Imperial College London

Dr Thomas Hone

Faculty of MedicineSchool of Public Health

Research Fellow
 
 
 
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Contact

 

thomas.hone12

 
 
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Location

 

Reynolds BuildingCharing Cross Campus

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Summary

 

Publications

Publication Type
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23 results found

Hone T, Szklo AS, Filippidis F, Laverty A, Sattamini I, Been J, Vianna C, de Souza MC, de Almeida LM, Millett Cet al., 2019, Smoke-free legislation and neonatal and infant mortality in Brazil: a longitudinal quasi-experimental study, Tobacco Control, ISSN: 0964-4563

Objective To examine the associations of partial and comprehensive smoke-free legislation with neonatal and infant mortality in Brazil using a quasi-experimental study design.Design Monthly longitudinal (panel) ecological study from January 2000 to December 2016.Setting All Brazilian municipalities (n=5565).Participants Infant populations.Intervention Smoke-free legislation in effect in each municipality and month. Legislation was encoded as basic (allowing smoking areas), partial (segregated smoking rooms) or comprehensive (no smoking in public buildings). Associations were quantified by immediate step and longer term slope/trend changes in outcomes.Statistical analyses Municipal-level linear fixed-effects regression models.Main outcomes measures Infant and neonatal mortality.Results Implementation of partial smoke-free legislation was associated with a −3.3 % (95% CI −6.2% to −0.4%) step reduction in the municipal infant mortality rate, but no step change in neonatal mortality. Comprehensive smoke-free legislation implementation was associated with −5.2 % (95% CI −8.3% to −2.1%) and −3.4 % (95% CI −6.7% to −0.1%) step reductions in infant and neonatal mortality, respectively, and a −0.36 (95% CI −0.66 to−0.06) annual decline in the infant mortality rate. We estimated that had all smoke-free legislation introduced since 2004 been comprehensive, an additional 10 091 infant deaths (95% CI 1196 to 21 761) could have been averted.Conclusions Strengthening smoke-free legislation in Brazil is associated with improvements in infant health outcomes—particularly under comprehensive legislation. Governments should accelerate implementation of comprehensive smoke-free legislation to protect infant health and achieve the United Nation’s Sustainable Development Goal three.

Journal article

Castro M, Massuda A, Menezes-Filho N, Andrade MV, de Souza Noronha K, Rocha R, Macinko J, Hone T, Tasca R, Giovanella L, Malik AM, Werneck H, Fachini L, Atun Ret al., Brazil's unified health system: the first 30 years and prospects for the future, Lancet, ISSN: 0140-6736

In 1988, Brazilian Constitution definedhealth as a universal right and stateresponsibility. Progress towards universal health coverage (UHC) has been achievedthrough a Unified Health System (Sistema Único de Saúde, SUS)which was created in 1990. Withsuccesses and setbacksin the implementation of health programmes and organization of its health system, Brazil has achieved nearly-universal access to health servicesfor her citizens. Thetrajectory of the development and expansion of the SUS offers valuable lessons on how to scale UHC in a health system in a highly-unequal country and relatively low resources. Theanalysis of the 30 years since the inception of SUS shows that innovations in the Brazilian health system extendbeyond the development of new models of care and highlightsthe importance of establishing political, legal, organizational and management-related structures, and the role of the federal and local governmentsin the governance, planning, financing, and provision of health services. Theexpansion of SUS has allowed Brazilto rapidly address the changing health needs, withdramatic scaling up health service coverage in justthree decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographic inequalities, insufficient funding, and the suboptimal private-public collaboration. Recent fiscal policies that ushered austerity measures, environmental, educational and health policies of the new administraion introduced in Brazilcould reverse the hard-earned achievements of the SUS and threaten itssustainability and its ability to fulfilits constitutional mandate of providing‘health for all’.

Journal article

Rasella D, Hone T, de Souza LE, Tasca R, Basu S, Millett Cet al., 2019, Mortality associated with alternative primary health care policies: a nationwide microsimulation modelling study in Brazil, BMC Medicine, Vol: 17, ISSN: 1741-7015

BackgroundBrazil’s Estratégia Saúde da Família (ESF) is one of the largest and most robustly evaluated primary healthcare programmes of the world, but it could be affected by fiscal austerity measures and by the possible end of the Mais Médicos programme (MMP)—a major intervention to increase primary care doctors in underserved areas. We forecast the impact of alternative scenarios of ESF coverage changes on under-70 mortality from ambulatory care-sensitive conditions (ACSCs) until 2030, the date for achievement of the Sustainable Development Goals (SDGs).MethodA synthetic cohort of 5507 Brazilian municipalities was created for the period 2017–2030. A municipal-level microsimulation model was developed and validated using longitudinal data and estimates from a previous retrospective study evaluating the effects of municipal ESF coverage on mortality rates. Reductions in ESF coverage, and its effects on ACSC mortality, were forecast based on two probable austerity scenarios, compared with the maintenance of the current coverage or the expansion to 100%. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, healthcare-related variables, and programme duration effects.ResultsUnder austerity scenarios of decreasing ESF coverage with and without the MMP termination, mean ACSC mortality rates would be 8.60% (95% CI 7.03–10.21%; 48,546 excess premature/under-70 deaths along 2017–2030) and 5.80% (95% CI 4.23–7.35%; 27,685 excess premature deaths) higher respectively in 2030 compared to maintaining the current ESF coverage.Comparing decreasing ESF coverage and MMP termination with achieving 100% ESF coverage (Universal Health Coverage scenario) in 2030, mortality rates would be 11.12% higher (95% CI 9.47–12.76%; 83,937 premature deaths). Reductions in ESF coverage would have stronger effects on mortality from infectious diseases and

Journal article

Patterson R, Webb E, Hone T, Millett C, Laverty AAet al., 2019, Associations of public transport use with cardio-metabolic health: a systematic review and meta-analysis, American Journal of Epidemiology, ISSN: 1476-6256

Public transport provides an opportunity to incorporate physical activity into journeys, but potential health impacts have not been systematically examined. Literature searches were carried out up to December 2017 using Medline, Embase, Transport Database, Scopus, Cochrane Library, opengrey.eu and Google. We identified longitudinal studies which examined associations between public transport and cardio-metabolic health including: adiposity, type II diabetes, and cardiovascular disease. We assessed study quality using the Newcastle-Ottawa Scale for cohort studies and performed meta-analyses where possible. Ten studies were identified, seven investigating use of public transport and three examining proximity to public transport. Seven studies used individual level data on changes in BMI with objective outcomes measured in six studies. Study follow-up ranged from one to ten years with three studies adjusting for non-transport physical activity. We found a consistent association between public transport use and lower BMI. Meta-analysis of data from five comparable studies found that switching from car to public transport was associated with lower BMI: −0.30 kg/m2 (−0.47, −0.14). Few studies have investigated associations between public transport use and non-adiposity outcomes. These findings suggest that sustainable urban design which promotes public transport use may produce modest reductions in population BMI.

Journal article

Qin V, Hone T, Millett C, Moreno-Serra R, McPake B, Atun R, Lee TYet al., 2019, The impact of user charges on health outcomes in low-income and middle-income countries: a systematic review, BMJ Global Health, Vol: 3, ISSN: 2059-7908

Background User charges are widely used health financing mechanisms in many health systems in low-income and middle-income countries (LMICs) due to insufficient public health spending on health. This study systematically reviews the evidence on the relationship between user charges and health outcomes in LMICs, and explores underlying mechanisms of this relationship.Methods Published studies were identified via electronic medical, public health, health services and economics databases from 1990 to September 2017. We included studies that evaluated the impact of user charges on health in LMICs using randomised control trial (RCT) or quasi-experimental (QE) study designs. Study quality was assessed using Cochrane Risk of Bias and Risk of Bias in Non-Randomized Studies—of Intervention for RCT and QE studies, respectively.Results We identified 17 studies from 12 countries (five upper-middle income countries, five lower-middle income countries and two low-income countries) that met our selection criteria. The findings suggested a modest relationship between reduction in user charges and improvements in health outcomes, but this depended on health outcomes measured, the populations studied, study quality and policy settings. The relationship between reduced user charges and improved health outcomes was more evident in studies focusing on children and lower-income populations. Studies examining infectious disease–related outcomes, chronic disease management and nutritional outcomes were too few to draw meaningful conclusions. Improved access to healthcare as a result of reduction in out-of-pocket expenditure was identified as the possible causal pathway for improved health.Conclusions Reduced user charges were associated with improved health outcomes, particularly for lower-income groups and children in LMICs. Accelerating progress towards universal health coverage through prepayment mechanisms such as taxation and insurance can lead to improved health outcomes

Journal article

Pacheco Santos LM, Millett C, Rasella D, Hone Tet al., 2018, The end of Brazil's More Doctors programme? Those in greatest need will be hit hardest, BMJ, Vol: 363, ISSN: 0959-8138

Journal article

Hone TV, Macinko J, Millett C, 2018, Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals?, Lancet, Vol: 392, Pages: 1461-1472, ISSN: 0140-6736

The Sustainable Development Goals (SDGs) are now steering the global health and development agendas. Notably, the SDGs contain no mention of Primary Health Care (PHC) – reflecting disappointing implementation of Alma-Alta over the past four decades. The recently-published draft Astana declaration (Alma-Ata 2.0) restates the key principles of PHC and renews these as driving forces for achieving the SDGs, emphasizing Universal Health Coverage (UHC). We use accumulating evidence to demonstrate that countries that reorientate their health systems towards primary care are better placed to achieve the SDGs than those with hospital-focused systems or limited investments in health. We then argue that an even bolder approach which fully embraces the Alma-Ata vision of PHC could deliver substantially greater SDG progress – by addressing the wider determinants of health, promoting equity and social justice throughout society, empowering communities, and as a catalyst for advancing and amplifying UHC and synergies among SDGs.

Journal article

Massuda A, Hone T, Gomes Leles FA, de Castro MC, Atun Ret al., 2018, The Brazilian health system at crossroads: progress, crisis and resilience, BMJ Global Health, Vol: 3, ISSN: 2059-7908

The Unified Health System (Sistema Único de Saúde (SUS)) has enabled substantial progress towards Universal Health Coverage (UHC) in Brazil. However, structural weakness, economic and political crises and austerity policies that have capped public expenditure growth are threatening its sustainability and outcomes. This paper analyses the Brazilian health system progress since 2000 and the current and potential effects of the coalescing economic and political crises and the subsequent austerity policies. We use literature review, policy analysis and secondary data from governmental sources in 2000–2017 to examine changes in political and economic context, health financing, health resources and healthcare service coverage in SUS. We find that, despite a favourable context, which enabled expansion of UHC from 2003 to 2014, structural problems persist in SUS, including gaps in organisation and governance, low public funding and suboptimal resource allocation. Consequently, large regional disparities exist in access to healthcare services and health outcomes, with poorer regions and lower socioeconomic population groups disadvantaged the most. These structural problems and disparities will likely worsen with the austerity measures introduced by the current government, and risk reversing the achievements of SUS in improving population health outcomes. The speed at which adverse effects of the current and political crises are manifested in the Brazilian health system underscores the importance of enhancing health system resilience to counteract external shocks (such as economic and political crises) and internal shocks (such as sector-specific austerity policies and rapid ageing leading to rise in disease burden) to protect hard-achieved progress towards UHC.

Journal article

Baker P, Hone T, Reeves A, Avendano M, Millett Cet al., 2018, Does government expenditure reduce inequalities in infant mortality rates in low- and middle-income countries? A time-series, ecological analysis of 48 countries from 1993-2013, Health Economics, Policy and Law, Vol: 14, Pages: 249-273, ISSN: 1744-1331

IntroductionInequalities in infant mortality rates (IMR) are rising in some Low and Middle-Income Countries (LMICs) and falling in others, but the explanation for these divergent trends is unclear. We investigate whether government expenditures and redistribution are associated with reductions in inequalities in IMR.MethodsWe estimated country-level fixed-effects panel regressions for 48 LMICs (142 country-observations). Slope and Relative Indices of Inequality in IMR (SII and RII) were calculated from Demographic and Health Surveys between 1993-2013. RII and SII were regressed on government expenditure (total, health, and non-health) and redistribution, controlling for GDP, private health expenditures, a democracy indicator, country fixed effects, and time.ResultsMean SII and RII was 39.12 and 0.69. In multivariate models, a one percentage-point increase in total government expenditure (% of GDP) was associated with a decrease in SII of -2.468 (95% CIs: -4.190, -0.746) and RII of -0.026 (95% CIs: -0.048, -0.004). Lower inequalities were associated with higher non-health government expenditure, but not higher government health expenditure. Associations with inequalities were nonsignificant for GDP, government redistribution, and private healthexpenditure.DiscussionUnderstanding how non-health government expenditure reduces inequalities in IMR, and why health expenditures may not, will accelerate progress towards the Sustainable Development Goals.

Journal article

Rasella D, Basu S, Hone TV, Paes-Sousa R, Octavio Ocke'-Reis C, Millett Cet al., 2018, Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study, PLoS Medicine, Vol: 15, ISSN: 1549-1277

Background.Since 2015, a major economic crisis in Brazil has led to increasing poverty and the implementation of long-term fiscal austerity measures which will substantially reduce expenditure on social welfare programmes as a percentage of the country's GDP over the next 20 years. The Bolsa Família Programme (BFP) - one of the largest conditional cash transfer programmes in the world - and the nationwide primary healthcare strategy (Estratégia Saúde da Família - ESF) are affected by fiscal austerity, despite being among the policy interventions with the strongest estimated impact on child mortality in the country. We compared how reduced coverage of BFP and ESF, or an alternative scenario where the level of social protection under these programmes is maintained, may affect the under-five mortality rate (U5MR) and socio-economic inequalities in child health in the country until 2030, the end date of the Sustainable Development Goals.Methods and Findings.We developed and validated a microsimulation model, creating a synthetic cohort of all 5,507 Brazilian municipalities for the period 2017-2030. This was based on the longitudinal dataset and effect estimates from a previously published study which evaluated the effects of poverty, BFP, and ESF on child health. We forecast the economic crisis and the effect of reductions in BFP and ESF coverage due to current fiscal austerity on U5MR, and compare with scenarios where these programmes maintain the levels of social protection by increasing or decreasing with the size of Brazil's vulnerable populations. We used fixed effects multivariate regression models including BFP and ESF coverage and accounting for secular trends, demographic and socioeconomic changes, and programme duration effects.With the maintenance of the levels of social protection provided by BFP and ESF, in the most likely economic scenario the U5MR is expected to be 8.57% (CI: 6.88%- 10.24%) lower in 2030 than under fiscal austerity - a cumulative 19,7

Journal article

Sum G, Hone T, Atun R, Millett C, Suhrcke M, Mahal A, Koh GC-H, Lee JTet al., 2018, Multimorbidity and out-of-pocket expenditure on medicines: a systematic review, BMJ Global Health, Vol: 3, ISSN: 2059-7908

Background: Multimorbidity, the presence of two or more non-communicable diseases (NCD), is a costly and complex challenge for health systems globally. Patients with NCDs incur high levels of out-of-pocket expenditure (OOPE), often on medicines, but the literature on the association between OOPE on medicines and multimorbidity has not been examined systematically. Methods: A systematic review was conducted via searching medical and economics databases including Ovid Medline, EMBASE, EconLit, Cochrane Library and the WHO Global Health Library from year 2000 to 2016. Study quality was assessed using Newcastle-Ottawa Scale. PROSPERO: CRD42016053538. Findings: 14 articles met inclusion criteria. Findings indicated that multimorbidity was associated with higher OOPE on medicines. When number of NCDs increased from 0 to 1, 2 and ≥3, annual OOPE on medicines increased by an average of 2.7 times, 5.2 times and 10.1 times, respectively. When number of NCDs increased from 0 to 1, 2, ≥2 and ≥3, individuals spent a median of 0.36% (IQR 0.15%-0.51%), 1.15% (IQR 0.62%-1.64%), 1.41% (IQR 0.86%-2.15%), 2.42% (IQR 2.05%-2.64%) and 2.63% (IQR 1.56%-4.13%) of mean annual household net adjusted disposable income per capita, respectively, on annual OOPE on medicines. More multimorbidities were associated with higher OOPE on medicines as a proportion of total healthcare expenditures by patients. Some evidence suggested that the elderly and low-income groups were most vulnerable to higher OOPE on medicines. With the same number of NCDs, certain combinations of NCDs yielded higher medicine OOPE. Non-adherence to medicines was a coping strategy for OOPE on medicines. Conclusion: Multimorbidity of NCDs is increasingly costly to healthcare systems and OOPE on medicines can severely compromise financial protection and universal health coverage. It is crucial to recognise the need for better equity and financial protection, and policymakers should consider health system financial optio

Journal article

Filippidis FT, Laverty AA, Hone T, Been JV, Millett Cet al., 2016, Association of cigarette price differentials and infant mortality in 23 European Union countries, JAMA Pediatrics, ISSN: 2168-6203

Importance: Raising the price of cigarettes by increasing taxation has been associated with improved perinatal and child health outcomes. Transnational tobacco companies have sought to undermine tobacco tax policy by adopting pricing strategies which maintain the availability of budget cigarettes.Objective: To assess associations betweenmedian cigarette prices, cigarette price differentials andinfant mortalityacross Europe.Design: Longitudinal ecological study of regions within the European Union. Setting: 23 European countries; 2004 –2014 (data from 276 sub-national regions).Participants: Infant populations in relevant countries.Interventions: Median cigarette prices and the differential between these and minimum cigarette prices were obtained from Euromonitor International.Pricing differentialswere calculated as the proportions(%) obtained by dividing minimum by median cigarette price. Priceswere adjusted for inflation.Main outcome measure: Annual infant mortality rates. Associations were assessed using linear fixed-effect panel regression modelsadjusted for smoke-free policies; Gross Domestic Product; unemployment rate; education; maternal age; and underlining temporal trends.Results: A €1 per pack increase in the median cigarette price was associated with a decline of -0.23 deaths per 1,000 live births in the same year (95% Confidence Interval [CI]: -0.37 to -0.09) and -0.16 per 1,000 live births the following year (95% CI: -0.30 to -0.03). An increase of 10% in the price differential between median and minimum priced cigarettes was associated with an increase of 0.07 deaths per 1,000 live births (95% CI: 0.01 to 0.13) the following year.Cigarette price increasesacross 23 European countries between 2004 and 2014 were associated with 9,208(95% CI: 8,601to 9,814) fewer infant deaths; 3,195(95% CI: 3,017to 3,372)infant deaths could have been avoided had there beenno differential between median and the minimum priced cigarettes during this period. Conclus

Journal article

Palladino R, Hone T, Filippidis FT, 2017, Changes in support for bans of illicit drugs, tobacco, and alcohol among adolescents and young adults in Europe, 2008–2014, International Journal of Public Health, Vol: 63, Pages: 23-31, ISSN: 0303-8408

Objectives This study assessed the support for bans fortobacco, alcohol, and illicit drugs in adolescents and youngadults across the European Union (EU).Methods Data were analysed for the years 2008, 2011, and2014 for 27 EU member states. 37,253 individuals aged15–24 years were interviewed ascertaining their supportfor banning tobacco, alcohol, cannabis, cocaine, heroin,and ecstasy. Changes over time were assessed using multilevellogistic regression.Results Support for banning heroin, ecstasy, and cocainewas constantly greater than 90%, although support fell overtime. Support for cannabis ban declined (from 67.6% in2008 to 53.7% in 2014) as well as support for alcohol ban(from 8.9% in 2008 to 6.9% in 2014) and tobacco ban(from 17.9% in 2008 to 16.5% in 2014).Conclusions Support for banning substances among EUadolescents and young adults varied, with high support forheroin, cocaine, and ecstasy, but less support for banningcannabis, tobacco, and alcohol. There was reduction insupport of banning all substances between 2008 and 2014,but this varied substantially between European countries.

Journal article

Bastos ML, Menzies D, Hone T, Dehghani K, Trajman Aet al., 2017, The impact of the Brazilian family health on selected primary care sensitive conditions: A systematic review, PLoS ONE, Vol: 12, ISSN: 1932-6203

BackgroundBrazil has the largest public health-system in the world, with 120 million people covered by its free primary care services. The Family Health Strategy (FHS) is the main primary care model, but there is no consensus on its impact on health outcomes. We systematically reviewed published evidence regarding the impact of the Brazilian FHS on selective primary care sensitive conditions (PCSC).MethodsWe searched Medline, Web of Science and Lilacs in May 2016 using key words in Portuguese and English, without language restriction. We included studies if intervention was the FHS; comparison was either different levels of FHS coverage or other primary health care service models; outcomes were the selected PCSC; and results were adjusted for relevant sanitary and socioeconomic variables, including the national conditional cash transfer program (Bolsa Familia). Due to differences in methods and outcomes reported, pooling of results was not possible.ResultsOf 1831 records found, 31 met our inclusion criteria. Of these, 25 were ecological studies. Twenty-one employed longitudinal quasi-experimental methods, 27 compared different levels the FHS coverage, whilst four compared the FHS versus other models of primary care. Fourteen studies found an association between higher FHS coverage and lower post-neonatal and child mortality. When the effect of Bolsa Familia was accounted for, the effect of the FHS on child mortality was greater. In 13 studies about hospitalizations due to PCSC, no clear pattern of association was found. In four studies, there was no effect on child and elderly vaccination or low-birth weight. No included studies addressed breast-feeding, dengue, HIV/AIDS and other neglected infectious diseases.ConclusionsAmong these ecological studies with limited quality evidence, increasing coverage by the FHS was consistently associated with improvements in child mortality. Scarce evidence on other health outcomes, hospitalization and synergies with cash transfer

Journal article

Hone TV, Rasella D, Barreto ML, Majeed, Millett Cet al., 2017, Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis, Plos Medicine, Vol: 14, ISSN: 1549-1676

BackgroundUniversal health coverage (UHC) can play an important role in achieving Sustainable Development Goal (SDG) 10, which addresses reducing inequalities, but little supporting evidence is available from low- and middle-income countries. Brazil’s Estratégia de Saúde da Família (ESF) (family health strategy) is a community-based primary healthcare (PHC) programme that has been expanding since the 1990s and is the main platform for delivering UHC in the country. We evaluated whether expansion of the ESF was associated with differential reductions in mortality amenable to PHC between racial groups.Methods and findingsMunicipality-level longitudinal fixed-effects panel regressions were used to examine associations between ESF coverage and mortality from ambulatory-care-sensitive conditions (ACSCs) in black/pardo (mixed race) and white individuals over the period 2000–2013. Models were adjusted for socio-economic development and wider health system variables. Over the period 2000–2013, there were 281,877 and 318,030 ACSC deaths (after age standardisation) in the black/pardo and white groups, respectively, in the 1,622 municipalities studied. Age-standardised ACSC mortality fell from 93.3 to 57.9 per 100,000 population in the black/pardo group and from 75.7 to 49.2 per 100,000 population in the white group. ESF expansion (from 0% to 100%) was associated with a 15.4% (rate ratio [RR]: 0.846; 95% CI: 0.796–0.899) reduction in ACSC mortality in the black/pardo group compared with a 6.8% (RR: 0.932; 95% CI: 0.892–0.974) reduction in the white group (coefficients significantly different, p = 0.012). These differential benefits were driven by greater reductions in mortality from infectious diseases, nutritional deficiencies and anaemia, diabetes, and cardiovascular disease in the black/pardo group. Although the analysis is ecological, sensitivity analyses suggest that over 30% of black/pardo deaths would have to be incorre

Journal article

Hone T, Lee JT, Majeed A, Conteh L, Millett Cet al., 2017, Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare? A systematic review., Health Policy and Planning, Vol: 32, Pages: 723-731, ISSN: 1460-2237

Policy-makers are increasingly considering charging users different fees between primary and secondary care (differential user charges) to encourage utilisation of primary health care in health systems with limited gate keeping. A systematic review was conducted to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published in MEDLINE, EMBASE, the Cochrane library, EconLIT, HMIC, and WHO library databases from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively. Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased primary care utilisation. One study identified an increase in primary care utilisation after primary care user charges were reduced. The introduction of a non-referral charge in secondary care was associated with lower primary care utilisation in one study. One study compared user charges across insurance plans, associating higher charges in secondary care with higher utilisation in both primary and secondary care. Overall, the impact of introducing differential user-charges on primary care utilisation remains uncertain. Further research is required to understand their impact as a demand side intervention, including implications for health system costs and on utilisation among low-income patients.

Journal article

Hone T, Rasella D, Barreto M, Atun R, Majeed A, Millett Cet al., 2017, Large reductions In amenable mortality associated with Brazil's primary care expansion and strong health governance, Health Affairs, Vol: 36, Pages: 149-158, ISSN: 0278-2715

Strong health governance is key to universal health coverage. However, the relationship between governance and health system performance is underexplored. We investigated whether expansion of the Brazilian Estratégia de Saúde da Família (ESF; family health strategy), a community-based primary care program, reduced amenable mortality (mortality avoidable with timely and effective health care) and whether this association varied by municipal health governance. Fixed-effects longitudinal regression models were used to identify the relationship between ESF coverage and amenable mortality rates in 1,622 municipalities in Brazil over the period 2000-12. Municipal health governance was measured using indicators from a public administration survey, and the resulting scores were used in interactions. Overall, increasing ESF coverage from 0 percent to 100 percent was associated with a reduction of 6.8 percent in rates of amenable mortality, compared with no increase in ESF coverage. The reductions were 11.0 percent for municipalities with the highest governance scores and 4.3 percent for those with the lowest scores. These findings suggest that strengthening local health governance may be vital for improving health services effectiveness and health outcomes in decentralized health systems.

Journal article

Hone TV, Habicht J, Domente S, Atun Ret al., 2016, Expansion of health insurance in Moldova and associated improvements in access and reductions in direct payments, Journal of Global Health, Vol: 6, ISSN: 2047-2986

BackgroundMoldova 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. MethodsUsing 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. FindingsPrivate 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).InterpretationMoldova h

Journal article

Atun R, Gurol-Urganci I, Hone T, Pell L, Stokes J, Habicht T, Lukka K, Raaper E, Habicht Jet al., 2016, Shifting chronic disease management from hospitals to primary care in Estonian health system: analysis of national panel data., Journal of Global Health, Vol: 6, ISSN: 2047-2986

BACKGROUND: Following independence from the Soviet Union in 1991, Estonia introduced a national insurance system, consolidated the number of health care providers, and introduced family medicine centred primary health care (PHC) to strengthen the health system. METHODS: Using routinely collected health billing records for 2005-2012, we examine health system utilisation for seven ambulatory care sensitive conditions (ACSCs) (asthma, chronic obstructive pulmonary disease [COPD], depression, Type 2 diabetes, heart failure, hypertension, and ischemic heart disease [IHD]), and by patient characteristics (gender, age, and number of co-morbidities). The data set contained 552 822 individuals. We use patient level data to test the significance of trends, and employ multivariate regression analysis to evaluate the probability of inpatient admission while controlling for patient characteristics, health system supply-side variables, and PHC use. FINDINGS: Over the study period, utilisation of PHC increased, whilst inpatient admissions fell. Service mix in PHC changed with increases in phone, email, nurse, and follow-up (vs initial) consultations. Healthcare utilisation for diabetes, depression, IHD and hypertension shifted to PHC, whilst for COPD, heart failure and asthma utilisation in outpatient and inpatient settings increased. Multivariate regression indicates higher probability of inpatient admission for males, older patient and especially those with multimorbidity, but protective effect for PHC, with significantly lower hospital admission for those utilising PHC services. INTERPRETATION: Our findings suggest health system reforms in Estonia have influenced the shift of ACSCs from secondary to primary care, with PHC having a protective effect in reducing hospital admissions.

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Hone TV, Gurol-Urganci I, Millett C, Başara B, Akdağ R, Atun Ret al., 2016, Effect of primary health care reforms in Turkey on health service utilisation and user satisfaction, Health Policy and Planning, Vol: 32, Pages: 57-67, ISSN: 1460-2237

Strengthening primary health care (PHC) is considered a priority for efficient and responsive health systems, but empirical evidence from low- and middle-income countries is limited. The stepwise introduction of family medicine across all 81 provinces of Turkey (a middle-income country) between 2005 and 2010, aimed at PHC strengthening, presents a natural experiment for assessing the effect of family medicine on health service utilisation and user satisfaction. The effect of health system reforms that introduced family medicine on utilisation was assessed using longitudinal, province-level data for 12 years and multivariate regression models adjusting for supply-side variables, demographics, socio-economic development and underlying yearly trends. User satisfaction with primary and secondary care services were explored using data from annual Life Satisfaction Surveys. Trends in preferred first point of contact (primary vs. secondary, public vs. private), reason for choice and health services issues, were described and stratified by patient characteristics, provider type, and rural/urban settings. Between 2002 and 2013, the average number of PHC consultations increased from 1.75 to 2.83 per person per year. In multivariate models, family medicine introduction was associated with an increase of 0.37 PHC consultations per person (p<0.001), and slower annual growth in PHC and secondary care consultations. Following family medicine introduction, the growth of PHC and secondary care consultations per person was 0.08 and 0.30 respectively a year. PHC increased as preferred provider by 9.5% over 7 years with the reasons of proximity and service satisfaction, which increased by 14.9% and 11.8% respectively. Reporting of poor facility hygiene, difficulty getting an appointment, poor physician behaviour and high costs of health care all declined (p<0.001) in PHC settings, but remained higher among urban, low-income and working-age populations.

Journal article

Palladino R, Lee JT, Hone T, Filippidis F, MIllett Cet al., 2016, The Great Recession And Increased Cost Sharing In European Health Systems, Health Affairs, Vol: 35, Pages: 1204-1213, ISSN: 0278-2715

European health systems are increasingly adopting cost-sharingmodels, potentially increasing out-of-pocket expenditures for patientswho use health care services or buy medications. Government policiesthat increase patient cost sharing are responding to incremental growthin cost pressures from aging populations and the need to invest in newhealth technologies, as well as to general constraints on publicexpenditures resulting from the Great Recession (2007–09). We used datafrom the Survey of Health, Ageing and Retirement in Europe to examinechanges from 2006–07 to 2013 in out-of-pocket expenditures amongpeople ages fifty and older in eleven European countries. Our resultsidentify increases both in the proportion of older European citizens whoincurred out-of-pocket expenditures and in mean out-of-pocketexpenditures over this period. We also identified a significant increaseover time in the percentage of people who incurred catastrophic healthexpenditures (greater than 30 percent of the household income) in theCzech Republic, Italy, and Spain. Poorer populations were less likely thanthose in the highest income quintile to incur an out-of-pocketexpenditure and reported lower mean out-of-pocket expenditures, whichsuggests that measures are in place to provide poorer groups with somefinancial protection. These findings indicate the substantial weakening offinancial protection for people ages fifty and older in European healthsystems after the Great Recession

Journal article

Hone T, Palladino R, Filippidis FT, 2016, Association of searching for health-related information online with self-rated health in the European Union., European Journal of Public Health, Vol: 26, Pages: 748-753, ISSN: 1464-360X

BACKGROUND: The Internet is widely accessed for health information, but poor quality information may lead to health-worsening behaviours (e.g. non-compliance). Little is known about the health of individuals who use the Internet for health information. METHODS: Using the Flash Eurobarometer survey 404, European Union (EU) citizens aged ≥15 (n = 26 566) were asked about Internet utilisation for health information ('general' or 'disease-specific'), the sources used, self-rated health, and socioeconomic variables. Multivariable logistic regression was employed to assess the likelihood of bad self-rated health and accessing different health information sources (social networks, official website, online newspaper, dedicated websites, search engines). RESULTS: Those searching for general information were less likely to report bad health [odds ratios (OR) = 0.80; 95% confidence intervals (CI): 0.70-0.92], whilst those searching for disease-specific information were more likely (OR = 1.22; 95% CI: 1.07-1.38). Higher education and frequent doctor visits were associated with use of official websites and dedicated apps for health. Variation between EU member states in the proportion of people who had searched for general or disease-specific information online was high. CONCLUSIONS: Searching for general health information may be more conducive to better health, as it is easier to understand, and those accessing it may already be or looking to lead healthier lives. Disease-specific information may be harder to understand and assimilate into appropriate care worsening self-rated health. It may also be accessed if health services fail to meet individuals' needs, and health status is currently poor. Ensuring individuals' access to quality health services and health information will be key to addressing inequalities in health.

Journal article

Stokes J, Gurol-Urganci I, Hone T, Atun Ret al., 2015, Effect of health system reforms in Turkey on user satisfaction, Journal of Global Health, Vol: 5, ISSN: 2047-2986

Journal article

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