Childhood Immunization and Competing Mortality Risks in Kenya: A Longitudinal Analysis for Multiparous Mothers.

OBJECTIVE: To assess the relationship between childhood immunization and mortality risks for nonvaccine-preventable diseases (competing mortality risks, or CMR) in Kenya. STUDY DESIGN: A combination of the Global Burden of Disease and Demographic Health Survey data was used to measure basic vaccination status, CMR, and control variables for each child in the Demographic Health Survey 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 13.00 to 738.32 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. In contrast, 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 was found, which has important implications for immunization policies, particularly in Kenya. Interventions aimed at reducing the most severe CMR, such as diarrhea, and targeted toward multiparous mothers may improve childhood immunization coverage.

Retirement and Household Expenditure in Turbulent Times.

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.

Strengthening health system governance in Germany: looking back, planning ahead.

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.

Older Europeans' health perception and their adaptive behaviour during the COVID-19 pandemic.

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.

Socio-economic inequalities in arts engagement and depression among older adults in the United Kingdom: evidence from the English Longitudinal Study of Ageing.

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.

Impacts of introducing and lifting nonpharmaceutical interventions on COVID-19 daily growth rate and compliance in the United States.

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.

Revisiting the Relationship Between Price Regulation and Pharmaceutical R&D Investment.

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.

Measuring geographical disparities in England at the time of COVID-19: results using a composite indicator of population vulnerability.

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.

Pharmaceutical expenditure and gross domestic product: Evidence of simultaneous effects using a two-step instrumental variables strategy.

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 at health facilities and social class: Evidence from the Indian caste system.

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.

Your retirement and my health behavior: Evidence on retirement externalities from a fuzzy regression discontinuity design.

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.

Vertical and horizontal equity of funding for malaria control: a global multisource funding analysis for 2006-2010.

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. FINDINGS: The level and direction of inequity varies across funding sources. Unicef and the President's Malaria Initiative were the most horizontally inequitable (pro-poor). Inequity as shown by the Health Inequity Index for Unicef decreased from -0.40 (P<0.05) in 2006 to -0.25 (P<0.10) in 2008, and increased again to -0.58 (P<0.01) in 2009. For President's Malaria Initiative, it increased from -0.19 (P>0.10) in 2006 to -0.38 (P<0.05) in 2008, and decreased to -0.36 (P<0.10) in 2010. Domestic funding was inequitable (pro-rich) with inequity increasing from 0.28 (P<0.01) in 2006 to 0.39 (P<0.01) in 2009, and then decreasing to 0.22 (P<0.10) in 2010. Funding from the World Bank and the Global Fund was distributed proportionally according to need. In terms of vertical inequity, all sources were progressive: Unicef and the President's Malaria Initiative were the most progressive with the Kakwani Indices ranging from -0.97 (P<0.01) to -1.29 (P<0.01), and -0.90 (P<0.01) to -1.10 (P<0.01), respectively. CONCLUSION: Our results suggest that external funding of malaria treatment tends to be allocated to countries with higher health and economic need but not in proportion to their relative health need and income when compared to other countries. While malaria eradication might require funders to disproportionally allocate funding that goes beyond (financial and health) need, our analysis highlights that funders might potentially be targeting in excess certain countries. Regular assessments of need and greater coordination among donors are necessary for equitable resource allocation, to improve and sustain progress with malaria control and elimination.