Financial influence on global risks of zoonotic emerging and re-emerging diseases: an integrative analysis.

BACKGROUND: Emerging and re-emerging infectious diseases (EIDs), such as Ebola virus disease and highly pathogenic influenza, are serious threats to human health and wellbeing worldwide. The financial sector has an important, yet often ignored, influence as owners and investors in industries that are associated with anthropogenic land-use changes in ecosystems linked to increased EIDs risks. We aimed to analyse financial influence associated with EIDs risks that are affected by anthropogenic land-use changes. We also aimed to provide empirical assessments of such influence to help guide engagements by governments, private organisations, and non-governmental organisations with the financial sector to advance a planetary health agenda. METHODS: For this integrative analysis, we identified regions in the world where there was evidence of a connection between EIDs and anthropogenic land-use changes between Nov 9, 1999, and Oct 25, 2021, through a targeted literature review of academic literature and grey literature to identify evidence of drivers of anthropogenic land-use change and their association with commodity production in these regions. We only included publications in English that showed a connection between deforestation and the production of one or more commodities. Publications merely describing spatial or temporal land-use change dynamics (eg, a reduction of forest or an increase of palm-oil plantations) were excluded. As we were assessing financial influence on corporate activities through ownership specifically, we focused our analysis on publicly listed companies. Equity data and data about ownership structure were extracted from Orbis, a company information database. We assessed financial influence by identifying financial entities with the largest equity ownership, descriptively mapping transboundary connections between investors and publicly listed companies. FINDINGS: 227 public and private companies operating in five economic sectors (ie, production of palm oil, pulp and wood products, cocoa, soybeans, and beef) between Dec 15, 2020, and March 8, 2021, were identified. Of these 227, 99 (44%) were publicly listed companies, with 2310 unique shareholders. These publicly listed companies operated in six geographical regions, resulting in nine case-study regions. 54 (55%) companies with complete geographical information were included in the countries network. Four financial entities (ie, Dimensional, Vanguard, BlackRock, and Norway's sovereign wealth fund) each had ownership in 39 companies or more in three of the case-study regions (ie, north America, east Asia, and Europe). Four large US-based asset managers (ie, Vanguard, BlackRock, T Rowe Price, and State Street) were the largest owners of publicly listed companies in terms of total equity size, with ownership amounts for these four entities ranging from US$8 billion to $21 billion. The specific patterns of cross-national ownership depended on the region of interest; for example, financial influence on EIDs risks that was associated with commodity production in southeast and east Asia came from not only global asset managers but also Malaysian, Chinese, Japanese, and Korean financial entities. India, Brazil, the USA, Mexico, and Argentina were the countries towards which investments were most directed. INTERPRETATION: Although commodity supply chains and financial markets are highly globalised, a small number of investors and countries could be viewed as disproportionally influential in sectors that increase EIDs risks. Such financial influence could be used to develop and implement effective policies to reduce ecological degradation and mitigate EIDs risks and their effects on population health. FUNDING: Formas and Networks of Financial Rupture-how cascading changes in the climate and ecosystems could impact on the financial sector.

Discovery and Development of Pregabalin (Lyrica): The Role of Public Funding.

BACKGROUND AND OBJECTIVES: Pregabalin (Lyrica), a widely used drug that has generated billions in revenue as a treatment for diabetic neuropathy and other conditions, was originally discovered in an academic medical center, largely supported by public funding. We aimed to define the extent of direct federal public funding that contributed to various stages of pregabalin's development prior to US Food and Drug Administration (FDA) approval. METHODS: We identified key research, scientists, and organizations involved in the development of pregabalin from its discovery through FDA approval. Using key terms (e.g., its indications and mechanism of action), we searched PubMed for relevant publications and determined whether each publication was based on federal public funding using the NIH RePORTER. For each award prior to the drug's FDA approval, we scored its potential relatedness to pregabalin's development based on its title, investigator, and organization, and then examined descriptions of the most relevant awards to aid in defining these relationships. The budgets for all related awards were converted to 2020 dollars. RESULTS: Pregabalin was discovered largely on the basis of publicly funded research at Northwestern University; in 1990, it was licensed to Parke-Davis, which further developed it through its FDA approval in 2004. Most key terms were related to the drug and drug target (n = 5) and organizations involved (n = 5), followed by patent-listed inventors (n = 3). These key terms linked 6,438 core project awards and we identified 37 NIH awards related to pregabalin's development: 9 awards through 1990 ($3.3 million) and 28 from 1991 through 2004 ($10.5 million). CONCLUSION: Like that of many other widely sold medications, the development of pregabalin relied on public sector as well as industry contributions to its discovery, with relevant NIH awards totaling $13.8 million during its preapproval development.

Availability, affordability and stock-outs of commodities for the treatment of snakebite in Kenya.

BACKGROUND: Annually, about 2.7 million snakebite envenomings occur globally. Alongside antivenom, patients usually require additional care to treat envenoming symptoms and antivenom side effects. Efforts are underway to improve snakebite care, but evidence from the ground to inform this is scarce. This study, therefore, investigated the availability, affordability, and stock-outs of antivenom and commodities for supportive snakebite care in health facilities across Kenya. METHODOLOGY/PRINCIPAL FINDINGS: This study used an adaptation of the standardised World Health Organization (WHO)/Health Action International methodology. Data on commodity availability, prices and stock-outs were collected in July-August 2020 from public (n = 85), private (n = 36), and private not-for-profit (n = 12) facilities in Kenya. Stock-outs were measured retrospectively for a twelve-month period, enabling a comparison of a pre-COVID-19 period to stock-outs during COVID-19. Affordability was calculated using the wage of a lowest-paid government worker (LPGW) and the impoverishment approach. Accessibility was assessed combining the WHO availability target (≥80%) and LPGW affordability (<1 day's wage) measures. Overall availability of snakebite commodities was low (43.0%). Antivenom was available at 44.7% of public- and 19.4% of private facilities. Stock-outs of any snakebite commodity were common in the public- (18.6%) and private (11.7%) sectors, and had worsened during COVID-19 (10.6% versus 17.0% public sector, 8.4% versus 11.7% private sector). Affordability was not an issue in the public sector, while in the private sector the median cost of one vial of antivenom was 14.4 days' wage for an LPGW. Five commodities in the public sector and two in the private sector were deemed accessible. CONCLUSIONS: Access to snakebite care is problematic in Kenya and seemed to have worsened during COVID-19. To improve access, efforts should focus on ensuring availability at both lower- and higher-level facilities, and improving the supply chain to reduce stock-outs. Including antivenom into Universal Health Coverage benefits packages would further facilitate accessibility.

Availability, affordability and price components of insulin products in different-level hospital pharmacies: Evidence from two cross-sectional surveys in Nanjing, China.

The essential medicine--insulin cannot be easily accessed and afforded in many countries. To help address this issue, we evaluated the availability, affordability and price of insulin products in Nanjing, eastern China. Two cross-sectional studies were conducted in 2016 and 2018. A total of 56 hospital pharmacies were sampled, using a simplified and adapted World Health Organization/Health Action International (WHO/HAI) methodology. Prices were expressed as Median Price Ratios (MPRs) to Australian Pharmaceutical Benefit Scheme (PBS) prices. In addition, we investigated the price components of seven selected insulin products as a case study before and after the Online Centralized Procurement Policy for Hospital Drugs in May, 2018. Affordability was presented as the number of daily wages of the lowest paid unskilled government worker (LPGW) required to purchase 1000IU of insulin based on the average courses of treatment, approximately 30 days' treatment. The availability of insulin products was very high in secondary hospitals and tertiary hospitals both in 2016 and 2018, but in community hospitals was very low. In 2018, the availability of prandial insulin products showed fluctuation compared to 2016. The availability of pre-mixed human insulin products was over 95% overall, and also very high (80%) in community hospitals in 2018. The prices of insulin products were much lower than PBS prices of Australian in this study, with the MPRs less than 1 (0.32 to 0.71 in 2016 vs. 0.30 to 0.68 in 2018) for all insulin types. But insulin products in Nanjing in 2016 and 2018 were considered unaffordable, because the number of daily wages of the LPGW needed to purchase for the 30 days treatment of insulin products ranged from 2.26 to 8.49 in 2016 and 1.88 to 7.09 in 2018. The manufacturers' selling price contributed the main part (74.15% to 77.70% before and 74.86% to 91.51% after the implementation of the bidding policy) of the price components of target insulin brands. The availability of insulin products was high in secondary hospitals and tertiary hospitals, but lower in community hospitals. However, the affordability in community hospitals was better than other hospitals, but the insulin products were still unaffordable for patients on low incomes. Further improvements of the availability accessibility and affordability of medicines in advancing health insurance policies and lowering drug prices should be put forward.

A total cost perspective of type 1 and 2 diabetes mellitus in two South African medical schemes servicing the public healthcare sector.

BACKGROUND: Diabetes is increasingly becoming a public health concern in South Africa (SA). There are limited available data on the costs of diabetes. OBJECTIVES: To provide a total cost perspective of diabetes using medical scheme claims data from two SA medical schemes servicing the public healthcare sector in 2015 and 2016. METHODS: We analysed data from 2 363 diabetes patients. Direct diabetes care costs included medication, consumables, hospitalisation and routine laboratory tests. Indirect costs were calculated by allocating economic costs related to disability-adjusted life years. RESULTS: The mean (standard deviation) age was 65.8 (13.4) years and women comprised 51% of the group. Hospitalisation (64.7% in 2015 and 65.5% in 2016) and medication (31.0% in 2015 and 21.1% in 2016) contributed the most to total direct costs. Total direct diabetes care costs mounted to ZAR2 452 per patient in 2015 and ZAR2 486 in 2016. Indirect costs were ZAR17 223 per patient in 2015 and ZAR18 711 in 2016. When direct and indirect costs were combined, the costs accrued to ZAR27.9 billion (ZAR19 675 per patient) in 2015 and ZAR29.9 billion (ZAR21 197 per patient) in 2016, representing 0.688% and 0.689% of the SA gross domestic product over the 2 years, respectively. CONCLUSIONS: Diabetes and its associated costs hold significant implications for the healthcare sector and the country's economy. Large numbers of diabetic individuals remain undiagnosed and the true costs of diabetes might even be higher.

Research on the cooperative mechanism of government and enterprise for basin ecological compensation based on differential game.

Ecological compensation is an important means of basin pollution control, the existing researches mainly focus on the government level ignoring the important role of enterprises. Therefore, this paper introduces enterprises into the process of ecological compensation. Firstly, suppose the ecological compensation system composed of government and enterprises, the government is in the dominant position. The ecological compensation input of the government and enterprise will produce social reputation, and the ecological compensation of enterprise will also produce advertising effect. Consumer demand will be affected by social reputation and advertising effect. Then, the compensation strategies of the government and enterprise are analyzed by constructing the differential game model. The research shows that under certain conditions, the cost-sharing mechanism can realize the Pareto improvement of the benefits of government, enterprise and the whole system. Under the cooperative mechanism, the benefit of the government, enterprise and the whole system is optimal. Finally, the validity of the conclusion is verified by case analysis, and the sensitivity analysis of the relevant parameters is carried out. The conclusion can provide reference for government to establish sustainable watershed ecological compensation mechanism.

Comparing apples with oranges: administrative expenses and finances in Medicare systems.

OBJECTIVES: Proponents of a single-payer or public option health care system often cite the lower administrative expenses in public Medicare compared with those in private Medicare, claiming that this difference represents efficiency. We check the validity of this comparison in terms of accuracy and definitions and suggest expanding its scope to include expanded financial data of the 2 Medicare systems. STUDY DESIGN: Using annual Medicare Boards of Trustees and National Health Expenditure Accounts data from CMS and health insurers' financial statement data, we compare the level and percentage of the administrative expenses of the Medicare systems and show incompatible and not reconcilable definitions of administrative expenses. We expand our analysis to income, benefits, gains and losses, and loss ratios of the programs. METHODS: Our methodology is a careful comparison of categories of expenses between public and private insurers using official data sources. The comparison is both qualitative and quantitative. RESULTS: We validate the low administrative expenses of Medicare parts A, B, and D (1.35% of benefits in 2018) compared with Medicare Part C (10.86% of benefits without loss adjustment expenses [LAE] and 14.84% with LAE for 2018). Expanding the focus, the income and benefits per beneficiary grew faster and larger in Medicare parts A, B, and D than in Medicare Part C-a reversal of earlier trends. The public Medicare program suffered losses in 11 years during 2002-2018, whereas private insurers' Medicare remained solvent with about an 85% loss ratio. CONCLUSIONS: Comparisons of the systems in the United States would benefit from expanding the focus beyond incomparable administrative expenses. For the current period of coronavirus disease 2019, if the trends continue, public Medicare may suffer greater deficits relative to the private Medicare Part C.

Responsibility for Funding Refractive Correction in Publicly Funded Health Care Systems: An Ethical Analysis.

Allocating on the basis of need is a distinguishing principle in publicly funded health care systems. Resources ought to be directed to patients, or the health program, where the need is considered greatest. In Sweden support of this principle can be found in health care legislation. Today however some domains of what appear to be health care needs are excluded from the responsibilities of the publicly funded health care system. Corrections of eye disorders known as refractive errors is one such domain. In this article the moral legitimacy of this exception is explored. Individuals with refractive errors need spectacles, contact lenses or refractive surgery to do all kinds of thing, including participating in everyday activities, managing certain jobs, and accomplishing various goals in life. The relief of correctable visual impairments fits well into the category of what we typically consider a health care need. The study of refractive errors does belong to the field of medical science, interventions to correct such errors can be performed by medical means, and the skills of registered health care professionals are required when it comes to correcting refractive error. As visual impairments caused by other conditions than refractive errors are treated and funded within the public health care system in Sweden this is an inconsistency that needs to be addressed.

Nationwide survey of the availability and affordability of asthma and COPD medicines in Nigeria.

OBJECTIVE(S): To determine the availability and affordability of asthma and COPD medicines across Nigeria. METHODS: This was a cross-sectional survey conducted in 128 pharmacies (51 in public sector hospitals, 51 private sector community pharmacies and 26 charity or big private hospitals) across the six geopolitical zones of Nigeria using the WHO/Health Action Initiative method. The proportion of pharmacies where medicines were available, the median retail prices of originator and generics and affordability were analysed. A medicine was available if found in ≥ 80% of surveyed pharmacies. Unaffordability was defined as paying> 1 day's wage (> US$1.68) for a standard 30-day supply of the medicine. RESULTS: The available medicines were oral corticosteroids and oral salbutamol which are not on the WHO Essential Medicine List. Medicines were found more frequently in private than public pharmacies and in the southern than northern zones. Inhalable corticosteroid was not available at any public pharmacy nationwide. None of the EML medicines were affordable. The least number of days' wages for a 30-day supply of any inhalable corticosteroid-containing medication was 3.5 days. CONCLUSIONS: There are very limited availability and affordability of recommended asthma and COPD medicines across Nigeria with disparity across regions. Medicines that were available and affordable are not recommended and are harmful for long-term use. This underpins the need for engagement of all stakeholders for the review of existing policies regarding access to asthma and COPD medicines to improve availability and affordability.

Retirement, Pensions, and Depressive Symptoms Among Older Adults in China, England, Mexico, and the United States.

This study explores the associations of retirement, and of public and private pensions, with older adults' depressive symptoms by comparing differences between countries and age groups. Harmonized data were analyzed from the family of Health and Retirement Study in 2012-2013 from China, England, Mexico, and the United States (n = 97,978). Respondents were asked if they were retired and received public or private pensions. Depressive symptom was measured by the Center for Epidemiologic Studies Depression Scale. Retirement was significantly associated with higher depressive symptoms for the United States and with lower depressive symptoms for Mexico and England. Public pension was significantly associated with lower depressive symptoms for Mexico and with higher depressive symptoms for the United States and China. Private pension was significantly associated with lower depressive symptoms for the United States, China, and England. Our study shows that continuity theory demonstrates cross-national variation in explaining the association between retirement and depressive symptoms.

Variation in the availability and cost of essential medicines for non-communicable diseases in Uganda: A descriptive time series analysis.

BACKGROUND: Availability of essential medicines for non-communicable diseases (NCDs) is poor in low- and middle-income countries. Availability and cost are conventionally assessed using cross-sectional data. However, these characteristics may vary over time. METHODS: We carried out a prospective, descriptive analysis of the availability and cost of essential medicines in 23 Ugandan health facilities over a five-week period. We surveyed facility pharmacies in-person up to five times, recording availability and cost of 19 essential medicines for NCDs and four essential medicines for communicable diseases. RESULTS: Availability of medicines varied substantially over time, especially among public facilities. Among private-for-profit facilities, the cost of the same medicine varied from week to week. Private-not-for-profit facilities experienced less dramatic fluctuations in price. CONCLUSIONS: We conclude that there is a need for standardized, continuous monitoring to better characterize the availability and cost of essential medicines, understand demand for these medicines, and reduce uncertainty for patients.

Media briefing on COVID-19 - 26/10/2020

Coletiva de imprensa: anúncios do Governo SP - 19/10/2020

O Governador João Doria anunciou nesta segunda-feira (19) que a vacina contra o coronavírus em desenvolvimento pelo Instituto Butantan é a mais segura em fase final de testes no Brasil. Estudos clínicos com 9 mil voluntários com idade entre 18 e 59 anos no país mostram que apenas 35% tiveram reações adversas leves após a aplicação, como dor no local da aplicação ou dor de cabeça. Não houve qualquer registro de efeito colateral grave durante a testagem. “Os primeiros resultados dos estudos clínicos realizados no Brasil comprovam que, entre todas as vacinas testadas no país, a Coronavac é a mais segura, a que apresenta os melhores e mais promissores índices no Brasil. É, de fato, a vacina mais avançada neste momento”, declarou o Governador. “A vacina do Butantan foi a que apresentou menor índice de efeitos adversos e melhores resultados até o presente momento”, acrescentou Doria. O desenvolvimento da vacina no Brasil foi iniciado em julho, por meio de parceria entre a biofarmacêutica Sinovac Life Science, com sede em Pequim, e o Butantan. A Coronavac é um dos imunizantes mais promissores em fase final de estudo em todo o mundo e produzida com base em tecnologia similar à de outras vacinas produzidas com sucesso pelo Butantan. As reações mais comuns entre os participantes do estudo após a primeira dose foram dor no local da aplicação (19%) e dor de cabeça (15%). Na segunda dose, as reações adversas mais comuns foram dor no local da aplicação (19%), dor de cabeça (10%) e fadiga (4%). Febre baixa foi registrada em apenas 0,1% dos participantes e não há nenhum relato de reação adversa grave à vacina até o momento. O estudo no Brasil foi iniciado em 21 de julho e prevê a participação total de 13 mil voluntários, todos profissionais da saúde que atuam no atendimento a pacientes com COVID-19. Eles estão sendo acompanhados pelos 16 centros de pesquisa distribuídos por sete estados e o Distrito Federal. A partir deste mês, a testagem do potencial imunizante contra o coronavírus está sendo ampliada para voluntários idosos, portadores de comorbidades e gestantes. “A vacina Butantan é a mais segura em termos de efeitos colaterais. É a vacina mais segura neste momento não só no Brasil, mas no mundo”, afirmou Dimas Covas, Diretor do Instituto Butantan. Até dezembro, o Butantan receberá 46 milhões de doses da Coronavac, sendo 6 milhões de doses da vacina já prontas para aplicação. Outras 15 milhões de doses devem chegar até fevereiro de 2021. A vacina desenvolvida entre a Sinovac e o Butantan é uma das mais promissoras do mundo. Ela utiliza tecnologia já conhecida e amplamente aplicada em outros imunizantes produzidos pelo Butantan.

How the 'plates' of a health system can shift, change and adjust during economic recessions: A qualitative interview study of public and private health providers in Brazil's São Paulo and Maranhão states.

BACKGROUND: Economic recessions carry an impact on population health and access to care; less is known on how health systems adapt to the conditions brought by a downturn. This particularly matters now that the COVID-19 epidemic is putting health systems under stress. Brazil is one of the world's most affected countries, and its health system was already experiencing the aftermath of the 2015 recession. METHODS: Between 2018 and 2019 we conducted 46 semi-structured interviews with health practitioners, managers and policy-makers to explore the impact of the 2015 recession on public and private providers in prosperous (São Paulo) and impoverished (Maranhão) states in Brazil. Thematic analysis was employed to identify drivers and consequences of system adaptation and coping strategies. Nvivo software was used to aid data collection and analysis. We followed the Standards for Reporting Qualitative Research to provide an account of the findings. RESULTS: We found the concept of 'health sector crisis' to be politically charged among healthcare providers in São Paulo and Maranhão. Contrary to expectations, the public sector was reported to have found ways to compensate for diminishing federal funding, having outsourced services and adopted flexible-if insecure-working arrangements. Following a drop in employment and health plans, private health insurance companies have streamlined their offer, at times at the expenses of coverage. Low-cost walk-in clinics were hit hard by the recession, but were also credited for having moved to cater for higher-income customers in Maranhão. CONCLUSIONS: The 'plates' of a health system may shift and adjust in unexpected ways in response to recessions, and some of these changes might outlast the crisis. As low-income countries enter post-COVID economic recessions, it will be important to monitor the adjustments taking place in health systems, to ensure that past gains in access to care and job security are not eroded.

Media briefing on COVID-19 - 25/09/2020

Atualização das ações do Governo para o combate ao novo Coronavírus - 02/06/2020

Webinar: reforma tributária e as iniquidades do tabagismo

Lideranças na área sanitária e econômica discutem como a reforma tributária pode corrigir desigualdades geradas pelo mercado de tabaco entre consumidores e produtores.