = 0.56; 95% CI, 0.39–0.77). Having a usual source of care increased the likelihood of a blood pressure check in the past 2 years and a cholesterol check in the past 5 years. In this national sample, undocumented Latinos were less likely to report receiving blood pressure and cholesterol level checks, less likely to report having received excellent/good quality of care, and more likely to receive no health/health-care information from doctors, even after adjusting for potential confounders. Our study shows that differences in nativity/immigration status should be taken into consideration when we discuss perceived quality of care among Latinos

Comparing the Income Elasticity of Health Spending in Middle-Income and High-Income Countries: The Role of Financial Protection

Abstract Background: As middle-income countries become more affluent, economically sophisticated and productive, health expenditure patterns are likely to change. Other socio-demographic and political changes that accompany rapid economic growth are also likely to influence health spending and financial protection. Methods: This study investigates the relationship between growth on per-capita healthcare expenditure and gross domestic product (GDP) in a group of 27 large middle-income economies and compares findings with those of 24 high-income economies from the Organization for Economic Cooperation and Development (OECD) group. This comparison uses national accounts data from 1995-2014. We hypothesize that the aggregated income elasticity of health expenditure in middle-income countries would be less than one (meaning healthcare is a normal good). An initial exploratory analysis tests between fixed-effects and random-effects model specifications. A fixed-effects model with time-fixed effects is implemented to assess the relationship between the two measures. Unit root, Hausman and serial correlation tests are conducted to determine model fit. Additional explanatory variables are introduced in different model specifications to test the robustness of our regression results. We include the out-of-pocket (OOP) share of health spending in each model to study the potential role of financial protection in our sample of high- and middle-income countries. The first-difference of study variables is implemented to address non-stationarity and cointegration properties. Results: The elasticity of per-capita health expenditure and GDP growth is positive and statistically significant among sampled middle-income countries (51 per unit-growth in GDP) and high-income countries (50 per unit-growth in GDP). In contrast with previous research that has found that income elasticity of health spending in middle-income countries is larger than in high-income countries, our findings show that elasticity estimates can change if different criteria are used to assemble a more homogenous group of middle-income countries. Financial protection differences between middle- and high-income countries, however, are not associated with their respective income elasticity of health spending. ` Conclusion: The study findings show that in spite of the rapid economic growth experienced by the sampled middleincome countries, the aggregated income elasticity of health expenditure in them is less than one, and equals that of high-income countries

Changing Hearts and Plates: The Effect of Animal-Advocacy Pamphlets on Meat Consumption

Social movements have driven large shifts in public attitudes and values, from anti-slavery to marriage equality. A central component of these movements is moral persuasion. We conduct a randomized-controlled trial of pro-vegan animal-welfare pamphlets at a college campus. We observe the effect on meat consumption using an individual-level panel data set of approximately 200,000 meals. Our baseline regression results, spanning two academic years, indicate that the pamphlet had no statistically significant long-term aggregate effects. However, as we disaggregate by gender and time, we find small statistically significant effects within the semester of the intervention: a 2.4 percentage-point reduction in poultry and fish for men and a 1.6 percentage-point reduction in beef for women. The effects disappear after 2 months. We merge food purchase data with survey responses to examine mechanisms. Those participants who (i) self-identified as vegetarian, (ii) reported thinking more about the treatment of animals or (iii) expressed a willingness to make big lifestyle changes reduced meat consumption during the semester of the intervention. Though we find significant effects on some subsamples in the short term, we can reject all but small treatment effects in the aggregate

Racial and ethnic disparities in telehealth use before and after California's stay-at-home order

IntroductionTelehealth can potentially improve the quality of healthcare through increased access to primary care. While telehealth use increased during the COVID-19 pandemic, racial/ethnic disparities in the use of telemedicine persisted during this period. Little is known about the relationship between health coverage and patient race/ethnicity after the onset of the COVID-19 pandemic.ObjectiveThis study examines how differences in patient race/ethnicity and health coverage are associated with the number of in-person vs. telehealth visits among patients with chronic conditions before and after California's stay-at-home order (SAHO) was issued on 19 March 2020.MethodsWe used weekly patient visit data (in-person (N = 63, 491) and telehealth visits (N = 55, 472)) from seven primary care sites of an integrated, multi-specialty medical group in Los Angeles County that served a diverse patient population between January 2020 and December 2020 to examine differences in telehealth visits reported for Latino and non-Latino Asian, Black, and white patients with chronic conditions (type 2 diabetes, pre-diabetes, and hypertension). After adjusting for age and sex, we estimate differences by race/ethnicity and the type of insurance using an interrupted time series with a multivariate logistic regression model to study telehealth use by race/ethnicity and type of health coverage before and after the SAHO. A limitation of our research is the analysis of aggregated patient data, which limited the number of individual-level confounders in the regression analyses.ResultsOur descriptive analysis shows that telehealth visits increased immediately after the SAHO for all race/ethnicity groups. Our adjusted analysis shows that the likelihood of having a telehealth visit was lower among uninsured patients and those with Medicaid or Medicare coverage compared to patients with private insurance. Latino and Asian patients had a lower probability of telehealth use compared with white patients.DiscussionTo address access to chronic care management through telehealth, we suggest targeting efforts on uninsured adults and those with Medicare or Medicaid coverage, who may benefit from increased telehealth use to manage their chronic care

Descriptive analysis of wine tourism in Querétaro and Baja California, Mexico

Objective: To present the characteristics of wine tourism that takes place in the states of Querétaro and Baja California, Mexico. Design/methodology/approach: descriptive analysis through primary information sources where 228 questionnaires were applied to those who carried out wine tourism in the states of Querétaro and Baja California or who in the last three years had carried out this activity in Mexico. Results: the respondents reflect interest in the knowledge, production and culture of wine. In addition, they state that the wine routes in the study areas give them satisfaction in the price-quality ratio, wine tastings and gastronomy and that these are key to the development of viticulture in Mexico. Study limitations/implications: people feel that they do not have enough knowledge about wine tourism, limiting their participation when answering the questionnaire. However, this work is a first approximation to carry out a study that relates wine tourism and the competitiveness of the wine industry in Mexico, for which the answers are timely. Findings/conclusions: Mexican wine is considered to have the potential to compete with foreign wines in factors such as quality, flavor and price. In addition, there is a preference for the consumption of Mexican wines, especially red, rose and white. Therefore, the production of wine from states such as Chihuahua, Sonora, Coahuila and Durango, which have a large territorial extension, should be taken advantage of, and more commercial wine routes should be created that help promote this industry at the national level to improve society through greater supply, job creation and reduction of imports.Objective: To present the characteristics of wine tourism that takes place in the states of Querétaro and Baja California, Mexico.Design/methodology/approach: Descriptive analysis through primary sources of information where 228 questionnaires were applied to those who carried out wine tourism in the states of Querétaro and Baja California, or who in the last three years have carried out this activity in Mexico.Results: The survey respondents reflect interest in the knowledge, production and culture of wine. In addition, they state that the wine routes in the study areas give them satisfaction in the price-quality ratio, wine tastings and gastronomy and that these are key to the development of viticulture in Mexico.Limitations on study/implications: People feel that they do not have enough knowledge about wine tourism, which limited their participation when answering the questionnaire. However, this work is a firstapproximation to carry out a study that relates wine tourism and thecompetitiveness of the wine industry in Mexico, for which the answers are timely.Findings/conclusions: Mexican wine is considered to have the potential¿ to compete with foreign wines in factors such as quality, flavor and price. In addition, there is a preference for the consumption of Mexican wines, especially red, rose and white. Therefore, the wine production from states such as Chihuahua, Sonora, Coahuila and Durango, which have a large territorial extension, should be taken advantage of, and more commercial wine routes should be created to help promote this industry at the national level to improve society through greater offer, job creation and reduction of imports

Pacientes con toxocariosis ocular atendidos en el Hospital Nacional Cayetano Heredia, el Hospital Nacional Arzobispo Loayza y el Instituto Nacional de Salud del Niño entre los años 1997 y 2010

Objetivo: Describir los hallazgos clínicos, imagenológicos y laboratoriales de los pacientes con toxocariosis ocular atendidos en 3 de los principales centros de referencia oftalmológica de Lima.   Material y método: Se revisaron historias clínicas de pacientes con diagnóstico probable de toxocariosis ocular diagnosticados entre enero de 1997 y enero de 2010 en el Hospital Nacional Cayetano Heredia, Hospital Nacional Arzobispo Loayza y el Instituto Nacional de Salud del Niño.   Resultados: Se encontraron 41 pacientes con diagnóstico probable de toxocariosis ocular, la edad varió entre 5 meses y 62 años (11,6 ± 8). El síntoma más frecuente fue disminución de la agudeza visual. Los hallazgos más frecuentes en el fondo de ojo y los exámenes de imagen fueron: granuloma periférico y uveítis posterior. La mayoría de pacientes tuvo serología positiva para Toxocara canis.   Conclusiones: La mayoría de pacientes fueron niños y adolescentes, de ellos muchos desarrollaron algún grado de discapacidad visual secundaria a toxocariosis ocular

Heterogeneity in Health Insurance Coverage Among US Latino Adults

We sought to determine the differences in observed and unobserved factors affecting rates of health insurance coverage between US Latino adults and US Latino adults of Mexican ancestry. Our hypothesis was that Latinos of Mexican ancestry have worse health insurance coverage than their non-Mexican Latino counterparts. The National Health Interview Survey (NHIS) database from 1999–2007 consists of 33,847 Latinos. We compared Latinos of Mexican ancestry to non-Mexican Latinos in the initial descriptive analysis of health insurance coverage. Disparities in health insurance coverage across Latino categories were later analyzed in a multivariable logistic regression framework, which adjusts for confounding variables. The Blinder-Oaxaca technique was applied to parse out differences in health insurance coverage into observed and unobserved components. US Latinos of Mexican ancestry consistently had lower rates of health insurance coverage than did US non-Mexican Latinos. Approximately 65% of these disparities can be attributed to differences in observed characteristics of the Mexican ancestry population in the US (e.g., age, sex, income, employment status, education, citizenship, language and health condition). The remaining disparities may be attributed to unobserved heterogeneity that may include unobserved employment-related information (e.g., type of employment and firm size) and behavioral and idiosyncratic factors (e.g., risk aversion and cultural differences). This study confirmed that Latinos of Mexican ancestry were less likely to have health insurance than were non-Mexican Latinos. Moreover, while differences in observed socioeconomic and demographic factors accounted for most of these disparities, the share of unobserved heterogeneity accounted for 35% of these differences