STUDY QUESTION: What are the direct costs of assisted reproductive technology (ART), and how affordable is it for patients in low- and middle-income countries (LMICS)?SUMMARY ANSWER: Direct medical costs paid by patients for infertility treatment are significantly higher than annual average income and GDP per capita, pointing to unaffordability and the risk of catastrophic expenditure for those in need.WHAT IS KNOWN ALREADY: Infertility treatment is largely inaccessible to many people in LMICs. Our analysis shows that no study in LMICs has previously compared ART medical costs across countries in international dollar terms (US$PPP) or correlated the medical costs with economic indicators, financing mechanisms, and policy regulations. Previous systematic reviews on costs have been limited to high-income countries while those in LMICs have only focussed on descriptive analyses of these costs.STUDY DESIGN, SIZE, DURATION: Guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA), we searched PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature, EconLit, PsycINFO, Latin American & Caribbean Health Sciences Literature, and grey literature for studies published in all languages from LMICs between 2001 and 2020.PARTICIPANTS/MATERIALS, SETTING, METHODS: The primary outcome of interest was direct medical costs paid by patients for one ART cycle. To gauge ART affordability, direct medical costs were correlated with the GDP per capita or average income of respective countries. ART regulations and public financing mechanisms were analyzed to provide information on the healthcare contexts in the countries. The quality of included studies was assessed using the Integrated Quality Criteria for Review of Multiple Study designs.MAIN RESULTS AND THE ROLE OF CHANCE: Of the 4062 studies identified, 26 studies from 17 countries met the inclusion criteria. There were wide disparities across countries in the direct medical costs paid by patients for ART ranging from USD2109 to USD18 592. Relative ART costs and GDP per capita showed a negative correlation, with the costs in Africa and South-East Asia being on average up to 200% of the GDP per capita. Lower relative costs in the Americas and the Eastern Mediterranean regions were associated with the presence of ART regulations and government financing mechanisms.LIMITATIONS, REASONS FOR CAUTION: Several included studies were not primarily designed to examine the cost of ART and thus lacked comprehensive details of the costs. However, a sensitivity analysis showed that exclusion of studies with below the minimum quality score did not change the conclusions on the outcome of interest.WIDER IMPLICATIONS OF THE FINDINGS: Governments in LMICs should devise appropriate ART regulatory policies and implement effective mechanisms for public financing of fertility care to improve equity in access. The findings of this review should inform advocacy for ART regulatory frameworks in LMICs and the integration of infertility treatment as an essential service under universal health coverage.STUDY FUNDING/COMPETING INTEREST(S): This work received funding from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO). The authors declare no competing interests.TRIAL REGISTRATION NUMBER: This review is registered with PROSPERO, CRD42020199312.

The use of e-health and m-health technologies in health promotion and primary prevention among older people is largely unexplored. This study provides a systematic review of the evidence on the scope of the use of e-health and m-health tools in health promotion and primary prevention among older adults (age 50+). A systematic literature review was conducted in October 2015. The search for relevant publications was done in the search engine PubMed. The key inclusion criteria were: e-health and m-health tools used, participants’ age 50+ years, focus on health promotion and primary prevention, published in the past 10 years, in English, and full-paper can be obtained. The text of the publications was analyzed based on two themes: the characteristics of e-health and m-health tools and the determinants of the use of these tools by older adults. The quality of the studies reviewed was also assessed. The initial search resulted in 656 publications. After we applied the inclusion and exclusion criteria, 45 publications were selected for the review. In the publications reviewed, various types of e-health/m-health tools were described, namely apps, websites, devices, video consults and webinars. Most of the publications (60 %) reported studies in the US. In 37 % of the publications, the study population was older adults in general, while the rest of the publications studied a specific group of older adults (e.g. women or those with overweight). The publications indicated various facilitators and barriers. The most commonly mentioned facilitator was the support for the use of the e-health/m-health tools that the older adults received. E-health and m-health tools are used by older adults in diverse health promotion programs, but also outside formal programs to monitor and improve their health. The latter is hardly studied. The successful use of e-health/m-health tools in health promotion programs for older adults greatly depends on the older adults’ motivation and support that older adults receive when using e-health and m-health tools.

There is an increasing recognition that non communicable diseases impose large economic costs on households, societies and nations. However, not much is known about the magnitude of diabetes expenditure in African countries and to the best of our knowledge no systematic assessment of the literature on diabetes costs in Africa has been conducted. The aim of this paper is to capture the evidence on the cost of diabetes in Africa, review the methods used to calculate costs and identify areas for future research. A desk search was conducted in Pubmed, Medline, Embase, and Science direct as well as through other databases, namely Google Scholar. The following eligibility criteria were used: peer reviewed English articles published between 2006 and 2016, articles that reported original research findings on the cost of illness in diabetes, and studies that covered at least one African country. Information was extracted using two data extraction sheets and results organized in tables. Costs presented in the studies under review are converted to 2015 international dollars prices (I$). Twenty six articles are included in this review. Annual national direct costs of diabetes differed between countries and ranged from I$3.5 billion to I$4.5 billion per annum. Indirect costs per patient were generally higher than the direct costs per patient of diabetes. Outpatient costs varied by study design, data source, perspective and healthcare cost categories included in the total costs calculation. The most commonly included healthcare items were drug costs, followed by diagnostic costs, medical supply or disposable costs and consultation costs. In studies that reported both drug costs and total costs, drug costs took a significant portion of the total costs per patient. The highest burden due to the costs associated with diabetes was reported in individuals within the low income group. Estimation of the costs associated with diabetes is crucial to make progress towards meeting the targets laid out in Sustainable Development Goal 3 set for 2030. The studies included in this review show that the presence of diabetes leads to elevated costs of treatment which further increase in the presence of complications. The cost of drugs generally contributed the most to total direct costs of treatment. Various methods are used in the estimation of diabetes healthcare costs and the costs estimated between countries differ significantly. There is room to improve transparency and make the methodologies used standard in order to allow for cost comparisons across studies.

To assess the financial burden due to out of pocket (OOP) payments, two mutually exclusive approaches have been used: catastrophic health expenditure (CHE) and impoverishment. Sub-Saharan African (SSA) countries primarily rely on OOP and are thus challenged with providing financial protection to the populations. To understand the variations in CHE and impoverishment in SSA, and the underlying determinants of CHE, a scoping review of the existing evidence was conducted. This review is guided by Arksey and O’Malley scoping review framework. A search was conducted in several databases including PubMed, EBSCO (EconLit, PsychoInfo, CINAHL), Web of Science, Jstor and virtual libraries of the World Health Organizations (WHO) and the World Bank. The primary outcome of interest was catastrophic health expenditure/impoverishment, while the secondary outcome was the associated risk factors. Thirty-four (34) studies that met the inclusion criteria were fully assessed. CHE was higher amongst West African countries and amongst patients receiving treatment for HIV/ART, TB, malaria and chronic illnesses. Risk factors associated with CHE included household economic status, type of health provider, socio-demographic characteristics of household members, type of illness, social insurance schemes, geographical location and household size/composition. The proportion of households that are impoverished has increased over time across countries and also within the countries. This review demonstrated that CHE/impoverishment is pervasive in SSA, and the magnitude varies across and within countries and over time. Socio-economic factors are seen to drive CHE with the poor being the most affected, and they vary across countries. This calls for intensifying health policies and financing structures in SSA, to provide equitable access to all populations especially the most poor and vulnerable. There is a need to innovate and draw lessons from the ‘informal’ social networks/schemes as they are reported to be more effective in cushioning the financial burden.

Networks of family and friends are a source of support and are generally associated with higher life satisfaction values among older adults. On the other hand, older adults who are satisfied with their life may be more able to develop and maintain a wider social network. For this reason, the causal link between size and composition of the social networks and satisfaction with life is yet to be explored. This paper investigates the effect of the ‘size’, (number of family and friends, and network) and the ‘composition’ (the proportion of friends over total number of persons) of the social network on life satisfaction among older adults (50+). Moreover, we also investigate the patterns of this relation between different European countries. Data from the 4^th wave of Survey of Health, Ageing and Retirement in Europe and an instrumental variable approach are used to estimate the extent of the relation between life satisfaction and size and composition of social networks. Respondents in Western and Northern European (WNE) countries report larger networks than respondents in Eastern and Southern European (ESE) countries. However, the positive relationship between network size and life satisfaction is consistent across countries. On the other hand, the share of friends in the network appears to be generally negatively related to satisfaction with life, though results are not statistically significant for all countries. Apparently, a larger personal network is important for older adults (50+) to be more satisfied with life. Our results suggest that this relation is particularly positive if the network is comprised of family members.

To sustain a viable public pension system, many governments have increased the statutory retirement age and delayed the age of entitlement to public pension benefits. This systematic literature review investigates the empirical evidence on the effects of increasing the retirement age on the health, well-being, and labor force participation of older workers. Optimized and broad search queries were used to search for empirical evidence in four databases: EconLit, PsycINFO, PubMed, and SocINDEX. The systematic literature search was conducted in May 2019. Snowballing was performed on the reference lists of the publications to find additional studies. The quality of the included studies was also examined. The PRISMA guidelines were used to guide this systematic literature review. Nineteen studies were included in this review. Twelve studies estimated the effect of an increase in the statutory retirement age, and seven studies examined working beyond the retirement age. The reported findings were classified into health-related outcomes, well-being, and the effects on labor force participation and the perception of the retirement age. The reported findings regarding health-related outcomes and well-being were not comparable. The increase of the retirement age has increased labor force participation among older workers and has increased the preferred and expected retirement age in the direction of the public pension reform. However, evidence on the effects of an increase of the retirement age on the health and well-being of older workers remains scarce and inconclusive.