This study estimates productivity losses resulting from intellectual decrement due to paediatric lead exposure in low- and middle-income countries (LMICs). The published literature on blood lead levels in LMICs was reviewed and summarised. Intelligence Quotient decrement and consequent productivity losses were calculated for a one-year cohort of 5-year-old children in each country. We calculated the present value of lifetime earnings as the discounted average earning potential for workers in a specific economy. Blood lead level (BLL) data for children were available for 39 countries and could be interpolated for additional 82 countries, resulting in 121 countries in the final analysis. Total lead-attributable productivity losses in LMICs ranged from USD 305 billion in our high discount scenario to USD 499 billion in our low discount scenario for each one-year cohort of 5-year-old children (2019 USD). As a share of GDP, these costs ranged from 0.7 to 4.2% by region, depending on discount scenario used. Total economic impacts were generally consistent with previous estimates and further validate those efforts with a substantially expanded dataset. Differences in the findings resulted primarily from the use of a more conservative dose–response model in the present study. Improved reporting of BLLs is essential and could be facilitated through a centralised registry of study results.

The framework presented in the World Bank report Open and Inclusive: Fair processes for Financing Universal Health Coverage effectively connects proposed decision-making principles with practical examples that country governments can use to pursue greater fairness. In this commentary, we consider the suggestion that international development partners might use the report's criteria to examine their own processes. We consider what the report's primary Fair Process principles – equality, impartiality and consistency – imply for development partners. Specifically, we address two questions in turn: (i) how relevant the Fair Processes report is to development assistance for health; (ii) if it is deemed relevant, what practical implications does the report have for how aid works? We address the second question by briefly applying the framework to a particular global health initiative, namely the United States President's Emergency Plan for AIDS Relief (PEPFAR). Our analysis suggests that development partners' additional sets of accountabilities, particularly linked to funding sources, may pose more fundamental challenges to impartiality than to equality and consistency in decision-making processes. A question inviting further examination, then, is how development partners can redesign their processes to optimise impartiality given institutional constraints that bind them independently of the populations they purport to serve.

The Australian health system is characterised by high quality care by international standards, produced by a mix of public and private provision and funding of healthcare services. Despite good overall results, three issues are of concern. The first issue relates to the public procurement of healthcare, whose flaws have impacted individuals' access to care, and the high out-of-pocket spending. The second issue concerns the sustainability of the private health insurance market, given the government's goal of relieving cost and capacity from the public scheme, incentivising participation. Third, there are existing inefficiencies and inequities related to the duplication resulting from the interaction between public and private schemes. To ensure a sustainable, efficient and equitable health system, structural reforms are necessary to achieve long-term performance improvements. Using a framework for mixed public–private health systems, we assess the extent to which the Australian healthcare system achieves preconditions for efficiency and affordability in competitive healthcare markets.

We examine the impact of decentralisation on COVID-19 mortality and various health outcomes. Specifically, we investigate whether decentralised health systems, which facilitated greater regional participation and information sharing, were more effective in saving lives. Our analysis makes three contributions. First, we draw on evidence from several European countries to assess whether the decentralisation of health systems influenced COVID-19 mortality rates. Second, we explore the regional disparities in one of the most decentralised health systems, Spain, to untangle some of the determinants shaping health outcomes. Third, we estimate the regional loss of Quality Adjusted Life Years (QALYs) due to COVID-19 mortality, broken down by the wave of the pandemic. Our findings suggest that coordinated decentralisation played a critical role in saving lives throughout the COVID-19 pandemic.

In response to our critics, we clarify and defend key ideas in the report Open and Inclusive: Fair Processes for Financing Universal Health Coverage. First, we argue that procedural fairness has greater value than Dan Hausman allows. Second, we argue that the Report aligns with John Kinuthia's view that a knowledgeable public and a capable civil society, alongside good facilitation, are important for effective public deliberation. Moreover, we agree with Kinuthia that the Report's framework for procedural fairness applies not merely within the health sector, but also to the wider budget process. Third, we argue that while Dheepa Rajan and Benjamin Rouffy-Ly are right that robust processes for equal participation are often central to a fair process, sometimes improvements in other aspects of procedural fairness, such as transparency, can take priority over strengthening participation. Fourth, while we welcome Sara Bennett and Maria Merritt's fascinating use of the Report's principles of procedural fairness to assess the US President's Emergency Plan for AIDS Relief, we argue that their application of the Report's principle of equality to development partners' decision-making requires further justification.

Managed competition frameworks aim to control healthcare costs and promote access to high-quality health insurance and services through a combination of public policies and market forces. In the United States, managed competition delivery systems are varied and diffused across a patchwork of divided markets and populations. This, coupled with extremely high national health spending per capita, makes a more unified managed competition strategy an appealing alternative to a currently struggling healthcare system. We examine the relative effectiveness of three existing programmes in the U.S. that each rely upon some principles of managed competition: health insurance exchanges instituted by the Affordable Care Act, Medicaid managed care organisations, and Medicare Advantage plans. Although each programme leverages some competitive features, each faces significant hurdles as a candidate for expansion. We highlight these challenges with a survey of academic health economists, and find that provider and insurer consolidation, highly segmented markets, and failing to incentivise competitive efficiencies all dampen the success of existing programmes. Although managed competition for all is a potentially desirable framework for future health reform in the U.S., successful expansion relies on addressing fundamental issues revealed by imperfect existing programmes.

We present a methodology for a new composite, quantitative “mash-up” index of health system sustainability and resilience, drawing on a qualitative framework developed to assess these dimensions of the health system. The paper summarises quantifiable measures of sustainability and resilience, with sustainability defined through 7 domains and 50 indicator variables, while health system resilience is based on 6 domains and 23 variables. Each domain is captured by a separate index. A composite index is constructed through aggregation across the two dimensions, and their associated domains and indicators. All indices are aggregated through estimation of a geometric means, and are bound between 0 and 100. We pilot across 5 countries over 23 years, with the ultimate aim of identifying health policy strategies for improving national health system capacities and performances; as well as facilitating policy responses to address problematic issues of sustainability and resilience. Face validity suggests that the index captures the non-resilience to the COVID-19 pandemic. The pilot study reveals considerable differences at both the dimension and domain levels within and between the examined countries, while suggesting scope for improvement in both dimensions across all countries. The index thus provides an indicative approach for temporal and spatial yardstick comparison.

The impact of health technologies may extend beyond the patient and affect the health of people in their network, like their informal carers. The National Institute for Health and Care Excellence (NICE) methods guide explicitly allows the inclusion of health-related quality of life (HRQoL) effects on carers in economic evaluations when these effects are substantial, but the proportion of NICE appraisals that includes carer HRQoL remains small. This paper discusses when inclusion of carer HRQoL is justified, how inclusion can be substantiated, and how carer HRQoL can be measured and included in health economic models. Inclusion of HRQoL in economic evaluations can best be substantiated by data collected in (carers for) patients eligible for receiving the intervention. To facilitate combining patient and carer utilities on the benefit side of economic evaluations, using EQ-5D to measure impacts on carers seems the most successful strategy in the UK context. Alternatives to primary data collection of EQ-5D include vignette studies, using existing values, and mapping algorithms. Carer HRQoL was most often incorporated in economic models in NICE appraisals by employing (dis)utilities as a function of the patient's health state or disease severity. For consistency and comparability, economic evaluations including carer HRQoL should present analyses with and without carer HRQoL.

Physician databases constitute an essential component of health workforce planning. However, while some countries have established functioning national physician databases, others have failed to do so. We compared the healthcare systems of two technologically and economically developed countries, Canada and Israel, which represent cases of respective success and failure in establishing physician databases. A comparative analysis was conducted using a historical-institutionalist approach to examine contemporary health policy outcomes. White papers, studies on healthcare human resources, and reports by professional committees were examined to explore the aims, interests, positions, and actions of stakeholders. In Canada, state–medical profession cooperation, deep-rooted in a longstanding regulatory bargain between the two parties, has facilitated the creation and management of physician databases, albeit limited and in need of urgent improvement, on national and jurisdictional levels. The lack of such regulatory arrangement coupled with enduring conflicted relations between stakeholders due to particular historical developments have hindered the development of an Israeli equivalent database so far. Finally, health policy outcomes may be explained against the backdrop of broader political, governance, and organisational contexts. How medical organisations respond to governmental healthcare initiatives is heavily influenced by their institutional position vis-à-vis the state, shaped by historical processes and regulatory arrangements.

The Colombian health system has made a deep transition into managed competition since a major reform in 1993. A market for insurers was created, the consumer has free choice of insurer and a national-level equalisation fund distributes revenues via a per-capita payment. Fully subsidised insurance for the poor and informal, and a comprehensive standardised benefit package for subsidised and contributory schemes (both schemes covering 98 per cent of the population), has led to a low level of out-of-pocket expenses and high financial protection, as well as to reduced gaps in equity in access. The preconditions for managed competition are largely met, but improving health care providers' organisation towards integrated care, to enable them to deliver more value, is a necessary step to achieve the expected results of managed competition in terms of efficiency and quality. Although the current system is likely to be reformed in the coming months, the nature and extent of those reforms are not defined yet, so our analysis is based on the current system.

Ireland has a long-standing voluntary private health insurance market (PHI) which is regulated to meet the public policy objective of achieving risk solidarity to promote affordability of PHI. Under the regulations underpinning the market, many features are common to those of universal mandatory health insurance markets, that have wider equity objectives of ensuring universal equitable access to care for everyone. The market acts a complete/partial alternative to the public health system, and has been criticised for leading to a two-tier system with consequent implications for equity. To improve equity, these criticisms led to the adoption of a new public health reform plan, called Sláintecare, which seeks to build towards equal access to services based on patient need and not their ability to pay. Given this context, this paper re-examines how might the current voluntary health insurance system be adapted to meet the central Sláintecare objective of increasing health coverage on an equitable basis. It does so by considering to what extent does Ireland meet the preconditions for equity and efficiency under the Enthoven managed competition model. It provides a roadmap for the use of health insurance as a tool for bring this equity.

In Ukraine, patients and their family members face numerous barriers to health care services. In response, they use coping strategies, that are manifold and complex activities aimed at overcoming these barriers, the financial burden of the treatment, and the poor quality of health care services. These activities include formal and informal practices. Based on representative survey data from 2015 (N = 2,022), we identify patterns in the use of coping strategies, specific coping strategies used to secure good quality consultation and treatment, and analyse opinions and actions towards coping practices. We further analyse the factors associated with the last experience of coping and look at patterns of connection building. We find that the chances of using both money and connection as a coping strategy are higher for people with incomplete higher and highest levels of education. The size of this effect increases with the level of education. Older people, people with better health, and people with a higher opinion of the state use informal practices less, while women are more active in developing connections. The closer the relationship is with a medical doctor, the higher is the chance that such connection will be used in case of health service consumption.

This paper considers whether and how managed competition arrangements could be introduced into the Aotearoa health and disability system. The paper describes the key features of the system, including new organisational arrangements established from 1 July 2022. It discusses major reforms and managed competition plans that were developed in the 1990s, with the managed competition plans abandoned fairly early on, as a result of major issues with the reforms that had been implemented and with problems in designing a fair payment system for competing health plans. The paper goes on to argue that the development of capitated, risk-bearing and competing Primary Health Organisations set up in the 2000s should be considered in terms of managed competition, and the paper points to the issues that have arisen in Aotearoa due to a lack of regulations that would have better supported the better achievement of effectiveness, efficiency, and equity goals over the past 20 years. Finally, the paper also looks ahead to whether and how managed competition might again be considered in Aotearoa and the extent to which the system currently includes key pre-conditions to support such arrangements.