Abstracts

OP59

FINANCING UNIVERSAL HEALTH COVERAGE: EFFECTS

OF ALTERNATIVE TAX STRUCTURES ON PUBLIC HEALTH
SYSTEMS IN 89 LOW- AND MIDDLE-INCOME
COUNTRIES

A Reeves*, 2Y Gourtsoyannis, 2,3S Basu, 4D McCoy, 2M McKee, 1,2D Stuckler.

Department of Sociology, University of Oxford, Oxford, UK; 2European Centre on Health
of Societies in Transition, London School of Hygiene and Tropical Medicine, London, UK;
3
Department of Medicine, Stanford University, Palo Alto, USA; 4Department of Primary
Care and Public Health, Queen Mary University of London, London, UK
1

10.1136/jech-2014-204726.62

Background Progressive realisation of universal health coverage

is a widely accepted goal for the post-2015 Millennium Development Goals and the Grand Convergence of health envisioned
by the Lancets Commission on Investing in Health. Yet the
means to pay for it is a subject of intense debate. We investigated
how alternative tax systems affect the breadth, depth, and height
of coverage by public health systems and associated child and
maternal health outcomes.
Methods Cross-national fixed effects models were used to assess
the relationships between tax revenue, tax systems, and health
system coverage in 89 low- and middle-income countries from
19952011.
Results We identified tax revenue as a major statistical determinant of progress towards universal health coverage. Each $100
per capita per year of additional tax revenues corresponded to
$9.86 yearly increase in government health spending (95% CI
3.92, 15.8). This association was particularly strong for taxes on
capital gains, profits and income ($16.7, 95% CI 9.1624.3),
compared with those on goods and services (-$4.37, 95% CI 12.9, 4.11). In countries with low tax revenues (<$1000 per capita per year), an additional $100 tax revenue per year substantially increased the proportion of births attended by a skilled
attendant by 6.74 percentage points (95% CI 0.87, 12.6) and
the extent of health coverage by 11.4 percentage points (95%
CI 5.51, 17.2). However, in contrast, $100 per capita increase
in regressive forms of taxation, such as taxes on goods and services, which may reduce the ability of the poor to afford essential
goods, was associated with higher rates of post-neonatal mortality by 0.17 (95% CI 0.065, 0.28), increases in infant mortality
rate (15 years) by 0.18 per 1000 live births (95% CI 0.05,
0.32) and increases in under five mortality rate by 0.43 per
100,000 population (95% CI 0.14, 0.72).
Conclusion Increasing domestic tax revenues is a key element of
a strategy to achieving universal health coverage, particularly in
countries with low tax bases. Pro-poor taxes on profits and capital gains appear to support expansion of health coverage without
the adverse effects on health outcomes of higher taxes on goods
and services.

Background The General Medical Services (GMS) scheme, a

means tested public health insurance covering approximately
40% of the population, has traditionally provided prescription
medicines without charge. In 2010, a 50c/item charge was introduced, which was increased to 1.50/item in 2013. The international literature points to an association between prescription
charges and decreased adherence with consequential increases in
morbidity and mortality. However, to date, there are no data on
the impact of prescription charges on the GMS scheme on
adherence. The aim was to assess the impact of two charges on
adherence to prescription medicines.
Methods A longitudinal repeated measures design was used to
measure individual adherence to medicines before and after the
introduction of charges. Pharmacy claims data from the national
database (HSE-PCRS) were used for intervention and comparator groups. Two consecutive cohorts, including new users of
anti-hypertensive, anti-hyperlipidaemic and oral anti-diabetic
medicines, were established to analyse the effect of both charges.
Follow up was 12 and 8 months. Segmented regression with
generalised estimating equations was used. Sensitivity analyses
according to age, sex and essential/non-essential drug status were
conducted. All anlayses were carried in out in R version 2.15.2.
Results Immediately after the introduction of the 50c charge,
adherence to anti-hyperlipidaemic medicines was reduced by
2.2% (95% CI 1.243.12, p < 0.0001) relative to the comparator group. For anti-hypertensives, the decrease was 4.8% (95%
CI 45.7, p < 0.0001). For anti-diabetic medicines adherence
declined by 2.4% (95% CI 1.33.5, p < 0.0001). Directly after
the 1.50 charge was introduced, adherence to anti-hypertensive
medicines decreased by 5.1% (95% CI, 4.26.1, p < 0.0001)
compared to the comparator. Reductions of 1% in adherence to
anti-hyperlipidaemics were non-significant (95% CI 0.0532.1,
p = 0.063) and were non-existent for anti-diabetic medicines.
Neither charge was associated with reductions in long-term
adherence for any medicine. A greater drop in adherence to
non-essential medicines was observed; adherence to proton
pump inhibitors dropped by 11.1% (95% CI 10.81.4, p <
0.0001) immediately after the introduction of the 50c charge.
Conclusion The introduction of the 50c charge had a greater
immediate effect on adherence to anti-hyperlipidaemic and antidiabetes medicines than the 1.50 charge, suggesting reducing
price elasticity of demand. This is the first analysis of the impact
of prescription charges on adherence on the GMS. Further
changes to cost-sharing policies in Ireland should be informed by
national and international evidence.

Maternal and child health 2

OP61

PERCEIVED MATERNAL STRESS AND EMOTIONAL

WELLBEING AS RISK FACTORS FOR MISCARRIAGE

OP60

THE IMPACT OF TWO CONSECUTIVE PRESCRIPTION

CHARGES ON ADHERENCE TO CHRONIC MEDICATIONS
IN THE IRISH GENERAL MEDICAL SERVICES
POPULATION

SJ Sinnott*, 2N Woods, 3S Byrne, 4H Whelton. 1Department of Epidemiology and Public

Health, University College Cork, Cork, Ireland; 2Centre for Policy Studies, University
College Cork, Cork, Ireland; 3Pharmaceutical Care Research Group, School of Pharmacy,
University College Cork, Cork, Ireland; 4School of Dentistry, University of Leeds, Leeds,
UK
10.1136/jech-2014-204726.63

J Epidemiol Community Health 2014;68(Suppl 1):A3A84

S Meaney, 1P Corcoran*, 1,2JE Lutomski, 3S Gallagher, 4N Spillane, 4K ODonoghue.

National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland;
2
Nijmegen Centre for Evidence Based Practice, Radboud University Nijmegen Medical
Centre, Nijmegen, Netherlands; 3Centre for Social Issues Research, University of Limerick,
Limerick, Ireland; 4Department of Obstetrics and Gynaecology, University College Cork,
Cork, Ireland
1

10.1136/jech-2014-204726.64

Background Miscarriage is the most common adverse outcome

in pregnancy. Investigations suggest numerous risk factors however the cause remains poorly understood. The study aimed to

A31