Evidence suggests that growth in providers' prices drives growth in health care spending on the privately insured. However, existing work has not systematically differentiated between the growth rate ...of hospital prices and that of physician prices. We analyzed growth in both types of prices for inpatient and hospital-based outpatient services using actual negotiated prices paid by insurers. We found that in the period 2007-14 hospital prices grew substantially faster than physician prices. For inpatient care, hospital prices grew 42 percent, while physician prices grew 18 percent. Similarly, for hospital-based outpatient care, hospital prices grew 25 percent, while physician prices grew 6 percent. A majority of the growth in payments for inpatient and hospital-based outpatient care was driven by growth in hospital prices, not physician prices. Our work suggests that efforts to reduce health care spending should be primarily focused on addressing growth in hospital rather than physician prices. Policy makers should consider a range of options to address hospital price growth, including antitrust enforcement, administered pricing, the use of reference pricing, and incentivizing referring physicians to make more cost-efficient referrals.
To develop a simulation framework for assessing how combinations of taxes, nutrition warning labels and advertising levels could affect purchasing of ultra-processed foods (UPF) in Latin American ...countries and to understand whether policies reinforce or reduce pre-existing social disparities in UPF consumption.
We developed an agent-based simulation model using international evidence regarding the effect of price, nutrition warning labels and advertising on UPF purchasing.
We estimated policy effects in scenarios representing two stages of the 'social transition' in UPF purchasing: (1) a pre-transition scenario, where UPF purchasing is higher among high-income households, similar to patterns in Mexico; and (2) a post-transition scenario where UPF purchasing is highest among low-income households, similar to patterns in Chile.
A population of 1000 individual agents with levels of age, income, educational attainment and UPF purchasing similar to adult women in Mexico.
A 20 % tax would decrease purchasing by 24 % relative to baseline in both the pre- and post-transition scenarios, an effect that is similar in magnitude to that of a nutrition warning label policy. A 50 % advertising increase or decrease had a comparatively small effect. Nutrition warning labels were most effective among those with higher levels of educational attainment. Labelling reduced inequities in the pre-transition scenario (i.e. highest UPF purchasing among the highest socio-economic group) but widened inequities in the post-transition scenario.
Effective policy levers are available to reduce UPF purchasing, but policymakers should anticipate that equity impacts will differ depending on existing social patterns in UPF purchasing.
This scoping review sought to describe the policy actions that urban local governments globally have implemented to facilitate healthy and environmentally sustainable diet-related practices.
Urban ...local government authorities.
Five databases were searched to identify publications which cited policies being implemented by local governments within the 199 signatory cities of the Milan Urban Food Policy Pact (MUFPP) that targeted at least one healthy and sustainable diet-related practice. Grey literature was then searched to retrieve associated policy documentation. Data from both sources were charted against the MUFPP's monitoring framework to analyse the policy actions included in each overarching policy.
From 2624 screened peer-reviewed studies, 27 met inclusion criteria and cited 36 relevant policies amongst signatory cities to the MUFPP. Most were from high income countries (n 29; 81 %), considered health (n 31; 86 %), equity (n 29; 81 %) and the broader food system beyond dietary consumption (n 34; 94 %). Of the 66 policy actions described, the most common involved food procurement within public facilities (n 16; 44 %) and establishing guidelines for school-feeding programs (n 12; 33 %).
This review has demonstrated that urban local government authorities are implementing policies that consider multiple phases of the food supply chain to facilitate population-wide uptake of healthy and sustainable diet-related practices. Opportunities exist for local governments to leverage the dual benefits to human and planetary health of policy actions, such as those which discourage the overconsumption of food including less meat consumption and the regulation of ultra-processed foods.
Lack of access to essential medicines presents a significant threat to achieving universal health coverage (UHC) in sub-Saharan Africa. Although it is acknowledged that essential medicines policies ...do not rise and stay on the policy agenda solely through rational deliberation and consideration of technical merits, policy theory is rarely used to direct and guide analysis to inform future policy implementation. We used Kingdon's model to analyse agenda setting for essential medicines policy in sub-Saharan Africa during the formative phase of the primary healthcare (PHC) concept.
We retrospectively analysed 49 published articles and 11 policy documents. We used selected search terms in EMBASE and MEDLINE electronic databases to identify relevant published studies. Policy documents were obtained through hand searching of selected websites. We also reviewed the timeline of essential medicines policy milestones contained in the Flagship Report, Medicines in Health Systems: Advancing access, affordability and appropriate use, released by WHO in 2014. Kingdon's model was used as a lens to interpret the findings.
We found that unsustainable rise in drug expenditure, inequitable access to drugs and irrational use of drugs were considered as problems in the mid-1970s. As a policy response, the essential drugs concept was introduced. A window of opportunity presented when provision of essential drugs was identified as one of the eight components of PHC. During implementation, policy contradictions emerged as political and policy actors framed the problems and perceived the effectiveness of policy responses in a manner that was amenable to their own interests and objectives.
We found that effective implementation of an essential medicines policy under PHC was constrained by prioritization of trade over public health in the politics stream, inadequate systems thinking in the policy stream and promotion of economic-oriented reforms in both the politics and policy streams. These lessons from the PHC era could prove useful in improving the approach to contemporary UHC policies.
•We review policies of agricultural commercialisation for smallholders in Africa.•We critique commercialisation as a metanarrative for heterogeneous rural peoples.•A case study of Zambian cassava ...growers explores the implications of context.•We highlight the need for ‘locality’ and ‘particularity’ in policy formulation.
This paper presents a critique of commercialising smallholder farming for agriculture in Sub-Saharan Africa. First it questions the validity of an overarching ‘metanarrative’ approach to development. Then it discusses the different types of knowledge, values and method and draws attention to the increasingly heterogeneous development policy context and also the heterogeneity among the smallholder ‘targets’ of agrifood policies.
Second, a case study exemplifies this critique in the context of an existing multistakeholder strategy of commercialising the Zambian cassava sector. Although limited in scope, the primary research illustrates how a commercial supply response should not be assumed from within a rural sector more concerned with food security.
The study casts doubt on the validity of a commercialising metanarrative. Rather, it endorses the need for a multidisciplinary understanding of the particular and local context which influences knowledge generation and development design, accounting for different value systems and perceptions of reality and smallholder farmer decision making within heterogeneous contexts.
Systematic evidence relating to the performance of carbon pricing - carbon taxes and greenhouse gas (GHG) emissions trading systems (ETSs) - is sparse. In 2015, 17 ETSs were operational in 55 ...jurisdictions while 18 jurisdictions collected a carbon tax. The papers in this special thematic section review the performance of many of these instruments over the 2005-2015 period. The performance of existing carbon taxes and GHG ETSs can help policy makers make informed choices about whether to introduce these instruments and to improve their design. The purpose of carbon pricing instruments is to reduce GHG emissions cost effectively. Assessing their performance is difficult because emissions are also affected by other policies and exogenous factors such as economic conditions. Carbon taxes in Europe prior to 2008 and in British Columbia reduced emissions from business-as-usual but actual emissions continued to rise. Since 2008 emissions subject to European carbon taxes have declined, but in most countries, other mitigation policies have probably contributed more to the reductions than the carbon taxes. Emissions subject to ETSs, with the exception of four systems without emissions caps, have declined. The ETSs contributed to the emissions reductions, but their share of the overall reduction is not known. Most tax rates are low relative to levels thought to be needed to achieve climate change objectives. Few jurisdictions regularly adjust their tax rates. All ETSs have accumulated surplus allowances and implemented measures to reduce these surpluses. The largest ETSs now specify annual reductions in their emissions cap several years into the future. Emissions trading system allowance prices are generally lower than the tax rates.
Key policy insights
Theoretical discussions usually portray carbon taxes and GHG ETSs as alternatives. In practice, a jurisdiction often implements both instruments to address emissions by different sources.
Designs of ETSs have evolved based on experience shared bilaterally and via dedicated institutions.
Carbon tax designs, in contrast, have hardly evolved and there are no institutions dedicated to sharing experience.
Every jurisdiction with an ETS and/or carbon tax also has other policies that affect its GHG emissions.
While climate change action plans are becoming more common, it is still unclear whether communities have the capacity, tools, and targets in place to trigger the transformative levels of change ...required to build fundamentally low-carbon, resilient, healthy communities. Evidence increasingly supports the finding that this transformation is not triggered by climate policy alone, but rather is shaped by a broad array of decisions and practices that are rooted in underlying patterns of development. Even so, these findings have rarely penetrated the domain of practice, which often remains squarely focused on a relatively narrow set of climate-specific policies. This article builds a conceptual framework for understanding the dynamics of community-level development path transformations that may both dramatically reduce GHG emissions and significantly enhance community resilience. This framework illuminates eight critical enablers of innovation on climate change, each of which is illustrated by compelling examples of community-level experimentation on climate change across the province of British Columbia, Canada. It is concluded that community-based climate (or sustainability) policy might be more likely to trigger development path shifts if it employs a longer time horizon, recognition of adaptability and feedbacks, integrated decision making, and systems thinking.
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► Agricultural pesticide use intensity was analyzed for 119 countries, using FAO data. ► A 1% growth in crop yields is associated with a 1.8% growth in pesticide use per hectare. ► ...Growth in pesticide use intensity levels off at higher income levels. ► Few high income countries have managed to decrease their pesticide use intensity. ► We recommend a package of measures for rationalizing pesticide use.
We study levels and trends in agricultural pesticide use for a large cross-section of countries using FAO data for the period 1990–2009. Our analysis shows that a 1% increase in crop output per hectare is associated with a 1.8% increase in pesticide use per hectare but that the growth in intensity of pesticide use levels off as countries reach a higher level of economic development. However, very few high income countries have managed to significantly reduce the level of intensity of their pesticide use, because decreases in insecticide use at higher income levels are largely offset by increases in herbicide and fungicide use. The results also show very rapid growth in the intensity of pesticide use for several middle income countries such as Brazil, Mexico, Uruguay, Cameroon, Malaysia and Thailand. Complementing our analysis with data from the Rotterdam Convention on Prior Informed Consent (PIC), we show that hazardous pesticides covered in the PIC procedure are more weakly regulated in lower than in higher income countries. We discuss the policy challenges facing developing countries with a rapid growth in pesticide use and recommend a four-pronged strategy, including an environmental tax on pesticides with revenues allocated to long-term investments in awareness building, the development of integrated crop management methods and the setting of food safety standards. The interactions between these measures should help contribute to the effectiveness of the overall strategy package.
This study examines how Mexican-origin women construct and navigate racialized identities in a postindustrial northern border community during a period of prolonged restrictive immigration and ...immigrant policies, and it considers mechanisms by which responses to racialization may shape health. This grounded theory analysis involves interviews with 48 Mexican-origin women in Detroit, Michigan, who identified as being in the first, 1.5, or second immigrant generation. In response to institutions and institutional agents using racializing markers to assess their legal status and policing access to health-promoting resources, women engaged in a range of strategies to resist being constructed as an “other.” Women used the same racializing markers or symbols of (il)legality that had been used against them as a malleable set of resources to resist processes of racialization and to form, preserve, and affirm their identities. These responses include constructing an authorized immigrant identity, engaging in immigration advocacy, and resisting stigmatizing labels. These strategies may have different implications for health over time. Findings indicate the importance of addressing policies that promulgate or exacerbate racialization of Mexican-origin communities and other communities who experience growth through migration. Such policies include creating pathways to legalization and access to resources that have been invoked in racialization processes, such as state-issued driver's licenses.
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