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Climate change poses an unprecedented challenge to population health and health systems’ resilience, with increasing fluctuations in extreme temperatures through pressures on hospital capacity. While earlier studies have estimated morbidity attributable to hot or cold weather across cities, we provide the first large-scale, population-wide assessment of extreme temperatures on inequalities in excess emergency hospital admissions in England. We used the universe of emergency hospital admissions between 2001 and 2012 combined with meteorological data to exploit daily variation in temperature experienced by hospitals (N = 29,371,084). We used a distributed lag model with multiple fixed-effects, controlling for seasonal factors, to examine hospitalisation effects across temperature-sensitive diseases, and further heterogeneous impacts across age and deprivation. We identified larger hospitalisation impacts associated with extreme cold temperatures than with extreme hot temperatures. The less extreme temperatures produce admission patterns like their extreme counterparts, but at lower magnitudes. Results also showed an increase in admissions with extreme temperatures that were more prominent among older and socioeconomically-deprived populations - particularly across admissions for metabolic diseases and injuries.

Introduction: In low-middle income countries (LMICs) the role of food environments on obesity has been understudied. We address this gap by 1) examining the effect of food environments on adults’ body size (BMI, waist circumference) and obesity; 2) measuring the heterogeneity of such effects by income and sex. Methods: This cross-sectional study analysed South Asia Biobank surveillance and environment mapping data for 12,167 adults collected between 2018-2020 from 33 surveillance sites in Bangladesh and Sri Lanka. Individual-level data (demographic, socio-economic, and health characteristics) were combined with exposure to healthy and unhealthy food environments measured with geolocations of food outlets (obtained through ground-truth surveys) within 300 m buffer zones around participants' homes. Multivariate regression models were used to assess association of exposure to healthy and unhealthy food environments on waist circumference, BMI, and probability of obesity for the total sample and stratified by sex and income. Findings: The presence of a higher share of supermarkets in the neighbourhood was associated with a reduction in body size (BMI, β = - 3∙23; p

We evaluate the impacts of implementing and lifting non-pharmaceutical 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.

ObjectivesTo examine changes in planning, selecting, and preparing healthy foods in relation to personal factors (time, money, stress) and social distancing policies during the COVID-19 crisis.MethodsUsing cross-sectional online surveys collected in 38 countries worldwide in April-June 2020 (N = 37,207, Mage 36.7 SD 14.43, 73.6% women), we compared changes in food literacy behaviors to changes in personal factors and social distancing policies, using hierarchical multiple regression analyses controlling for sociodemographic variables.ResultsIncreases in planning (4.7 SD 1.2, 4.9 SD 1.3), selecting (3.8 SD 1.7, 3.8 SD 1.7), and preparing (4.6 SD 1.3, 4.7 SD 1.3) healthy foods were found for women and men, and positively related to perceived time availability among women and stay-at-home policies for planning and preparing in women. Psychological distress was a barrier for women, and an enabler for men. COVID-19 induced financial stress was a barrier depending on various sociodemographic variables (all p < 0.01).ConclusionStay-at-home policies and feelings of having more time during COVID-19 seem to have improved food literacy among women. Stress and other social distancing policies relate to food literacy in more complex ways, highlighting the necessity of a health equity lens.

There is a trade-off between the education sector and other economic sectors in the control of SARS-Cov-2 transmission. Here we integrate a dynamic model of SARS-CoV-2 transmission with a 63-sector economic model reflecting sectoral heterogeneity in transmission and economic interdependence between sectors. We identify COVID-19 control strategies which optimize economic production while keeping schools and universities operational and constraining infections such that emergency hospital capacity is not exceeded. The model estimates an economic gain of between £163bn and £205bn for the United Kingdom compared to a blanket lockdown of non-essential activity over six months, depending on hospital capacity. Sectors identified as potential priorities for closure are contact-intensive and/or less economically productive.

To meet the growing demand for hospital care due to the COVID-19 pandemic, England implemented a range of hospital provision interventions including the procurement of equipment, the establishment of additional hospital facilities and the redeployment of staff and other resources. Additionally, to further release capacity across England’s National Health Service (NHS), elective surgery was cancelled in March 2020, leading to a backlog of patients requiring care. This created a pressure on the NHS to reintroduce elective procedures, which urgently needs to be addressed. Population-level measures implemented in March and April 2020 reduced transmission of SARS-CoV-2, prompting a gradual decline in the demand for hospital care by COVID-19 patients after the peak in mid-April. Planning capacity to bring back routine procedures for non-COVID-19 patients whilst maintaining the ability to respond to any potential future increases in demand for COVID-19 care is the challenge currently faced by healthcare planners. In this report, we aim to calculate hospital capacity for emergency treatment of COVID-19 and other patients during the pandemic surge in April and May 2020; to evaluate the increase in capacity achieved via five interventions (cancellation of elective surgery, field hospitals, use of private hospitals, and deployment of former and newly qualified medical staff); and to determine how to re-introduce elective surgery considering continued demand from COVID-19 patients. We do this by modelling the supply of acute NHS hospital care, considering different capacity scenarios, namely capacity before the pandemic (baseline scenario) and after the implementation of capacity expansion interventions that impact available general and acute (G&A) and critical care (CC) beds, staff and ventilators. Demand for hospital care is accounted for in terms of non-COVID-19 and COVID-19 patients. Our results suggest that NHS England would not have had sufficient daily capacity to treat all patients without implementing hospital provision interventions. With interventions in place at the peak of the epidemic, there would be no capacity to treat elective CC patients. CC shortfalls would have been driven by a lack of nurses, beds and junior doctors; G&A care would have been limited by bed numbers. If interventions are not maintained, 10% of elective CC patients can be treated once the number of COVID-19 patients has fallen to 1,210; 100% of elective CC patients can be treated once the number of COVID-19 CC patients has fallen to 320. Hospital provision interventions would allow 10% of CC electives to be treated once the number of COVID-19 CC patients has fallen to 2,530 and 100% of CC electives once the number of COVID-19 CC patients has fallen to 1,550. To accommodate all elective G&A patients, the interventions should not be scaled back until the number of COVID-19 G&A patients falls below 7,500. We conclude that such interventions need to be sustained for patients requiring care to be treated, especially if there are future surges in COVID-19 patients requiring hospitalisation.

Planning for extreme surges in demand for hospital care of patients requiring urgent life-saving treatment for COVID-19, and other conditions, is one of the most challenging tasks facing healthcare commissioners and care providers during the pandemic. Due to uncertainty in expected patient numbers requiring care, as well as evolving needs day by day, planning hospital capacity is challenging. Health systems that are well prepared for the pandemic can better cope with large and sudden changes in demand by implementing strategies to ensure adequate access to care. Thereby the burden of the pandemic can be mitigated, and many lives saved. This report presents the J-IDEA pandemic planner, a hospital planning tool to calculate how much capacity in terms of beds, staff and ventilators is obtained by implementing healthcare provision interventions affecting the management of patient care in hospitals. We show how to assess baseline capacity, and then calculate how much capacity is gained by various healthcare interventions using impact estimates that are generated as part of this study. Interventions are informed by a rapid review of policy decisions implemented or being considered in 12 European countries over the past few months , an evaluation of the impact of the interventions on capacity using a variety of research methods, and by a review of key parameters in the care of COVID-19 patients. The J-IDEA planner is publicly available, interactive and adaptable to different and changing circumstances and newly emerging evidence. The planner estimates the additional number of beds, medical staff and crucial medical equipment obtained under various healthcare interventions using flexible inputs on assumptions of existing capacities, the number of hospitalisations, beds-to-staff ratios, and staff absences due to COVID-19. A detailed user guide accompanies the planner. The planner was developed rapidly and has limitations which we will address in future iterations. It supports decision-makers in delivering a fast, effective and coordinated response to the pandemic that upholds the aims that societies have set for their healthcare systems and the medical treatment of their citizens. We welcome feedback from users of the tool and readers of this report to help us to update the tool iteratively.

Noncommunicable diseases (NCDs) are the leading causes of death, disease and disability in the WHO European Region and are largely preventable. The private sector has long been using marketing to influence and change people’s lifestyles. In some cases, particularly the food sector, health-compromising content is prioritized over health-promoting content. However, this case study aims to illustrate how governments working on tight budgets can partner with private media companies to their own advantage in order to increase the impact of health messages and thus improve the health literacy of the population. The omnichannel communication platform and associated campaigns initiated by the Portuguese government and described in this case study serve as a practical example of a national health literacy initiative successfully reaching a wide audience. Indeed, the Portuguese National Health Service entered high on the list of the most impactful communication campaigns in Portugal.This might have implications for other countries as although further progress is required to analyse any impact of the campaigns, this example showcases the potential advantages of partnering with the media in that by using the same communication channels as multinational food and tobacco companies, governments may be able to level the playing field in terms of influence through marketing and communication, which might help to reverse unhealthy lifestyles among their populations.

Background. Voluntary licences are increasingly being utilised as a mechanism to increase access to patented essential medicines in low- and middle-income countries (LMICs). Since 2014, non-exclusive voluntary licences have been issued for key medicines for the treatment of hepatitis C (HCV), an important challenge to global health for which elimination targets have recently been set. We utilized HCV treatment rate data to carry out the first evaluation of the impact of these licences on access to treatment. Methods. We exploit the staggered and selective introduction of voluntary licensing in different countries to identify the impact of voluntary licensing agreements on access to treatment measured as the HCV treatment rate. We do so with difference-in-differences methods applied to a panel of 35 LMICs over a 13-year period (2004-2016). The analyses control for country and year fixed effects and a range of country-level factors that may influence access and treatment uptake. Findings. The intervention group consisted of 19 countries; the remaining 16 countries formed the control group. In the simplest model adjusting only for country and year fixed effects, voluntary licences were associated with an increase in annual treatment rate of 69·3 per 1,000 diagnosed with HCV (95%CI 46·7,91·9; p=0·006). After adjusting for country-level covariates, the impact of licences was 53·6 per 1,000 diagnosed with HCV (95%CI 25·8,81·5; 0·035). The effect of licensing increased over time and was largest in the second year after implementation. Results were robust to alternative specifications. Interpretation. Voluntary licensing initiatives appear to have had a significant impact on increasing HCV treatment rate in eligible countries. This evidence provides support for expansion of licensing strategies to include more countries and more treatments. The results suggest voluntary licensing may be an effective mechanism for increasing access to patented drugs in other therapeutic areas.

Objective In this paper we model the reduction in premature mortality associated with Noncommunicacle Diseases as a result of the establishment of a co-regulation agreement between the Portuguese Ministry of Health and the Portuguese food industry. We also assess whether Portugal is on track to meet the international targets of reducing baseline 2010 premature deaths from noncommunicable diseases by 25% by 2025, and by 30% before 2030. We also aimed to model the impact of the industry co-regulation agreement on premature mortality. Methods The 2015co-regulation agreement agreement between the Portuguese food industry and the Portuguese government sets targets of reducing sugar by 20%, salt content by 16% (30% for bread), and

Objectives Despite continuous efforts to improve influenza vaccination coverage, uptake among highrisk groups remains suboptimal. We aimed to identify policy amenable factors associated with vaccination and to measure their importance in order to assist in the monitoring of vaccination sentiment and the design of communication strategies and interventions to improve vaccination rates. Setting The USA, the UK and France. Participants A total of 2412 participants were surveyed across the three countries. Outcome measures Self-reported influenza vaccination. Methods Between March and April 2014, a stratified random sampling strategy was employed with the aim of obtaining nationally representative samples in the USA, the UK and France through online databases and random-digit dialling. Participants were asked about vaccination practices, perceptions and feelings. Multivariable logistic regression was used to identify factors associated with past influenza vaccination. Results The models were able to explain 64%–80% of the variance in vaccination behaviour. Overall, sociopsychological variables, which are inherently amenable to policy, were better at explaining past vaccination behaviour than demographic, socioeconomic and health variables. Explanatory variables included social influence (physician), influenza and vaccine risk perceptions and traumatic childhood experiences. Conclusions Our results indicate that evidence-based sociopsychological items should be considered for inclusion into national immunisation surveys to gauge the public’s views, identify emerging concerns and thus proactively and opportunely address potential barriers and harness vaccination drivers.

While it is commonly argued that there is a mismatch between drug innovation and disease burden, there is little evidence on the magnitude and direction of such disparities. In this paper we measure inequality in innovation, by comparing R&D activity with population health and GDP data across 493 therapeutic indications to globally measure: (i) drug innovation, (ii) disease burden, and (iii) market size. We use concentration curves and indices to assess inequality at two levels: (i) broad disease groups; and (ii) disease subcategories for both 1990 and 2010. For some of top burden disease subcategories (i.e. cardiovascular and circulatory diseases, neoplasms, and musculoskeletal disorders) innovation is disproportionately concentrated in diseases with high burden and larger market size, whereas for others (i.e. mental and behavioural disorders, neonatal disorders, and neglected tropical diseases) innovation is disproportionately concentrated in low burden diseases. These inequalities persisted over time, suggesting inertia in pharmaceutical R&D in tackling the global health challenges. Our results confirm quantitatively assertions about the mismatch between disease burden and pharmaceutical innovation in both developed and developing countries and highlight the disease areas for which morbidity and mortality remain unaddressed.

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In this paper we estimate hospital costs and evaluate economies of scale and scope using a generalised multiproduct cost function and a sample of English NHS Trusts with different types of ownership, namely Foundation Trusts and non Foundation Trusts. Evaluating the behaviour of different types of hospitals separately might be particularly helpful for the design, and future developments, of the optimal provider reimbursement tariff. Also it might shed some light on the ability of different types of hospitals pro t from the existence of economies of scale and scope. Results show that, even though these two group of providers do not exhibit differences regarding economies of scale, Foundation Trusts exhibit global diseconomies of scope while non Foundation Trusts exhibit global scope economies. Working Paper

In this paper we estimate hospital costs and evaluate economies of scale and scope using a generalised multiproduct cost function and a sample of English NHS trusts with different types of ownership, namely Foundation Trusts and non Foundation Trusts. Evaluating the behaviour of different types of hospitals separately might be particularly helpful for the design, and future developments, of the optimal provider reimbursement tariff. Also it might shed some light on the ability of different types of hospitals to profit from the existence of economies of scale and scope. Results show that, even though these two group of providers do not exhibit differences regarding economies of scale, Foundation Trusts exhibit global diseconomies of scope while non Foundation Trusts exhibit global scope economies.

We analyse incentives for collusive behaviour when heterogeneous providers are faced with regulated prices under two forms of yardstick competition, namely discriminatory and uniform schemes. Providers are heterogeneous in the degree to which their interests correspond to those of the regulator, with close correspondence labelled altruism. Deviation of interests may arise as a result of de-nationalisation or when private providers enter predominantly public markets. We assess how provider strategies and incentives to collude relate to provider characteristics and across different market structures. We differentiate between "pure" markets with either only self-interested providers or with only altruistic providers and "pluralistic" markets with a mix of provider type. We find that the incentive for collusion under a discriminatory scheme increases in the degree to which markets are self-interested whereas under a uniform scheme the likelihood increases in the degree of provider homogeneity. Providers' choice of cost also depends on the yardstick scheme and market structure. In general, costs are higher under the uniform scheme, reflecting its weaker incentives. In a pluralistic market under the discriminatory scheme each provider's choice of cost is decreasing in the degree of the other provider's altruism, so a self-interested provider will operate at a lower cost than an altruistic provider. Under the uniform scheme providers always choose to operate at the same cost. The prospect of defection serves to moderate the chosen level of operating cost. Working Paper

A key element of the reform agenda for the health service has been to encourage a plurality of provision for NHS patients and so improve the quality of care. In introducing plurality, the Department of Health is committed to establishing a „fair playing field‟. This means that the objective of competitive neutrality across NHS and Independent Sector (IS) providers of NHS services („a level playing field‟) is tempered by the obligation upon the public sector to act in the public interest. This fair playing field must be supported by the system of reimbursement – called Payment by Results (PbR) – that is being implemented to fund NHS patients. PbR is a prospective payment system in which prices for treating particular types of patients are fixed in advance by the Department of Health rather than being negotiated locally. As prices are fixed, any competition between providers should be on the basis of the quality of services, rather than their cost.

We study the impact of different contractual arrangements within the hospital on the optimal contracts designed by third party payers when severity is hospital's private information. We develop a multi-issue bargaining process between doctors and managers within the hospital. Results are then compared with a scenario where doctors and managers decide independently by maximizing their own profit, with managers proposing to doctors a take-it-or leave-it offer. Results show that, when the cost of capital is sufficiently low, the informational rent arising on information asymmetry is higher in a set up where managers and doctors decide together through a strategic bargaining process than when they act as two decision-making units.

We analyse incentives for collusive behaviour when heterogeneous providers are faced with regulated prices under two forms of yardstick competition, namely discriminatory and uniform schemes. Providers are heterogeneous in the degree to which their interests correspond to those of the regulator, with close correspondence labelled altruism. Deviation of interests may arise as a result of de-nationalisation or when private providers enter predominantly public markets. We assess how provider strategies and incentives to collude relate to provider characteristics and across different market structures. We differentiate between “pure” markets with either only self-interested providers or with only altruistic providers and “pluralistic” markets with a mix of provider type. We find that the incentive for collusion under a discriminatory scheme increases in the degree to which markets are self-interested whereas under a uniform scheme the likelihood increases in the degree of provider homogeneity. Providers’ choice of cost also depends on the yardstick scheme and market structure. In general, costs are higher under the uniform scheme, reflecting its weaker incentives. In a pluralistic market under the discriminatory scheme each provider’s choice of cost is decreasing in the degree of the other provider’s altruism, so a self-interested provider will operate at a lower cost than an altruistic provider. Under the uniform scheme providers always choose to operate at the same cost. The prospect of defection serves to moderate the chosen level of operating cost.

We study the influence of different reimbursement systems, namely Prospective Payment System, Cost Based Reimbursement System and Mixed Reimbursement System on the development and adoption of different technologies with an endogenous supply of these technologies. We focus our analysis on technology development and adoption under two models: private R&D and R&D within the hospital. One of the major findings is that the optimal reimbursement system is a pure Prospective Payment System or a Mixed Reimbursement System depending on the market structure.