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We evaluate the impacts of implementing and lifting nonpharmaceutical interventions (NPIs) in US counties on the daily growth rate of COVID-19 cases and compliance, measured through the percentage of devices staying home, and evaluate whether introducing and lifting NPIs protecting selective populations is an effective strategy. We use difference-in-differences methods, leveraging on daily county-level data and exploit the staggered introduction and lifting of policies across counties over time. We also assess heterogenous impacts due to counties’ population characteristics, namely ethnicity and household income. Results show that introducing NPIs led to a reduction in cases through the percentage of devices staying home. When counties lifted NPIs, they benefited from reduced mobility outside of the home during the lockdown, but only for a short period. In the long term, counties experienced diminished health and mobility gains accrued from previously implemented policies. Notably, we find heterogenous impacts due to population characteristics implying that measures can mitigate the disproportionate burden of COVID-19 on marginalized populations and find that selectively targeting populations may not be effective.
Objectives: The growth of COVID-19 infections in England raises questions about system vulnerability. Several factors that vary across geographies, such as age, existing disease prevalence, medical resource availability and deprivation, can trigger adverse effects on the National Health System during a pandemic. In this paper, we present data on these factors and combine them to create an index to show which areas are more exposed. This technique can help policy makers to moderate the impact of similar pandemics.
Design: We combine several sources of data, which describe specific risk factors linked with the outbreak of a respiratory pathogen, that could leave local areas vulnerable to the harmful consequences of large-scale outbreaks of contagious diseases. We combine these measures to generate an index of community-level vulnerability.
Setting: 91 Clinical Commissioning Groups (CCGs) in England.
Main outcome: measures We merge 15 measures spatially to generate an index of community-level vulnerability. These measures cover prevalence rates of high-risk diseases; proxies for the at-risk population density; availability of staff and quality of healthcare facilities.
Results: We find that 80% of CCGs that score in the highest quartile of vulnerability are located in the North of England (24 out of 30). Here, vulnerability stems from a faster rate of population ageing and from the widespread presence of underlying at-risk diseases. These same areas, especially the North-East Coast areas of Lancashire, also appear vulnerable to adverse shocks to healthcare supply due to tighter labour markets for healthcare personnel. Importantly, our index correlates with a measure of social deprivation, indicating that these communities suffer from long-standing lack of economic opportunities and are characterised by low public and private resource endowments.
Conclusions: Evidence-based policy is crucial to mitigate the health impact of pandemics such as COVID-19. While current attention focuses on curbing rates of contagion, we introduce a vulnerability index combining data that can help policy makers identify the most vulnerable communities. We find that this index is positively correlated with COVID-19 deaths and it can thus be used to guide targeted capacity building. These results suggest that a stronger focus on deprived and vulnerable communities is needed to tackle future threats from emerging and re-emerging infectious disease.
Health perception biases can have serious consequences on health. Despite their relevance,the role of such biases in determining healthcare utilisation is severely underexplored. Herewe study the relationship between health misperception, doctor visits, and concomitant out-of-pocket expenditures for the population 50+ in Europe. We conceptualise health misper-ception as arising from either overconfidence or underconfidence, where overconfidence ismeasured as overestimation of health and underconfidence is measured as underestimationof health. Comparing objective performance measures and their self-reported equivalentsfrom the Survey of Health, Ageing and Retirement in Europe, we find that individuals whooverestimate their health visit the doctor 14% less often than individuals who correctly as-sess their health, which is crucial for preventive care such as screenings. Lower healthcareutilisation is accompanied by lower out-of-pocket spending (38% less). In contrast, indi-viduals who underestimate their health visit the doctor more often (28% more) and havehigher out-of-pocket spending (17% more). We project that underestimating health of thepopulation 50+ will cost the average European country Intl$ 71 million in 2020 and Intl$ 81million by 2060. Country-specific estimates based on population and demographic projec-tions show that countries such as Germany, Denmark and The Netherlands will experiencesignificantly large costs of such misperception. The results are robust to several sensitivitytests and, more important, to various conceptualisations of the misperception measure.
Finanzierung und Vergütung eines nachhaltigen Gesundheitssystems – Ansätze und Möglichkeiten
(2021)
Die hier genannten Punkte stellen eine kurze Zusammenfassung an Themen dar, die sich wie rote Fäden in allen unten beschriebenen Feldern der Governance entdecken lassen. Sie können als die Quintessenz, Leitbilder oder Prinzipien der Governance für das Gesundheitssystem der Zukunft angesehen werden. Die einzelnen Felder der Governance werden in den nachfolgenden Kapiteln näher beschrieben und basieren auf den Expertengesprächen im Rahmen der Initiative „Neustart! Reformwerkstatt für unser Gesundheitswesen“ und der existierenden Literatur.
• Notwendigkeit erhöhter Transparenz – Transparenz über die Entscheidungen ist das A und O für Governance, wenn gegenseitiges Vertrauen zwischen Stakeholdern und bei Bürgern und Patienten geschaffen werden soll. Transparenz ist Voraussetzung, dass sich letztere ein eigenes Bild machen können und auf die eine oder andere Art sinnvoll an der Governance beteiligt werden können.
• Etablierte Standards mit lokaler Ergänzung – Neben der Anpassung der Versorgung an lokal-regionale Bedarfe sollten (Qualitäts-)Standards und (Behandlungs-)Leitlinien auf übergeordneter, nationaler (oder internationaler) Ebene erstellt werden und Anwendung finden, um landesweit einen hohen Qualitätsstandard sicherzustellen.
• Governance vom regionalen Bedarf herdenken – Ein Verständnis für den regionalen Bedarf einer Bevölkerung und deren spezifischen Bedürfnisse sollte entwickelt werden als Handlungsorientierung für die Governance vor Ort. Die nationalen Standards können darüber hinaus durch regional entwickelte Praktiken ergänzt werden. Nur auf diese Weise kann die regional beste Passung zwischen angemessener Versorgung und Gesundheitssystem erreicht werden.
• Bedarf für geeignete Daten in hoher Qualität – Trotz einer Vielzahl vorhandener Daten fehlt es häufig noch an geeigneten Daten, auf denen Governance-Entscheidungen verlässlich fußen können. Hierzu müssen relevante und geeignete Daten identifiziert werden, die möglichst ohne großen Aufwand im Prozess erhoben werden und dennoch die Realität der Versorgung und der Lebensqualität von Patienten abbilden können.
Objectives
Arts engagement has been positively linked with mental health and well-being; however, socio-economic inequalities may be prevalent in access to and uptake of arts engagement reflecting on inequalities in mental health. This study estimated socio-economic inequality and horizontal inequity (unfair inequality) in arts engagement and depression symptoms of older adults in England. Trends in inequality and inequity were measured over a period of ten years.
Study design
This is a repeated cross-sectional study.
Methods
In this analysis, we used data from six waves (waves 2 to 7) of the nationally representative English Longitudinal Study of Ageing. We estimated socio-economic inequality using concentration curves that plot the distribution of arts engagement and depression symptoms against the distribution of wealth. A concentration index was used to measure the magnitude of the inequality. Unfair inequality was then calculated for need-standardised arts engagement using a horizontal inequity index (HII).
Results
The study sample included adults aged 50 years and older from waves 2 (2004/2005, n = 6620) to 7 (2014/2015, n = 3329). Engagement with cinema, galleries and theatre was pro-rich unequal, i.e. concentrated among the wealthier, but inequality in depression was pro-poor unequal, i.e. concentrated more among the less wealthy. While pro-rich inequality in arts engagement decreased from wave 2 (conc. index: 0·291, 95% confidence interval 0·27 to 0·31) to wave 7 (conc. index: 0·275, 95% confidence interval 0·24 to 0·30), pro-poor inequality in depression increased from wave 2 (conc. index: −0·164, 95% confidence interval -0·18 to −0·14) to wave 7 (conc. index: −0·189, 95% confidence interval -0·21 to −0·16). Depression-standardised arts engagement showed horizontal inequity that increased from wave 2 (HII: 0·455, 95% confidence interval 0·42 to 0·48) to wave 7 (HII: 0·464, 95% confidence interval 0·42 to 0·50).
Conclusions
Our findings suggest that while socio-economic inequality in arts engagement might appear to have reduced over time, once arts engagement is standardised for need, inequality has actually worsened over time and can be interpreted as inequitable (unfair). Relying on need-unstandardised estimates of inequality might thus provide a false sense of achievement to policy makers and lead to improper social prescribing interventions being emplaced.
Background
A trade-off exists between affordability of pharmaceutical products today and incentives for firms to provide new and better drugs in the future; an activity that prior studies suggest correlates with profitability, which in turn depends on price regulation.
Objective
In this paper we re-examined the relationship between price regulation and pharmaceutical research and development (R&D) intensity, and explored the role of profitability and cash flow in mediating this relation using the latest available data from 2000 to 2017 for the 10 most innovative pharmaceutical companies.
Methods
Following a framework similar to a previous study, we exploited stylized facts about sales volumes in Europe and USA, which give rise to variation in exposure to price regulation. Using ordinary least squares fixed effects models, we assess whether price regulation is related to R&D investment through cash flow effects and profitability.
Results
While exposure to price regulation (measured by relative market share in EU/USA) is related negatively to R&D intensity, and this result is driven by price regulation being negatively related to cash flow and profitability, the results were not significant when firm fixed effects were added to the regression models. Modeling firm dynamics showed that cash flow and profitability of European- and US-based firms responded differently to exposure to price regulation. Thus, firm specific effects play an important role in explaining the negative relationship between price regulation and R&D intensity. These results were robust to the inclusion of different time-varying firm level variables.
Conclusion
The findings suggest that investment decisions of firms are most likely driven by long-run inter-firm differences, and that firm effects strongly determine firm strategies in terms of R&D investment.
Health misperception can have serious consequences on health. Despite their relevance, the role of such biases in determining healthcare utilisation is severely underexplored. Here we study the relationship between health perception and doctor visits for the population 50+ in Europe. We conceptualise health misperception as arising from either overconfidence or underconfidence, where overconfidence is measured as overestimation of health and underconfidence is measured as underestimation of health. Comparing objective performance measures and their self-reported equivalents from the Survey of Health, Ageing and Retirement in Europe, we find that individuals who overestimate their health visit the doctor 17.0% less often than individuals who correctly assess their health, which is crucial for preventive care such as screenings. In contrast, individuals who underestimate their health visit the doctor more often (21.4% more). Effects are similar for dentist visits, but we find no effects on hospital stays. The results are robust to several sensitivity tests and, more important, to various conceptualisations of the health perception measure.
Background
Although older adults are more vulnerable to the COVID-19 virus, a significant proportion of them do not follow recommended guidelines concerning preventive actions during the ongoing pandemic. This article analyses the role of biased health beliefs for adaptive health behaviour such as reduced mobility, protection in public spaces and hygiene measures, for the population aged 50 and older in 13 European countries.
Methods
Health perception is measured based on the difference between self-reported health and physical performance tests for over 24 000 individuals included in the most recent Survey of Health, Ageing and Retirement in Europe. Logistic regressions are employed to explore how over- and underestimating health are related to preventive behaviours.
Results
Results suggest that older adults who underestimate their health are more likely to show adaptive behaviour related to mobility reductions. In particular, they are more likely to stay at home, shop less and go for walks less often. In contrast, overestimating health is not significantly associated with reduced mobility. Protective behaviour in public spaces and adopting hygiene measures do not vary systematically between health perception groups.
Conclusion
As health beliefs appear relevant for the adoption of preventive health behaviours related to mobility, they have serious consequences for the health and well-being of older Europeans. Although adaptive behaviour helps to contain the virus, exaggerated mobility reduction in those who underestimate their health might be contributing to the already high social isolation and loneliness of older adults during the ongoing pandemic.
Objective
To assess the relationship between childhood immunization and mortality risks for non-vaccine-preventable diseases (Competing Mortality Risks or CMR) in Kenya.
Study Design
A combination of the Global Burden of Disease and Demographic Health Survey (DHS) data is used to measure basic vaccination status, CMR, and control variables for each child in the DHS data. A longitudinal analysis was performed. This uses within-mother variation between children to compare the vaccine decisions for different children, who are exposed to different mortality risks. The analysis also distinguishes between overall and disease-specific risks.
Results
The study included 15,881 children born between 2009 and 2013, who were at least 12 months old at the time of interview and not part of a twin birth. Mean basic vaccination rates ranged from 27.1% to 90.2% and mean CMR from 85.80 to 913.63 deaths per 100,000 across different counties. A one-unit increase in mortality risk from diarrhea, the most prevalent disease among children in Kenya, is associated with a 1.1 percentage point decline in basic vaccination status. On the other hand, mortality risks for other diseases and HIV increase the likelihood of vaccination. The effect of CMR was found to be stronger for children with higher birth orders.
Conclusions
A significant negative correlation between severe CMR and vaccination status is found, which has important implications for immunization policies, particularly in Kenya. Interventions aimed at reducing the most severe CMR, such as diarrhea, and targeted towards multiparous mothers may improve childhood immunization coverage.
We examine how expenditure changes at retirement during an institutionally and economically uncertain period when a series of pension reforms and cuts were implemented. Overall, we fail to confirm that consumption declines at retirement using data from Greece (2008–2018). Any estimated declines come from turbulent years when major pension cuts were applied. Expenditure drops at retirement were due to pension income shocks, especially for those who were particularly dependent on pension income. Further checks support the presence of an income shock mechanism for retirees who are relatively more treated during the crisis sub-period. Given an aging population and the ongoing global turbulence, our results offer valuable insights.
Health system governance has been receiving increasing attention in health system research since the 1980s. The contemporary challenges that the German health system is faced with are often closely linked to governance issues. Although Germany has the highest health expenditure as a share of Gross Domestic Product (GDP) in the European Union (EU), the spending on healthcare is out of proportion to the health outcomes of the population. The reason for this lies mainly in the complexity of the German health system which is hard to steer due to several administrative levels in the country and numerous policy actors to whom the decision-making power on healthcare provision is delegated. In this paper, we present the results of focus group discussions on governance and build upon the insights gained through the Neustart project of the Robert Bosch Foundation. Based on an internationally recognised health governance framework from the World Health Organization (WHO), experts who work in, on or for the German health system addressed health governance challenges. They provided evidence-based recommendations for the new legislative period (2021-2025) on transparency, accountability, participation, integrity and capacity of the German health system.
This paper presents evidence on intra-household retirement externalities by assessing the causal effect of spousal retirement on various health behaviors and health status across 19 European countries. We identify partner's and own retirement effects by applying a fuzzy regression discontinuity design using retirement eligibility as exogenous instruments for spousal and own retirement status. We find significant increases in the frequency and intensity of alcohol consumption combined with a significant decrease in moderate physical activities as a response to partner's retirement. In line with the existing literature, we find that own retirement has significant positive effects on engaging in moderate and vigorous physical activities but also leads to a significant increase in the frequency of alcohol intake. Overall, subjective health is negatively affected by spousal retirement and positively by own retirement.
This paper estimates the income elasticity of government pharmaceutical spending and assesses the simultaneous effect of such spending on gross domestic product (GDP). Using a panel dataset for 136 countries from 1995 to 2006, we employ a two‐step instrumental variable procedure where we first estimate the effect of GDP on public pharmaceutical expenditure using tourist receipts as an instrument for GDP. In the second step, we construct an adjusted pharmaceutical expenditure series where the response of public pharmaceutical expenditure to GDP is partialled out and use this endogeneity adjusted series as an instrument for pharmaceutical expenditure. Our estimations show that GDP has a strong positive impact on pharmaceutical spending with elasticity in excess of unity in countries with low spending on pharmaceuticals and countries with large economic freedom. In the second step, we find that when the quantitatively large reverse effect of GDP is accounted for, public pharmaceutical spending has a negative effect on GDP per capita particularly in countries with limited economic freedom.
Waiting time for non-emergency medical care in developing countries is rarely of immediate concern to policy makers that prioritize provision of basic health services. However, waiting time as a measure of health system responsiveness is important because longer waiting times worsen health outcomes and affect utilization of services. Studies that assess socio-economic inequalities in waiting time provide evidence from developed countries such as England and the United States; evidence from developing countries is lacking. In this paper, we assess the relationship between social class i.e. caste of an individual and waiting time at health facilities—a client orientation dimension of responsiveness. We use household level data from two rounds of the Indian Human Development Survey with a sample size of 27,251 households in each wave (2005 and 2012) and find that lower social class is associated with higher waiting time. This relationship is significant for individuals that visited a male provider but not so for those that visited a female provider. Further, caste is positively related to higher waiting time only if visiting a private facility; for individuals visiting a government facility the relationship between waiting time and caste is not significant. In general, caste related inequality in waiting time has worsened over time. The results are robust to different specifications and the inclusion of several confounders.
Background: International and domestic funding for malaria is critically important to achieve the Sustainable Development Goals. Its equitable distribution is key in ensuring that the available, scarce, resources are deployed efficiently for improved progress and a sustained Response that enables eradication.Methods. We used concentration curves and concentration indices to assess inequalities in Malaria funding by different donors across countries, measuring
both horizontal and vertical equity. Horizontal equity assesses whether funding is distributed in proportion to health needs, whereas vertical equity examines whether unequal economic needs are addressed by appropriately unequal funding. We computed the Health Inequity Index and the Kakwani Index to assess the former and the latter, respectively. We used data from the World Bank, Global Fund, Unicef, President’s Malaria Initiative and the Malaria Atlas Project to assess the distribution of funding against need for 94 countries. National gross domestic product
per capita was used as a proxy for economic need and ‘population-at-risk’ for health need.
Domestic violence represents the most important component of violence against women. Whilst some literature report female empowerment as a protective factor against domestic violence, some literature find the opposite because the husband may attempt to compensate for the enhanced status of his wife. This paper aims to investigate the effects of female empowerment in the form of marital age and education on domestic violence in India, where intimate partner violence is amongst the highest in Asia. The analysis is based on the sample of eligible women aged 15-49 with valid response on domestic violence in the 2015- 2016 National Family Health Survey (NFHS-4) (n=9722). Upon estimating a series of instrumental variable (IV) regressions using age at menarche as an exogenous and strong instrument, we establish a causal relationship between empowerment and domestic violence taking into account the endogeneity of marital age and education. We further disentangle the relationships between domestic violence and age at marriage and education, separately. In addition, we investigate how maritage age and education influence domestic violence through labour market participation and spouse quality channels. We find that: i) empowered women do experience less domestic violence; ii) marital age and education are partially complementary; iii) labour market participation and spousal quality are relevant mediators of these relationships. Policies aiming at reducing domestic violence in India hence should be holistic, focussing on investing in education both for women and men and improving the conditions of the women’ labour market.
The European Union (“EU”) and India, two of the most significant jurisdictions in the world, are in the process of introducing transformative legal and policy instruments that seek to leverage digital technologies for health. On 15 August 2020, India unveiled its National Digital Health Mission policy - later rolled out as the Ayushman Bharat Digital Mission (“ABDM”) - that seeks to create an open, interoperable digital health ecosystem in the country, enabling various digital health systems to engage with each other and empower individuals to be in control of their health data. On the other hand, on 3rd May 2022, the EU released a proposal for a regulation for a European Health Data Space (“EHDS”) to address health-specific challenges to electronic health data access and sharing and create a common space where natural persons can easily control their electronic health data.
However, considering these jurisdictions' geographical, cultural, and historical dispositions, various concerns emerge that may cause hindrance to these projects. While the EU has demonstrated its highlyadvanced approach towards policy-making in data-relevant domains, including health, India has showcased its efficiency and experience in scaling data systems and making them interoperable. Accordingly, this research paper highlights certain specific policy- and implementation-level concerns that both jurisdictions need to pay heed to while going ahead with their respective projects. Additionally, after studying the various digital healthcare ecosystems in these jurisdictions, the paper makes certain recommendations to work towards a seamless design, development, deployment, and operation of the frameworks.