Domenico Gasbarro

Background
Urban-rural inequality in accessing quality antenatal care (ANC) is a well-documented challenge in low- and middle-income countries like Bangladesh and Pakistan, hindering maternal healthcare utilization and progress towards the Sustainable Development Goals. This study explores the key factors contributing to this inequality in Bangladesh and Pakistan and highlights inter-country differences.

Methods
We analyzed data from Demographic Health Surveys (2017–2018) of Bangladesh and Pakistan for women aged 15–49 who had at least one live birth in the three years preceding the survey. To identify the extent and sources of inequality, we decomposed urban-rural differences in quality ANC utilization into explained (attributable to variations in socioeconomic and demographic characteristics) and unexplained (reflecting differences in the effects of these characteristics) components using Blinder-Oaxaca type models adapted for nonlinear response variables.

Results
Urban women were significantly more likely to receive quality ANC than rural women in both Bangladesh and Pakistan, with disparities of about 20%-25% points. Most of the inequality was explained by differences in socioeconomic and educational characteristics rather than behavioral factors. Wealth status was the dominant contributor, explaining nearly 58% of the inequality in Bangladesh and 46% in Pakistan, followed by women’s and husbands’ education, media exposure, and women’s autonomy. The pattern of predictors was broadly consistent across both countries, though education contributed more in Pakistan, while media exposure and husband’s education played a larger role in Bangladesh.

Conclusion
Significant urban-rural inequality exists in Bangladesh and Pakistan, which is more pronounced in Pakistan. Among the common significant predictors for both countries, wealth disparity has the highest contribution percentage. In Pakistan, women’s education is the second largest contributor to inequality, whereas in Bangladesh, both media exposure and husband’s education played notable roles. Reducing urban-rural inequality in quality ANC requires targeted policies addressing wealth and educational disparities, along with interventions that promote media access and women’s autonomy to ensure equitable maternal healthcare utilization.

Mental health conditions impose substantial economic burdens on healthcare systems globally, with growing evidence indicating disproportionate impacts on household-level out-of-pocket (OOP) expenditures. Despite Australia's universal healthcare system, the financial burden of mental health conditions on households remains underexplored.
To examine the longitudinal relationship between mental health status and OOP healthcare expenditures among Australian adults, and assess how education and income moderate this relationship.
We analyzed 17 waves (2006-2022) of the Household, Income and Labour Dynamics in Australia (HILDA) survey, encompassing 57,647 person-year observations from 3,391 unique individuals. Mental health was measured using the Mental Health Inventory-5 (MHI-5) scale and newly proposed expanded MHI-9 scales. We employed fixed-effects panel regression models and instrumental variable analysis to address unobserved heterogeneity.
A one-unit decrease in MHI-5 score is associated with 0.18-0.25% increase in inflation-adjusted OOP healthcare expenditure, equivalent to AU$2.10-$3.00 per unit decline, with a 10-point decline in MHI-5 costing households an additional AU$21-$30. Instrumental variable estimates revealed larger causal effects of 0.80-1.00%. Individuals with good mental health and higher education demonstrated expenditure patterns consistent with Grossman's health capital theory, while those with poor mental health showed disrupted relationships between education and healthcare spending. Urban residents faced 11.00% higher inflation-adjusted OOP costs than the rural residents.
Mental health deterioration significantly increases household healthcare expenditure burdens in Australia. Traditional health economics theories apply primarily to individuals with good mental health, indicating the need for targeted rather than universal policy approaches.

Abstract
Background

The burden of out-of-pocket (OOP) healthcare expenses for pregnancy-related conditions is a significant concern in resource-prone countries. Bangladesh and Pakistan, two historically connected countries with similar socioeconomic standings, rank among the highest globally in OOP share in total health expenditures. Excessive OOP costs pose financial barriers to maternal healthcare utilisation, leading to catastrophic health expenditures (CHE) and deepening poverty. Our study aims to compare pregnancy-related OOP expenditures between Bangladesh and Pakistan, examining key disparities in spending patterns and financial burden.

Methods

This study utilises data from the Bangladesh Household Income and Expenditure Survey (HIES) 2022 and published secondary evidence for Pakistan in the absence of primary data. For Bangladesh, we included all women of reproductive age who reported pregnancy-related health issues in the past 30 days or were hospitalised in the last 12 months. We estimated the share of OOP in total household expenditure on pregnancy-related healthcare, assessed CHE using budget share, actual, and normative food expenditure methods, and evaluated impoverishment effects. Descriptive and equity-based analyses were conducted to examine expenditure variations across socioeconomic groups.

Results

In Bangladesh, pregnancy-related OOP expenditures (USD 434.4) accounted for 50% of total household healthcare spending (USD 892.6). The share of OOP in total household expenditure was significantly higher for private healthcare facilities (USD 417.1) and among rural women (USD 384.8). Low-income households spent a greater proportion (two-thirds) of their total expenditure on pregnancy-related care. The CHE incidence was around 94.6%-80.9% among the lowest quintile households and 26.8%-66.5% among rural households under normative capacity-to-pay (CTP) method. Impoverishment rates were highest, with 31.7% low-income and 3.9% rural households falling into poverty due to OOP expenses. In Pakistan, OOP costs for pregnancy care were significantly higher in private facilities (USD 209.88-255.49) than in public facilities (USD 23.30-63.87).

Conclusion

Pregnancy-related OOP healthcare costs constitute a significant financial burden in Bangladesh and Pakistan, with higher expenses in private facilities. Low-income and rural families in Bangladesh face the greatest hardship, often leading to financial catastrophe and poverty. Strengthening public healthcare funding, expanding maternal health insurance, and regulating private sector pricing could reduce OOP costs and improve maternal healthcare equity.

This study explores the factors influencing firms’ cash holdings and their impact on shareholder returns. Firms are grouped into deciles based on Median Industry-Adjusted Cash Ratios (MACR). We examine the influence of market risk measures, operational and financial ratios, macroeconomic conditions, and key variables: business strategy, life cycle stage, and managerial ability. Our findings show that incorporating MACR with these variables improves the understanding of firm returns. ‘Prospector’ firms with high MACRs deliver strong excess returns, while ‘analyzer’ firms also outperform. Growth-phase firms with high MACRs show significant excess returns, while maturity-phase firms consistently perform well regardless of MACR. Managers with high ability generate excess returns at all MACR levels. Additionally, value-weighted portfolios outperform equally-weighted ones.

Background Rural‒urban disparity in catastrophic healthcare expenditure (CHE) is a well-documented challenge in low-and middle-income countries, including Bangladesh, limiting financial protection and hindering the achievement of the Universal Health Coverage target of the United Nations Sustainable Development Goals. However, the factors driving this divide remain poorly understood. Therefore, this study aims to identify the key determinants of the rural‒urban disparity in CHE incidence in Bangladesh and their changes over time. Methods We used nationally representative data from the latest three rounds of the Bangladesh Household Income and Expenditure Survey (2005, 2010, and 2016). CHE incidence among households seeking healthcare was measured using the normative food, housing, and utilities method. To quantify covariate contributions to the rural‒urban CHE gap, we employed the Oaxaca-Blinder multivariate decomposition approach, adapted by Powers et al. for nonlinear response models. Results CHE incidence among rural households increased persistently during the study period (2005: 24.85%, 2010: 25.74%, 2016: 27.91%) along with a significant (p-value ≤ 0.01) rural‒urban gap (2005: 9.74%-points, 2010: 13.94%-points, 2016: 12.90%-points). Despite declining over time, substantial proportions of CHE disparities (2005: 87.93%, 2010: 60.44%, 2016: 61.33%) are significantly (p-value ≤ 0.01) attributable to endowment differences between rural and urban households. The leading (three) covariate categories consistently contributing significantly (p-value ≤ 0.01) to the CHE gaps were composition disparities in the lowest consumption quintile (2005: 49.82%, presence of chronic illnesses in households emerged as a significant factor in 2016 (9.14%, p-value ≤ 0.01), superseding the contributions of composition differences in household heads with no education (4.40%, p-value ≤ 0.01) and secondary or higher education (7.44%, p-value ≤ 0.01), which were the fourth and fifth significant contributors in 2005 and 2010. Conclusions Rural‒urban differences in household economic status, educational attainment of household heads, and healthcare sources were the key contributors to the rural‒urban CHE disparity between 2005 and 2016 in Bangla-desh, with chronic illness emerging as a significant factor in the latest period. Closing the rural‒urban CHE gap necessitates strategies that carefully address rural‒urban variations in the characteristics identified above.

This study assesses the financial risk protection (FRP) of heart disease‐affected households in Bangladesh by analyzing three rounds of Household Income and Expenditure Survey data (2005, 2010, and 2016). Amidst a global surge in cardiovascular diseases, particularly in low‐ and middle‐income countries, Bangladesh encounters an escalating burden of heart disease, with an over‐reliance on out‐of‐pocket (OOP) healthcare expenses. Our findings reveal a substantial increase in annual OOP spending for households affected by heart disease, from USD 307.4 in 2005 to USD 346.1 in 2010, and then surging to USD 650.5 in 2016. Concurrently, catastrophic health expenditure (CHE) and impoverish-ment incidences rose (17.6% to 18.2% to 29.3% and 3.2% to 2.2% to 3.3%, respectively), with a notable increase post‐2010. These expenses and CHE incidences were consistently higher than those in households with any ailment, underscoring a disparity in FRP, especially among economically disadvantaged, rural households and those headed by individuals without formal education. The study contributes to the literature by providing a first‐time analysis of FRP dynamics against heart disease in Bangladesh using comprehensive national data. It uncovers the worsening FRP status among affected households and highlights the need for targeted interventions to enhance FRP, particularly among the most vulnerable groups. Additionally, it emphasizes the importance of strategic public health investments to mitigate the financial repercussions of heart disease care, providing insights that are globally applicable to similar contexts.