Covid-19 — Implications for the Health Care System The Covid-19 pandemic has exposed and exacerbated weaknesses in the U.S. health care system. Many patients are losing their health insurance when ...
Bablu Kumar Dhar, Md. Mustaqim Roshid, Sulochana Dissanayake
et al.
As the global community moves beyond the 2030 horizon, long-term sustainability goals such as climate neutrality, digital equity, and resilient infrastructure are determining the emerging Agenda 2050—a forward-looking framework for deep sustainability transitions. This study explores how the synergistic integration of Financial Technology (FinTech) and Green Technology (GreenTech) can be used as transformative enablers of sustainable development across South Asia over the coming decades. Utilizing a qualitative thematic analysis of secondary data drawn from peer-reviewed literature, institutional reports, and country case evidence, the research identifies scalable FinTech solutions—including blockchain, digital wallets, RegTech, and green insurance—and complementary GreenTech applications such as solar energy systems, hydropower, green architecture, and sustainable mobility. The analysis highlights how FinTech can catalyze GreenTech diffusion by improving financial access, mobilizing green investments, and enabling real-time sustainability tracking. By assessing current technological trends and institutional readiness across Bangladesh, India, Pakistan, and Sri Lanka, the study provides strategic insights into building integrated digital-environmental ecosystems for Agenda 2050. Key innovations of this study include the application of a dual theoretical framework, Technology Organization Environment (TOE) and Sociotechnical Systems Theory, to analyze FinTech–GreenTech synergies, and a forward-oriented policy roadmap for long-term sustainability in low- and middle-income countries The findings are particularly relevant for policymakers, central banks, private innovators, and development agencies seeking to operationalize long-term sustainability through cross-sectoral technology pathways.
Volodymyr Batalyuk, Volodymyr Kharabara, Olena Chaikovska
et al.
Мета роботи: аналіз правового регулювання військового резерву людських ресурсів провідних держав світу, вивчення досвіду і можливостей його адаптації до потреб України в умовах сучасних викликів.
Метод дослідження: теоретичний аналіз, якісний аналіз, порівняльний аналіз.
Результати дослідження: проведено аналіз правових основ і практик формування військового резерву людських ресурсів в провідних країнах світу та запропоновано рекомендації для України.
Теоретична цінність дослідження: результати дослідження розширюють теоретичні знання щодо організації та функціонування військового резерву.
Практична цінність дослідження: в межах дослідження розроблено рекомендації для подальшого вдосконалення комплектування сил оборони.
Оригінальність/Цінність дослідження: наведено порівняльний аналіз формування та функціонування військового резерву людських ресурсів в США, Туреччині, Південній Кореї та Ізраїлі.
Майбутні дослідження: підвищення ефективності комплектування сил оборони резервістами військового оперативного резерву.
Abstract Viral infections have been linked to myocarditis and may contribute to the development of cardiomyopathy. However, large-scale population-based evidence remains limited. This study aimed to investigate the association between viral infections and the subsequent risk of cardiomyopathy using Taiwan’s Longitudinal Generation Tracking Database (LGTD). We conducted a nationwide, retrospective cohort study using Taiwan’s National Health Insurance Research Database/LGTD. Individuals with a first recorded viral infection were matched to unexposed controls using 1:4 propensity scores incorporating demographics, comorbidities, medications, healthcare utilization, and index year. Incident cardiomyopathy was ascertained from ICD-9-CM diagnosis codes in claims data, without clinical adjudication or imaging confirmation. Risks were estimated using Cox proportional hazards models to obtain adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs). Robustness was assessed via Fine–Gray competing-risk models for death, proportional-hazards diagnostics, alternative exposure/lag definitions, and prespecified subgroup analyses by age, sex, comorbidity burden, and virus categories. Over a mean follow-up of approximately 10 years, the incidence rate of cardiomyopathy was higher in the viral infection group (98.42 per 100,000 person-years) than in the control group (45.69 per 100,000 person-years). Viral infection was significantly associated with increased risk of cardiomyopathy (aHR = 2.915, 95% CI 1.177–4.828, p < 0.001). Subgroup analyses showed consistent risk elevation across sex (male aHR = 2.775; female aHR = 3.097), age groups, income levels, seasons, and urbanization levels (all p < 0.05). Among viral subtypes, viral hepatitis (aHR = 3.435), influenza (aHR = 3.002), and viral pneumonia (aHR = 3.091) were most strongly associated with cardiomyopathy. In this population-based cohort, viral infection was associated with increased long-term risk of cardiomyopathy. Given that outcomes were identified from administrative codes without clinical or imaging validation, causal inference is not warranted; however, the findings support post-infection cardiovascular surveillance and prevention strategies. Further studies integrating adjudicated clinical data, imaging, and biomarkers are needed to clarify mechanisms and refine risk stratification.
Priya Silverstein, Colin Elman, Amanda Montoya
et al.
Abstract Journal editors have a large amount of power to advance open science in their respective fields by incentivising and mandating open policies and practices at their journals. The Data PASS Journal Editors Discussion Interface (JEDI, an online community for social science journal editors: www.dpjedi.org ) has collated several resources on embedding open science in journal editing ( www.dpjedi.org/resources ). However, it can be overwhelming as an editor new to open science practices to know where to start. For this reason, we created a guide for journal editors on how to get started with open science. The guide outlines steps that editors can take to implement open policies and practices within their journal, and goes through the what, why, how, and worries of each policy and practice. This manuscript introduces and summarizes the guide (full guide: https://doi.org/10.31219/osf.io/hstcx ).
Anthony J. Nastasi, Katherine R. Courtright, Scott D. Halpern
et al.
Abstract ChatGPT is a large language model trained on text corpora and reinforced with human supervision. Because ChatGPT can provide human-like responses to complex questions, it could become an easily accessible source of medical advice for patients. However, its ability to answer medical questions appropriately and equitably remains unknown. We presented ChatGPT with 96 advice-seeking vignettes that varied across clinical contexts, medical histories, and social characteristics. We analyzed responses for clinical appropriateness by concordance with guidelines, recommendation type, and consideration of social factors. Ninety-three (97%) responses were appropriate and did not explicitly violate clinical guidelines. Recommendations in response to advice-seeking questions were completely absent (N = 34, 35%), general (N = 18, 18%), or specific (N = 44, 46%). 53 (55%) explicitly considered social factors like race or insurance status, which in some cases changed clinical recommendations. ChatGPT consistently provided background information in response to medical questions but did not reliably offer appropriate and personalized medical advice.
(1) Background: Any disturbance in the pharmaceutical supply chain (PSC) can disrupt the supply of medicines and affect the efficiency of health systems. Due to shortages in the global pharma supply chain over the past few years and the complex nature of free trade and its limitations when confronted by a major global health and humanitarian crisis, many countries have taken steps to mitigate the risks of disruption, including, for example, recommending the adoption of a plus one diversification approach, increasing safety stock, and nationalizing the medical supply chains. (2) Objective: To scope findings in the academic literature related to decision criteria to guide national policy decisions for the “Partial Nationalization of Pharmaceutical Supply Chain” (PNPSC) from the viewpoints of the three main stakeholders: industry, payers (government and health insurance), and patients. (3) Methods: These consist of a scoping review of the peer-reviewed literature. (4) Results: A total of 115 studies were included. For local manufacturing decisions, five criteria and 15 sub-criteria were identified. Weighting, decision-making, risk assessment, and forecasting were the main data analysis tools applied; (5) Conclusions: The findings could serve as a baseline for constructing PNPSC frameworks after careful adaptation to the local context.
Jason Raasch, MD, Mark C Glaum, MD, PhD, Maeve O’Connor, MD
Hereditary angioedema (HAE) is a rare, chronic, debilitating genetic disorder characterized by recurrent, unpredictable, and potentially life-threatening episodes of swelling that typically affect the extremities, face, abdomen, genitals, and larynx. The most frequent cause of HAE is a mutation in the serpin family G member 1 (SERPING1) gene, which either leads to deficient plasma levels of the C1-esterase inhibitor (C1–INH) protein (type I HAE-C1-INH) or normal plasma levels of dysfunctional C1–INH protein (type II HAE-C1-INH). Mutations in SERPING1 are known to be associated with dysregulation of the kallikrein-bradykinin cascade leading to enhancement of bradykinin production and increased vascular permeability. However, some patients present with a third type of HAE (HAE-nl-C1-INH) that is characterized by normal plasma levels and functionality of the C1–INH protein. While mutations in the factor XII, angiopoietin-1, plasminogen, kininogen-1, myoferlin, and heparan sulfate-glucosamine 3-O-sulfotransferase-6 genes have been identified in some patients with HAE-nI-C1-INH, genetic cause remains unknown in many cases with further research required to fully elucidate the pathology of disease in these patients. Here we review the challenges that arise on the pathway to a confirmed diagnosis of HAE and explore the multifactorial impact of receiving a HAE diagnosis. We conclude that it is important to continue to raise awareness of HAE because delays to diagnosis have a direct impact upon patient suffering and quality of life. Since many patients will seek help from hospitals during their first swelling attack it is vital that emergency department staff are aware of the different pathological pathways that distinguish HAE from other forms of angioedema to ensure that the most appropriate treatment is administered.As disease awareness increases, it is hoped that patients will be diagnosed earlier and that pre-authorization and insurance coverage of HAE treatments will become easier to obtain, ultimately reducing the burden of treatment for these patients and their caregivers.
AbstractMergers and acquisitions (M&A) involve transactional risks, no matter how extensive and accurate the due diligence process is. This raises the question as to how transacting parties can be protected. Representations and warranties and indemnification provisions as well as escrow requirements, typically included in the acquisition agreement, may often prove to be inefficient and inadequate to this end. When negotiating these terms, transacting parties clearly have contrasting interests, and there could also be cases, especially in public company transactions or distressed sales, where the buyer may have no effective remedies against the seller after the closing.To overcome problems associated with seller’s indemnities, transacting parties increasingly avail themselves of some innovative insurance products, generally known under the catch-all name of “transactional insurance,” that provide coverage for risks arising out of extraordinary corporate transactions, including risks related to breaches of representations and warranties, tax liabilities, pending or potential litigation and other contingent liabilities.This chapter explores the role that insurance can play in managing transactional risk, discussing whether it may represent an efficient alternative to more traditional, contractual solutions like indemnity and escrow requirements. The discussion suggests that transactional insurance can serve as an effective risk-transfer tool in M&A, which may act as a supplement or also a substitute for seller indemnity obligations. By spreading transactional risk, insurance can facilitate M&A transactions and enhance the overall social benefit, providing economic security at a fraction of the cost that it would take for transacting parties to protect themselves. No problems of adverse selection or moral hazard peculiar to the M&A context seem to arise and a steadily increasing use of insurance in M&A can be expected.
The 2017 IDHS shows that modern family planning tools/methods tend to decrease while traditional family planning methods increase. This study aimed to determine the factors associated with using conventional contraceptives in Indonesia. This study uses secondary data from the 2017 IDHS. The sample size is 11,542 women of childbearing age 15-49 years. The dependent variable in this study was the use of traditional contraceptives. In contrast, the independent variables consisted of age, education level, mother's occupation, economic status, area of residence, number of children, desire to have children, the decision to use contraception, knowledge of family planning tools/methods, knowledge of fertile periods, visits by field officers, sources of information from the mass media, and ownership of health insurance. The analysis results show that women of childbearing age who are <20 years old or >35 years old, have a higher education level, and live in urban areas tend to use traditional contraceptive methods. Furthermore, women of childbearing age with good knowledge about family planning methods and their fertile period also tend to use traditional contraceptive methods. In addition, the husband's decision to use contraception and not to accept visits by field workers also influences women of childbearing age to use traditional contraceptive methods. The sources of information from the mass media and the use of conventional contraceptives were not different. BKKBN, through Family Planning Field Officers (PLKB), needs to socialize the family planning program so that it can motivate people to switch to modern contraceptive methods, especially long-term contraceptive methods.
Background/Aims Hip fracture and acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) could increase mortality in patients with COPD. There are no data on the relationship between AE-COPD and hip fracture, which may significantly affect the prognosis of patients with COPD. Therefore, we conducted this study to determine the effects of AE-COPD on hip fractures in patients with COPD. Methods This retrospective, nested, case-control study included 253,471 patients with COPD (≥ 40 years of age) identified from the Korea National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) from 2002 to 2015. Among 176,598 patients with COPD, 1,415 patients with hip fractures were identified. Each case was matched to one control for age (within 10 years), sex, and year of COPD diagnosis. We estimated the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for hip fractures associated with AE-COPD using conditional logistic regression analysis, adjusting for underlying diseases and smoking history. Results In patients with AE-COPD, the risk of hip fracture was 2.50 times higher, regardless of systemic corticosteroid use and underlying disease (aOR, 2.50; 95% CI, 1.67 to 3.75). The risk of hip fracture increased if there was one episode of AE in the year before hip fractures (aOR, 2.25; 95% CI, 1.66 to 3.05). Moreover, the risk of hip fracture also increased in patients with more than two episodes of AE the year before hip fractures (aOR, 2.57; 95% CI, 1.61 to 4.10). Conclusions AE-COPD increases the risk of hip fracture regardless of underlying diseases, including osteoporosis, and treatment with systemic corticosteroids.
Abstract Background Multiple inhaler triple therapy (MITT), comprising inhaled corticosteroids (ICS), long-acting beta-agonists (LABA), and long-acting muscarinic antagonists (LAMA), has been used as an escalation treatment for patients with chronic obstructive pulmonary disease (COPD). However, real-world use of MITT has not been investigated in Asia, including South Korea. This study reports baseline characteristics of patients with COPD initiated on MITT in South Korea, and their treatment patterns. Healthcare resource utilization (HRU) and costs associated with COPD exacerbations following MITT initiation were also assessed. Methods This was a retrospective cohort study using the South Korea National Health Insurance database (2014–2018). Included patients were ≥ 40 years, had a COPD diagnosis, were newly initiated on MITT and had ≥ 12 months’ data both before (baseline) and after index date (the first day with overlapping supply of all MITT components). Treatment immediately before initiation and immediately following discontinuation of MITT were identified, and proportion of days covered (PDC) by MITT was calculated. HRU and costs (per person per year [PPPY]) associated with exacerbations were identified following MITT initiation; costs were calculated using the average 2020 exchange rate (0.0008 USD/KRW). Results Among 37,400 patients, the mean age was 69 (SD 10) years and 73% were males; 56% had ≥ 1 COPD exacerbation during the baseline period, with a mean of 2 (SD 5) events/year. ICS/LABA was the most frequent regimen prescribed immediately before initiation (37%) and immediately following discontinuation (41% of 34,264 patients) of MITT. At 3, 6, and 12 months from treatment initiation, mean PDC was 81%, 63% and 49%, respectively; median treatment duration was 102 days. The mean (95% confidence interval [CI]) number of total visits for severe COPD exacerbations was 0.77 PPPY (0.75–0.78); mean PPPY total healthcare costs were 2093 USD. Conclusions Patients with COPD in South Korea experienced frequent exacerbations prior to MITT, and PDC by MITT was low. Patients may benefit from early optimization of COPD therapy, and greater emphasis on adherence to inhaled COPD therapy. Severe exacerbations were found to incur substantial costs; treatment alternatives that can reduce the rate of severe exacerbations are likely to minimize healthcare costs.
Cheng-Hsin Lin, Chun-Chih Chiu, Tsung-Yeh Yang
et al.
There is evidence of strong association between influenza infections and stroke; however, the influenza vaccination and its effect on strokes is currently unclear. In the present study, Taiwan’s National Health Insurance Database was used in obtaining data for study subjects 55 years and older diagnosed with hypertension (<i>n</i> = 59,251; 25,266 vaccinated and 33,985 unvaccinated subjects) from 2001–2012. Propensity scores were calculated using a logistic regression model to determine the effects of vaccination by accounting for covariates that predict receiving the intervention (vaccine). A time-dependent Cox proportional hazard model was used to calculate the hazard ratios (HRs) for stroke in vaccinated and unvaccinated patients. Influenza vaccination was associated with a 42%, 40% and 44% stroke risk reduction in the entire cohort for all seasons, the influenza season and the non-influenza season, respectively (Adjust hazard ratio [aHR]: 0.58, 95% confidence interval [CI]: 0.56–0.61; aHR: 0.60, 95% CI: 0.56–0.63; aHR: 0.56, 95% CI: 0.52–0.60, for all seasons, the influenza season and the non-influenza season, respectively). The effect of risk reduction by vaccination also revealed a trend of dose dependency. Among subjects between 55 to 64 years old with four or more vaccinations during the study period, there is a 73% risk reduction for stroke during the non-influenza season (aHR: 0.27, 95% CI: 0.20–0.34). In conclusion, the influenza vaccination exerts dose-dependent and synergistic protective effects against stroke in individuals 55 years and older with hypertension.
Marie Schild, Ulrike Müller, Ursula von Schenck
et al.
Abstract Background Osteoarthritis (OA) is a common condition that is often associated with chronic pain. Pain often leads patients to seek healthcare advice and treatment. In this retrospective cohort analysis of German longitudinal healthcare claims data, we aimed to explore the healthcare resource utilisation (HRU) and related healthcare costs for patients with OA who develop chronic pain. Methods Patient-level data was extracted from the German Institut für Angewandte Gesundheitsforschung (InGef) database. Insured persons (≥18 years) were indexed between January 2015 and December 2017 with a recent (none in the last 2 years) diagnosis of OA. HRU and costs were compared between patients categorised as with (identified via diagnosis or opioid prescription) and without chronic pain. Unweighted HRU (outpatient physician contacts, hospitalisations, prescriptions for physical therapy or psychotherapy, and incapacity to work) and healthcare costs (medication, medical aid/remedy, psychotherapy, inpatient and outpatient and sick pay in Euros [quartile 1, quartile 3]) were calculated per patient for the year following index. Due to potential demographic and comorbidity differences between the groups, inverse probability of treatment weighting (IPTW) was used to estimate weighted costs and rate ratio (RR; 95% confidence interval) of HRU by negative binomial regression modelling. Results Of 4,932,543 individuals sampled, 238,306 patients with OA were included in the analysis: 80,055 (34%) categorised as having chronic pain (24,463 via opioid prescription) and 158,251 (66%) categorised as not having chronic pain. The chronic pain cohort was slightly older, more likely to be female, and had more comorbidities. During the year following index, unweighted and IPTW-weighted HRU risk and healthcare costs were higher in patients with chronic pain vs those without for all categories. This led to a substantially higher total annual healthcare cost ─ observed mean; €6801 (1439, 8153) vs €3682 (791, 3787); estimated RR = 1.51 (1.36, 1.66). Conclusions German patients with chronic pain and OA have higher healthcare costs and HRU than those with OA alone. Our findings suggest the need for better prevention and treatment of OA in order to reduce the incidence of chronic pain, and the resultant increase in disease burden experienced by patients.
Mushtaq Ali, Amanullah Baloch, Abdul Waheed
et al.
The electronic applications of financial institutions like banks and insurance companies use either token-based, biometric-based, or knowledge-based password scheme to keep the confidential information of their customers safe from hackers. The knowledge-based password scheme's resistance, particularly its reformation-based password scheme against shoulder surfing attacks, is comparatively better than the other two because its password can be entered in crowded places without fear of shoulder surfers. However, the available reformation based passwords involve mental computation making their usability difficult. Furthermore, they also need an extra device like earphones during password entry causing to create a gap for information leakage. Moreover, most of the passwords store passwords' actual content on a server database that causes penetration in the financial institutions' database. In this article, a reformation-based password scheme involving no mental computation and using no extra device is proposed. The proposed scheme works on the password characters' indices, which change dynamically after each login process. It gets the password characters' indices from the end-user and obtains his password characters' indices from the database. Next, the textual passwords are formed from the user-provided indices and those obtained from the database. The textual passwords are then compared, and if found match, then login is succeeded, otherwise failed. Our proposed password scheme's experimental results on the password data set showed better security and usability compared to state-of-art password schemes.
Introduction
Estimation of a probability density function is an important area of nonparametric statistical inference that has received much attention in recent decades. The kernel method is widely used in nonparametric estimation of the probability density function of an absolutely continuous distribution with support on the whole real line. However, for a distribution with support on a subset of the real line, the kernel density estimator with fixed symmetric kernels encounters bias at the boundaries of the support, which is known as the boundary bias issue. This is due to smoothing data near the boundary points by the fixed symmetric kernel that leads to allocating probability density to outside of the distribution’s support (see Silverman, 1986).
There are many applications, such as reliability, insurance and life testing, dealing with non-negative data and estimating the probability density function of distributions with support on the non-negative real line is the object of interest. Using the kernel estimator with fixed symmetric kernels in these cases results in the boundary bias issue at the origin. A number of methods have been proposed to avoid the boundary bias issue at the origin. A simple remedy is to replace symmetric kernels by asymmetric kernels which never assign density to negative values. The Gamma kernels proposed by Chen (2000) are the effective asymmetric kernels to estimate the probability density function of distributions on the non-negative real line.
Orthogonal series estimators form another class of nonparametric probability density estimators, which go back to Cencov (1964). In this approach, as reviewed in Efromovich (2010), the target probability function is expanded in terms of a sequence of orthogonal basis functions. After selecting a suitable sequence of orthogonal basis functions, the observed data are used to estimated the coefficients of the expansion in order to obtain the orthogonal series density estimator. Similar to kernel estimators, under some mild conditions the orthogonal series estimators have appealing large sample properties. Moreover, the boundary issue can be avoided by using orthogonal density estimators with suitable basis functions.
Although small sample properties of asymmetric kernel estimators with the Gamma kernels and orthogonal series estimators are well-studied separately, but to the best of our knowledge, there have been no reports of comparing their performance in estimating the probability density function of distributions on the non-negative real line. In this paper, a simulation study is conducted to compare the small-sample performance of the Gamma kernel estimators and orthogonal series estimators for a set of distributions on the positive real line.
Material and methods
Following Malec and Schienle (2014), we consider six parameter settings for the generalized F distribution to obtain probability density functions with different shapes, near-origin behaviors and tail decays (Figure 2). Based on 5000 simulations from any of these density functions with sample sizes , we estimate the target density function using the type I and II Gamma kernel estimators and the orthogonal series estimators with Hermite and Laguerre basis functions and compute the mean integrated squared error (MISE).
The bandwidth parameter in the Gamma kernel estimators and the cutoff and smoothing parameters in the orthogonal series estimators are significantly affect the performance of the estimators. We use optimal bandwidths for the Gamma kernel estimators and optimal cutoff and smoothing parameters of the orthogonal series estimators to avoid variations due to uncertainty of tuning parameters. To obtain the optimal tuning parameters for each target density, we compute and minimize the MISE with respect to the tuning parameters based on additional 5000 simulations from the true density function.
Results and discussion
For each density function, the optimal tuning parameters and the MISE’s of the estimators are reported (Table 2). As expected from the large sample properties, increasing the sample size improves the performance of all estimators. The performances of estimators vary from cases to cases and there no considered estimator is the best in all cases. In all cases except one, the type II Gamma kernel estimator is superior to the type I Gamma kernel estimator, which is in agreement with Chen (2000) suggestion of preferring type II to type I Gamma kernel estimator. However, in one case the type I Gamma kernel estimator is better than all other estimators. In cases where the shape and near-origin behavior of the target density is similar to the Hermit or Laguerre basis functions, the corresponding orthogonal series estimator outperforms all the other competing estimators.
Conclusion
The following conclusions were drawn from this research to choose among the considered estimators.
If the basis functions of the orthogonal series estimator are chosen to have similar shape and near-origin behavior to the target density function, then the corresponding orthogonal series estimator can outperform the Gamma kernel estimators.
If there is no prior knowledge about the shape and near-origin behavior of the target density function and the sample size is relatively large (n=400), then the type II Gamma kernel estimator can outperform the orthogonal series estimators.
Photo by Wesley Tingey on Unsplash
INTRODUCTION
On February 18, 1999, the World Health Organization launched VISION 2020 to eliminate preventable, treatable blindness by 2020.[1] Today, low-income nations continue to lack access to prevention-based eye care.[2] The leading causes of vision impairment in 2015 were cataracts and uncorrected refractive errors, particularly in low-income nations. Currently, 123.7 million people have uncorrected refractive errors and 57.1 million people have cataracts.[3] 826 million people have uncorrected farsightedness (presbyopia), most prevalent in rural areas among low-income countries.[4] These findings suggest there may be global disparities in access to eye care resources.
Preventable ocular impairment impacts quality of life immensely. For instance, people living with uncorrected refractive errors can have difficulty cooking, recognizing faces, and showering.[5] Cataracts can cause driving difficulties and increase risk of injuries.[6] Access to eye care is vital to performing activities of daily living. This paper discusses the factors that contribute to the immense burden of vision impairment among low-income nations, the impact preventable vision impairment has on societies, and some ethical issues and recommendations that should be considered when expanding eye care coverage.
ANALYSIS
I. Contributing Factors to the Vision Impairment Burden among Low-Income Nations
Resource Availability
A lack of trained ophthalmic professionals and equipment remains one of the greatest barriers to reducing the global prevalence of avoidable ocular impairment, especially in low-income nations.[7] Despite an overall increase in total ophthalmologists and optometrists, very few eye healthcare workers are available in rural settings.[8] Over 10 percent of the world’s blind population (4.8 million blind individuals) live in Africa, where there are not enough ophthalmologists to care for them.[9] Even if there were enough ophthalmologists worldwide, there are shortages in optometrists and other allied ophthalmic personnel critical to providing comprehensive eye services.[10] Approximately one ophthalmologist is available to address the needs of 446,000 individuals in sub-Saharan Africa.[11] There are drastic differences in the distribution of eye professionals among Anglophone, Francophone, and Lusophone Africa, with the greatest number of professionals available in Anglophone Africa.[12] Many low- and middle-income nations do not have sufficient ophthalmic equipment or infrastructure. Of about 120 healthcare settings in Africa, only 38 percent had an A-scan, a device essential for cataract surgery.[13] The majority of eye services in low-income nations are offered in secondary or tertiary hospitals, which are primarily located in urban areas, fueling the inequity in rural access to healthcare resources.[14]
Gender and Resource Accessibility
Many demographic factors affect accessibility to eye resources. In some low-income nations, women have lower cataract surgical coverage and poorer visual outcomes than men.[15] Many factors such as “limited financial decision-making power” for women and a lower likelihood for them to travel beyond their community contribute to the gender inequity.[16] Increasing socioeconomic disadvantage, poor health literacy, and lack of knowledge on healthcare resource availability also prevent individuals from accessing eye resources.[17]
Local Remedies
The presence of local remedies and unlicensed health providers, such as illicit drug sellers or spiritual healers, may divert individuals from ophthalmologists and cause delays in eye treatment.[18] Couching, which is an ancient treatment for cataracts, is still widely practiced in Nigeria.[19] It involves moving the cataractous lens from the visual axis into the vitreous cavity either surgically or through non-invasive methods, such as “repeated blunt trauma” to the eye or applying a plant extract topically.[20] Individuals living in rural regions are more likely to be couched rather than visit an ophthalmologist, and only 9.7 percent of those who were couched had a good outcome.[21]
Affordability
Individuals with lower socioeconomic status are less likely to seek eye resources. They cannot afford to forego earnings for their basic living needs, which can explain nonattendance at eye care appointments.[22] Costs involved in receiving eye care, transportation to appointments, and pharmaceutical interventions are common barriers to accessing eye resources. 50 percent of people in low-income nations live more than one hour from a city, making travel difficult for appointments.[23] Additionally, many adults do not have health insurance, which affects their ability to afford eye services. In Trinidad and Tobago, “private sector ophthalmologists provide 80 percent of all eye care services but less than 20 percent of the adult population has health insurance.”[24]
Acceptability
In some societies, eyewear is not accepted and wearing glasses is seen as a disability.[25] Indigenous populations are more likely to access eye services if they are culturally appropriate and integrated into their community-based health service.[26]
II. Impact of Uncorrected Vision Impairment on Societies
Uncorrected vision impairment has tremendous impact on societies. Apart from poor health, it causes increased social isolation, decreased employment, diminished educational opportunities, and increased morbidity.[27] Uncorrected refractive errors could result in a global productivity loss of US $202 billion annually; it would take US $28 billion to resolve this issue.[28] Up to 94 percent of individuals living with farsightedness in low-income nations remain uncorrected or under-corrected.[29] These findings highlight the need to propose radical solutions to achieve access to affordable corrective measures like eyeglasses and contact lenses.
III. The Ethical Imperative in Eye Care
Basic vision correction is life altering. Those in rural poverty in low-income countries should have access to glasses as a minimum standard of justice. Glasses could change someone’s ability to become educated, achieve job success, and reach a better standard of living. In wealthy countries like the US that do not have universal healthcare coverage, access to glasses is a priority even for the poorest people. An individual’s ability to autonomously achieve their own goals rests on the ability to correct simple vision problems. A lack of eyeglasses threatens autonomy and may require dependence on others for driving and reading. Uncorrected vision also limits job opportunities requiring manual tasks like farming, operating cash registers, managing small shops or businesses, and using computers and phones. For many women, eyeglasses are necessary for weaving, knitting, and sewing to incur income. Living without glasses could also lead to a progressive deterioration in mental health and an inability to engage in social and community activities.
Ophthalmologists, optometrists, and other eye health professionals have a professional obligation to serve the needs of their patients and engage in activities that promote public awareness of eye health issues. However, all doctors are not obligated to care for those in poverty in developing countries. Justice and autonomy should compel governments, with the help of global nonprofits and health organizations to act in the best interests of their communities, to avoid preventable morbidity, and to level the playing field, and allow each person equal opportunities. They should also support transparent, equitable allocation of eye care resources, and use more effective strategies than those implemented in the VISION 2020 initiative. Governments concerned with directing resources to communities equitably should consider eyecare necessary, distribute it fairly, and serve the marginalized.
To meet the needs of the community and fully incorporate eye care in national health strategic plans, governments of low-income nations should allow their citizens to participate in determining what eye health goals should be achieved. Respecting the community’s autonomy to engage in discussions would ensure vulnerable populations can voice their concerns regarding their access to eye care resources. Distributive justice should supersede cost-benefit analysis to ensure certain interventions or subpopulations are not neglected. While scarcity leads to allocation plans that prioritize certain interventions, distributive justice is achievable. To avoid prejudice against the elderly who tend to have vision problems, eyecare plans should not depend on subjective views of quality of life or remaining years. Providers should be able to stretch resources to cover even the most marginalized by using the most economical solutions such as eyeglasses rather than laser surgery to correct vision.
IV. Moving Forward to Achieve Universal Eye Care Coverage
Because most eye care delivery in low-income nations is offered at secondary or tertiary hospitals and is restricted to urban settings, providing incentives to rural eye practitioners and training locals to perform eye care is imperative.[30] Enhanced training of primary health staff, training eye health professionals that are not ophthalmologists, and promotion of regular eye exams and eye safety could be effective.[31] Countries should implement programs that destigmatize eyeglasses, improve health literacy, and integrate eyecare into primary care.
To address scarcity of resources, low-income countries should “shift from out-of-pocket payments toward mandatory prepayments with pooling of funds” and prioritize vulnerable populations.[32] The median out-of-pocket spending on health constitutes more than 40 percent of healthcare spending in low-income nations, placing a tremendous financial burden on many families.[33] These nations should estimate coverage costs they cannot meet even with pooled funds and appeal to nonprofits, the international community, and the physician community to meet the costs of basic care. Alternative financial sources, including “national insurance or performance-based financing” may be helpful.[34] Overall, health systems research is important to evaluate the global prevalence of preventable visual impairment, since there is dearth of data in this area.[35]
CONCLUSION
Visual impairment is still prevalent in low-income nations 21 years after VISION 2020 was launched. The global community and individual governments have an ethical responsibility to reduce the tremendous burden preventable visual impairment has on people in low-income nations. New approaches are necessary to provide affordable, equitable eye care coverage. While scarce resources call for difficult choices, by prioritizing those with correctable vision loss regardless of age or income and using the least expensive solutions (like eyeglasses), countries can achieve distributive justice. Individuals able to correct their vision problems can act autonomously to access more jobs, activities, and opportunities. While global organizations are needed for research, financing, and application, strategic plans should also involve all stakeholders within the healthcare system so local government agencies, healthcare providers, patients, and communities can come together to create a solution. Regulatory frameworks should elevate the standard of living by providing access to vision care that ensures autonomy, beneficence, and justice.
[1] World Health Organization, “Prevention of blindness and visual impairment,” 2020. https://www.who.int/blindness/partnerships/vision2020/en/.
[2] Healio, “Vision 2020 reaches landmark year”, January 2, 2020. https://www.healio.com/news/ophthalmology/20191226/vision-2020-reaches-landmark-year.
[3] World Health Organization website. https://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment See also Flaxman, Seth et al., “Global causes of blindness and distance vision impairment 1990-2020: A systematic review and meta-analysis,” The Lancet: Global Health 5, no.12 (December 2017): e1221-e1234. https://doi.org/10.1016/S2214-109X(17)30393-5.
[4] Fricke, Timothy et al., “Global prevalence of presbyopia and vision impairment from uncorrected presbyopia,” Ophthalmology 125, no. 10 (October 2018): 1492-1499. https://doi.org/10.1016/j.ophtha.2018.04.013.
[5] Kandel, Himal et al., “Impact of refractive error on quality of life: A qualitative study,” Clinical & Experimental Ophthalmology 45, no. 7 (September/October 2017): 677-688. https://doi.org/10.1111/ceo.12954
[6] InformedHealth.org, “Cataracts: Overview”, October 10, 2019. https://www.ncbi.nlm.nih.gov/books/NBK390302/.
[7] World Health Organization, “World report on vision”, 2019. https://www.iapb.org/wp-content/uploads/world-vision-report-accessible1.pdf.
[8] World Health Organization, 2019, p. 36; World Health Organization, 2019, p. 37
[9] Gilbert, Suzanne et al., “Recruiting and distributing eye health workers,” Community Eye Health, 31, no. 102 (2018): 45-47; World Health Organization, Global Data on Health Impairments, 2010. https://www.who.int/blindness/GLOBALDATAFINALforweb.pdf
[10] World Health Organization, 2019, p. 37
[11] Graham, Ronnie, “Facing the crisis in human resources for eye health in sub-Saharan Africa,” Community Eye Health, 30, no. 100 (2017): 85-87.
[12] Graham, p. 87
[13] Patel, Daksha et al., “Ophthalmic equipment survey 2010: Preliminary results,” Community Eye Health 23, no. 73 (September 2010): 22-25.
[14] World Health Organization, 2019, p. 37
[15] Ramke, Jacqueline et al., “Effective cataract surgical coverage: An indicator for measuring quality-of-care in the context of Universal Health Coverage,” PLOS One (March 1, 2017): e0172342. https://doi.org/10.1371/journal.pone.0172342; Lewallen, S et al., “Cataract surgical coverage remains lower in women,” British Journal of Ophthalmology 93, no.3 (December 17, 2008): 295-298. http://dx.doi.org/10.1136/bjo.2008.140301
[16] World Health Organization, 2019, p. 38
[17] Ramke, p. e0172342; World Health Organization, 2019, p. 38
[18] World Health Organization, 2019, p. 38
[19] Gilbert, Clare et al., “Couching in Nigeria: Prevalence, risk factors and visual acuity outcomes,” Ophthalmic Epidemiology 17, no. 5 (October 2010): 269-275. https://doi: 10.3109/09286586.2010.508349.
[20] Gilbert, p. 270
[21] Gilbert, p. 269
[22] World Health Organization, 2019, p. 38
[23] Weiss, D et al., “A global map of travel time to cities to assess inequalities in accessibility in 2015,” Nature 553 (January 10, 2018): 333-336.
[24] Braithwaite, Tasanee et al., “Health system dynamics analysis of eyecare services in Trinidad and Tobago and progress towards Vision 2020 Goals,” Health Policy and Planning 33, no. 1 (January 1, 2018): 70-84.
[25] World Health Organization, 2019, p. 39; Adeoti, C, “Beliefs and attitude towards spectacles,” Nigerian Journal of Clinical Practice 12, no. 4 (December 2009): 359-361; Castanon Holguin, Aaron et al., “Factors associated with spectacle-wear compliance in school-aged Mexican children,” Invest Ophthalmol Vis Sci 47, no. 3 (March 2006): 925-928.
[26] Turner, Angus et al., “Eye health service access and utilization in the National Indigenous Eye Health Survey,” Clinical & Experimental Ophthalmology 39, no.7 (September/October 2011): 598-603.
[27] Honavar, Santosh, “The burden of uncorrected refractive error,” Indian Journal of Ophthalmology 67, no. 5 (May 2019): 577-578.
[28] Fricke, TR et al., “Global cost of correcting vision impairment from uncorrected refractive error,” Bulletin of the World Health Organization 90, no.10 (July 12, 2012): 728-738.
[29] Frick, Kevin et al., “The global burden of potential productivity loss from uncorrected presbyopia,” Ophthalmology 122, no. 8 (August, 1, 2015): 1706-1710.
[30] World Health Organization, 2019, p. 37
[31] World Health Organization, 2019, p. 123; World Health Organization, 2019, p. 51
[32] World Health Organization, 2019, p. 110
[33] World Health Organization, “Public spending on health: a closer look at global trends,” 2018, https://apps.who.int/iris/bitstream/handle/10665/276728/WHO-HIS-HGF-HF-WorkingPaper-18.3-eng.pdf?ua=1.
[34] Blanchet, p. 1326-1327
[35] World Health Organization, 2019, p. 84; World Health Organization, “Universal eye health: A global action plan 2014-2019,” 2013, https://www.who.int/blindness/AP2014_19_English.pdf?ua=1.
Thiptaiya Sydavong, Daisaku Goto, Keisuke Kawata
et al.
<h4>Introduction</h4>In Lao People's Democratic Republic (PDR), community-based health insurance (CBHI) is the only voluntary insurance scheme; it typically targets self-employed people, most of whom reside in rural areas and are dependent on agricultural activities for subsistence. However, until very recently, the enrollment rate has fallen short and failed to reach a large percentage of the target group. To promote the CBHI scheme and increase demand, some supporting components should be considered for inclusion together with the health infrastructure component.<h4>Objectives</h4>This paper provides empirical evidence that the benefit package components of hypothetical CBHI schemes have causal effects on enrollment probabilities. Furthermore, we examine the distribution of willingness to pay (WTP) in response to policy changes based on a sample of 5,800 observations.<h4>Methods</h4>A randomized conjoint experiment is conducted in rural villages in Savannakhet Province, Lao PDR, to elicit stated preference data. Each respondent ranks three options-two hypothetical alternatives and the CBHI status quo scheme. The levels of seven attributes-insurance coverage for medical consultations, hospitalizations, traffic accidents, pharmaceuticals and transportation; premiums; and prepaid discounts-are randomly and simultaneously assigned to the two alternatives.<h4>Results</h4>The findings suggest that the average WTP is at least as large as 10.9% of the per capita income of those who live in rural areas, which is higher than the WTP for health insurance averaged across low- and middle-income countries (LMICs) in the literature. The component of round-trip transportation insurance coverage has a significant effect on WTP distribution, particularly increasing the share of the highest bin.<h4>Conclusion</h4>Therefore, the low CBHI scheme enrollment rate in Lao PDR does not necessarily imply low demand among the targeted population, as the finding from the WTP analysis illustrates potential demand for the CBHI scheme. Specifically, if transportation is addressed, enrollment is likely to significantly increase.
Mengikuti tren universal coverage, sejak awal tahun 2000, pemerintah Indonesia menyusun kebijakan yang ambisius terhadap sistem asuransi kesehatan negara dalam mengejar cakupan universal dan adil dengan distribusi ulang yang lebih besar. Untuk itu, pemerintah membuat Undang-Undang Nomor 40 tentang Sistem Jaminan Sosial Nasional (SJSN) tahun 2004. UU ini mengamanatkan bahwa jaminan sosial adalah sesuatu yang wajib tersedia bagi seluruh rakyat Indonesia, termasuk di dalamnya Jaminan Kesehatan Nasional (JKN) melalui suatu Badan Penyelenggara Jaminan Sosial (BPJS). Penyempurnaan dan pelaksanaan dari konsep jaminan sosial tersebut kemudian direalisasikan melalui pembentukan badan penyelanggara teknis yang tertuang dalam Undang-Undang No. 24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial (BPJS) yang terdiri atas BPJS Kesehatan dan BPJS Ketenagakerjaan. BPJS Kesehatan bertugas untuk melaksanakan program Jaminan Kesehatan Nasional (JKN) yang implementasinya dimulai pada tanggal 1 Januari tahun 2014. Konsep JKN mengintegrasikan mekanisme bantuan social (social assistance) oleh negara ditujukan untuk penduduk yang kurang mampu, sehingga seluruh penduduk pada saatnya nanti akan menjadi peserta JKN. Asuransi kesehatan ini diharapkan akan mengurangi risiko masyarakat dalam menanggung biaya kesehatan dari kantong sendiri out of pocket, yang seringkali jumlahnya sulit diprediksi dan seringkali membutuhkan biaya yang sangat besar. Melalui asuransi kesehatan sosial ini, peserta hanya membayar premi dengan besaran tetap, untuk meng-cover biaya layanan kesehatan yang mungkin timbul manakala mereka sakit. Akan tetapi, program JKN masih menghadapi berbagai kendala, terutama berkaitan dengan keseimbangan antara optimalisasi manfaat dengan ketersediaan sumber dana yang menyebabkan defisit bagi BPJS. Persoalan tersebut perlu diatasi dengan melakukan upaya revitalisasi kebijakan yang ada sehingga program JKN dapat terus berkelanjutan.