Health and labor market effects of an unanticipated rise in retirement age. Evidence from the 2012 Italian pension reform.

As retirement ages increase around the world, not all workers may be equally able to extend their working lives. In this article, we examine the health and labor market effects of an Italian pension reform that suddenly increased the normal retirement age up to 7 years for women and up to 2 years for men. To do this, we use linked labor and healthcare administrative data, jointly with survey data and difference-in-difference methods. Our results show that the reform was effective in postponing retirement among both genders, as pension claiming dropped substantially for older workers. However, there were also side effects as the reform significantly pushed previously employed men and women into unemployment and disability pension. Among women only, the reform also increased sick leave and hospitalizations related to mental health and injuries. These effects were driven by women with previously low health status, suggesting that undifferentiated and abrupt increases in pension age might harm more vulnerable workers. Coherently with the milder tightening of retirement age experienced by men, labor market responses were smaller in size, and they did not suffer any significant health effects.

The far-right and anti-vaccine attitudes: lessons from Spain's mass COVID-19 vaccine roll-out.

BACKGROUND: Far-right politicians in several countries have been vocal opponents of COVID-19 vaccination. But can this threaten vaccine roll-out? METHODS: We take advantage of repeated cross-sectional surveys with samples of around 3800 individuals across Spain conducted monthly from December 2020 to January 2022 (n = 51 294) to examine any association between far-right politics and vaccine hesitancy through the whole vaccine roll-out. RESULTS: Consistent with prior data, we found that far-right supporters were almost twice as likely to be vaccine-hesitant than the overall population in December 2020, before vaccines became available. However, with a successful vaccine roll out, this difference shrank, reaching non-significance by September 2021. From October 2021, however, vaccine hesitancy rebounded among this group at a time when the leadership of the far-right promoted a 'freedom of choice' discourse common among anti-vax supporters. By the latest month analysed (January 2022), far-right voters had returned to being twice as likely to be vaccine-hesitant and 7 percentage points less likely to be vaccinated than the general population. CONCLUSIONS: Our results are consistent with evidence that far-right politicians can encourage vaccine hesitancy. Nonetheless, we show that public attitudes towards vaccination are not immutable. Whereas a rapid and effective vaccine rollout can help to overcome the resistance of far-right voters to get vaccinated, they also seem to be susceptible to their party leader's discourse on vaccines.

Global financing for health policy and systems research: a review of funding opportunities.

Health policy and systems research (HPSR) is a neglected area in global health financing. Despite repeated calls for greater investment, it seems that there has been little growth. We analysed trends in reported funding and activity between 2015 and 2021 using a novel real-time source of global health data, the Devex.com database, the world's largest source of funding opportunities related to international development. We performed a systematic search of the Devex.com database for HPSR-related terms with a focus on low- and middle-income countries. We included 'programs', 'tenders & grants' and 'contract awards', covering all call statuses (open, closed or forecast). Such funding opportunities were included if they were related specifically to HPSR funding or had an HPSR component; pure biomedical funding was excluded. Our findings reveal a relative neglect of HPSR, as only ∼2% of all global health funding calls included a discernible HPSR component. Despite increases in funding calls until 2019, this situation reversed in 2020, likely reflecting the redirection of resources to rapid assessments of the impacts of the coronavirus disease 2019 (COVID-19) pandemic. Most identified projects represented small-scale opportunities-commonly for consultancies or technical assistance. To the extent that new data were generated, these projects were either tied to a specific large intervention or were narrow in scope to meet a specific challenge-with many examples informing policy responses to the Covid-19 pandemic. Nearly half of advertised funding opportunities were multi-country projects, usually addressing global policy priorities like health systems strengthening or development of coordinated public health policies at a regional level. The Covid-19 pandemic has shown why investing in HPSR is more important than ever to enable the delivery of effective health interventions and avoid costly implementation failures. The evidence presented here highlights the need to scale up efforts to convince global health funders to institutionalize the inclusion of HPSR components in all funding calls.

Donor support for Health Policy and Systems Research: barriers to financing and opportunities for overcoming them.

BACKGROUND: The vast investments that have been made in recent decades in new medicines, vaccines, and technologies will only lead to improvements in health if there are appropriate and well-functioning health systems to make use of them. However, despite the growing acceptance by major global donors of the importance of health systems, there is an enthusiasm gap when it comes to disbursing funds needed to understand the intricacies of how, why and when these systems deliver effective interventions. To understand the reasons behind this, we open up the black box of donor decision-making vis-à-vis Health Policy and Systems Research (HPSR) financing: what are the organizational processes behind the support for HPSR, and what are the barriers to increasing engagement? METHODS: We conducted 27 semi-structured interviews with staff of major global health funders, asking them about four key issues: motivations for HPSR financing; priorities in HPSR financing; barriers for increasing HPSR allocations; and challenges or opportunities for the future. We transcribed the interviews and manually coded responses. RESULTS: Our findings point to the growing appreciation that funders have of HPSR, even though it is often still seen as an 'afterthought' to larger programmatic interventions. In identifying barriers to funding HPSR, our informants emphasised the perceived lack of mandate and capacities of their organizations. For most funding organisations, a major barrier was that their leadership often voiced scepticism about HPSR's long time horizons and limited ability to quantify results. CONCLUSION: Meeting contemporary health challenges requires strong and effective health systems. By allocating more resources to HPSR, global donors can improve the quality of their interventions, and also contribute to building up a stock of knowledge that domestic policymakers and other funders can draw on to develop better targeted programmes and policies.

Governing and Measuring Health Security: The Global Push for Pandemic Preparedness Indicators.

Providing collective solutions to global pandemics requires the coordination of information that is accurate and accountable. In recent years there has been a global push for reliable pandemic preparedness indicators. This push has come from U.S. foreign policy, the World Health Organization (WHO), NGOs, and private foundations. These actors want control over how data for preparedness indicators is collected, analysed, and promoted. Governments want to influence how they are assessed, using poor performance to attract attention and good performance to deflect blame. In this article we discuss how the push for pandemic preparedness indicators comes from the dual aims of repelling national risk, the spread of disease, while reducing global harm through stronger transnational governance arrangements. We delve into the development of indicators from the WHO and the privately-run Global Health Security Index, and examine how their claims to authority measure-up against standards of transparency, veracity, and accountability. We stress the importance of understanding how these indicators are composed. This is vital given the current drive to include social and governance metrics in revised efforts at data collection, as well as efforts to include pandemic preparedness indicators in how intergovernmental organizations, NGOs, donors, and funders devise health and development policies.

Impact of COVID-19 lockdowns on mental health: Evidence from a quasi-natural experiment in England and Scotland.

The COVID-19 pandemic has been associated with worsening mental health but it is unclear whether this is a direct consequence of containment measures, like "Stay at Home" orders, or due to other considerations, such as fear and uncertainty about becoming infected. It is also unclear how responsive mental health is to a changing situation. Exploiting the different policy responses to COVID-19 in England and Scotland and using a difference-in-difference analysis, we show that easing lockdown measures rapidly improves mental health. The results were driven by individuals with lower socioeconomic position, in terms of education or financial situation, who benefited more from the end of the strict lockdown, whereas they suffered a larger decline in mental health where the lockdown was extended. Overall, mental health appears to be more sensitive to the imposition of containment policies than to the evolution of the pandemic itself. As lockdown measures may continue to be necessary in the future, further efforts (both financial and mental health support) are required to minimize the consequences of COVID-19 containment policies for mental health.

Are we making the same mistakes in fighting COVID­19 as in past pandemics? Lessons from HIV show the urgent need to invest in HPSR.

Are we repeating the mistakes of the human immunodeficiency virus (HIV) epidemic in our approach to combating coronavirus disease 2019 (COVID-19)? Is the world's emphasis on developing vaccines overshadowing investment in the health systems that can deliver them? We analyse a report on the politics of investing in health policy and systems research (HPSR) and conclude by outlining three critical actions, using the Stuckler-McKee model of social change in health. These are: exploiting a political window of opportunity; changing the conversation; and mobilising a campaign to drive the agenda. When implemented together, these actions could help accelerate investment in health systems to combat the immediate COVID-19 pandemic and prepare health systems for the next crisis.

Organising knowledge to prevent global health crises: a comparative analysis of pandemic preparedness indicators.

Preparing for the possibility of a global pandemic presents a transnational organisational challenge: to assemble and coordinate knowledge over institutionally diverse countries with high fidelity. The COVID-19 pandemic has laid these problems bare. This article examines the construction of the three main cross-national indicators of pandemic preparedness: a database with self-reported data by governments, external evaluations organised by the WHO and a global ranking known as the Global Health Security Index. Each of these presents a different model of collecting evidence and organising knowledge: the collation of self-reports by national authorities; the coordination of evaluation by an epistemic community authorised by an intergovernmental organisation and on the basis of a strict template; and the cobbling together of different sources into a common indicator by a transnational multi-stakeholder initiative. We posit that these models represent different ways of creating knowledge to inform policy choices, and each has different forms of potential bias. In turn, this shapes how policymakers understand what is 'best practice' and appropriate policy in pandemic preparedness.

Whatever it takes? The global financial safety net, Covid-19, and developing countries.

Multilateral financial institutions have pledged to do whatever it takes to enable emerging market and developing countries to fill a $2.5 trillion financing gap to combat Covid-19 and subsequent economic crises. In this article, we present new datasets to track the extent to which multilateral financial institutions are meeting these goals, and conduct a preliminary assessment of progress to date. We find that the International Monetary Fund and the principal regional financial arrangements have made relatively trivial amounts of new financing available and have been slow to disburse the financing at their disposal. As of July 31, 2020, these institutions had committed $89.56 billion in loans and $550 million in currency swaps, totaling $90.11 billion-just 12.6% of their current capacity. The new datasets allow scholars, policymakers, and civil society to continue to track these trends, and eventually examine the impact of such financing on health and development outcomes.

Legitimacy challenges to the liberal world order: Evidence from United Nations speeches, 1970-2018.

The liberal international economic order has been facing high-profile legitimacy challenges in recent years. This article puts these challenges in historical context through a systematic analysis of rhetorical challenges towards both the order per se and specific global economic institutions. Drawing on Albert Hirschman's classic typology of exit, voice and loyalty, we coded leaders' speeches in the General Debate at the UN General Assembly between 1970 and 2018 as articulating intentions to abandon elements of the order, challenges or calls for reform, unequivocal support, or factual mentions of cooperation. Surprisingly, we find that explicit criticisms towards the liberal order are at an all-time low and that exit threats remain rare. An analysis of the historical evolution of criticisms to global economic institutions reveals a move away from the Cold War insider-outsider conflict towards insider contestation. For example, we find that as countries' economies become more open, their leaders expressed more support for global economic institutions during the Cold War but less support since. Finally, we demonstrate consistency between the public policy positions leaders announce in UNGA General Debate speeches and their government positions on consequential reform debates on debt relief.

Globalization and health equity: The impact of structural adjustment programs on developing countries.

Among the many drivers of health inequities, this article focuses on important, yet insufficiently understood, international-level determinants: economic globalization and the organizations that spread market-oriented policies to the developing world. One such organization is the International Monetary Fund (IMF), which provides financial assistance to countries in economic trouble in exchange for policy reforms. Through its 'structural adjustment programs,' countries around the world have liberalized and deregulated their economies. We examine how policy reforms prescribed in structural adjustment programs explain variation in health equity between nations-approximated by health system access and neonatal mortality. Our empirical analysis uses an original dataset of IMF-mandated policy reforms for a panel of up to 137 developing countries between 1980 and 2014. We employ regression analysis to evaluate the relationship between these reforms and health equity, taking into account the non-random selection and design of IMF programs. We find that structural adjustment reforms lower health system access and increase neonatal mortality. Additional analyses show that labor market reforms drive these deleterious effects. Overall, our evidence suggests that structural adjustment programs endanger the attainment of Sustainable Development Goals in developing countries.

Power asymmetries in global governance for health: a conceptual framework for analyzing the political-economic determinants of health inequities.

BACKGROUND: Recent scholarship has increasingly identified global power asymmetries as the root cause of health inequities. This article examines how such asymmetries manifest in global governance for health, and how this impacts health outcomes. RESULTS: We focus on the political-economic determinants of global health inequities, and how these determinants operate at different levels of social action (micro, meso, and macro) through distinct but interacting mechanisms. To clarify how these mechanisms operate, we develop an integrative framework for examining the links between global neoliberalism-the currently dominant policy paradigm premised on advancing the reach of markets and promoting ever-growing international economic integration-and global health inequities, and show how these mechanisms have macro-macro, macro-meso-macro, and macro-micro-macro manifestations. CONCLUSIONS: Our approach enables the design of theoretically-nuanced empirical strategies to document the multiple ways in which the political economy entrenches or, alternatively, might ameliorate global health inequities.

How structural adjustment programs affect inequality: A disaggregated analysis of IMF conditionality, 1980-2014.

This article highlights an important yet insufficiently understood international-level determinant of inequality in the developing world: structural adjustment programs by the International Monetary Fund (IMF). Studying a panel of 135 countries for the period 1980 to 2014, we examine income inequality using multivariate regression analysis corrected for non-random selection into both IMF programs and associated policy reforms (known as 'conditionality'). We find that, overall, policy reforms mandated by the IMF increase income inequality in borrowing countries. We also test specific pathways linking IMF programs to inequality by disaggregating conditionality by issue area. Our analyses indicate adverse distributional consequences for four policy areas: fiscal policy reforms that restrain government expenditure, external sector reforms stipulating trade and capital account liberalization, financial sector reforms entailing inflation-control measures, and reforms that restrict external debt. These effects occur one year after the incidence of an IMF program, and persist in the medium term. Taken together, our findings suggest that the IMF's recent attention to inequality neglects the multiple ways through which the organization's own policy advice has contributed to inequality in the developing world.

Infectious disease health services for refugees and asylum seekers during a time of crisis: A scoping study of six European Union countries.

BACKGROUND: Systematic information on infectious disease services provided to refugees and asylum seekers in the European Union (EU) is sparse. We conducted a scoping study of experts in six EU countries in order to map health system responses related to infectious disease prevention and control among refugees and asylum seekers. METHODS: We conducted 27 semi-structured in-depth interviews with first-line staff and health officials to collect information about existing guidelines and practices at each stage of reception in first-entry (Greece/Italy), transit (Croatia/Slovenia), and destination countries (Austria/Sweden). Thematic coding was used to perform a content analysis of interview material. RESULTS: Guidance on infectious disease screening and health assessments lack standardisation across and-partly-within countries. Data collection on notifiable infectious diseases is mainly reported to be performed by national public health institutions, but is not stratified by migrant status. Health-related information is not transferred in a standardized way between facilities within a single country. International exchange of medical information between countries along the migration route is irregular. Services were reported to be fragmented, and respondents mentioned no specific coordination bodies beyond health authorities at different levels. CONCLUSION: Infectious disease health services provided to refugees and asylum seekers lack standardisation in health assessments, data collection, transfer of health-related information and (partly) coordination. This may negatively affect health system performance including public health emergency preparedness.

Impact of International Monetary Fund programs on child health.

Parental education is located at the center of global efforts to improve child health. In a developing-country context, the International Monetary Fund (IMF) plays a crucial role in determining how governments allocate scarce resources to education and public health interventions. Under reforms mandated by IMF structural adjustment programs, it may become harder for parents to reap the benefits of their education due to wage contraction, welfare retrenchment, and generalized social insecurity. This study assesses how the protective effect of education changes under IMF programs, and thus how parents' ability to guard their children's health is affected by structural adjustment. We combine cross-sectional stratified data (countries, 67; children, 1,941,734) from the Demographic and Health Surveys and the Multiple Indicator Cluster Surveys. The sample represents ∼2.8 billion (about 50%) of the world's population in year 2000. Based on multilevel models, our findings reveal that programs reduce the protective effect of parental education on child health, especially in rural areas. For instance, in the absence of IMF programs, living in an household with educated parents reduces the odds of child malnourishment by 38% [odds ratio (OR), 0.62; 95% CI, 0.66-0.58]; in the presence of programs, this drops to 21% (OR, 0.79; 95% CI, 0.86-0.74). In other words, the presence of IMF conditionality decreases the protective effect of parents' education on child malnourishment by no less than 17%. We observe similar adverse effects in sanitation, shelter, and health care access (including immunization), but a beneficial effect in countering water deprivation.