The European Food Regulatory Environment Index: a tool to monitor progress in implementing food environment policies.

BACKGROUND: Evidence based health policy, such as that put forward in the European Food and Nutrition Action Plan 2015-2020 and the WHO Global Action Plan on the Prevention and Control of Noncommunicable Diseases, has a role in curbing the consumption of unhealthful foods and drink. We ask how countries are performing in the adoption of these policies and how the comprehensiveness of their food environment policies explains variations in consumption of unhealthful products across Europe. METHODS: In order to assess the state of policy adoption, we developed a composite indicator-the Food Regulatory Environment Index (FREI) for which we calculated unweighted and weighted formulations according to the strength of the evidence base. We used linear regression models to explain variations in the consumption of unhealthful products as well as variations in a composite indicator of obesogenic diets. RESULTS: Overall, wealthier countries in the Region perform better. The weighting of the constituent policies does not affect the rankings. We find negative associations between unweighted and weighted formulations of the Index and household consumption of sugary and carbonate drinks as well as with the composite indicator for obesogenic diets. CONCLUSIONS: The main strength of this study is the comprehensiveness and comparability of the policy data across the relatively large number of countries covered. There is a negative association that is statistically significant, between all formulations of the FREI and the household consumption of sugary and carbonated drinks. There is also a negative association between some FREI formulations and obesogenic diets.

Leaving no one behind: health equity as a catalyst for the sustainable development goals.

2019 has been a milestone year for catalyzing changes to improve health equity in the WHO European Region through concomitant progress in the sustainable development goal (SDG) targets. The WHO European Health Equity Status Report Initiative (HESRi) has captured and analyzed the relationships between inequities in health and the conditions that are essential for all to be able to live healthy and prosperous lives. The five essential conditions map directly onto a number of SDG targets, with a much broader span than SDG3 on health. They are: (i) Universal access to good-quality, affordable health services; (ii) Basic income security and social protection; (iii) Safe and decent living conditions; (iv) Inclusive social and human capital building opportunities; and (v) Decent and non-discriminatory employment and working conditions. There is certainly room for improvement in the way ahead, particularly in the availability of fine-grained and disaggregated data, and in the quality of monitoring and analysis of policy options that this would allow. However, the work of the HESRi shows that by harnessing such data it is possible to show what actions policymakers can take in the present to ensure that no one is left behind. This equity framing allows to measure whether the progress on SDGs benefits all, including those who need them most.

Corporate practices and health: a framework and mechanisms.

BACKGROUND: The Global Burden of Disease estimates that approximately a third of deaths worldwide are attributable to behavioural risk factors that, at their core, have the consumption of unhealthful products and exposures produced by profit driven commercial entities. We use Steven Lukes' three-dimensional view of power to guide the study of the practices deployed by commercial interests to foster the consumption of these commodities. Additionally, we propose a framework to systematically study corporations and other commercial interests as a distal, structural, societal factor that causes disease and injury. Our framework offers a systematic approach to mapping corporate activity, allowing us to anticipate and prevent actions that may have a deleterious effect on population health. CONCLUSION: Our framework may be used by, and can have utility for, public health practitioners, researchers, students, activists and other members of civil society, policy makers and public servants in charge of policy implementation. It can also be useful to corporations who are interested in identifying key actions they can take towards improving population health.

Kyrgyzstan: Health System Review.

This analysis of the Kyrgyz health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. A mandatory health insurance is in place, with the Mandatory Health Insurance Fund (MHIF) under the Ministry of Health acting as single public payer for almost all hospitals and providers of primary care. The benefits package of publicly covered services is defined in the State-Guaranteed Benefits Programme (SGBP). However, many services require co-payments and in 2019 only 69% of the population was covered by mandatory health insurance. Health expenditure per capita is one of the lowest in the WHO European Region, due to the country's small GDP per capita. Private spending, almost entirely in the form of out-of-pocket expenditure and including informal payments, accounted for 46.3% of health expenditure in 2019. Financial protection is undermined by low levels of public spending for health, resulting in financial hardship for people using health services. While there is a well-developed network of health facilities, the geographical distribution of health workers is uneven and there is an overall shortage of family doctors. Access to health services remains a challenge, which has been exacerbated by the COVID-19 pandemic. While improvements have been made in recent years, communicable and noncommunicable diseases still pose a major problem and life expectancy prior to the COVID-19 pandemic was one of the lowest in the WHO European Region.

The Corporate Permeation Index - A tool to study the macrosocial determinants of Non-Communicable Disease.

Commercial interests have long been identified as a macrosocial determinant of health. We present a composite indicator of corporate permeation- the Corporate Permeation Index (CPI) -, a novel tool for explaining variations in the consumption of products such as alcohol or tobacco and in the comprehensiveness of health policy regarding these products. Using a published framework for the analysis of commercial influences on health as a theoretical basis, we collected 25 indicators of corporate permeation comparable across 148 countries in five continents for six years 2010-2015. Two alternative approaches were used in each of the steps taken to build the measure - imputation of missing data, multivariate analysis, and weighing and aggregation of the subcomponents. We assessed the Index's criterion-related validity by calculating the strength of the association among the different formulations of the Index. Alternative formulations of the CPI are highly correlated. Whilst High Income Countries are generally overrepresented among the lowest scores, some High Income Countries have high permeation scores. There is no clear regional pattern, with scores showing as much intra-regional as inter-regional variability. The CPI appears to be a robust measure of corporate permeation at the national level, suggesting tremendous variability in permeation worldwide. There are limitations to the CPI, the most notable of which is the lack of large scale cross-country comparable data on some important mechanisms of corporate permeation (e.g., lobbying expenditures by large corporations). Further work will target proxy measures for these phenomena to be incorporated in the Index calculation.

Alcohol control policies and alcohol consumption: an international comparison of 167 countries.

BACKGROUND: Alcohol control policy has a fundamental role in limiting negative health, economic and social harm caused by alcohol consumption. However, there is substantial international heterogeneity in country-level policy adoption, implementation and monitoring. Comparative measures so far focused on Europe or the Organisation for Economic Co-operation and Development countries. METHODS: We created an Alcohol Control Policy Index (ACPI) for 167 countries using five different methodological approaches. National policies were sourced from WHO's Global Information System on Alcohol and Health. We assessed ACPI's criterion-related validity by calculating the strength of the association among the different approaches. As for content validity, we tested whether the resulting scores explained variations in alcohol per capita consumption cross-nationally, controlling for gross domestic product, population age, urbanisation and world region using OLS and random coefficients models. RESULTS: Index scores and ranks from different methodological approaches are highly correlated (r=0.99). Higher scores were associated with lower consumption across the five methods. For each 1 score increase in the ACPI, the reduction in per capita alcohol consumption varies from -0.024 L (95% CI (-0.043 to -0.004) to -0.014 L (95% CI (-0.034 to 0.005). We obtain larger coefficients and p values <0.005 when estimating random coefficients. CONCLUSION: ACPI offers a measure of alcohol control policy across countries that makes use of a larger number of countries than its predecessors, as well as a wider range of methodologies for its calculation, both of which contribute to its validity. Furthermore, it shows that the statutory strictness of alcohol control policies is associated with lower levels of alcohol consumption.

The Great Recession and inequalities in access to health care: a study of unemployment and unmet medical need in Europe in the economic crisis.

Background: Unmet medical need (UMN) had been declining steadily across Europe until the 2008 Recession, a period characterized by rising unemployment. We examined whether becoming unemployed increased the risk of UMN during the Great Recession and whether the extent of out-of-pocket payments (OOP) for health care and income replacement for the unemployed (IRU) moderated this relationship. Methods: We used the European Survey on Income and Living Conditions (EU-SILC) to construct a pseudo-panel (n = 135 529) across 25 countries to estimate the relationship between unemployment and UMN. We estimated linear probability models, using a baseline of employed people with no UMN, to test whether this relationship is mediated by financial hardship and moderated by levels of OOP and IRU. Results: Job loss increased the risk of UMN [ß = 0.027, 95% confidence interval (CI) 0.022-0.033] and financial hardship exacerbated this effect. Fewer people experiencing job loss lost access to health care in countries where OOPs were low or in countries where IRU is high. The results are robust to different model specifications. Conclusions: Unemployment does not necessarily compromise access to health care. Rather, access is jeopardized by diminishing financial resources that accompany job loss. Lower OOPs or higher IRU protect against loss of access, but they cannot guarantee it. Policy solutions should secure financial protection for the unemployed so that resources do not have to be diverted from health.